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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)"
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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
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Estimated amount of Roma in CCE (%)
Percentage in population
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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
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reproductive health parameters
cardiovascular health parameters
infectious diseases
Main issues for MEHO:
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Slovak republic
Czech republic
Hungary, versus Romania, depends on existing data
Countries
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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:
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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:
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Kosice, Slovakia
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REPRODUCUTIVE HEALTH
• possibilities to evaluate many indicators including gender issues and woman health issues
• discrimination issues
• teenage pregnancies
• classical gynecological, pregnancy and newborn outcomes
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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
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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
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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
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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
*** ***
*** ***
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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
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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.***
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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 ***
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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.
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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 ***
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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 ***
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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 ***
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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 ***
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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)
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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:
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
"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."