| Bridging the gap: health mediators help reach Roma |
in Bulgaria are working to improve vaccination rates among Roma groups by
talking with parents and even bringing some children to the GP for
immunisations. However, overcoming cultural and health system barriers is essential if immunisation goals
are to be reached.
of the National Network of the Health Mediators in Bulgaria told Vaccines
Today that health mediators are a trusted source of health information and
key players in a tailored immunisation campaigns designed for Roma populations.
The need could
hardly be greater. Vaccination rates are typically lower among Roma groups,
putting them on the frontline of the 2010 measles outbreak in Bulgaria and the ongoing rubella epidemic in Romania. Both diseases can lead to
serious complications, especially where access to health services is weak.
At a European
level, efforts to wipe out measles and rubella by 2015 are likely to run
aground unless vaccine uptake in hard-to-reach communities is dramatically
Many of the
common concerns about vaccines in Roma populations echo those outside the
community: parents worry about side effects and under-estimate the risk posed
by vaccine-preventable childhood diseases.
“In the Roma
community these views are also present plus the suspicion that vaccination
could cause sterility. In general, the Roma community needs more health
information about vaccines and how they work,” says Dilkova.
also miss out either because their parents do not have health insurance and
have fewer contacts with health services as a result, or because the children
are not registered with GPs.
In some cases,
says Dilkova, doctors are reluctant to register children from Roma communities
because of the workload involved in tracking their immunisation status. Here
again, health mediators can help.
mediators work with GPs to find the parents of unvaccinated children and
explain why vaccination is important. In cases where the parents promise to
take their child to the doctor but doesn’t follow through, sometimes the health
mediator takes the child to the GP,” Dilkova explains.
One of the
simplest things health authorities can do is make immunisation services
available locally. We have better results when the vaccination campaigns are
organised in the field, within the community, at a place where Roma people
could gather without leaving their locality,” she says.
Full text of
Q&A with Diliana Dilkova of the National Network of the Health Mediators
Today: What is the role of health mediators?
Dilkova: The health
mediator (HM) is an intermediary who facilitates access to health and social
services for vulnerable groups of the population, with focus on ethnic
minorities including Roma. HMs in Bulgaria have been included in the national
classificatory of professions since 2007 and one of their most important
duties, according to their job description, is to work for better vaccination
coverage of Roma population.
Today: How does this work?
Dilkova: In the first
months of their work, newly-trained health mediators have several important
tasks one of which is to establish contacts with all health and social
institutions representatives working on the territory of the municipality. One
of these important contacts is with the general practitioners that work with
Roma patients. The GPs prepare lists with non-vaccinated children and give them
to the HM. The HM finds the parents of these children and explains to them why
it is important to vaccinate their children: sometimes the HM takes the child
to the GP – in cases when the parents promise to do this several times but
don’t do it.
In recent years
HMs have participated in several complementary vaccination campaigns organised
by the Ministry of Health. HMs did this in partnership with the regional
divisions of the Ministry (the Regional Health Inspectorates who are in charge
of dealing with missed vaccinations). HMs organised health information
campaigns in Roma communities about 1 week before the date for vaccination in
order to explain parents why they should vaccinate their children.
Today: Can you give examples of campaigns HMs have worked on?
Dilkova: In 2010 during
the EU measles epidemic outbreak, more than 24,000 people in Bulgaria were
infected with measles and 24 children died. In 2010, HMs participated in
complementary vaccinations against measles to help control the outbreak. In
2011 HMs were involved in complementary vaccinations against polio. 2012 and
continuing saw HM participation in information campaigns for cervical cancer
vaccination – since November 2012 the cervical cancer vaccination is
free-of-charge for all 12-year old girls in Bulgaria.
Today: Are there many HMs working in Bulgaria at present?
Dilkova: In 2013 in
Bulgaria 130 HMs are working in more than 70 municipalities, paid by the state
budget. Another 17 are trained and work in 3-year GSK financed project “Together
for health” implemented in Bulgaria, Hungary, Romania and Slovakia.
Today: In your experience, what is the attitude of the Roma community to
Dilkova: In Bulgarian
society the old-fashioned persists that measles and rubella are diseases the
child should just “pull through”. In some cases healthy children are taken to
meet infected ones because some still believe that the earlier the child
“passes” through this, the better. In the Roma community these views are also
present plus the suspicion that vaccination could cause sterility. In general,
the Roma community needs more health information about vaccines and how they
Today: Do parents have other concerns?
Dilkova: Roma parents
are concerned that vaccination could make their child ill. They are not
acquainted with the normal side-effects of vaccination such as redness etc; the
GPs usually don’t have the time to explain to every parent what is normal and
what is not and sometimes parents get concerned if the child feels discomfort.
This is also a task of the HM – to explain all this – why this vaccine is
important, why it should be administered within a given period, what are the
possible complications if the child gets ill from a vaccine-preventable
explanation from GP or HM, Roma parents usually agree that vaccination is
needed and important but still some of them don’t take their children to the
GP’s consulting room. In this respect we have better results when the
vaccination campaigns are organised in the field, within the community, at a
place where Roma people could gather without leaving their locality. The other
successful method is the health-informational work of a HM in the community and
in certain cases – the accompaniment of some children to the GP.
Today: Where do parents get information and who do they trust?
Dilkova: They get a lot
of information from their GP – when the GP is willing and has the time to give
it. Unlike the trends in mainstream population not to trust in doctors, Roma
still have high rates of trust in health professionals. This should be used and
doctors should be advised to pay more attention to providing Roma parents with
health information and advice. HMs are also a trusted source of information in
communities where they work.
Roma parents get
health information via cable TV channels and trust it but usually this is the
easiest way to get wrong information. For example, a few months ago a Turkish
TV channel had a broadcast about the danger of vaccinating girls with cervical
cancer vaccine and in many Roma communities where the Turkish language is
spoken HMs reported refusals of Roma parents to vaccinate their 12-year old
girls with the free-of-charge vaccine.
Today: Why are vaccination rates typically lower in the Roma community than the
Dilkova: There are a
number of reasons some of which are cultural others are health system issues.
in the Roma community is usually lower compared to the health culture of the
mainstream population for many reasons including lower literacy levels, poorer
access to health information, lower social status – parents think first about
survival: food, clothes, housing – the cultural specifics according to which
health is not top priority. As a rule, adult Roma visit health services mainly
in cases of emergency, when their health condition has worsened considerably.
Due to unemployment and poverty, a big share of Roma people does not have
health insurance, although all children in Bulgaria are insured until 18 years
of age. They general visit the GP on very rare occasions, sometimes only when
their children are ill – but still the rare contacts with health professionals
reflect in lower level of health culture and awareness.
Today: What about systems or organisational issues?
Dilkova: In Bulgaria
vaccinations are the obligation of GPs. Each child should be subscribed to a GP
immediately after his or her birth. However, because of the problems in the
health system and in the distribution of GPs throughout the country, there are
many GP practices that are vacant. This is usually the case in rural
municipalities where one GP takes care of patients in between three and five
villages and travels to each of them for 1 day per week; sometimes the GP
doesn’t even visit all the villages that they are responsible for and the
patients have to arrange their own transportation to go for a check-up or
there are a number of cases reported by HMs when GPs refuse to register Roma
babies on their lists – they say the list is full but the real reason is that
GPs often don’t want to have Roma patients because they cannot communicate well
measles epidemic outbreak in 2010 there were serious grounds for concluding
that many GPs have reported as vaccinated more children than they vaccinated in reality. We cannot
provide data to prove it but this was a kind of “open secret” between
professionals in the health field in 2010.
The reason for
this is that GPs have to search for these children – going from house to house –
and they don’t have the time for this. On the other hand, GPs are responsible
for administering vaccinations – if they report children that are not
vaccinated, they have to explain why to the Health Insurance Fund. In this case
one option is to cooperate with HMs who could search for these children and
talk with the parents. The other option is to report that come children are not
vaccinated and the third option is to write down that everyone is vaccinated.
Today: What can be done to address these problems?
Dilkova: It is
important to recognise that Roma sometimes have their own concepts and fears
concerning vaccination and addressing them. Intermediaries – like HMs –
connected to the community should be used as they know the language, have the
trust of the community, are suitably trained, and have knowledge in the sphere
of health and social problems.
professionals should also be trained to work in a multi-ethnic environment with
a focus on Roma health beliefs, Roma values and Roma groups. RRoma are not a
homogenous group, each group has its specifics and it is important for each
health professional to know with which group or groups he is working.
vaccines should be made easier by organising vaccinations in the community. For
this, preliminary health-information work with parents is crucial.
must be provided with information concerning vaccines and vaccine-preventable
diseases. As many Roma are not able to read, this is best done via short
videos, brochures with more pictures, less text and clear messages.
evangelical churches are very popular in Roma quarters – in some cases the
pastors of these churches are open for discussing health issues with the
community and are willing to help in sharing health information so the
importance of vaccination could be one of the health issues addressed in this
setting. Some of the best HMs in the country are pastors in evangelical