Karolina Kósa

A comparative health survey of the inhabitants of Roma settlements in Hungary.

OBJECTIVES We compared the health of people living in Roma settlements with that of the general population in Hungary. METHODS We performed comparative health interview surveys in 2003 to 2004 in representative samples of the Hungarian population and inhabitants of Roma settlements. RESULTS In persons older than 44 years, 10% more of those living in Roma settlements reported their health as bad or very bad than did those in the lowest income quartile of the general population. Of those who used any health services, 35% of the Roma inhabitants and 4.4% of the general population experienced some discrimination. In Roma settlements, the proportion of persons who thought that they could do much for their own health was 13% to 15% lower, and heavy smoking and unhealthy diet were 1.5 to 3 times more prevalent, than in the lowest income quartile of the general population. CONCLUSIONS People living in Roma settlements experience severe social exclusion, which profoundly affects their health. Besides tackling the socioeconomic roots of the poor health of Roma people, specific public health interventions, including health education and health promotion programs, are needed.

Does socioeconomic status fully mediate the effect of ethnicity on the health of Roma people in Hungary

Background: Several models have been proposed to explain the association between ethnicity and health. It was investigated whether the association between Roma ethnicity and health is fully mediated by socioeconomic status in Hungary. Methods: Comparative health interview surveys were performed in 2003–04 on representative samples of the Hungarian population and inhabitants of Roma settlements. Logistic regression models were applied to study whether the relationship between Roma ethnicity and health is fully mediated by socioeconomic status, and whether Roma ethnicity modifies the association between socioeconomic status and health. Results: The health status of people living in Roma settlements was poorer than that of the general population (odds ratio of severe functional limitation after adjustment for age and gender 1.8 (95% confidence interval 1.4 to 2.3)). The difference in self-reported health and in functionality was fully explained by the socioeconomic status. The less healthy behaviours of people living in Roma settlements was also related very strongly to their socioeconomic status, but remained significantly different from the general population when differences in the socioeconomic status were taken into account, (eg odds ratio of daily smoking 1.6 (95% confidence interval 1.3 to 2.0) after adjustment for age, gender, education, income and employment). Conclusion: Socioeconomic status is a strong determinant of health of people living in Roma settlements in Hungary. It fully explains their worse health status but only partially determines their less healthy behaviours. Efforts to improve the health of Roma people should include a focus on socioeconomic status, but it is important to note that cultural differences must be taken into account in developing public health interventions.

Studying vulnerable populations: lessons from the Roma minority.

There are important disparities in health outcomes between racial/ethnic minorities and majorities in all countries where minority health has been investigated. This holds true for the largest minority population of Europe, the Roma, although research data related to Roma are scarcer and more contested than for other minorities. We discuss major obstacles that hinder or prevent the collection of reliable data in Roma and other minorities. The definitions and classification systems on race/ethnicity vary widely, pointing to the social construction of both race and ethnicity. Imprecision in taxonomy and definition of target groups is compounded by challenges in data collection, analysis, and interpretation, along with ethnocentricity that shapes the perspectives and approaches of the researchers. However, administrative data collection on race/ethnicity serves legitimate purposes although such data must comply with less-stringent quality requirements as opposed to data meant for scientific analysis. Research on minorities should consider race/ethnicity as proxy indicators of complex health determinants, and should aim at dissecting these determinants into separate items. Careful documentation of methodology and active involvement of the minorities themselves can increase trust between the investigators and the research subjects, which can in turn improve research on minority health.

The role of vitamin A in differentiation and skin carcinogenesis

Abstract The field of vitamin A research has witnessed a remarkable surge in interest since the late 1980s, when the retinoid receptors were discovered and their genes cloned. Heterodimeric interactions between the retinoid X receptors (RXRs α, β, and γ), which bind 9-cis-retinoic acid, and other hormone receptors, including the retinoic acid receptors (RARs α, β, and γ), the thyroid hormone receptor (TR), the vitamin D receptor (VDR), the peroxisomal proliferator activated receptor (PPAR), and others make hormone action dependent on retinoid homeostasis. Retinoid response elements (RAREs) are present in the promoter and/or enhancer regions of several genes, including some of the homeobox genes, which control development and differentiation. The interaction between hormones and retinoids is added additional orders of complexity by the diversity of the RAREs including the spacer length, their 5′ or 3′ position, and their coexistence in composite sequences with other hormone response elements (e.g., an estrogen response element in the lactablbumin gene promoter, see Table 2). Control of normal epithelial differentiation is a fundamental function of retinoids. The histogenesis of squamous metaplasia caused by vitamin A deficiency is a stepwise process, which permits the gradual transition of phenotypes from simple-columnar, typical of the endocervical epithelium, to pseudostratified, to stratified-squamous and, eventually, to keratinizing. Conversely, the maintenance of the squamous keratinizing differentiation in the ectocervix and vagina requires estrogen. In the absence of this hormone, the squamous stratified ectocervical epithelium retrogrades to a simpler, two or three cell layer morphology, with the topmost layer expressing keratin K8, typical of the endocervical epithelium and mucous cells. Retinoid and estrogen receptor transcript expression is governed by dietary retinoid status and by estrogen availability, with squamous cells mostly expressing RARγ and estrogen receptor transcripts, and columnar cells mostly expressing RARβ. RXR transcripts appear mostly expressed in proliferating cells. The relevance of the retinoid receptors to carcinogenesis is highlighted in the work on acute promyelocytic leukemia. This work has demonstrated that the fusion gene PML-RARα, resulting from the t(15;17) chromosomal translocation, is etiologically connected with the disease and with complete remission after oral retinoid administration. Developments in retinoid metabolism, including the cloning of the cytochrome P450RAI and the connection between RA metabolism and cell growth inhibition, have recently taken place. Recent work has also shown that pharmacological dietary retinoic acid specifically inhibits malignant conversion in the mouse two-stage carcinogenesis system. Because RA upregulates retinoid receptor expression, it seems that retinoid receptors function as tumor suppressors. p]This field should serve as a paradigm for things to come for other essential nutrients, and spells out the notion that nutritional sciences are indeed fundamentally important, because they can contribute significantly to our understanding of different diseases and provide effective therapeutic approaches.

Environmental survey of segregated habitats of Roma in Hungary: a way to be empowering and reliable in minority research

BACKGROUND Roma people, the largest minority in Europe live in segregated communites in several countries. The size of the Roma population is based on estimations deriving from various sources, whereas only narrative accounts of their living conditions have been available. METHODS A comprehensive environmental survey of all settlements in Hungary (n = 3145) was carried out employing Roma field workers in order to locate and characterize segregated parts (colonies) of human habitats. Based on the collected data on environmental conditions and aggregate population numbers of the colonies, ranking of colonies and maps on their characteristics were prepared for all counties of Hungary. RESULTS Seven hundred fifty-eight colonies were identified with approximately 134,000 inhabitants. Ninety-four percent of all colonies are populated dominantly by Roma. Most frequent environmental problems in the colonies were found to be lack of sewage and gas mains, garbage deposits, waterlogged soil and lack of water mains. CONCLUSION Census data cannot be used for policy design aiming at those Roma who are in greatest need of help; that is, living in segregated settlements (colonies). Colonies constitute disadvantaged living conditions of varying severity which can be quantified by a composite score based on indicators of access to services and presence of environmental dangers. The proportion of colony-dwelling Roma is approximately one-fifth to one-quarter of the estimated number of Roma people in Hungary.

General practitioners' cluster: A model to reorient primary health care to public health services

ARTICLE ARTICLE ‘Why a renewal of primary health care (PHC), and why now, more than ever?’ is the question by which the World Health Report 2008 is introduced.1 A primary care system in which health professionals are just simply entry points into the health system can respond neither to the challenges of a changing world nor to the growing expectations of people for better performance. The question of how to renew PHC is answered in the Report by ‘putting people first’, that is, by visioning a people-centred PHC service ‘delivered by teams that focus on health needs, create enduring personal relationships, take responsibility for the health of all in the community along the life cycle, as well as for tackling determinants of ill-health, and in which people are partners in managing their own health and that of their community’. The vision has remained a vision until now,2 and it will remain a vision forever if its implementation is considered just a health care system reform. A definitive link between PHC and public health services has to be formed to transform the vision into reality, in line with the Health 2020,3 the new World Health Organization European health policy framework and strategy, which indicates as one of its four priority areas ‘the strengthening of people-centred health systems along with public health capacity’. Lacking preventive services is one of the many previously identified anomalies of the Hungarian primary care system that needs to be corrected.4 Primary care presently is provided by one general practitioner (GP) and one nurse per practice, assisted by an …

Health impact assessment and evaluation of a Roma housing project in Hungary

An outstanding feature of marginalized Roma communities is their severely substandard living conditions, which contribute to their worse health status compared to the majority. However, health consequences of international and local-level housing initiatives in most cases fail to be assessed prospectively or evaluated after implementation. This paper summarizes the result of a retrospective health impact assessment of a Roma housing project in Hungary in comparison with the outcome evaluation of the same project. Positive impacts on education, in- and outdoor conditions were noted, but negative impacts on social networks, housing expenses and maintenance, neighbourhood satisfaction and no sustained change in health status or employment were identified. Recommendations are made to improve efficiency and sustainability of housing development initiatives among disadvantaged populations.

Survey of the state of health and health behavior among medical students in Hungary

UNLABELLED Medical doctors are not only highly trained professionals but also role models in matters of health and disease. That is what makes the health behaviour of future doctors an important research issue. AIMS AND METHODS A health behaviour survey was conducted among a representative sample of medical students of a university in Hungary by a standardized self-administered questionnaire. The questionnaire related to demographic data, health status and health behaviour using validated items from previous surveys. RESULTS Self-perceived (subjective) health was found to be good/very good in more than three-quarters of the students; nearly all of them thought that they can do much/very much for their health. Nearly two-thirds of the students are non-smokers, but 15% smoke daily. More than four-fifth of the students drink alcohol, mainly occasionally. One-quarter had already tried some drugs, mostly marijuana and non-prescription narcotics and sedatives. Comparison of our data to the same age-group of the general population revealed that the proportion of smokers, daily smokers, and weekly alcohol drinkers is lower among medical students. CONCLUSIONS The prevalence of risk behaviour does not seem to have risen in the past years based on comparing our data to those of earlier surveys conducted among medical students in Hungary. However, students had a significantly higher mean score in the general health questionnaire compared to the mean of the same age group of the general population indicating mental health problems that deserve attention.

College Students’ Response Rate to an Incentivized Combination of Postal and Web-Based Health Survey

A questionnaire survey on health among students of higher education was planned. To produce a response rate high enough for the analysis in a cost-effective manner, a pilot study was carried out to test various methods of data collection. Electronic invitation by the university messaging system to fill a Web-based questionnaire, invitation by the same means to fill paper-based questionnaires at a predefined place and time with or without conditional incentives yielded response rates below 10%. Therefore, a combination of postal and Internet-based questionnaires was used for data collection enhanced with a small up-front gift and conditional incentives suggested by a student focus group. This modality resulted in a 68.6% response rate (65.2% after data cleaning). Those who responded through the Web were more likely to be males and residing in larger settlements. However, no statistically significant differences were observed on the primary health status variables with respect to modality. Use of Web-based questionnaires is recommended in combination with other data collection methods and incentives.

Rapid health impact appraisal of eviction versus a housing project in a colony-dwelling Roma community

Background: During implementation of a community development project involving a severely disadvantaged Roma community, the community was threatened with eviction. Two scenarios, eviction with placement on the waiting list for social housing versus a replacement housing development, were identified and specified. A health impact assessment (HIA) was carried out to inform subsequent negotiations. Aims: To assess the health effects of eviction in comparison with that of a housing project for a Roma community; to make recommendations on short-term and long-term benefits of the two scenarios in order to inform the local government; and to develop a demonstration HIA that can act as a model for other disadvantaged Roma populations. Method: A prospective assessment, based on a broad model of health, was carried out to assess health effects of a housing project compared with eviction. By design, it ensured full involvement of members of the community, local decision makers and relevant stakeholders. Results and conclusion: This HIA identified numerous positive and some probable negative health effects of a housing project. Despite the uncertainty around some of its predicted effects, the overall health benefit of a housing project clearly outweighed that of eviction. Although the immediate financial advantages of eviction for the municipal government are clear, this example provides further evidence to support the adoption of a statutory requirement to assess both economic and health outcomes. It also provides an example that other Roma communities can emulate.