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The health needs of the Slovak Roma community in Sheffield.

Introduction

The World Health Organization defines health as a 'state of complete physical, psychological and social wellbeing and not merely the absence of disease and infirmity' (p100). (1) Measures of health suggest that it is related to many factors, including income, education, housing conditions, occupation and environmental conditions. When we consider health inequalities, we are generally considering the health differences that are shaped by social and economic factors. (2) Wilkinson argues that the driving forces behind health inequalities in developed societies are not absolute differences in income and social status, but relative differences. (2)

Health visiting practice is guided by a set of clearly defined and interrelated principles identified by the Council for the Education and Training of Health Visitors--to determine and stimulate an awareness of health needs, influence health policies and promote health-enhancing activities. (3) This places health visitors at the forefront of the public health agenda in promoting health and reducing health inequalities. Assessment of family health need is a core health visiting skill and key to uncovering need, safeguarding children and determining levels of health interventions offered to children and their families. (4)

In May 2004, the Slovak Republic joined the European Union (EU). South Yorkshire became a base for migrant Slovak Roma workers from villages and a regional city centre called Kosice in Eastern Slovakia. A classic chain migration has resulted in growing numbers of workers and their families arriving in Sheffield over the last four years. An understanding of their background and socioeconomic position in the UK is essential in determining health needs within this community. An appreciation of their attitudes and beliefs about health and health care is equally crucial when attempting to raise awareness of these needs. Work to address identified health needs effectively requires good communication with both the public and voluntary sectors, and the involvement of the community itself. This paper outlines some of these issues and draws on experiences of working with the Slovak Roma community in Sheffield since 2005.

Background

The Roma are Europe's poorest and largest minority ethnic population--approximately 2% of the 450 million EU residents. Institutional racism is frequently alleged. (5) Roma in Slovakia make up 10% of the population. In Eastern Slovakia, this can be up to 40% of some settlements. They were predominantly coalminers, steelworkers and labourers under the Communist regime, and its collapse in 1989 led to widespread Roma unemployment. Occupational, residential and social segregation pushed Roma communities into enclaves. They lived in appalling housing conditions, isolated from their Slovakian neighbours. There was almost 100% Roma unemployment. (6) Health inequalities have been well documented in recent years. (7,8) In general, Roma men and women live 10 to 15 fewer years than their non-Roma counterparts from the same region in the EU. (9) The UK's estimated 200 000 to 300 000 Gypsy and Traveller population have about the worst health status in the country. (10)

Migrants come to Sheffield to find work. The Slovak Roma migrant population is unusual, in that whole families quickly join male members who find employment. This contrasts with other migrants from central Europe who are often young and single.

Poverty and health

Case study

Igor and Marcela arrived in Sheffield with their eight children in 2007. They originated from Bystrany, a small village in Eastern Slovakia. Igor had been unemployed in Slovakia, but was keen to work in the UK. However, with few skills, limited education and occupational experience he found only low-paid employment in the food processing industry through an agency. He registered on the Worker Registration Scheme and applied for a National Insurance (NI) number as required. Igor was aware of his entitlement to 'in-work' benefits from his first day at work--child, working and council tax credits and housing benefit--and he knew he could claim child benefit once he had received his NI number. But he struggled to complete the relevant forms, and health contacts were dominated by demands for help with these. He was referred to a local advice centre for support. Bureaucracy was then slow and he found himself having to wait many weeks before he received his financial entitlements. Family finances were a major concern. Their limited resources meant they struggled to cope during this period. Local residents voiced their concerns to health visitors regarding the older children seen wandering the streets on one occasion. They had appeared dishevelled and inadequately dressed, their poverty clearly evident. The family valued the support of local community projects and churches with providing clothing and shoes for the children, and fresh fruit and vegetables to supplement the family diet.

Igor lost his job after eight months and was unable to find alternative employment for several weeks. As he had not completed one year of continuous work, he was not entitled to claim jobseeker's allowance (a state benefit) and his break of more than 30 days without working meant he had to start the one-year qualifying period again. He suffered from repeated episodes of muscular pain and was admitted to hospital on two occasions with palpitations. He was unable to sustain regular employment and the family returned home to Slovakia last year, having been unable to become established in the UK.

Local authority duties and responsibilities are initially limited toward the new migrant communities. Section three of the Nationality, Immigration and Asylum Act 2002 prohibits local authorities from using various provisions to support these households, including Section 21 of the National Assistance Act, Section 17 of the Children Act and Section Two of the Local Government Act. However, families can be helped to return to their country of origin.

Blackburn (11) argues that poverty affects every aspect of health, from physical, mental and social health through to health behaviour. Income influences how much money is available for food. Physiologically, an inadequate diet directly affects children's growth and development. Poor maternal diet affects lactation. Poverty takes its toll on mental wellbeing, leading to stress and its associated physical illness symptoms. It can also create a lack of freedom and relative powerlessness within society. Compromising a child's health in poverty may not always be a matter of choice. (11)

Housing and health

Case study

Josef and Maria arrived in Sheffield in 2007 with their two young children. They moved into a privately rented, three-bedroom terraced house with Maria's brother and sister and their families, close to a busy road. Shared accommodation meant their limited finances could stretch further. Although overcrowded, noisy and chaotic at times, it was a mutually supportive home environment.

During the next six months, health visitors advised the families on treatment for headlice, impetigo and threadworms. The children experienced frequent respiratory and gastrointestinal infections. Emelia--a lively two-year-old--sustained a partially amputated finger after a door was slammed on it. Health visitors were alerted by local residents when she was seen playing on the road, supervised only by her six- and seven-year old cousins.

When the hot-water boiler broke down and evidence of damp appeared in the back bedroom, requests for repairs were ignored by the landlord until a professional referral to the local authority department responsible for the monitoring and regulation of private sector landlords was made. When the family reported problems with vermin, both inside and outside the property, communication with environmental health agencies was crucial. Extra refuse bins were provided for their rubbish.

In 2008, Josef and Maria decided to move into their own home. They valued the support of Nomad--a local housing organisation--in helping them secure a new tenancy.

Migrant workers are eligible to apply for council housing if there is no other housing available to them, but with strict criteria. The reality is that most families are driven toward the private rented sector. The quality of this varies considerably. Families quote exorbitant rents for unsafe and poor standard housing. Unacceptable landlord practice in terms of tenancy agreements and property maintenance, systematic harassment of tenants and forcible eviction of families from their homes have all been reported. As with employment, exploitation of the Slovak Roma community is rife.

Overcrowding was recognised in the UK as a health hazard linked to the spread of disease as early as the 19th century. A family history of tuberculosis is often disclosed by the Roma. Discussions with the neonatal department in Sheffield have resulted in most babies from the Slovak Roma community now being offered a BCG vaccine at birth, even though Slovakia is not on the list of countries from where this would be routine.

Housing conditions influence childrearing practices strongly. Crowded living areas are related to high home accident rates among children. For example, a small kitchen makes it physically and mentally difficult for parents to cook safely and supervise children at the same time. Yet the opportunity to allow a child to play safely outdoors instead of inside an unsafe home is generally not available. Low income families often live in locations where the outdoors offer little protection to children. (11)

Housing and health are inextricably linked. Studies on their relationship have indicated that health inequalities are closely linked to housing inequalities. (12) Absolute and relative housing inequality are experienced disproportionately by the poorest and most vulnerable members of society.

Access to health services

Case study

Roman and Margita arrived in Sheffield in November 2007. They had previously lived briefly in Cardiff and Peterborough following work opportunities, but were unknown to primary care services. They had four children aged from 22 months to six years. The family were initially defensive and suspicious of the health visitor. Several home visits were needed to establish trust and complete the necessary child and family health needs assessments. They had a poor understanding of how to use NHS services. They had approached a local GP surgery when Margita was unwell, but failed to keep an appointment due to poor time-keeping. The level of need within the family was considerable.

Maros was four years old, with poor communication skills and challenging behaviour. Three-year old Jana had a reported heart murmur and hearing impairment, but their parents appeared to have little understanding of her health needs. Her dentition was poor with evidence of widespread dental decay. Referrals for specialist assessments and support were agreed, but appointments were all defaulted. Further dates were arranged.

At 22 months, Klaudia was still breastfeeding. Her growth was below the second centile and her dietary intake was very limited. Later blood tests revealed iron deficiency anaemia and chronic vitamin deficiency.

Vanesa was not attending school and her parents were informed of the legal requirement for children aged over five years to attend fulltime education on a consistent basis. Liaison with the Missing Children From Education Team ensured that this was addressed. A nursery application for Maros was encouraged, but never completed by the family.

Six months later, the family moved house. Extended family members reported that they had experienced difficulties with their landlord and returned home to Slovakia for a holiday. Follow-up appointments for Maros and Jana were lost. Their on-going health needs would appear to have been ignored in the midst of such decisions.

The subject of migration and health has been the focus of reports by the Council of Europe (13) and the Portuguese presidency of the EU. (14) European migrants are entitled to NHS care. However, their entitlement to full health care depends on the main household member being registered for work with the Worker Registration Scheme. Education of families on access to health care and the appropriate use of primary care services is crucial, but this takes time and requires an interpreter for every contact. Good practice guidelines highlight the right of all citizens in an inclusive and democratic society to understand and receive appropriate communication support. (15) Literacy issues can have implications for the widespread use of translated written material, particularly among older Slovak Roma who might not read or write Slovakian.

Many Roma children arrive from Slovakia with genetic abnormalities, developmental delay and untreated or undiagnosed medical problems. Consanguineous marriage within the Roma community is not uncommon.

As a vulnerable and disadvantaged community in both origin and host societies, the Slovak Roma appear to be suspended between the UK and Slovakia. The mobility of the Slovak Roma community impacts not only on the ability to follow up identified health issues, but also on the provision of care from other partners in health. GP practices in Sheffield have reported a high level of need, often with regard to addressing longstanding and often neglected health issues. Anecdotal evidence indicates that defaulted appointments have had an impact on practice targets, particularly regarding childhood immunisations.

Health is not always a high priority for families with many other worries. (16) Studies have found that everyday living experiences shape ideas about health and illness. As with other low income groups, the Slovak Roma community may conceive of health as a functional state, concerned with surviving and being able to carry on with the necessities of everyday life, rather than a positive state of fitness and wellbeing. (17)

Pregnancy and neonatal health

Case study

Alena was 17 years old and five months pregnant when she first came to Sheffield with her young partner Jan and their 14-month old daughter Vanesa in 2008. They lived with Jan's parents and his four younger siblings in a privately rented, three-bedroom property. Both Jan and his father were in employment. Health visitors were first alerted to the family's arrival in the UK by the local accident and emergency department. Vanesa had been taken there by her parents, after pulling a hot drink over her legs. A subsequent health visitor home visit established that the family had not yet registered with a GP surgery and that Alena had received no antenatal care. Support was offered to address these issues, and Alena booked in for hospital delivery. Blood screening revealed that she had hepatitis B antibodies and iron deficiency anaemia.

At 30 weeks' gestation, Alena returned to Slovakia. Three months later, health visitors were informed that the family were back in the UK with their new baby, born at 37 weeks' gestation with a birthweight of 2.6kg. Alena had travelled back three weeks after the baby's birth. Neonatal audiology screening and appointments for a postnatal review, GP eight-week medical and primary immunisations were arranged. Alena agreed to both her children receiving the meningitis C vaccine, which was not available in Slovakia but routine in the UK. Arrangements were also made for baby Jan to continue his hepatitis B course of immunisations. He had reportedly received BCG and initial hepatitis B vaccines in Slovakia, but there was no documented evidence of this. A set of parent-held records was provided and his parents were encouraged to share these with other professionals, both in the UK and Slovakia. Contraception was discussed at length with Alena, to ensure that any further pregnancy was not through a lack of awareness. Arrangements were made for her to have a hormonal implant.

Advice around the prevention of sudden infant death syndrome was a key area of work with the family. Alena was wrapping the baby in a 'perinka'--a swaddling wrap often used by Roma mothers. The dangers of potential overheating were highlighted. Bed-sharing was acknowledged by the parents, but they agreed to put the baby to sleep in a Moses basket sourced locally from a charity. Space constraints in the bedroom would make the use of a cot difficult later in the year. The family listened to advice regarding the dangers of passive smoking to babies and young children, but the house's atmosphere remained smoky during follow-up contacts.

According to recent figures, half of the Roma are under the age of 20 years. (5) Teenage pregnancy is common in this community. It is estimated that the number of teenage pregnancies in one area of Sheffield has doubled since the arrival of Slovak migrant families.

Girls aged 17 years or over have the right to free pregnancy care, but only if they or their partner are in employment. A fear of being charged for hospital delivery has been expressed to health visitors. It is apparent that many pregnant women are presenting late or not at all for antenatal care. The potential consequences of such situations are a concern. Studies have found that Roma women start having babies at an earlier age and give birth to smaller babies than non-Roma women. In one province in Slovakia, low birthweight was about four times more common among Roma (13.2 versus 3.3 per 1000 live births in 1997). (18)

Infant mortality rates in Slovakia are high. In 2006, UNICEF reported a rate of seven deaths per 1000 live births. The infant mortality rate among Roma is placed at about double that of non-Roma residents. (19) In 2003, the United Nations Development Programme found that, while Roma children represented 8.4% of all live births, they accounted for 17.8% of all infant deaths. These figures compare with an infant mortality rate in England and Wales of 4.9 deaths per 1000 live births. (20) According to the World Health Organization, there were more than 12 child deaths under the age of five years per 1000 live births in the Kosice Region of Eastern Slovakia in 2002. The EU average was seven and the UK rate was six.

Conclusions

While government policies around migrant workers in the UK may limit their initial access to public funding, other government directives such as Health for all (21) and Every child matters (22) state the responsibilities of health visitors toward this vulnerable group. Their health needs are extensive, but many of the health problems of migrants are the product of social and environmental factors that cannot be addressed by health services working alone, a conclusion reached by the Conference on Health and Migration in the EU. (23)

It has been suggested that an acknowledgment of different expectations and experiences needs to be part of the foundation of any healthcare provision for migrants. (16) Blackburn argues that fieldworkers need to demonstrate to parents that they understand the context within which parents care for their own and their children's health and wellbeing, and to show that they understand the constraints under which families live and care. (11)

Wilkinson (2) contends that any health promotion programme should consider the critical relationship between health, income and social position. The benefits of involving migrant communities in health promotion work have been recognised. (16)

Families need access to health services that are responsive to their particular needs, easy to use and welcoming. (11)

The role of English and literacy classes in order to improve their ability to access appropriate health and social care in the UK is key. The development of pictorial material for use with clients is being considered in Sheffield.

Interagency collaboration should be a fundamental aspect of any strategy that aims to tackle the health concerns of migrant families, as well as communication with the migrant community itself. Health visitors are well placed to share knowledge and influence policies and initiatives targeting the health needs of the Slovak Roma.

Acknowledgments

The author would like to thank senior health manager Shona Ashworth and colleagues in Burngreave and Firvale health visiting teams for their support of her work with the Slovak Roma community in Sheffield.

Key points

* Household income is a key health resource for families from the Slovak Roma community

* The housing conditions of the Slovak Roma strongly influence child rearing practices

* A recognition by fieldworkers that health is not always a high priority within families with many other issues is essential

* Health visitors are well placed to share knowledge and influence policies and initiatives targeting the health needs of the Slovak Roma community

References

(1) World Health Organization. Primary health care: report of the International Conference of Primary Health Care (Alma-Ata, USSR, 6 to 12 September 1978). Geneva: World Health Organization, 1978

(2) Wilkinson RG. Unhealthy societies. London: Routledge, 1996.

(3) Council for the Education and Training of Health visitors. An investigation into the principles of health visiting. London: Council for the Education and Training of Health Visitors, 1977.

(4) Appleton J, Cowley S. Health visiting assessment-unpacking critical attributes in health visitor needs assessment practice: a case study. International Journal of Nursing Studies, 2008; 45(2): 232-45.

(5) Horton M. Workshop paper on Roma, Gypsies and Travellers. London: Community Development Foundation, 2005.

(6) Znamenackova Z. Migration of Romani people from Bystrany (Slovakia) to Sheffield (UK) (conference presentation). Sheffield: Roma New Migrants Conference (8 March), 2008.

(7) Zeman CL, Depken DE, Senchina DS. Roma health issues: a review of the literature and discussion. Ethnicity and Health, 2003; 8(3): 223-49.

(8) Vozarova de Courten B, de Courten M, Hanson RL, Zahorakova A, Egyenes HP, Tataranni PA, Bennett PH, Vozar J. Higher prevalence of type 2 diabetes, metabolic syndrome and cardiovascular diseases in gypsies than in non-gypsies in Slovakia. Diabetes Research and Clinical Practice, 2003; 62(2): 95-103.

(9) Sepkowitz KA. Health of the world's Roma population. Lancet, 2006; 367(9524): 1707-8.

(10) Parry G, Van Cleemput P, Peters J, Moore J, Walters S, Thomas K, Cooper C. The health status of Gypsies and Travellers in England: report of Department of Health Inequalities in Health Research Initiative Project. Sheffield: University of Sheffield, 2004.

(11) Blackburn C. Poverty and health: working with families. Milton Keynes: Open University, 1991.

(12) Townsend P, Davidson N. Inequalities in health (the Black Report). Harmondsworth: Penguin, 1982.

(13) Council of Europe. Bratislava declaration on health, human rights and migration. Paris: Council of Europe, 2007.

(14) Portugal R, Padilla B, Ingleby D, de Freitas C, Lebas J, Pereira Miguel J (Eds.). Good practices on health and migration in the EU. Lisbon: Ministerio da Saude, 2007.

(15) Scottish Translation, Interpreting and Communication Forum. Good practice guidelines. Edinburgh: Scottish Executive, 2004.

(16) Maffia C. Health in the age of migration: migration and health in the EU. Community Practitioner, 2008; 81(8): 32-5.

(17) Stacey M. Concepts of health and illness and the division of labour in health care. In: Currer C, Stacey M (Eds.). Concepts of health, illness and disease. Leamington Spa: Berg, 1986.

(18) Koupilova I, Epstein H, Jan Holcik J, Hajioff S, McKee M. Health needs of the Roma population in the Czech and Slovak Republics. Social Science and Medicine, 2001; 53(9): 1191-204.

(19) United Nations Development Programme. Avoiding the dependency trap: the Roma human development report. New York: United Nations Development Programme, 2003.

(20) Department of Health. Review of the health inequalities infant mortality PSA target. London: Department of Health, 2007.

(21) Hall D, Elliman D. Health for all children (fourth edition). Oxford: Oxford University, 2006.

(22) HM Government. Every child matters: change for children. London: Stationery Office. 2004.

(23) Ministerio da Saude. Conference on Health and Migration in the European Union, Lisbon (28 September 2007). Lisbon: Ministerio da Saude, 2007.

Gillian Gill BA, SRN, HV

Health visitor, Burngreave and Firvale health visiting team, Sheffield
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Title Annotation:PROFESSIONAL
Author:Gill, Gillian
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Mar 1, 2009
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