OBJECTIVES: The health status of segregated Roma is poor. To understand why segregated Roma engage in health-endangering practices, we explored their nonadherence to clinical and public health recommendations. METHODS: We examined one segregated Roma settlement of 260 inhabitants in Slovakia. To obtain qualitative data on local-level mechanisms supporting Roma nonadherence, we combined ethnography and systematic interviewing over 10 years. We then performed a qualitative content analysis based on sociological and public health theories. RESULTS: Our explanatory framework summarizes how the nonadherence of local Roma was supported by an interlocked system of seven mechanisms, controlled by and operating through both local Roma and non-Roma. These regard the Roma situation of poverty, segregation and substandard infrastructure; the Roma socialization into their situation; the Roma-perceived value of Roma alternative practices; the exclusionary non-Roma and self-exclusionary Roma ideologies; the discrimination, racism and dysfunctional support towards Roma by non-Roma; and drawbacks in adherence. CONCLUSIONS: Non-Roma ideologies, internalized by Roma into a racialized ethnic identity through socialization, and drawbacks in adherence might present powerful, yet neglected, mechanisms supporting segregated Roma nonadherence.

Department of Community and Occupational Medicine University Medical Center Groningen Groningen The Netherlands

Department of General Anthropology Faculty of Humanities Charles University Prague Czech Republic

Department of Health Psychology Faculty of Medicine P J Safarik University Trieda SNP 1 040 11 Kosice Slovakia

Kosice Institute for Society and Health Faculty of Medicine P J Safarik University Kosice Slovakia

Olomouc University Society and Health Institute Palacky University Olomouc Olomouc Czech Republic

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Int J Public Health. 2019 Jun;64(5):803-804. doi: 10.1007/s00038-019-01233-0. PubMed

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Int J Public Health. 2019 Jun;64(5):805-807. doi: 10.1007/s00038-019-01250-z. PubMed

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Andreassen T, Weiderpass E, Nicula F, Suteu O, Itu A, Bumbu M, Tincu A, Ursin G, Moen K. Controversies about cervical cancer screening: a qualitative study of Roma women’s (non) participation in cervical cancer screening in Romania. Soc Sci Med. 2017;183:48–55. doi: 10.1016/j.socscimed.2017.04.040. PubMed DOI

Archer MS. Being human: the problem of agency. Cambridge: Cambridge University Press; 2000.

Babinska I, Geckova AM, Jarcuska P, Pella D, Marekova M, Stefkova G, Veselska ZD. Does the population living in Roma settlements differ in physical activity, smoking and alcohol consumption from the majority population in Slovakia? Cent Eur J Public Health. 2014;22:S22–S27. doi: 10.21101/cejph.a3897. PubMed DOI

Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389:1453–1463. doi: 10.1016/S0140-6736(17)30569-X. PubMed DOI

Belak A. Health-system limitations of Roma health in Slovakia: a qualitative study. Bratislava: WHO Country Office in Slovakia; 2013.

Belak A, Geckova AM, van Dijk JP, Reijneveld SA. Health-endangering everyday settings and practices in a rural segregated Roma settlement in Slovakia: a descriptive summary from an exploratory longitudinal case study. BMC Public Health. 2017;17:128. doi: 10.1186/s12889-017-4029-x. PubMed DOI PMC

Bobakova D, Dankulincova Veselska Z, Babinska I, Klein D, Madarasova Geckova A, Cislakova L. Differences between Roma and non-Roma in how social support from family and friends helps to overcome health care accessibility problems. Int J Equity Health. 2015;14:37. doi: 10.1186/s12939-015-0165-z. PubMed DOI PMC

Bourdieu P. Practical reason: on the theory of action. Cambridge: Polity Press; 1998.

Bourdieu P. Pascalian meditations. Stanford: Stanford University Press; 2000.

Cockerham WC. Health lifestyle theory and the convergence of agency and structure. J Health Soc Behav. 2005;46:51–67. doi: 10.1177/002214650504600105. PubMed DOI

Cook B, Wayne GF, Valentine A, Lessios A, Yeh E. Revisiting the evidence on health and health care disparities among the Roma: a systematic review 2003–2012. Int J Public Health. 2013;58:885–911. doi: 10.1007/s00038-013-0518-6. PubMed DOI

Crowe D. A history of the gypsies of Eastern Europe and Russia. 2. New York: Palgrave/Macmillan; 2007.

Dressler WW. What’s cultural about biocultural research? Ethos. 2005;33:20–45. doi: 10.1525/eth.2005.33.1.020. DOI

Dressler WW, Oths KS, Gravlee CC. Race and ethnicity in public health research: models to explain health disparities. Annu Rev Anthropol. 2005;34:231–252. doi: 10.1146/annurev.anthro.34.081804.120505. DOI

EUC (2014) Roma Health Report. Health status of the Roma population. Data collection in the Member States of the European Union, p 153

Fanon F. Black skin, white masks. New York: Grove Press; 2008.

Fassin D. Racialization. How to do races with bodies. In: Mascia-Lees FE, editor. A companion to the anthropology of the body and embodiment. Oxford: Wiley-Blackwell; 2011. pp. 419–434.

Filadelfiova J, Gerbery D. Report on the living conditions of Roma households in Slovakia 2010. Bratislava: UNDP; 2012. p. 234.

Földes M, Covaci A. Research on Roma health and access to healthcare: state of the art and future challenges. Int J Public Health. 2012;57:37–39. doi: 10.1007/s00038-011-0312-2. PubMed DOI PMC

FRAEU, UNDP . The situation of Roma in 11 EU Member States. Survey results at a glance. Luxembourg: European Union Agency for Fundamental Rights & UNDP; 2012. p. 31.

Frohlich KL, Corin E, Potvin L. A theoretical proposal for the relationship between context and disease. Sociol Health Illn. 2001;23:776–797. doi: 10.1111/1467-9566.00275. DOI

Garthwaite K, Smith KE, Bambra C, Pearce J. Desperately seeking reductions in health inequalities: perspectives of UK researchers on past, present and future directions in health inequalities research. Sociol Health Illn. 2016;38:459–478. doi: 10.1111/1467-9566.12374. PubMed DOI PMC

Geckova AM, Babinska I, Bobakova D, Veselska ZD, Bosakova L, Kolarcik P, Jarcuska P, Pella D, Halanova M. Socioeconomic characteristics of the population living in Roma settlements and their association with health and health-related behaviour. Cent Eur J Public Health. 2014;22:S57–S64. doi: 10.21101/cejph.a3903. PubMed DOI

Grill J. ‘In England, they don’t call you black!’Migrating racialisations and the production of Roma difference across Europe. J Ethnic Migr Stud. 2017;44:1136–1155. doi: 10.1080/1369183X.2017.1329007. DOI

Halanova M, Jarcuska P, Kalinova Z, Carikova K, Oravcova J, Jarcuska P, Pella D, Marekova M, Geckova AM, Cislaková L. The prevalence of Chlamydia trachomatis in the population living in Roma settlements: a comparison with the majority population. Cent Eur J Public Health. 2014;22:S32–S36. doi: 10.21101/cejph.a3899. PubMed DOI

Hausmann-Muela S, Muela Ribera J, Nyamongo I (2003) Health-seeking behaviour and the health system response. DCPP working paper no. 14. Disease Control Priorities Project, pp 1–37

Hedström P, Ylikoski P. Causal mechanisms in the social sciences. Annu Rev Sociol. 2010;36:49–67. doi: 10.1146/annurev.soc.012809.102632. DOI

Hijova E, Geckova AM, Babinska I. Do eating habits of the population living in Roma settlements differ from those of the majority population in Slovakia? Cent Eur J Public Health. 2014;22:S65–S68. doi: 10.21101/cejph.a3797. PubMed DOI

Janevic T, Sripad P, Bradley E, Dimitrievska V. “There’s no kind of respect here” A qualitative study of racism and access to maternal health care among Romani women in the Balkans. Int J Equity health. 2011;10:53. doi: 10.1186/1475-9276-10-53. PubMed DOI PMC

Janevic T, Jankovic J, Bradley E. Socioeconomic position, gender, and inequalities in self-rated health between Roma and non-Roma in Serbia. Int J Public Health. 2012;57:49–55. doi: 10.1007/s00038-011-0277-1. PubMed DOI

Jarcuska P, Bobakova D, Uhrin J, Bobak L, Babinska I, Kolarcik P, Veselska Z, Madarasova Geckova A. Are barriers in accessing health services in the Roma population associated with worse health status among Roma? Int J Public Health. 2013;58:427–434. doi: 10.1007/s00038-013-0451-8. PubMed DOI

Kelly JA, Amirkhanian YA, Kabakchieva E, Csepe P, Seal DW, Antonova R, Mihaylov A, Gyukits G. Gender roles and HIV sexual risk vulnerability of Roma (Gypsies) men and women in Bulgaria and Hungary: an ethnographic study. AIDS Care. 2004;16:231–245. doi: 10.1080/09540120410001641075. PubMed DOI

Kolarcik P, Geckova AM, Orosova O, van Dijk JP, Reijneveld SA. To what extent does socioeconomic status explain differences in health between Roma and non-Roma adolescents in Slovakia? Soc Sci Med. 2009;68:1279–1284. doi: 10.1016/j.socscimed.2008.12.044. PubMed DOI

Kolarcik P, Geckova AM, Orosova O, van Dijk JP, Reijneveld SA. Predictors of health-endangering behaviour among Roma and non-Roma adolescents in Slovakia by gender. J Epidemiol Community Health. 2010;64:1043–1048. doi: 10.1136/jech.2009.092098. PubMed DOI

Kolarcik P, Geckova AM, Reijneveld S, van Dijk J. Social support, hopelessness and life satisfaction among Roma and non-Roma adolescents in Slovakia. Int J Public Health. 2012;57:905–913. doi: 10.1007/s00038-012-0413-6. PubMed DOI

Krajcovicova-Kudlackova M, Blazicek P, Spustova V, Valachovicova M, Ginter E. Cardiovascular risk factors in young Gypsy population. Bratisl Lek Listy. 2004;7–8:7. PubMed

LeCompte MD, Schensul JJ. Analysis and interpretation of ethnographic data: a mixed methods approach. 2. Lanham: AltaMira Press; 2013.

Majdan M, Coman A, Gallová E, Ďuricová J, Kállayová D, Kvaková M, Bošák Ľ. Assessment of the indoor environment and implications for health in Roma villages in Slovakia and Romania. Cent Eur J Public Health. 2012;20:199. doi: 10.21101/cejph.a3719. PubMed DOI PMC

Merrild CH, Andersen RS, Risør MB, Vedsted P. Resisting “reason”: a comparative anthropological study of social differences and resistance toward health promotion and illness prevention in Denmark. Med Anthropol Q. 2017;31:218–236. doi: 10.1111/maq.12295. PubMed DOI

Reeves S, Kuper A, Hodges BD. Qualitative research methodologies: ethnography. BMJ. 2008;337:a1020. doi: 10.1136/bmj.a1020. PubMed DOI

Reijneveld S. Ethnic differences in health and use of health care: the questions to be answered. Int J Public Health. 2010;55:353–355. doi: 10.1007/s00038-010-0189-5. PubMed DOI PMC

Sasinka M, Nyulassy S, Badalik L. Vademecum medici. 6. Martin: Osveta; 2003.

Singer MK, Dressler W, George S, NIH Expert Panel Culture: the missing link in health research. Soc Sci Med. 2016;170:237–246. doi: 10.1016/j.socscimed.2016.07.015. PubMed DOI

Singh-Manoux A, Marmot M. Role of socialization in explaining social inequalities in health. Soc Sci Med. 2005;60:2129–2133. doi: 10.1016/j.socscimed.2004.08.070. PubMed DOI

Smith GD. Learning to live with complexity: ethnicity, socioeconomic position, and health in Britain and the United States. Am J Public Health. 2000;90:1694–1698. doi: 10.2105/AJPH.90.11.1694. PubMed DOI PMC

Stewart M. The time of the gypsies. Boulder: Westview Press; 1997.

Stewart M. The gypsy menace: populism and the new anti-gypsy politics. London: Hurst & Company; 2012.

Tauber E. Du wirst keinen Ehemann nehmen!: Respekt, die Bedeutung der Toten und Fluchtheirat bei den Sinti Estraixaria [You will not take a husband! Respect, the significance of the dead and flight marriage among Sinti Estraixaria] Münster: LIT Verlag; 2006.

Trostle JA. Epidemiology and culture. Cambridge: Cambridge University Press; 2004.

Voko Z, Csepe P, Nemeth R, Kosa K, Kosa Z, Szeles G, Adany R. Does socioeconomic status fully mediate the effect of ethnicity on the health of Roma people in Hungary? J Epidemiol Community Health. 2009;63:455–460. doi: 10.1136/jech.2008.079715. PubMed DOI

WHO (2010) A conceptual framework for action on the social determinants of health. Discussion paper series on social determinants of health, no. 2. World Health Organization, Geneva

Williams SJ. Theorizing class, health and life-styles—can Bourdieu help us? Sociol Health Illn. 1995;17:577–604. doi: 10.1111/1467-9566.ep10932093. DOI

Williams P. Gypsy world: the silence of the living and the voices of the dead. Chicago: University of Chicago Press; 2003.

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