A Community-Based Participatory Action Research for Roma Health Justice in a Deprived District in Spain

Addressing Health Disparities through Community Participation: A Scoping Review of Co-Creation in Public Health

BACKGROUND

There is general agreement regarding the relevance of community involvement in public health policy, practice, and research to reduce health inequities.

OBJECTIVE

This review aims to analyse the experiences of community engagement in public health actions, with particular attention to methodologies used and how community participation is articulated.

METHOD AND ANALYSIS

We searched the Web of Science, EBSCO, and ProQuest for scientific articles published in peer-reviewed journals. We recorded methodological aspects, the approach to equity, actors that participated in the actions, and participation of the community in different phases (agenda setting, design, implementation, and evaluation).

RESULTS

Of 4331 records, we finally included 31 studies published between 1995 and 2021. Twelve studies referred to Community-Based Participatory Research as the framework used. The actions addressed equity, mainly by tackling economic vulnerability (n = 20, 64%) and racial discrimination (n = 18, 58%). Workshops were the most used method. Participation was frequently observed in the design and implementation phases of the action, but it was reduced to community feedback in the evaluation.

CONCLUSIONS

Co-created public health actions offer the opportunity to reduce health inequity and promote social change; yet, further effort is needed to involve communities in the entire cycle of decision making.

Romani Girls Matter: Developing a Participatory Action Research Protocol for Reproductive Justice

Despite the last few decades' advances towards social and gender justice, reproductive decisions are still a source of oppression for many European Romani women and girls. This protocol aims to propose a model to empower Romani women and girls' reproductive decisions, inspired by Reproductive Justice-the recognition of women and girls' ability to make safe and free decisions about their bodies and reproduction. Through Participatory Action Research, 15-20 Romani girls and their families, two Romani platforms, and key agents from a rural and an urban context in Spain will participate. They will (1) contextualize Romani women and girls' inequities, (2) build partnerships, (3) implement Photovoice and advocate for their gender rights, and (4) assess the initiative's related changes, using self-evaluation techniques. Qualitative and quantitative indicators will be collected to assess impacts among participants, while tailoring and assuring the quality of the actions. Expected outcomes include the creation and consolidation of new social networks, and the promotion of Romani women and girls' leadership. For this, Romani organizations must be transformed into empowering settings for their communities, spaces where Romani women and girls assume responsibility of the initiatives, being these tailored to their real needs and interests, and guaranteeing transformative social changes.

[Repercussions of COVID-19 in a participatory action-research process with adolescent Roma women]

The objective of this article is to describe the impact of the COVID-19 pandemic on the implementation of the RoMoMatter project, using a community-based participatory action research methodology, in Córdoba (Spain). Five academic researchers and 30 community members participated. Individual interviews, focus groups and field notes were used as data collection techniques. The interviews were audio-recorded with the consent of the participants and transcribed verbatim. The information collected was coded using Atlas Ti software. The efforts of adaptation to the new pandemic scenario made by the participants and the technical and emotional support role played by the adaptation team are highlighted. It is concluded that the main impact of the pandemic was evidenced in the participatory process of all the people involved, and in the format and number of activities.

A Community-Based Participatory Action Research with Women from Disadvantaged Populations: Strengths and Weaknesses of a Multiple Health Behaviour Change Intervention

Disadvantaged populations usually adopt risk behaviours, resulting in obesity and mental health-related disorders. Grounded in the socioecological model and self-determination theory, the aims were firstly to describe and implement a two-year multiple health behaviour change intervention, and secondly, to assess the strengths and weaknesses of the intervention. In total, 11 women from a disadvantaged population participated in this programme, which encompassed 117 sessions. Qualitative techniques were used to collect data and a thematic analysis was conducted. The variety of activities and the group-based intervention were the main strengths, and the decrease in attendance and the programme’s tight schedule were the main weaknesses. This is the first intervention in a disadvantaged population mainly comprised of Roma women. The design described in detail and its assessment provide relevant knowledge to improve their health status and decrease inequalities. The practical implications for future research are useful for replicating interventions in similar contexts.

Beliefs, Perceptions, and Behaviors Regarding Chronic Respiratory Diseases of Roma in Crete, Greece: A Qualitative FRESH AIR Study

Background

The global burden of chronic respiratory diseases (CRDs) disproportionally affects Roma populations. Health interventions addressing CRD among Roma or other vulnerable groups often fail to be effective, as their implementation strategy misaligns with the local context. To design context-driven strategies, we studied CRD-related beliefs, perceptions, and behaviors among a Greek Roma population, focussing on asthma and COPD.

Methods

For this qualitative study in Crete, Greece, we used a Rapid Assessment Process. We conducted interviews and focus groups with purposively selected Roma community members (CMs), key informants (KIs) and healthcare professionals (HPs) serving the population. Data were triangulated using observations of households and clinical consultations. Key themes were identified using Thematic Content Analysis. The Health Belief Model, the Explanatory Model of Illness, and the Theory of Planned Behavior that are complementary is some aspects, guided our methodology with the several variables from them to be integrated to better understand CRD risk preventative behavior.

Results

We conducted six focus groups, seven interviews and 13 observations among 15 CMs, four KIs, and three HPs. Five themes emerged: (1) Poor CRD-awareness (smoking and household air pollution were perceived as harmful, but almost exclusively associated with acute rather than chronic symptoms); (2) Low perceived susceptibility to CRD (and CMs tended to ignore respiratory symptoms); (3) High risk exposure (smoking was common, and air pollution was perceived inevitable due to financial constraints); (4) Healthcare seeking (healthcare was sought only for persistent, severe symptoms, daily needs were a priority); (5) Perceived barriers/facilitators to care (health illiteracy, perceived discrimination and financial constraints were main barriers; established trust the main facilitator).

Conclusion

These five themes highlight that strategies to tackle CRD in the studied Roma setting require a multilevel approach: bridging awareness gaps at the population level, providing resources to enhance the adoption of healthy behaviors, and fighting discrimination at the societal level, whilst establishing trusted relationships at the local level. Similar methodologies to address local context may strengthen the implementation of effective interventions for similarly vulnerable and/or low-resource populations.

Discrimination as A Barrier to Romani Women's Health and Empowerment: A Qualitative Study

This qualitative descriptive case study investigates perceptions of health and empowerment among Romani women and social workers in Marseille, France. I used constructivist grounded theory to develop theory emerging from interviews and participant observation data. Results suggest intersectional discrimination at individual and structural levels led to inequalities in accessing resources essential to their survival in France, including healthcare, housing, and employment. This study provides insight into the ways discrimination impacts health inequalities experienced by Romani migrant women. Ultimately, this research highlights essential knowledge and strategies for social workers and public health professionals to empower Romani women by connecting them with essential resources and by envisioning anti-racist interventions to alleviate their experience of individual and structural discrimination.

Is Prescription Nonredemption a Source of Poor Health Among the Roma? Cross-Sectional Analysis of Drug Consumption Data From the National Health Insurance Fund of Hungary

Background: The health status of the Roma is inferior to that of the general population. The causes of poor health among this population are still ambiguous, but they include low utilization of healthcare services. Our study aimed to investigate prescription redemptions in segregated Roma colonies (SRC) where the most disadvantaged quartile of Roma people are living.

Methods: A cross-sectional study was carried out with data obtained from the National Institute of Health Insurance Fund Management in the settlements belonging to the study area of the “Public Health-Focused Model Program for Organizing Primary Care Services.” The study included 4,943 residents of SRC and 62,074 residents of the complementary area (CA) of the settlements where SRC were located. Crude and age- and sex-standardized redemption ratios for SRC and CA were calculated for each Anatomic Therapeutic Chemical (ATC) group and for the total practice by ATC group. Standardized relative redemptions (RR) with 95% confidence intervals were calculated for SRC, with CA as a reference.

Results: The crude redemption ratios were 73.13% in the SRC and 71.15% in the CA. RRs were higher in the SRC than in the CA for cardiovascular, musculoskeletal system, and alimentary tract and metabolism drugs (11.5, 3.7, and 3.5%, respectively). In contrast, RRs were lower in the SRC than in the CA for anti-infective agents (22.9%) due to the poor redemption of medicines prescribed for children or young adults. Despite the overall modest differences in redemption ratios, some ATC groups showed remarkable differences. Those include cardiovascular, alimentary and musculoskeletal drugs.

Conclusion: Redemption of prescriptions was significantly higher among Roma people living in SRC than among those living in CA. The better redemption of cardiovascular and alimentary tract drugs was mainly responsible for this effect. These findings contradict the stereotype that the Roma do not use health services properly and that prescription non-redemption is responsible for their poor health.

How to improve access to health care for Roma living in social exclusion: a concept mapping study

Background

Half of the people living in social exclusion in the Czech Republic are of Roma origin. The worse health of Roma could be partly explained by numerous barriers to accessing health care. Therefore, our study aimed to explore the perceptions of various stakeholders and experts who may have an impact on the inclusion of Roma and/or their access to health care on how to improve health care access for Roma living in social exclusion in the Czech Republic.

Methods

We conducted a concept mapping study and obtained data from 32 participants from health and social services, policymakers and others who were involved in different study phases (brainstorming, sorting, rating, interpretation).

Results

Out of 64 proposed measures sorted into six distinct clusters, 20 were rated as the most urgent and the most feasible and should be implemented with a priority to improve access to health care for Roma living in social exclusion. The proposed measures covered various topics, such as education and awareness of the target group as well as education and supervision of helping professionals, strengthening capacities and streamlining the health care system, health promotion and associated services and increasing the local and financial accessibility of health care. Overall, measures concerning the education and supervision of helping professionals were rated as both the most urgent and the most feasible. Individual priority measures targeted, for example, the health needs assessment of Roma living in social exclusion to set up interventions or to include topics such as participation, empowerment, cultural competence and communication training in the curricula of health care and helping professionals in postgraduate and continuing studies.

Conclusions

Stakeholders proposed a set of relevant and acceptable measures that may help improve access to health care for Roma living in social exclusion. The way they rated the proposed measures reflects both the current unfavourable mainstream and public discourse concerning Roma living in social exclusion and the most acute policy issues identified by several European and national bodies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01396-4.

Building Meaningful Community Advocacy for Ethnic-based Health Equity: The RoAd4Health Experience

The pervasive failure of policies aimed at overcoming health inequities suffered by European Roma reflects the oppressive and impoverished living conditions of many ethnic minorities in the Western world. The multiple social inequities that Roma experience and the cumulative effect on their health prove that the failure of health policies that impact Roma must be attributed to their ameliorative nature. These policies legitimize the mechanisms of oppression that sustain inequities, fueling fatalistic attitudes toward minorities, while these minorities internalize the stigma and attempt to survive on the margins of society. This paper presents the RoAd4Health project, a community initiative in which academic researchers partnered with Roma communities to overcome health inequities. We present the multiple methods utilized for building meaningful advocacy, such as photovoice and asset mapping led by Roma agents of change. These methods provided the capacity to develop a local narrative of disparities, build alliances to gain capacity to respond to injustices, and take actions to promote social change. The results of effectively involving all significant stakeholders (i.e., community agents of change, residents, health and social care providers, Roma community grassroots organizations, and institutional actors) are discussed along with lessons learned.

[Training for Roma health advocacy: a case study of Torreblanca, Seville]

OBJECTIVE

The objective of this study is to build advocacy capacity among a group of gipsy Roma neighbours living in contexts of risk of social exclusion.

METHODS

A Community Based Participatory Action Research design was used, in which 4 members of the community participated in the process of collecting evidence by photo-voice, analysing it using the ReACT method and disseminating the results.

RESULTS

A total of 96 pieces of evidence were collected and analysed for qualitative data analysis. These were categorised according to (a) the type of unhealthy conditions and (b) the area of the neighbourhood where they were located. The subsequent thematic grouping made it possible to identify the causes: (a) the abandonment of public services; (b) discrimination; and (c) the lack of Roma presence in community spaces. The consequences identified were (a) mental and physical health problems and (b) the normalisation of undignified living conditions. The plan was designed to advocate for the presence of Roma in community spaces.

CONCLUSIONS

Our study highlighted the relevance of the photo-voice to transcend the biomedical perspective and develop advocacy actions based on the knowledge created by the community. Future research should look more deeply into the impact of health advocacy on reducing inequalities and consider the importance of involving researchers, public health professionals and the community in addressing it.

Qualitative evaluation of a community-based intervention to reduce social isolation among older people in disadvantaged urban areas of Barcelona

This study analyses participants' and coordinators' perceptions of the implementation process and perceived benefits of a community-based intervention to reduce social isolation among older adults. The 'School of Health for Older People' is a weekly community intervention that promotes resources among individuals and communities in order to enhance their ability to identify problems and activate solutions, encouraging participation in the community. A qualitative approach was employed, based on semi-structured interviews and focus groups (FGs). This study was carried out in Barcelona. Two coordinators (community nurses) and 26 community-dwelling people aged 65 and over who attended the School of Health for Older People in the neighbourhoods of Besòs and Guineueta, participated in in-depth interviews and FGs between January and February 2016. Views and experiences about the intervention were explored. The main perceived effects of the intervention were expanding knowledge of health issues and of community activities, encouraging participants to go out, giving them a feeling of being heard, and peer relationships, increasing participants' contacts and knowledge while the main negative features were related to repetition of certain contents. The benefits identified included learning something about health and their own neighbourhood and breaking the habit of staying at home. Social isolation might be prevented by increasing the number of contacts with peers and sharing a common interest, since it could help to give them a sense of belonging to a community.

The Role of Perceived Unjust Treatment in Unmet Needs for Primary Care Among Finnish Roma Adults

The main goal in developing services is to guarantee equal access to healthcare services that are suited to the patients’ needs. Previous studies have shown that the Roma are more likely to experience unjust treatment in health services than the general population. This study examines the association between perceived unjust treatment in healthcare and self-assessed unmet need for primary care provided by general practitioners (GPs) and nurses among the Finnish Roma. The data from the Finnish Roma Wellbeing Study (Roosa), conducted in 2017–2018, were used. Snowball sampling was used in recruiting study participants (n = 365, 61% women). Logistic regression was used to test the association between perceived unjust treatment and unmet need for primary care. Confounders used were gender, age, marital status, education, employment, and self-rated health. Those who had experienced unjust treatment in healthcare were more likely to report unmet need for care provided by GPs (odds ratios (OR) = 6.44; p < 0.001) and nurses (OR = 11.18; p < 0.001) than those who felt that they had been treated justly. This association remained after adjustments for the confounders. Bidirectional guidance between the Roma and service providers should be improved and the Roma communities involved in service development using participatory methods.

To Comply or Not to Comply: Roma Approach to Health Laws

According to the general public in Slovakia, compliance with the law is problematic when it comes to Roma and health. Roma compliance with laws has not yet been studied. The aim of this is study was to explore the determinants of Roma behavior in the field of health laws. We used the concept of a semi-autonomous field proposed by Moore (1973) and the theory of planned behavior by Ajzen (1985). We found that Roma (non-)compliance with health laws was influenced by many different factors, such as beliefs, traditions, living conditions and culture. Group beliefs overrule national laws and also individual preferences, which tend to be subordinate to the group view. The less contact Roma from settlements have with non-Roma, the stronger their own rules are in the field of health. Roma health status is influenced by many factors: group beliefs and community traditions are stronger and overrule individual and state behavioral influence. A community-based participatory approach together with improvement of living conditions in cooperation with Roma is desirable.

Involvement in maternal care by migrants and ethnic minorities: a narrative review

BACKGROUND

Guidelines for improving the quality of maternal health services emphasise women's involvement in care. However, evidence about migrant and ethnic minorities' preferences for participation in maternal care remains unsystematised. Understanding these populations' experiences with and preferred forms of involvement in care provision is crucial for imbuing policies and guidelines with sensitivity to diversity and for implementing people-centred care. This paper presents a narrative synthesis of empirical studies of involvement in maternal health care by migrants and ethnic minorities based on four key dimensions: information, communication, expression of preferences and decision-making.

METHODS

Studies indexed in PubMed and Scopus published until December 2019 were searched. Original quantitative, qualitative and mixed methods studies written in English and reporting on migrant and ethnic minority involvement in maternal care were included. Backward reference tracking was carried out. Three researchers conducted full-text review of selected publications.

RESULTS

In total, 22 studies met the inclusion criteria. The majority of studies were comparative and addressed only one or two dimensions of involvement, with an emphasis on the information and communication dimensions. Compared to natives, migrants and ethnic minorities were more likely to (1) lack access to adequate information as a result of health care staff's limited time, knowledge and misconceptions about women's needs and preferences; (2) report suboptimal communication with care staff caused by language barriers and inadequate interpreting services; (3) be offered fewer opportunities to express preferences and to have preferences be taken less into account; and (4) be less involved in decisions about their care due to difficulties in understanding information, socio-cultural beliefs and previous experiences with care provision less attuned with playing an active role in decision-making and care staff detracting attitudes.

CONCLUSION

Constraints to adequate and inclusive involvement in maternal care can hinder access to quality care and result in severe negative health outcomes for migrant and ethnic minority women. More research is needed into how to tailor the dimensions of involvement to migrant and ethnic minorities' needs and preferences, followed by provision of the resources necessary for effective implementation (e.g. sufficient time for consultations, optimal interpreter systems, health care staff training).