Health of Roma children in Vilnius and Ventspils

According to the literature data, Roma health and living conditions in Central and Eastern Europe are poorer than of the rest of population. However, the more detailed information about Roma health is lacking. The aim of the study was to evaluate morbidity, health self-assessment, and prevalence of addictions among Roma children in Vilnius and Ventspils and to compare with health indicators of non-Roma children. PARTICIPANTS AND METHODS. A descriptive epidemiological study was carried out, anonymously questioning all volunteer Roma children - 59 in Vilnius (Lithuania) and 31 in Ventspils (Latvia) schools. Results were compared with identical study, carried out in five Vilnius schools (reference group, 640). RESULTS. The appliance rate of Roma children to doctor did not differ from reference group - half of all questioned children visited doctor 1-3 times during the last year. However, more Roma children (74.6% from Vilnius and 64.6% from Ventspils) considered their health as poor and very poor as compared to reference group (4.3%). The proportion of children indicating somatic symptoms often and very often did not differ statistically significantly among groups with exception of vomiting and nausea, which was most prevalent among Vilnius Roma and Ventspils Roma. The proportion of children indicating emotional symptoms often and very often differed significantly in all groups and was the biggest in Ventspils Roma group. The proportion of daily alcohol, drug users, and smokers was higher in Vilnius Roma and Ventspils Roma groups, although the differences among all three groups were not statistically significant. CONCLUSION. Although the morbidity of Vilnius Roma and Ventspils Roma groups did not differ from reference group, essential discrepancy was found in health self-assessment - more Roma children considered their health as poor and very poor.


Introduction
Many Roma (about 7 millions) are settled in the countries of Central and Eastern Europe.Before joining European Union, previous Eastern European countries had to accept "Copenhagen criteria," one of which was the respect and protection of minorities.Those countries declared "The Decade of Roma Integration" for the period of 2005-2015 and developed an ambitious action plan how to improve Roma housing, employment, education, and access to health care (1).Despite all those good intentions, there is scarce information about Roma health; therefore, the evaluation of effectiveness of planned interventions becomes more complicated.
Data from different sources show that one of the main health indicators -newborn mortality -in Roma population is two-three (sometimes five) times higher than the one in the country they live.Lower weight (up to 2500 g) in newborns occurs four times more often among Roma.Bearing women are younger (from 17 years).Average life expectancy of Roma women and men is 10-15 years lower than the population of the country they live (2,3).The causes of such great differences, however, are unknown.Some of the studies show that it might be associated with a higher prevalence of diseases such as diabetes, coronary heart disease, obesity among this minority.Social factors are also very important -poverty, poor access to health care, inappropriate nutrition, and traditions.Besides this, Roma get sick with the illnesses, which are recessively inherited, because in this closed community, families are created between close relatives (cousins) very often (2)(3)(4).Closed life style, long-term poor housing, big families, high illiteracy, not knowing national language, unemployment, poor hygienic skills, peculiar traditions, and lifestyle are characteristic of Roma minorities.Therefore, they and particularly their kids have more risk factors, which are influenced by social environment more than the rest of population (5)(6)(7)(8).Specific risk factor for Roma health in Baltic region are the problems associated with drugs, their use, and distribution (6).
As mentioned above, Lithuania and Latvia are the countries, where this ethnic group is not big -approximately 10 thousand.However, health problems of Roma children and teenagers have never been investigated.Accordingly, this study was carried out based on participation in the program "The Task Force on Communicable Disease Control in the Baltic Sea Region."The aim of our study was to evaluate morbidity, health self-assessment, and prevalence of addictions among Roma children in Vilnius and Ventspils and to compare with health indicators of non-Roma children.

Methods
Two Roma schools were selected for the study: one in Lithuania (Vilnius) and one in Latvia (Ventspils).The study was carried out in October 2004.
A special anonymous questionnaire was designed based on the Polish questionnaire, which was tested in the study of health indicators between Lithuanian and Polish children (9).English questionnaire was translated into Lithuanian and Latvian languages.A total of 59 closed questions were involved to enlighten demographical situation, housing, income resources of their parents, social support, health self-assessment, visits to doctor during past year, somatic and emotional symptoms, prevalence of addictions (smok-ing, alcohol and drug use), sexual experience, knowledge about sexually transmitted diseases, their future plans.Questions about somatic symptoms (dizziness, vomiting and nausea, abdominal pain, headache, back pain) and emotional symptoms (feeling loneliness, fear, helplessness, self-dissatisfaction, tiredness, depression) were given to respondents with intention to reveal the presence and frequency of these complaints (categories: very often, often, sometimes, seldom, very seldom, never).
All Roma volunteers in these schools participated in interview (response rate was 100%).Fifty-nine children in Vilnius, Lithuania (further -Roma LT) and 31 children in Ventspils, Latvia (further -Roma LV), were included into the sample (Table 1).Mean age of Vilnius Roma children was 12.3 years and of those in Ventspils -13.6 years (range, 9 to 19 years).The results were compared with the identical study (the same questionnaire) that was carried out in May 2004 in five Vilnius schools (further -reference group).The reference group consisted of randomly selected 639 children (14-15 years).The mean age of reference group was 14.5 years.The mean age of all three groups differed significantly, and this was mainly influenced by the small number of Roma children in both groups and their heterogeneity (P<0.001).Gender distribution in both groups was very similar (c 2 =0.109; df=2, P=0.947).
Data were analyzed with Epi Info version 6.04.Chi-square (c 2 ) and F tests were used to assess the difference between groups, and significance level was established at the 95% confidence and P£0.05.

One of the children's health indicators in this study
was the rate of visits to doctor for any health disorder during the past year (Table 2).Most of all children (49.1% of Vilnius Roma, 38.8% of Ventspils Roma, and 56.2% of reference group) visited the doctor onethree times during the last year (c 2 =4.54; df=2; The prevalence of chronic diseases among Roma children was 3.3% in Ventspils and 8.9% in Vilnius, and it was higher in the reference group (12.6%), but the difference was not statistically significant (c 2 =3.0, df=2; P=0.220).Roma children indicated suffering from such chronic diseases as bronchitis, neurodermitis, heart diseases, and diseases of immune system.
Own health was considered as poor or very poor by the most of Roma children -49.2% and 25.4% in Vilnius and 45.2 and 19.4% in Ventspils, while in the reference group -only 3.4% and 0.9%.Contrary, the most of the reference group considered their own health as good (55.9%) and very good (22.2%)(Table 3).
Somatic symptoms were ever present (very often, often, sometimes, seldom, or very seldom) among most of the respondents: 91.8-99.4% in reference group, 69-94% in Vilnius Roma, and 67-87% in Ventspils Roma group (differences were statistically significant comparing all groups for all somatic symptoms).
All symptoms of mental health were most prevalent in the reference group as compared to Ventspils Roma and Vilnius Roma (89.0-99.2%vs 64.5-83.8% and 37.3-81.1%,respectively; differences were statistically significant among all groups for all emotional symptoms).The frequency of depression varied the most among the groups -from 37.3% among Vilnius Roma children to 94.3% among reference group children.
The bigger proportion of children that have never used alcohol was in both Roma groups, especially among Ventspils Roma -51.6% (c 2 =9.6; df=2; P=0.008).However, daily alcohol consumption was mentioned by 2.1-3.4% of children (more often in both Roma groups) (Fig. 4).
Answers to questions about drug use revealed that it is more common among both Roma groups: 95.6% of children in the reference group have never tried drugs, 90% of Vilnius Roma, and 79.7% of Ventspils Roma children group (c 2 =15.54; df=2; P<0.001).The high daily use was found among Roma groups, particularly from Ventspils -3.3% (Fig. 5).

Discussion
According to the census of Lithuania of 2001, 2571 Roma live in Lithuania (0.07% of all Lithuanian population); however, this number could be more than twice bigger in reality.In Latvia, there are 8200 Roma (0.35% of all country population) (10,11).Some of  them do not have any identification documents, health insurance; therefore, they cannot get health care services.Consequently, it becomes very complicated to get realiable information even about their health.Some of them live in their closed communities; thus, the possibilities to improve their poor hygiene habits are very limited (6)(7)(8).
The problems of ethnic minorities are still relevant in Baltic as in other European countries.There is scarce information about Roma health status.In literature, one can find mostly about Roma rights in Central and Eastern Europe, but not the comprehensive knowledge regarding Roma health, which quite often is just stated as poor.Accordingly, there is lack of exact information about health of Roma and their children in Lithuania also.The only attempt to evaluate Roma health in Lithuania was done based on the "National Program of Integration of Roma 2001-2004," which proved Roma health as poor because of specific Roma social environment and social isolation (5).
Our study aimed to enlighten health problems and their risk factors among Roma children.As the living and studying conditions differed for Vilnius and Ventspils Roma children (Vilnius Roma live in close community and study in general school while Ventspils Roma live in city and study in separate Roma school), it was decided not to merge these groups for analysis.Data analysis supported this approach as in some cases the studied rates differed a lot between two Roma groups.At the same time, we tried to find peculiarities common to both studied Roma populations and distinguishing them from non-Roma (reference) group The rate of Roma children's applications to doctor for any health problem during the last year was similar to the other children in Vilnius schools.Half of respondents missed the school because of some sickness one-three times per year in average.Although Roma children live in worse social environment than the other children, but they are more hard-bitten.Despite that, Roma are not used to apply for health care even being sick.Therefore, this rate might not show the real morbidity of Roma children.
Hungarian scientists also confirm that Roma children health does not differ from other children in their country.However, hygienic situation in colonies is not acceptable and dangerous not just to Roma, but to all other inhabitants (12).
The lower prevalence of chronic diseases among Roma children could be explained by underdiagnosis.That occurs due to seldom consultation of Roma parents with medical doctors because of their poor social skills.Data showed that Roma children were sick with bronchitis, neurodermitis, heart diseases, and diseases of immune system.
Roma children have considered their health as poor and very poor although frequency of visits to doctors during the last year was similar between Roma and reference group.Such baseless negative health self- assessment could be influenced by long-term preconceptions to this socially isolated community about their life style, housing, health, future perspectives.Data from other studies support our findings.Study in Hungary revealed that elder Roma population (older than 44 years) considered their health as bad and very bad more often than the inhabitants of the lowest social groups (what accounts for almost onefourth of Hungarian population).The experienced discrimination in health service was indicated by 35% of Roma and only by 4% of people from the mentioned above lowest social groups (13).Despite this, studies show that Roma accept their poor health as normal phenomenon -inevitable consequence of bad social environment, and they concede all this with specific stoicism and fatalism (14).Indicators of physical and mental health in Vilnius and Ventspils Roma communities were not exclusive.Ventspils Roma children pointed out more often about having different somatic (particularly dizziness and headache) and emotional (particularly loneliness, depression) symptoms.The least complaints of mental health were found among Vilnius Roma children.Meanwhile children from other Vilnius schools mentioned back pains twice more often, also they felt fear and tiredness more frequently.Contrary, tiredness was not characteristic of Roma children.They are very spry hyperactive, not willing to study, do homework, they have difficulties to concentrate, but they do not worry about.Consequently, they might not feel tiredness (6).
According to the results of studies in Czech and Slovakia, besides some seldom exceptions, Roma health is worse than the one of country populationcommunicable diseases are more frequent, many ailments are influenced by poor hygiene.More close contacts between health care professionals and Roma are lacking, prevention work in Roma communities is conceived wrongly.Authors think that it is essential to investigate Roma health with particular attention to noninfectious diseases and to carry out interventions for health improvement (15).
Worse Roma health comparing to the rest of population in the same country is proved by different studies in England and other countries (16)(17)(18).The same trend is found comparing with other socially vulnerable or the lowest social groups and other ethnic minorities.Roma living in colonies or separate communities are socially isolated, and this factor effects their health negatively.Health promotion and health improvement program are suggested by scientists to decrease influence of social environment on Roma health.
We have included information on various addictions as main health risk in our study.There were about 11% of regular alcohol users (daily or once per week) in the reference and Roma groups, and these data were compatible with results from other studies performed in Lithuania (19).Results of our study showed that prevalence of various addictions (smoking, alcohol and drug use) among Roma children did not differ much from reference group.Daily alcohol users, smokers, and drug users were more prevalent among Roma children.The findings, however, were not statistically significant, as the groups were very small due to naturally low prevalence of daily users in such age groups.In general, the risk to use drugs for Roma children is higher, especially in Vilnius, where drug sales in Roma community are common.Roma parents are illiterate or bad spellers; therefore, they lack knowledge about prevention of addictions.Roma children as other children in school get some information on health risk but they are influenced by lifestyle of parents and usually do not pay attention (6,8,11).
Data from literature suggest that smoking is more prevalent among Roma and their children according to Slovenia investigators; this habit is a very strong feature of their cultural, ethnic, and individual identity (20).Roma believe that harm of smoking to the health depends on their fate, and diseases related to smoking are not influenced by smoking as such.Their poor financial facilities also are not the reason to cease smoking.Consequently, traditional prevention measures to decrease smoking are not effective because of such specific attitude.Therefore, innovative prevention means should be suggested, and they should be acceptable to Roma in cultural aspect.

Conclusions
1.The appliance rate to doctor did not differ in all groups -about half of respondents visited doctors one-three times per year.Essential discrepancy was found in health self-assessment -more children in Vilnius Roma and Ventspils Roma considered their health as poor and very poor, while more children in the reference group considered it as good and very good.
2. Somatic symptoms were ever present among most of the respondents in all three groups (67.7-99.4%).The proportion of children indicating them often and very often did not differ statistically significant between groups with exception vomiting and nausea, which was most prevalent among Vilnius Roma and Ventspils Roma.
3. All emotional symptoms were most prevalent

Table 1 .
Sample characteristicsThe proportion of children who visited doctor 10 and more times differed significantly comparing groups (c 2 =5.78, df=2, P=0.055) and was greater in both Roma groups (10.2% among Vilnius Roma and 16.5% among Ventspils Roma).