According to various sources, it is estimated that 430,000 Roma live in Slovakia, which represents 8% of the Slovak population (Marcinčin & Marcinčinová 2009, Vašečka&Džambazovič 2000). More than a seventh of the Roma population is schoolchildren (Marcinčin&Marcinčinová 2009). The problem is the extremely high level of territorial segregation, poverty and perceived discrimination (EU-MIDIS 2009, Vašečka&Džambazovič 2000). It is characterized by a low level of education and a high rate of unemployment (EU-MIDIS 2009, Vašečka & Džambazovič 2000). Only a small part of Roma youth in Slovakia (39%) continues their education after finishing primary school (EU-MIDIS 2009). The health of the majority of the Roma population is worse than the health of the non-Roma population living in Slovakia (Ginter et al. 2001, Vašečka & Džambazovič 2000). Moreover, all available data indicate that the health of most Roma is currently deteriorating again, which is especially true for those living in growing large and isolated Roma settlements (Vašečka & Džambazovič 2000). Published research on Roma health is fragmentary and often burdened by methodological problems (Voko et al. 2009, Kelly et al. 2004, Hajioff & McKee 2000). For decades, various strategies, programs, measures, interventions aimed at the inclusion of the Roma ethnic group, mitigating differences in health, have been implemented, but the prevailing opinion is that the situation is not improving. In fact, we know very little about the effectiveness and efficiency of these activities. The issue of social determinants of health and differences in health in this population group is thus an example of a research problem that is requested by society ("policy based research"), especially with the hope that it can provide research-based activities aimed at promoting health and mitigating differences in health ("research based policy").
In this paper, the focus is narrowed to the adolescent group. In the period of adolescence, it can be assumed that the potential for health is still preserved, and at the same time it is a period in which important social determinants of health are formed, such as the formation of health-related behavior, integration into social networks, the adoption of strategies for managing difficult life situations, the formation of the future socio-economic position through success or failure in the education system (Madarasová Gecková 2005). The findings of some studies indicate that even in very unfavorable conditions, a part of the population can maintain good health, a healthy lifestyle and break out of generational poverty (Payne et al. 2010, Sagy & Dotan 2001, Cederblader et al. 1994).
The health of Roma youth can be marked by disadvantage in earlier periods of life. Ecological epidemiological studies indicate that the Roma population significantly participates in the increased rate of infant mortality in the districts of Slovakia (Rosičová et al. 2010, 2007). Worse perinatal indicators among Roma have been confirmed by several studies (Dostál et al. 2010, Bobak et al. 2005, Rimárová et al. 2004, Ginter et al. 2001, Correteger et al. 1992). The incidence of flu, otitis media, infectious diseases of the digestive tract and viral diseases was statistically significantly higher in the group of Roma children under 2 years of age (Dostál et al. 2010). A higher incidence of contact with hepatitis type A and type B as well as a lower rate of vaccination against hepatitis B vaccine were confirmed in a group of Roma children aged 5 to 15 years compared to their peers living in deprived suburbs of Athens (Michos et al. 2008). A higher incidence of diarrhea, cough, and respiratory difficulties in the group of children living in Roma camps was related to the number of years spent in the camp, overcrowding, living conditions, use of wood stoves, the presence of rats, and the quality of sanitary facilities and waste (Monasta et al. 2008). Compared to their peers from the majority population, Roma adolescents at the age of 15 were characterized by a worse overall health assessment, a higher incidence of injuries, more frequent use of health services, but also a lower rate of subjective health problems (Kolarčik et al. 2009).
Thus, many findings indicate poorer health of Roma youth compared to their peers, but this does not seem to apply equally to all health indicators, and also within the life cycle there are more or less sensitive periods in terms of health differences compared to the majority population.
Several hypotheses can be identified in the literature trying to explain the worse health of the Roma population compared to the majority population (Bastos et al. 2010, Voko et al. 2009, Peters et al. 2009, Dressler et al. 2005, Wilkinson&Marmot 1998): (1) The observed differences in health may be the result of differences in living conditions, in access to goods and services, in the degree of poverty, so the main cause of the differences is not ethnicity but different socio-economic characteristics, socio-economic disadvantage. Some findings indicate this (Škodová et al. 2010, Kolarčík et al. 2009, Voko et al. 2009). (2) Cultural differences are the cause of differences in health literacy, in health related to behavior (dietary habits, use of psychoactive substances, physical activity, disease prevention), which lead to differences in health. Many studies confirm the health-threatening patterns of smoking (Popper et al. 2009, Kosa et al. 2007, Skaric-Juric et al. 2007), alcohol consumption (Puporka & Zadori 1999), drug use (Puporka & Zadori 1999), physical activity (Kolarčik et al. 2010), sexual behavior (de Cortazar et al. 2009, Kelly et al. 2004, Kabakchieva et al. 2002) or nutritional habits (Ostrihoňová & Bérešová 2010), while their incidence is higher than in groups of their peers from the majority population. Knowing cultural differences in the area of naïve theories of health, health literacy and health attitudes is important for understanding differences in health, but also for building effective health care models (DeWalt & Hink 2010). The existence of these differences in the Roma population group is indicated by several studies (Sutherland 2009, Vivian & Dundes 2004). (3) Psycho-social hypothesis draws attention to the health consequences of stress from discrimination, social exclusion, material and financial lack, lower socio-economic position. The higher incidence of discrimination and unfair treatment in Roma population groups has been attributed to an adverse effect on health (Bastos et al. 2010, EU-MIDIS 2009), but the mechanism of action is not clarified (Bastos et al. 2010). (4) Conditions in early childhood can be disadvantageous, and this disadvantage tends to accumulate at each subsequent critical period of life, resulting in widening health disparities. The period of schooling and the school environment can be an opportunity to break the cycle of disadvantage. Success in the educational system is important for upward mobility within SE stratification (Marcinčin & Marcinčinová 2009, Madarasová Gecková 2005). That is, how adolescents threatened by socio-economic disadvantage feel at school, what level of social support they perceive in the school environment, what their relationships with classmates are like (including bullying, violence) affects their attitude towards school, the creation of educational aspirations, school performance, but also truancy and other types of educationally problematic behavior (Madarasová Gecková et al. 2010, Bobáková et al. 2010). (5) There are studies indicating genetic differences that could explain part of the differences in health (Bzdúch 2001, Genčík et al. 1989, Ferák et al. 1987).
Research into the social determinants of the health of Roma youth involves several methodological challenges: (1) identifying and defining the population itself is problematic. Data on ethnicity is absent in most routinely collected data (Kosa et al. 2008), the use of self-identification, identification based on mother tongue, but also identification by another person or identification based on location is problematic. (2) Another problem is the heterogeneity of the population. The Roma are not a homogeneous group and their cultural frameworks differ, they differ in the degree of assimilation, they differ depending on whether they live in cities or in the countryside, and even significant differences can be observed between settlements in the countryside. (3) Availability of respondents is problematic due to the high rate of migration and truancy. (4) The use of a questionnaire survey is financially and organizationally less demanding, is less susceptible to the facilitation of social desirability, but increases the likelihood of cognitive distortion compared to a survey based on an interview (Bowling 2005 Brenner et al. 2003). For research on the health and social determinants of the health of Roma youth, it seems more advantageous to use an interview, but surveys in the majority population are mostly carried out using a questionnaire. A better understanding of the possible biases that occur in different types of data collection allows more adequate comparison and interpretation of findings. (5) Cultural sensitivity of methodologies is an unsolved problem. Despite the fact that Slovakia has a solid tradition of taking into account the cultural sensitivity of tests of cognitive abilities, this is not the case in the field of personality questionnaires, health literacy, parental control, and social desirability. (6) Evaluation of the possible impact of social desirability affects the validity of the findings and their interpretation. Some findings indicate a different degree of social desirability in different cultural frameworks (Verardi et al. 2010, Kolarčik et al. 2009). The findings indicate a higher level of social desirability in the group of Roma youth compared to peers from the majority population, more significant bias in models investigating delinquent behavior and aggression, moderate differences in models investigating health, and very little bias in models investigating health-related behavior (Kolarčik et al. 2010, 2009 a - b).
The aim of the research should be to identify modifiable behavioral and psycho-social determinants of health, which are involved in differences in health, as well as effective ways of influencing and changing them. Research can offer practitioners the necessary knowledge, understanding and inspiration for more effective work with migrants.
Authors: Doc. Andrea Madarasová Gecková, PhD, Mgr. Peter Kolarčik, MD. Jana Kollárová, Mgr. Daniela Bobáková List of references
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The paper was presented at the 5th annual conference entitled ,,Psychology of health 2010", which took place on May 19, 2010 in Bratislava. The conference was organized by the health psychology section of the SPS at SAV in cooperation with the health section of the Ministry of Health of the Slovak Republic. The following participated in the preparation of the event: National Institute of Heart and Vascular Diseases in Bratislava, VŠZaSP St. Elizabeth in Bratislava, WHO Office in Slovakia, KISH Košice, Department of Psychology FF KU in Ružomberok and Department of Psychology FF TU in Trnava.
Proceedings from the 5th conference of health psychology, Bratislava, 2010 was published only in electronic form Availability: http://www.prohuman.sk/psychologia/zbornik-prispevkov-z-konferencie-psychologia-zdravia-2010