Institute of Public Health, University of PJ Safarik, Medical Faculty, Kosice, Slovakia

Roma and non-Roma health in EU - main priorities

Kvetoslava Rimárová

MEHO PROJECT WP 10

 

"This project is funded under the framework of Public Health Programme 2003-2008 of the European Commission (contract number 2005122)"

Overview:

• Roma communities around Europe create estimated amount of

8 – 10 millions Roma people living prevalently in Eastern and

Central Europe

• Identifying Roma as an ethnic group brings the problem due the

national policy in former CEE countries where nationality is

voluntary in the census and the person can conceive a nationality

as a personal feeling

• Roma people themselves do not like to be called Roma or

Gypsies, most of identification is coming from external observers

featuring main visible signs

Estimated amount of Roma in CCE (%)

Percentage in population

Geographic distribution of Roma population in Slovakia

(official statistics by nationality)

Region Citizens total Official number of Roma

national Percentage of Roma (%)

Bratislavský kraj 599 015 755 0,13

Trnavský kraj 551 003 3 163 0,57

Trenčiansky kraj 605 582 1 574 0,26

Nitriansky kraj 713 422 4 741 0,66

Žilinský kraj 692 332 2 795 0,4

Banskobystrický kraj 662 121 15 463 2,34

Prešovská kraj * 789 968 31 653 4,01

Košický kraj 766 012 29 803 3,89

Slovak Republic 5 379 455 89 947 1,67

Source: Infostat Slovakia

reproductive health parameters

cardiovascular health parameters

infectious diseases

Main issues for MEHO:

Slovak republic

Czech republic

Hungary, versus Romania, depends on existing data

Countries

no national register

voluntary nationality not valid (see previous graphs)

no birth register

no birth place identification

surname classification no possible

different internal categorization, some countries use

also integrated, semi-, non-integrated Roma

Main differences between migrants and Roma:

indicators possible to compare with national data or

semi/country data or regional data

misclassification f.e. in national registry are Roma as

well as in the both of groups -- in control and in

exposed, the same Roma persons are also in most

cross/sectional studies

questionnaires and self/evaluation very problematic

different transcultral issues

Indicators development:

Kosice, Slovakia

REPRODUCUTIVE HEALTH

• possibilities to evaluate many indicators including gender issues and woman health issues

• discrimination issues

• teenage pregnancies

• classical gynecological, pregnancy and newborn outcomes

REPRODUCTIVE PARAMETERS

Sample

947 Roma and 2713 non-Roma mothers

cross-sectional study

data collection: 7 centre s in Slovakia ,

Faculty Hospital, Kosice in years 2004-2008 ongoing

Underlying determinants

SES, marital status, education, employment, residency

Proximate determinants

smoking, drinking alcohol, coffee, weight gain during

pregnancy, teenage pregnancy

Methods 2

Mother’s reproductive outcomes preterm delivery

gestational age

aborts spontaneous / arteficialis

type of delivery spontaneous vs. other or Caesarean

parity

complications during pregnancy

Outcomes

Newborn medical outcomes

newborn’s parameters sex of newborn

birth weight / length/LBW

chest / head circumference

Apgar score for newborn vitality

Dichotomisation of variables

LOW:Birth weight < 2500 g

Birth length < 45 cm

Chest circumference < 30 cm

Head circumference < 32 cm

Apgar newborn score < 9

Gestational age < 38 weeks

Mother’s weight increase < 10 kg

Abortus spontaneous 1

Abortus artificialis 1

Primipara - 1st delivery vs. multipara - 2nd or other delivery

Spontaneous delivery vs. Caesar section or other

complications

Frequency of SES underlying factors between Roma and Non-Roma

*** p<0,001 n.s. = not significant

94,6

68,071,7

95,2

36,239,1

7,5

29,4

0

10

20

30

40

50

60

70

80

90

100

Un

emp

loym

ent

Ele

men

tary

edu

cati

on

Sin

gle

mar

ital

stat

us

Ru

ral

resi

den

ce

%

Roma

Non-Roma

*** ***

*** ***

Risk factor OR 95% CIRel.Risk

Stat.sign.

Unemployment 27,35 20,2 - 37,07 2,44 ***

Elementaryeducation

247,84 175 – 350 12,73 ***

Marital status 6,08 5,14 – 7,19 2,43 ***

Rural residence

3,75 3,19 – 4,4 1,88 ***

OR of SES – underlying factors for Roma mothers

14,1

60,49

16,3

47,5

6,8

33,7

7,2

15,2

2,1

8,22

0

10

20

30

40

50

60

70

Tee

ang

em

oth

er

Sm

oki

ng

Co

ffe

Alc

oh

ol

Lo

ww

eig

ht

inc

reas

e

%

Roma

Non-Roma

Frequency of proximate factors between Roma and Non-Roma

***p<0,001n.s. = not significant

***

***

n.s.

n.s.***

OR of proximate - intermediate factors for Roma mothers

Risk factor OR 95% CIRel.risk

Stat.sign.

Teenage mother’s <19

12,61 8,5 – 18,79 10,97 ***

Smoking 8,52 7,18 – 10,11 3,98 ***

Coffe 0,56 0,48 – 0,65 0,71 n.s.

Alcohol 0,86 0,64 – 1,16 0,87 n.s.

Low weight increase

2,11 1,65 – 2,70 1,96 ***

Father’s age <20 5,79 3,70 – 9,08 5,47 ***

4,7

1,85

3,85

2,010,93

0

1

2

3

4

5

6

7L

BW

- lo

w b

irth

wei

gh

t

LB

L -

low

bir

thle

ng

th

Lo

w h

ead

circ

um

fere

nce

Lo

w c

hes

tci

rcu

mfe

ren

ce

Lo

w A

pg

arsc

ore

OR

an

d 9

5% C

IOR and 95% CI of Roma newborns

risk parameters

***p<0,001** p<0,01* p<0,05n.s. = not significant

***

*** ******

n.s.

Ethnic differences in birth weight (g) (Roma vs. Non-Roma)

ADJUSTMENT Diff. SE p Stat.sign.

CRUDE -401 (20) <0,001 ***

GENDER -122 (11) <0,001 ***

BIRTH ORDER -79 (7) <0,05 *

EMPLOYMENT -121 (10) <0,001 ***

EDUCATION (1) -356 (16) <0,001 ***

SMOKING (2) -316 (13) <0,001 ***

ALCOHOL -55 (9) 0,12 n.s.

SINGLE STATUS (3) -150 (18) <0,001 ***

RESIDENCE RURAL -142 (17) <0,001 ***

TEENAGE MOTHER -131 (12) <0,001 ***

ALL COVARIATES -198 (10) <0,001 ***

Ethnic differences in gestational age (weeks)(Roma vs. Non-Roma)

ADJUSTMENT Diff. SE p Stat.sign.

CRUDE -2,2 (0,13) 0,001 ***

GENDER -0,63 (0,09) 0,523 n.s

BIRTH ORDER -0,5 (0,03) 0,568 n.s.

EMPLOYMENT (3) -1,3 (0,08) <0,001 ***

EDUCATION (2) -1,4 (0,06) <0,001 ***

SMOKING (1) -1,9 (0,12) <0,001 ***

ALCOHOL -0,7 (0,07) 0,634 n.s.

SINGLE STATUS -1,2 (0,03) <0,001 ***

RESIDENCE RURAL -0,4 (0,01) 0,928 n.s.

TEENAGE MOTHER -1,2 (0,04) 0,05 *

ALL COVARIATES -1,5 (0,09) < 0,001 ***

Ethnic differences in low birth weight(logistic regression)

ADJUSTMENTLBW

OR 95% CI p Stat.sign.

CRUDE 4,7 (2,3-6,8) <0,001 ***

GENDER 4,6 (2,2-6,7) <0,001 ***

EMPLOYMENT 4,3 (2,8-5,8) <0,001 ***

EDUCATION 3,9 (2,6-4,6) <0,001 ***

SMOKING 2,5 (1,9-3,4) <0,001 ***

ALCOHOL 1,3 (0,9-3,1) 0,92 n.s.

SINGLE STATUS 2,5 (1,9-3,2) <0,01 **

RESIDENCE 1,9 (1,2-3,5) <0,001 **

TEENAGE MOTHER 2,3 (1,8-3,3) <0,001 ***

ALL 1,9 (1,1-2,6) <0,001 ***

Differences in selected indicators Roma and non-Roma

(ANOVA)

Parameter Roma (n=947)non-Roma (n=2713) t-test

p-value

  Mean SD Mean SD    

Birth weight (g) 2866.9 452.3 3267.5 538.5 12.99 ***

Birth length (cm) 48.4 2.3 49.7 2.6 18.22 ***

Head circumference (cm) 33.0 1.7 34.1 1.6 19.43 ***

Chest circumference (cm) 32.1 2.1 33.1 2.0 13.19 ***

Apgar score 9.3 1.4 9.2 1.2 0.27 n.s.

Gestational age 37.0 1.5 39.2 1.6 22.67 ***

Outputs 1

Between Roma and non-Roma significant differences exist in:

SES – distal factors

(education, unemployment, single status, rural residence,)

proximate factors

(smoking, teenage pregnancy, low weight increase)

pregnancy outcomes

(preterm delivery, low gestational age)

newborn characteristics

(birth weight, birth length, chest and head circumference)

Outputs 2

proximate factors

(drinking alcohol, coffee)

pregnancy outcomes

(number of abortions)

newborn characteristics

(Apgar score)

positive issues for Roma

frequency of spontaneous delivers , 4x lower frequency of

Caesarean section, frequency of abortions, Apgar score

Between Roma and non-Roma no significant differences in:

the most important risk factors for birth weight

reduction are education, smoking and martial status

for low gestational age the risk factors are smoking,

education and unemployment

LBW after adjustment for all possible variables is lower

in Roma

Conclusions 1

CARDIOVASCULAR HEALTH

• BMI index and others growth parameters

• body parameters

• food consumption survey

• evaluation of blood cholesterol triglycerides and other risk parameters

• risk factors as smoking, alcohol,

• difficult task to follow classic

RESULTS FROM NUTRITIONAL SURVEY • cross-sectional study 2007

• 150 Roma school-children

• interview and regulated questionnaires

• SES

• smoking

• food frequency in the family

• healthy food opinions

Number of smoked cigarettes per family in Roma group of children

 

CIGARETTES FREQUENCYPERCENTAGE

(%)

0 - 10 cigarettes

18 12,00%

10 – 20 cigarettes

69 46,00%

20 and more cigarettes

63 42,00%

Total amount 150 100,00%

CIGARETTES

Frequency of vegetables and fruit intake per week

FRUIT AND VEGETABLES

INTAKE FREQUENCY

PERCENTAGE (%)

5 times weekly 2 1,30%

3 times weekly 42 28,00%

2 times weekly 79 52,70%

No 27 18,00%

Total amount 150 100,00%

FRUIT AND VEGETABLES INTAKE

Frequency of daily food

FREQUENCY OF DAILY FOOD

FREQUENCY PERCENTAGE

(%)

5 times per day 26 17,30%

3 times per day 102 68,00%

less than 3 times

22 14,70%

Total amount 150 100,00%

FREQUENCY OF DAILY FOOD

Anthropometric studies

• cross-sectional anthropometrical survey,

including basic body parameters 2007

• subjects were Roma preschool and

schoolchildren aged 3-12 years

• 710 Roma (332 boys, 378 girls), semi-

segregated group

• compared to National Anthropometric Survey

Results from 2001 (no SES)

• part of group TCH total cholestrol blood pressure

Ethnic differences in height (boys)

SR - 2001 Roma - 2006

Age n (cm) s (cm) n (cm) s (cm) Diff. P(95%) Sig.

3 772 101.13 5.86 10 93.30 6.80 7.83 0.0054 **

4 477 107.84 5.90 16 100.16 4.21 7.68 0.0001 ***

5 581 115.22 6.22 17 105.26 5.10 9.96 0.0001 ***

6 492 123.15 6.16 58 111.27 9.17 11.88 0.0001 ***

7 884 127.46 6.55 67 111.30 10.53 16.16 0.0001 ***

8 982 132.72 6.46 55 120.15 8.90 12.57 0.0001 ***

9 816 138.53 6.62 60 122.70 10.09 15.83 0.0001 ***

10 747 143.47 7.36 38 133.04 6.55 10.43 0.0001 ***

11 782 148.61 7.49 18 136.83 6.95 11.78 0.0001 ***

12 813 155.03 8.39 3 140.33 2.52 14.70 0.0097 **

*p<0.05 ; ** p<0.01 ; *** p<0.001

Conclusions • use of body parameters if there is a national

anthropometric survey• use of local comparison and Roma • possibilities to compare between countries • new databases results are showing minimal

difference in TCH / total cholesterol and blood pressure in Roma and local non Roma

• but confirming difference in body parameters

Problems in Roma health evaluation • cross country comparison

• most of data are different in different countries• most of data - questionnaires data• medical records data not legal since policy and

discrimination • social factors data, level of integration • planning Roma health conference sept. 2009• small monograph trying to compare Roma

health data data

INFECTIOUS DISEASES

• precise vaccination survey in primary health care center 2006-2008

• cross-sectional study 18 years old Roma children (300 medical vaccination reports)

• the Roma have 87- 92 % shots which should be done in the age of 18

• delay in vaccination schedule very common between 2 shots

• question of antibody booster and outbreak of infection

• antibodies not measured

Conclusion:

support in regular visit of primary health care centers

vaccination os mandatory, parents can be prosecuted

Acknowledgements

Roma health research part was supported by the EU grant Public

health 2007-2009 MEHO

and national VEGA grant No.1231605, Slovak Republic

Address for correspondence

Kvetoslava Rimarova, MD, PhD. Institute of Public Health Medical FacultyUniversity of P.J. SafarikSrobarova 2040 01 Kosice, Slovakia

kvetoslava.rimarova@upjs.sk

"Disclaimer: The study has received funding from the European Commission under the Public Health Programme 2003-2008. However, the sole responsibility for the study lies with the author and the European Commission is not responsible for any use

that may be made of the information contained therein."