Improving the health of Roma communities in the Yorkshire and Humber Region a guide to good practice

Written and produced by Migration Yorkshire for the Roma SOURCE project

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Improving the health of Roma communities in the Yorkshire and Humber Region a guide to good practice

Contents: Contents:.................................................................................................................... 2 About this guide ......................................................................................................... 3 Background to Roma health....................................................................................... 4 About the Roma SOURCE project ............................................................................. 5 Examples of Best Practice: ........................................................................................ 6 Roma SOURCE health champion pilot, Sheffield ................................................... 7 Leeds Roma Health Needs Assessment ................................................................ 8 NHS Newham Pacesetters ..................................................................................... 9 Mediation Centres in Health Services, Valencia, Spain ........................................ 10 What works in Roma health ..................................................................................... 11 References and bibliography.................................................................................... 12 Contact Details ......................................................................................................... 13

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About this guide This is a short guide to good practice for health services in the Yorkshire and Humber region and those elsewhere who are working to improve the health of Roma communities. We hope the guide will provide inspiration and guidance for people and projects working in this area. It also gives us an opportunity to celebrate some good initiatives which seem to be effective in improving the health of Roma people. The guide does not claim to be exhaustive. The examples included have been selected from activities that are taking place within our region which demonstrate good or promising practice. We have also included examples previously identified as good practice in the UK and information provided by project partners from elsewhere in the EU. There will no doubt be initiatives and good practice that are not included, but we hope to have identified some of the key themes of good practice and effective working to improve the health of Roma communities. We welcome any recommendations for additional initiatives to include in any future updates to this guide. The guide has been written and produced by Migration Yorkshire. Migration Yorkshire is the Yorkshire and Humber regional migration partnership and is hosted by Leeds City Council. Migration Yorkshire works with national, regional and local partners to ensure that the region can deal with, and benefit from, migration.

This publication has been produced with the financial support of the Fundamental Right and Citizenship programme of the European Commission. The contents of this publication are the sole responsibility of the authors and can in no way be taken to reflect the views of the European Commission.

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Background to Roma health Who are Roma? 'Roma' is an umbrella term to describe groups of people with similar cultural characteristics including those who describe themselves for example as Roma, Sinti, Gypsies and Kalé. Roma have lived in Europe for over 1,000 years since originally migrating from India and are the largest minority in Europe. There are an estimated 10 - 12 million Roma in Europe, of which about 6 million live in the European Union 1. Roma rights The majority of Roma living in the European Union are citizens of the European Union and have exactly the same rights as other European citizens. These rights are laid out in the Charter of Fundamental Rights of the European Union. In each country of Europe, Roma should have the same rights as other citizens and should be treated equally without discrimination. Some Roma living in the European Union are legally-residing 'third country nationals' (migrants from outside the EU) and have the same rights as other third country nationals. Discrimination and its effects Discrimination on the grounds of racial or ethnic origins is prohibited by the Directive on Racial Equality in the European Union and is illegal in all EU member states. However, discrimination against Roma has a long history in Europe and continues. Many Roma in Europe face prejudice, intolerance, discrimination and exclusion in their daily lives. This has many effects on Roma, including: 2  Roma have a life expectancy 10 years lower than other European citizens .  Roma child mortality rates are between 2 and 6 times higher than the general population of Europe 3.  Less than half of Roma children complete primary school and a very low number attend secondary school.  Employment rates are lower for Roma than the general population.  Housing is often poor, with inadequate access to services. Roma health: The EU framework for national Roma strategies (2011) recognises health as an area where across Europe, Roma face significant levels of exclusion, and commits member states to reduce the gap in health status between the Roma and the rest of the population. The disparity in health indicators reflect poorer living conditions, reduced access to quality healthcare and higher exposure to risks. There is also evidence that Roma

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Council of Europe (2010) European Commission (2011) p6. 3 European Commission (2011) p6. 2

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communities are less well informed about health issues and can face discrimination in access to healthcare. This context of health exclusion is evident in Roma communities recently migrated to the Yorkshire and Humber Region of the UK. Local research 4 and anecdotal information from health practitioners within the region has highlighted a number of health concerns that are a consequence of generations of discrimination, poor living conditions and exclusion from services. Such conditions include: diabetes; coronary artery disease; obesity; teenage pregnancy and nutritional deficiencies. The same sources also draw attention to continuing factors within the UK that contribute to poor health, including: insecure employment; poor working conditions, often with minimal rights; inadequate access to education and care; long-term health conditions; unhealthy lifestyles and community tensions. About the Roma SOURCE project Roma SOURCE (Sharing of Understanding Rights and Citizenship in Europe) is a two year project co-funded by the European Union's Fundamental Rights and Citizenship Programme. The Roma SOURCE project involves eight organisations from six European countries. Migration Yorkshire (Leeds City Council) is lead partner, and manages the project. The partnership is made up of regional and local governments, Roma-led NGOs (non-governmental organisations), a university and a private organisation. Roma SOURCE aims to combat discrimination and exclusion of Roma and improve understanding between Roma and mainstream communities. The key themes of our work are:  children  citizenship  employment  health  research Some of the project partners work in regions which are traditionally home to Roma communities, others in regions which have more recently become a destination. Working in partnership allows regions, local areas and organisations to learn from each other about different ways of working with Roma communities. In Yorkshire and Humber we are:  working with local authorities to improve understanding and strategic response to Roma in the region  coordinating a cross-sector Roma Practitioner's Network for sharing good practice  running six pilot projects, three on health champions and three on citizenship in six areas in the region. 4

Rose et al (2011), Moor (2010), NHS Sheffield (2009)

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producing citizenship information booklets for Roma and good practice guides for organisations working with Roma

Examples of Best Practice: On the following pages, we have provided four practical examples of successful health initiatives involving Roma people. We have given examples that spread across a range of health-related activity. These include community health promotion, improving engagement with primary and secondary healthcare, and higher level health strategy. These are:  Roma SOURCE health champion pilot, Sheffield 

Leeds Roma Health Needs Assessment

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NHS Newham Pacesetters

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Mediation Centres in Health Services, Valencia, Spain

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Roma SOURCE health champion pilot, Sheffield Background Service provision The aim of the project was to involve Roma people in Roma SOURCE health champion pilot, promoting healthier lifestyles within their own communities. Sheffield This is one of three health champion pilot Health Champions: The project trained up two Roma projects run and funded through the Roma volunteers from the local community as ‘lead health SOURCE project. champions’ who received detailed training through Sheffield NHS and Altogether Better. They in turn trained other Roma The health champion approach was as ‘supporting health champions’. The total group of adopted because top-down approaches to champions included both men and women. The champions Roma health had proven less effective than helped to run and organise a number of sessions for local desired. Roma. The Sheffield initiative was led by NHS Sheffield, in collaboration with Sheffield Wellbeing Consortium and the Pakistan Advice and Community Association (PACA). It aimed to encourage healthier lifestyles amongst Sheffield’s Roma communities by use of health champions – people from within the Roma community who by example and encouragement could promote a community-led approach to health improvement. Contacts: [email protected] [email protected]

Zumba classes: The health champions capitalised on a widespread enthusiasm for dancing within the local Roma community to set up Zumba classes for Roma people. These combine dance with aerobic elements, as a means of exercise which the community would enjoy. There has been extensive take-up. In response to demand from Roma people, separate male and female classes were set up. Healthy eating: The champions ran a men’s lunch club for the Roma, which provided one-to-one dietary guidance and support. The health champions also developed posters on healthy eating in the Roma language to make the message easier to understand. Football: One of the health champions set up ‘Spartak Slovak’ a Roma football team, which is now taking part in the national ‘Integration through Football’ league.

Best or Promising practice Inclusion: Using Roma people to work within their own community, to set their own priorities for health improvement, and raise awareness of health issues within Sheffield’s Roma community was a significant element in ensuring community involvement in the pilot. Partnership: The project brought together public sector, voluntary organisations and community members. Each of these project partners provided an important contribution to the success of the project Personal development: The two lead health champions subsequently gained salaried employment in health-related areas on the strength of the skills they acquired through the project. These jobs were significantly better than they would have felt eligible for before the project. Community engagement: The success of the project, owed a lot to the active work already taking place within the Roma community by PACA, which gave it a springboard to successful engagement. The success of the health champions in finding work had the unexpected side effect of encouraging members of the Roma community to take a more active part in community voluntary work, which has continued after the lifetime of the scheme.

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Leeds Roma Health Needs Assessment Background Leeds Roma Health Needs Assessment NHS Leeds conducted their Roma Health Needs Assessment (RHNA) in 2011/2012, as a conscious attempt to systematically include Roma within local health strategy and policy. The main aims of the RHNA was to identify the health status and needs of Roma communities in Leeds, to reduce health inequalities and improve access to services. To achieve this, the RHNA intended to identify barriers in accessing primary and secondary health care services and any wider determinants affecting Roma health. Contacts: [email protected] [email protected] [email protected]

Service provision The RNHA adopted a range of approaches Cross sector involvement: NHS Leeds recognised they lacked detailed knowledge of the Roma community, and involved Advocacy Support, a leading Leeds-based voluntary sector organisation working with Roma, and Leeds City Council’s Gypsy Roma Traveller Achievement Service in the planning of the RHNA to address this. Voluntary sector facilitator: Advocacy Support, a leading Leeds-based voluntary sector organisation working with Roma was commissioned to facilitate community sessions. Recruiting local Roma people to assist the survey: Local Roma people were recruited and trained to assist in devising the survey and in delivering the focus group sessions. Multi-format surveys: Surveys were circulated in Czech, Slovak and Romani. A number of these surveys were delivered in the form of focus groups. Establishing priorities: The RHNA established the main issues affecting Roma in Leeds with respect to: general health and lifestyle issues; issues of access to primary and secondary care; mental health concerns and wider determinants of health such as housing, finance and the local environment. Leeds Health and Wellbeing Strategy: The findings of the RHNA are being incorporated in the Leeds Health and Wellbeing Strategy – the overall health plan for the city.

Best or Promising practice Strategic approach: Recognition that Roma health needs should be included in the development of health strategy. Partnership: The use of a voluntary sector partner that was trusted by Roma people increased the level of engagement with the local community Use of spoken word: In recognition of low levels of literacy, low levels of English skill, and a widespread preference for the spoken over the written word, survey information was gained through focus groups in addition to traditional printed survey forms. This helped increase the response rate. Use of community mediators: The use of community mediators proved a vital means of ensuring cultural sensitivity and increasing awareness of the surveys and focus groups, as well as of the whole RHNA process. Recognition of wider determinants of health: The RHNA recognised that poor health outcomes in Roma communities are often affected by wider issues such as housing, economics and the local environment. Identifying and acting upon these issues was a key part of the process.

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NHS Newham Pacesetters Background NHS Newham Pacesetters. This project was set up in 2008 to address the health needs of the Roma community in the London Borough of Newham, which was estimated at around 900 families. The main objective of the project was to increase registrations with GPs. The project also worked to improve the Roma community’s awareness of health issues and build confidence within NHS Newham in dealing with Roma people. The Pacesetters scheme was delivered in partnership between NHS Newham and Roma Support Group (RSG), a voluntary sector organisation working to improve the quality of life of Roma people. The project brought together a range of professionals from across clinical, acute care, mental health, education and other backgrounds to work towards better health outcomes for Roma in Newham. Contact: [email protected]

Service provision The project employed a number of initiatives to engage Roma people. Roma health communication worker. This person was employed for two days a week and was based within the Roma Support Group. They were the central access point within the Roma community and offered individual help to people regarding health issues and conducted interviews to assess health needs. Cultural awareness programme. This involved training sessions carried out amongst NHS Newham staff by Roma Support Group to raise awareness of the culture, tradition and health needs of Roma people, including age and gender issues and to build confidence in dealing with them. Health event and health MOT. This was held at the end of 2009 in conjunction with the Roma Support Group’s AGM. The event highlighted issues around smoking, diet and heart disease. Attendees were also offered a health MOT which measured BMI, blood pressure and blood sugar levels. Transitional terms of registration. This enabled Roma people to register with a GP with a proof of ID rather than a proof of residence. This was to take into account the fact that many Roma are overseas nationals and in housing situations that make providing proof of residence difficult, and was a direct means of addressing low levels of GP registration.

Best or Promising practice Focus. The project provided an opportunity to mainstream health providers to identify and address a range of health issues within the Roma community. Partnership. The collaboration between NHS Newham and Roma Support Group was central to the success of the project. As RSG are known to and trusted by the Roma community, there involvement helped support a level of access and engagement which would otherwise not have been possible. Professional development. As well as improving the health awareness of the Roma community, an essential element of the project was to build the knowledge and understanding of NHS staff so they can address the particular needs and challenges of the Roma community effectively and with sensitivity. Innovation. Through working with the Roma Support Group, the project was able to introduce discussion of certain health issues, such as mental health, which were sometimes a taboo within the community, against a backdrop of community and cultural events.

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Mediation Centres in Health Services, Valencia, Spain Background Service provision Roma mediators: the mediators performed a range of Mediation Centres in Health Services, functions, including Valencia, Spain One to one work with Roma extended families: The Background: The Department of Health hospitals where the project took place regularly experienced (Conselleria de Sanidad) allocated € difficulties coping with large extended families of Roma 45,000 in 2010 for a project developed by people who wished to accompany sick relatives while in the Federation of Roma Youth of the hospital, and this in turn caused the families added distress. Valencia Region (Federación de la The mediators were able to work with families and hospital Juventud Gitana) for the employment of authorities to find mutually agreeable solutions to the three mediators. challenges that this sometimes created. These mediators, who were themselves Conflict resolution. The mediators were able to take an Roma, were employed at the Hospital La active role in resolving conflicts that sometimes occurred Fe, Clinic Hospital and Hospital Amau de between health staff and Roma people. Villanova. Their purpose was to address issues that the Roma community faced when receiving health care, as well as to improve communication regarding health benefits, administrative processes, health services, prevention activities and other health matters. These issues had previously been the cause of challenging situations for Roma and for health workers. Contact: [email protected]

Health information: Providing patients with information on health issues, including both information on particular conditions as well as wider health and lifestyle issues. Improving communication between health professionals, patients and their families; Cultural awareness: The mediators were able to advise healthcare professionals on how to engage more effectively with Roma patients. These included generational issues, such as recognising the respected community position of some older members of the community. They also included gender issues such as multiple discrimination and problems of access to health care and child support. Information materials: The mediators developed a number of information materials which addressed issues such as health benefits, administrative processes, using health services, prevention activities

Best or Promising practice Results: the project was effective in achieving the main element of its remit, namely to reduce occasions of conflict between Roma families and health staff at the hospitals in question. Partnership: The project brought together public service, a voluntary sector group and members of the Roma community. This provided the initiative with important credibility with Roma community and with hospital staff. Involvement of Roma: The initiative recognised the importance of involving Roma people in finding solutions to issues affecting them. Recognising the needs of Roma within mainstream health settings: The scheme recognised the importance of providing appropriate health care for Roma communities within mainstream care settings, and provided a practical approach to resolving specific issues that had made this difficult. Intercultural approach: The work of the mediators brought together people from the Roma community with health staff. As a result, non-Roma staff were able to increase their understanding of the Roma community so they can address their particular needs and challenges more effectively and with greater sensitivity, and Roma people were able to increase their understanding of mainstream health services in Valencia.

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What works in Roma health Despite the disparity of the initiatives we have included, there are some key elements binding them together, and which each example helps demonstrate. 

Active participation of Roma people. All of these initiatives have taken active measures to engage and involve Roma people in some way. All the anecdotal information we have gained from talking with Roma communities and those who work with them indicate that Roma engage better when people from within their community are a part of the process. These best practice cases would appear to reinforce this.

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Involvement of the voluntary sector. All of the examples have involved close working with the voluntary sector. This is usually because the voluntary sector organisations in question are perceived as having closer links with the Roma community, and have developed bonds of trust. They are therefore a good way of helping the initiatives achieve the intended results.

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Aiming for the mainstream. All of these activities have had the aim of ensuring mainstream health services are appropriate to the needs of Roma people, whether by developing services which are suitably inclusive, or by supporting Roma people to engage more effectively with services.

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Awareness of the gender dimension. Most of these activities have been able to recognise and respond to the gender-specific issues prevalent within many Roma communities, such as multiple discrimination and problems of access to health care and child support.

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Involvement of regional and local authorities. Particularly in the UK where significant levels of migration and settlement by Roma of central and Eastern European origin is a relatively recent phenomenon, this shows an increasing recognition of Roma by formal statutory agencies. Efforts by them to support and include Roma communities are a necessary demonstration of leadership on this issue.

These echo the Council of the European Union Conclusions on the Inclusion of Roma, which identify and recommend general policy approaches towards Roma 5. On the basis of our current understanding of good work being done to improve health in Roma communities, we recommend others working with Roma to include some or all of these characteristics.

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Council of the European Union (2009)

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References and bibliography Cabinet Office, Social Exclusion Task Force and Department of Health (2010). Inclusion Health: Evidence Pack, available at http://webarchive.nationalarchives.gov.uk/+/http://www.cabinetoffice.gov.uk/media/34 6574/inclusion-health-evidencepack.pdf Council of Europe (2010). Statistics document prepared by the Council of Europe Roma and Travellers Division, available at www.coe.int/t/dg3/romatravellers/Source/documents/stats.xls Council of the European Union (2009). Council Conclusions on Inclusion of the Roma, available at www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/108377.pdf European Commission (2011). An EU Framework for National Roma Integration Strategies up to 2020, available at http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2011:0173:FIN:EN:PDF European Commission (2012). What works for Roma inclusion in the EU – policies and model approaches, available at http://ec.europa.eu/justice/discrimination/files/whatworksfor_romainclusion_en.pdf . Fundación Secretariado Gitano (2009). Health and the Roma community, analysis of the situation in Europe: Bulgaria, Czech Republic, Greece, Portugal, Romania, Slovakia, Spain, available at http://ec.europa.eu/social/BlobServlet?docId=4309&langId=en Moore, Lizzie (2010). A healthcare needs assessment of the Slovak Roma community in Tinsley, Sheffield, summary available at www.migrationyorkshire.org.uk/?page=researchdetails&itemid=373 NHS Sheffield (2009). A report on the health needs of new arrivals and service provision, available at www.sheffield.nhs.uk/boardmeetings/papers/spctagenda030309-11.pdf Rose, Nigel, et al (2011). Including migrant populations in joint strategic needs assessment: a guide, available at http://www.idea.gov.uk/idk/aio/26070159 United Nations Development Programme (2003). The Roma in Central and Eastern Europe, Avoiding the Dependency Trap, available at http://hdr.undp.org/en/reports/regional/europethecis/Avoiding_the_Dependency_Tra p_EN.pdf

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Contact Details John Donegan, Development Officer (Roma) Migration Yorkshire Civic Hall | 2nd Floor East | Calverley Street | Leeds | LS1 1UR

Tel: +44 (0)113 395 2448, Mob: +44 (0)7891 272854 Email [email protected] www.migrationyorkshire.org.uk www.romasource.eu © Roma SOURCE 2012

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