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Investigation of Healthcare Satisfaction of Roma Living in Camps or Urban Complex of Central Greece

Background: Roma in Greece face multiple discrimination, particularly in the areas of housing, education, employment and health. Objective: The aim of this study is to explore the perceptions and beliefs of Greek Roma living both in camps and in urban neighborhoods for public health structures as well as to assess their satisfaction with health care services. Methods: The study sample consisted of 185 subjects (94 females and 91 males) with a mean age of 39.8 years (SD = 15.7). Of the people involved in the study, 80 come from the settlement of Larissa and 105 from the camp of Tyrnavos. A special survey questionnaire, “The scale of attitudes, feelings and satisfaction of Roma health services”, was used for collecting the data. The statistical analysis was carried out using the SPSS statistical program. Results: The statistical indicators of the sample, taken together, indicate a moderate trend towards a negative escalation of attitudes, feelings and satisfaction of health services. Based on the t-test results for independent samples, the average score on the Roma satisfaction scale of the Larissa settlement (M = -0,41, SD = 0,74) was not found to differ, statistically significantly, from the Roma population of the Tyrnavos camp (M = -0,61, SD = 0,94), t (182) = 1,680 (p = 0,095). Conclusion: The results of this study, despite its reasonable limitations, lead to a redefinition of some views regarding the attitude of the Roma towards the public health and care system, as well as the needs created.


BACKGROUND
Roma populations live scattered throughout Greece. However, in recent years there has been a trend of permanent establishment in inner cities. Many of them live in settlements or permanent dwellings, while others still lead nomadic lives; true to their traditions and customary law they form a distinct cultural population group based on the principles of 'collectivism' (1).
It is reported that by the 15th century they lived in about 70 camps, mainly in the suburbs of major cities. After the Greek Revolution of 1821 there was a demographic increase of these populations while almost all the major villages of the country had their separate 'gypsy-side' (2).
As reported by the Region of Thessaly and based on the ROM network, the exact number of Roma in Greece is not easy to determine. It is estimated that it amounts to about 250,000 people. The Council of Europe estimates the population at 80,000-150,000 people, while the General Secretariat of Adult Education estimates that the Roma population in Greece is 300,000 people (3).
In Larissa, a town located in Central Greece there is a settlement called 'Damaria', which is located in the southern part of the neighborhood of Nea Smyrni, inhabited entirely by Roma. The settlement has an area of about 500 acres, is within the city plan and the Roma population there is estimated to 4,500 inhabitants (2,155 men and 2,345 women). According to the Thessaly Region (2015), the Roma populations appeared in this particular area around the mid-1940s and bought cheap plots of land from the inhabitants there called Kaliviotes. At the end of the same decade the northern part of the region began to develop and the population became larger. In the 1950s in the same area and around the Roma region, settlements were established with Greek Pontians, i.e. repatriated Greeks mainly from ex-USSR countries (3). In the 1960s additional inhabitants from all over Thessaly settled in the area.
In the Municipality of Tyrnavou, there is a substantial Roma population who have settled in a mixed camp (settlement of 'Kritiri'), which includes about 55 houses, 70 prefabricated and about 300 makeshift structures built with wood, sheet metal and plastic, in a particularly clustered, densely populated place. About 2,000 people live there on a permanent basis while about 100 dwells there occasionally. In comparison with other settlements, more adults live in this area and their age distribution is about 250 under the age of 6 years, 400:6-15 years, 100:15-18 years, 700: 19-40 years and 650>41 years of age. Regarding the infrastructure of the settlement, most roads are dirt roads and there is no central sewage system. Water supply covers 35% of housing, electricity supply 20% (most households meet their electricity needs with generators) while mobile phones are used for communication needs. There are no school units within the camp and the total lack of health and education services leads the Roma in the area to seek health services within walking distance either in Health Centers or in Hospitals of Larissa (3).

OBJECTIVE
The aim of this study is to explore the perceptions and beliefs of Greek Roma living both in camps and in urban neighborhoods for public health structures as well as to assess their satisfaction with health care services.

MATERIALS AND METHODS
The study population of the survey consists of the Greek Roma living in the settlement of Larissa and the camp of Tyrnavos (Central Greece). From this population a sample of 185 adult Roma was selected (as mentioned below -by the method of snowball sampling).
The sample consisted of 94 women and 91 men, with a mean age of 39.8 years (SD = 15.7). Thus, there were two sub-groups, one that included 105 people living in a camp in Tyrnavos Larissa and 80 people living within the urban area, i.e. the settlement by Larissa.

Inclusion Criteria
The sample in the study was to consist of men and women aged 18 and over who had the ability to communicate in Greek.

Research process
Participants were informed to complete a questionnaire and anonymity was ensured. Their participation was voluntary. The research team completed the questionnaires (as the majority of the participants were illiterate) by reading the questions to the participants and noting the answers. Due to various restrictions in getting direct access to the target population as a whole, the most appropriate method for collecting the data of this study was by snowball sampling, as people who initially wished to participate were eager to suggest further participants.

Research Tool
A purpose-specific questionnaire, i.e. 'The Scale of Attitudes, Feelings and Health Service Satisfaction of the Roma' was used as a research tool for collecting data which was anonymous and fully structured with closed-ended questions. It consisted of a total of 40 questions divided into two sub-modules (4). The SPSS statistical package was used for data analysis.
The questionnaire is divided in two parts, whereby part A has 26 questions related to the following five feature categories: (a) demographic and social details (gender, age, marital status, number of children, number of siblings, place of residence, religion), (b) educational (level of education, school attendance, reading knowledge, literacy), (c) professional and economic status (employment status, source of income, individual monthly income, homeownership, insurance), (d) living conditions (type of residence, number of rooms, existence of a bathroom, existence of a kitchen) and (e) use of health services and presence of a health problem (use of health services, chronic health problem of a family member and hospitalization of a family member or a relative).
Part B of the questionnaire was comprised of a Scale of attitudes, emotions and health service satisfaction among Roma. This section contains 14 questions, which were chosen as suitable to highlight positive or negative behavior of the person in case of illness, but also when in hospital or using general public health services. The questions are answered on a seven-point Likert scale (-3 to +3) with a grading from 'Not satisfied-I completely disagree' (-3) to 'Completely satisfied-I completely agree' (+3) with one neutrality point (0). The total score on the scale expresses the overall positive or negative behavior of the individual. In 7 questions with negative content, the score is given in reverse order to mean the total score of the scale. The more positive the overall score of the scale the more pronounced the positive behavior of the individual.

Statistical analysis
Data was imported to IBM SPSS, version 25 (IBM Corp., Armonk, NY, USA), for analysis and interpretation. Continuous variables were expressed as mean with standard deviation. Absolute numbers and percentages were used to express categorical variables. Statistical significance was set at p < 0.05. The normality of the data distribution was checked using Shapiro-Wilk test and 'Normal Q-Q plot', 'Detrended Normal Q-Q plot', and 'Box Plot' graphs. The reliability of Roma health service satisfaction scale is investigated using the measure of Cronbach's alpha. Twoway ANOVA and independent samples t-test were used for the statistical analyses, all tests were deemed significant at p < 0.05.

RESULTS
Half the sample population is married. Almost one in two people in the sample has attended primary school and two in five are illiterate. Three out of four people are Orthodox Christians. The existence of a bathroom in their home was estimated at 55% and the existence of a kitchen at 64%. Nearly two-thirds of the participants declared a monthly income of less than 200 euros while 50% are insured, while most have used health services. Three out of four people have a chronic health problem. Table 1 details the characteristics of the sample (Table 1).
Cronbach's alpha coefficient of the Roma health service satisfaction scale was estimated at 0.673 (67.3%).  Table 2 below provides the descriptive measures for the variable 'Scale of satisfaction of health services from the Roma' for all combinations of the categories of reading ability and place of residence.
A two-way ANOVA was performed to analyze the effect of place of residence and reading ability on scale of satisfac-tion. This reveals that there was a statistically significant interaction between the effects of residence and reading ability (F (1, 1) = 11.640, p = .001). Because the interaction effect between place of residence and reading ability is statistically significant, we cannot interpret the main effects without considering an interaction effect. In the housing estate there is about the same level of satisfaction regardless of reading ability. In contrast, in the camp, there is clearly more satisfaction in people who have the ability to read than in people who do not have that ability ( Table 3). Table 3 describes with the descriptive measures for the variable 'Scale of satisfaction of health services from the Roma' for all combinations of the categories of writing ability and place of residence.
A two-way ANOVA was performed to analyze the effect of place of residence and writing ability on scale of satisfaction. A two-way ANOVA revealed that there was a statistically significant interaction between the effects of residence and writing ability (F (1, 1) = 9.305, p = .003).  Because the interaction effect between place of residence and writing ability is statistically significant, we cannot interpret the main effects without considering the interaction effect. In the housing estate there is about the same level of satisfaction regardless of writing ability. In contrast, in the camp, there is clearly more satisfaction in people who have the ability to write than in people who do not have the ability (Table 4).

DISCUSSION
Initially, looking both at the national and international literature, it was observed that there is a significant variation with the findings of the present study. Most of the research carried out on the Roma concerned general health, living conditions, communicable diseases, vaccination coverage, access to health care, etc. While their satisfaction with the health system has hardly been studied, it is only been reported in a doctoral thesis on the Roma of Thessaly (4).
From the outset, we should state that the findings of this study concern the investigation of the level of satisfaction from health services for Roma residents living in a camp and Roma living in urban neighborhoods. Yet, it is not certain whether this variable is independent to the environment of Thessaly in which they reside or the period of time and/ or other socioeconomic circumstances in which Greece is going through.
The overall conclusion of the survey on Roma health service satisfaction was a modest trend of a negative escalation of attitudes, feelings and satisfaction of health services. The overall satisfaction showed a negative trend, both for sub-populations from the settlement of Larissa and the camp of Tyrnavos with no statistically significant difference in the satisfaction scale between the two settlements. This means that the negative trend observed in the scale of attitudes, emotions and satisfaction around health services does not depend on the place (or type of stay-urban settlement or camp).
In addition, the results of this survey can be compared with those of Kotrotsiou (2014), in which among the groups distinguished is the group referred to as 'alienated and unsatisfied', which indicates the non-satisfaction of a portion of Roma towards medical services. The findings of the present investigation are more consistent with another study by Kotrotsiou et al., (2019) carried out on a sample of Greek Roma, examining their satisfaction from the health services, at the General Hospital of Larissa, and in specifically on their level of satisfaction of nursing staff and doctors' input (5).
Another factor that may contribute to the low health satisfaction of Roma is the difficulties they may have in understanding and expressing the language. In the sample of the current job more than four out of ten Roma have been declared illiterate, and also four out of ten had only attended primary school. The high illiteracy rate is a possible reason for the low quality of Roma communication with health professionals.
Indeed, the statistical tests carried out in the framework of this survey have shown that people in the illiterate sub-group of the sample have a statistically significantly lower level of satisfaction than the Roma in the literate sub-group. Although this difference in level of satisfaction depending on literacy applies only to the sample from the Tyrnavos camp and not to the sample of Roma living in Larissa, it is nevertheless indicative of the difference that can exist between different levels of Roma populations. Correspondingly, similar was the correlation of satisfaction with writing ability. In the settlement of Larissa, there were no significant differences in satisfaction between the Roma with writing capacity and the Roma without writing ability. However, it was observed in the Tyrnavos camp that non-literate Roma had significantly lower satisfaction than the Roma with writing ability.
This finding is in consistence with other studies, i.e. a lower level of education of the Roma is one of the factors contributing to both the poor state of health and the limited knowledge and prevention actions, as for example they fail to understand the benefits of prevention (6-12).

CONCLUSION
The results of this study cannot be generalized to national level as Roma sub-populations differ across Greece. Yet, but most of the Roma surveyed expressed a negative attitude to healthcare service provision. In these lines we observed a notable differentiation in the health attitudes of this sample, as many commented that they had previously chosen to solve health issues based on what their local leader told them, while few chose modern healthcare services. This shows that the greater percentage of Roma displayed non-positive behavior, i.e. negative attitudes, emotions and dissatisfaction and even dis-trust to modern medical procedures and with public health structures and health care services overall.
In conclusion, it is important to stress how different approaches could develop Roma satisfaction from health services provided such as cultural awareness, respect and understanding of professionals for people with different cultural backgrounds. It is proposed to place greater emphasis on the ongoing education of health professionals in terms of cultural differences and similarities between cultures, in order to help them achieve and maintain meaningful and therapeutic health care and care practices for people of different cultures.
• Author's contribution: All authors were involved in all steps of preparation this article. Final proofreading was made by the first author.