Healthcare Utilization and All-Cause Premature Mortality in Hungarian Segregated Roma Settlements: Evaluation of Specific Indicators in a Cross-Sectional Study

Cross-sectional comparison of health care delivery and reimbursement between segregated and nonsegregated communities in Hungary

Introduction

Spatially segregated, socio-economically deprived communities in Europe are at risk of being neglected in terms of health care. In Hungary, poor monitoring systems and poor knowledge on the health status of people in these segregated areas prevent the development of well-informed effective interventions for these vulnerable communities.

Aims

We used data available from National Health Insurance Fund Management to better describe health care performance in segregated communities and to develop more robust monitoring systems.

Methods

A cross-sectional study using 2020 health care data was conducted on each general medical practice (GMP) in Hungary providing care to both segregated and nonsegregated (complementary) adult patients. Segregated areas were mapped and ascertained by a governmental decree that defines them as within settlement clusters of adults with low level of education and income. Age, sex, and eligibility for exemption certificate standardized indicators for health care delivery, reimbursement, and premature mortality were computed for segregated and nonsegregated groups of adults and aggregated at the country level. The ratio of segregation and nonsegregation specific indicators (relative risk, RR) was computed with the corresponding 95% confidence intervals (95% CI).

Results

Broad variations between GMPs were detected for each indicator. Segregated groups had a significantly higher rate of health care service use than complementary groups (RR = 1.22, 95% CI: 1.219;1.223) while suffering from significantly reduced health care reimbursement (RR = 0.940, 95% CI: 0.929;0.951). The risk of premature mortality was significantly higher among segregated patients (RR = 1.184, 95% CI: 1.087;1.289). Altogether, living in a segregated area led to an increase in visits to health care services by 18.1% with 6.6% less health spending.

Conclusion

Adults living in segregated areas use health care services more frequently than those living in nonsegregated areas; however, the amount of health care reimbursement they receive is significantly lower, suggesting lower quality of care. The health status of segregated adults is remarkably lower, as evidenced by their higher premature mortality rate. These findings demonstrate the need for intervention in this vulnerable group. Because our study reveals serious variation across GMPs, segregation-specific monitoring is necessary to support programs sensitive to local issues and establish necessary benchmarks.

Inequalities in Diabetes Mortality Between Microregions in Hungary

Objectives: Regional differences in diabetes mortality are high in Hungary. In our cross-sectional study, we aim to reveal the drivers of the inequalities in diabetes mortality across the 197 microregions of Hungary. To account for the influence of changes in healthcare and social conditions, we compared two periods (2009-12 and 2013-16). Methods: Traditional and re-conceptualized deprivation- and healthcare provison measures were used in OLS regression models. Results: Microregions with a high proportion of population living in "service deserts," especially in regard to the lack of grocery stores, suffer the highest rates of diabetes mortality. Alcohol-related mortality has been proven to be a similarly and surprisingly strong predictor of diabetes mortality. Conclusion: Food provision should be supported in areas characterized by low service density, and alcohol policy should be strengthened and targeted.

Can routine data be used to estimate the mental health service use of children and young people living on Gypsy and Traveller sites in Wales? A feasibility study

INTRODUCTION

Gypsies and Travellers have poorer physical and mental health than the general population, but little is known about mental health service use by Gypsy and Traveller children and young people. Finding this group in routine electronic health data is challenging, due to limited recording of ethnicity. We assessed the feasibility of using geographical markers combined with linked routine datasets to estimate the mental health service use of children and young people living on Traveller sites.

METHODS

Welsh Government supplied a list of Traveller site postcodes included in Caravan Counts between 2012 and 2020. Using spatial filtering with data from the Adolescent Mental Health Data Platform (ADP) at Swansea University's SAIL Databank, we created a cohort of Traveller site residents aged 11-25 years old, 2010-2019. ADP algorithms were used to describe health service use, and to estimate incidence and prevalence of common mental disorders (CMD) and self-harm.

RESULTS

Our study found a subgroup of young Gypsies and Travellers (n = 802). We found no significant differences between our cohort and the general population for rates of CMD or self-harm. The rate of non-attendance for psychiatric outpatient follow-up appointments was significantly higher in our cohort. Rates were higher (but not statistically significant) among Gypsies and Travellers for measures suggesting less well-managed care, including emergency department attendance and prescribed CMD medication without follow-up. The small size of the cohort resulted in imprecise estimates with wide confidence intervals, compared with those for the general population.

CONCLUSIONS

Gypsies and Travellers are under-represented in routine health datasets, even using geographical markers, which find only those resident in authorised traveller sites. Routine data is increasingly relied upon for needs assessment and service planning, which has policy and practice implications for this underserved group. To address health inequalities effort is required to ensure that health datasets accurately capture ethnicity.

Low prevalence of spectacle use in the Hungarian Roma population indicates unmet health needs

The Roma population is the largest transnational ethnic minority group in Europe, often facing socioeconomic inequalities and various health problems. In the present study, we investigated visual acuity and its influencing factors along with spectacle use of the Roma population in comparison with the general population in Hungary. A cross-sectional survey was carried out including 832 participants aged 20–64 years. We recorded the uncorrected visual acuity along with anthropometric, demographic, socioeconomic and health-related data of each individual. Although the average uncorrected visual acuity was somewhat higher, the use of a visual aid was significantly less frequent in the Roma population, especially in the group with a visual acuity below 0.5 in both eyes (14.3% vs. 77.1%, p < 0.001). Age, abdominal obesity and disturbances of carbohydrate metabolism had a negative impact on visual acuity in both populations; however, the latter was a much stronger risk factor in the Roma population (OR 5.789, 95% CI 2.239–14.964, p < 0.001) than in the general population (OR 2.075, 95% CI 1.097–3.926, p = 0.025). Our results show serious unmet health needs within the Roma population, which calls for public health programs to improve poor primary care indicators on regular eye examination and much more rigorous diabetes control.

COVID-19 vaccination coverage in deprived populations living in segregated colonies: A nationwide cross-sectional study in Hungary

The segregated colonies (SCs) in Hungary are populated mainly but not exclusively by Roma. Their health care use is restricted in many respects. It has not been studied yet, whether fair COVID-19 vaccination coverage achieved in Hungary is accompanied with fair effectiveness in SCs. Using census data, the vaccination coverage in SCs and the complementary areas (CAs) in the same settlements of the country was determined. To describe the settlement level differences, the vaccination coverage (until June 30, 2021) in SCs were compared to those in CAs by age, sex, and eligibility for exemption certificate standardized measures. Aggregating settlement level data, the level of geographic discrimination in Hungary was also determined. According to nationwide aggregates, crude vaccination coverage was significantly lower in SCs (40.05%, 95% CI 39.87%-40.23%) than in CAs (65.42%, 95% CI 65.37%-65.46%). The relative standardized vaccination coverage was 0.643 (95% CI 0.639-0.647) in SCs. A total of 437 of the 938 investigated settlements showed significant local vaccination disparities. Hungarian citizens living in SCs, mainly of Roma ethnicity, are a distinct high-risk group. Special intervention adapted to SCs is needed to mitigate inequality in vaccination coverage and further consequences of the pandemic.

The Effect of the COVID-19 Pandemic on the Social Inequalities of Health Care Use in Hungary: A Nationally Representative Cross-Sectional Study

Background: The social representation of restricted health care use during the COVID-19 pandemic has not been evaluated properly yet in Hungary. Objective: Our study aimed to quantify the effect of COVID-19 pandemic measures on general practitioner (GP) visits, specialist care, hospitalization, and cost-related prescription nonredemption (CRPNR) among adults, and to identify the social strata susceptible to the pandemic effect. Methods: This cross-sectional study was based on nationally representative data of 6611 (N_prepandemic = 5603 and N_pandemic = 1008) adults. Multivariable logistic regression models were applied to determine the sociodemographic and clinical factors influencing health care use by odds ratios (ORs) along with the corresponding 95% confidence intervals (CI). To identify the social strata susceptible to the pandemic effect, the interaction of the time of data collection with the level of education, marital status, and Roma ethnicity, was tested and described by iORs. Results: While the CRPNR did not change, the frequency of GP visits, specialist care, and hospitalization rates was remarkably reduced by 22.2%, 26.4%, and 6.7%, respectively, during the pandemic. Roma proved to be not specifically affected by the pandemic in any studied aspect, and the pandemic restructuring of health care impacted the social subgroups evenly with respect to hospital care. However, the pandemic effect was weaker among primary educated adults (iOR_{GP visits, high-school vs. primary-education} = 0.434; 95% CI 0.243–0.776, OR_{specialist visit, high-school vs. primary-education} = 0.598; 95% CI 0.364–0.985), and stronger among married adults (iOR_{GP visit, widowed vs. married} = 2.284; 95% CI 1.043–4.998, iOR_{specialist visit, widowed vs. married} = 1.915; 95% CI 1.157–3.168), on the frequency of GP visits and specialist visits. The prepandemic CRPNR inequality by the level of education was increased (iOR_{high-school vs. primary-education} = 0.236; 95% CI 0.075–0.743). Conclusion: Primary educated and widowed adults did not follow the general trend, and their prepandemic health care use was not reduced during the pandemic. This shows that although the management of pandemic health care use restrictions was implemented by not increasing social inequity, the drug availability for primary educated individuals could require more support.

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.

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.

Prevalence of Chronic Diseases and Activity-Limiting Disability among Roma and Non-Roma People: A Cross-Sectional, Census-Based Investigation

The lack of recommended design for Roma health-monitoring hinders the interventions to improve the health status of this ethnic minority. We aim to describe the riskiness of Roma ethnicity using census-derived data and to demonstrate the value of census for monitoring the Roma to non-Roma gap. This study investigated the self-declared occurrence of at least one chronic disease and the existence of activity limitations among subjects with chronic disease by the database of the 2011 Hungarian Census. Risks were assessed by odds ratios (OR) and 95% confidence intervals (95% CI) from logistic regression analyses controlled for sociodemographic factors. Roma ethnicity is a risk factor for chronic diseases (OR = 1.17; 95% CI: 1.16–1.18) and for activity limitation in everyday life activities (OR = 1.20; 95% CI: 1.17–1.23), learning-working (OR = 1.24; 95% CI: 1.21–1.27), family life (OR = 1.22; 95% CI: 1.16–1.28), and transport (OR = 1.03; 95% CI: 1.01–1.06). The population-level impact of Roma ethnicity was 0.39% (95% CI: 0.37–0.41) for chronic diseases and varied between 0 and 1.19% for activity limitations. Our investigations demonstrated that (1) the Roma ethnicity is a distinct risk factor with significant population level impact for chronic disease occurrence accompanied with prognosis worsening influence, and that (2) the census can improve the Roma health-monitoring system, primarily by assessing the population level impact.

Are Gypsy Roma Traveller communities indigenous and would identification as such better address their public health needs?

INTRODUCTION

Across Europe, large numbers of Gypsy Roma Traveller communities experience significant health inequities such as higher morbidity, mortality and infant mortality. This health inequity is perpetuated by wider determinants such as a lower social status, lower educational attainment and substandard accommodation. This is not dissimilar to other indigenous peoples, even though many Gypsy Roma Traveller communities are not identified as indigenous.

METHODS

This article presents contemporary literature and research alongside the internationally agreed principles of indigenous peoples, examining similarities between Gypsy Roma Traveller communities and other indigenous peoples.

RESULTS

We argue that Gypsy Roma Traveller communities could be recognised as indigenous in terms of the internationally agreed principles of indigeneity and shared experiences of health inequity, colonisation and cultural genocide. Doing so would enable a more robust public health strategy and development of public health guidelines that take into account their cultural views and practices.

CONCLUSION

Recognising Gypsy Roma Traveller communities in this way is important, especially concerning public health, as formal recognition of indigeneity provides certain rights and protection that can be used to develop appropriate public health strategies. Included within this are more nuanced approaches to promoting health, which focus on strengths and assets rather than deficit constructs that can perpetuate problematising of these communities.