In 2019, the World Health Organization confirmed the emergence of a new novel coronavirus. It was first identified in Wuhan, China. On February 11, 2020, the World Health Organization named the disease as coronavirus disease 2019, abbreviated as Covid-19 (CDC, 2020). Covid-19 has disproportionally impacted low-income and minority groups (Stokes et al., 2020), with minority and low-income Torontonians having higher positivity rates (Toronto Public Health, n.d.). Ontario Public Health (June 14, 2020) has been advocating for testing as many symptomatic people as possible and social distancing. The Toronto neighbourhood of Flemingdon Park has a high positivity rates, 7.4%, but a low testing rate of 12.6 per 1,000 (City of Toronto, 2020) (Jersak, S., personal communication, October 27, 2020).
A new refugee community within Flemingdon park is the Roma population, a historically marginalized group in Europe, formerly referred to as the pejorative of Gypsy. It is estimated that twenty percent (Hune-Brown, 2018) of Flemingdon Park population belongs to this ethnic group. They have notable co-morbidities and are highly distrustful of healthcare providers. Based on Ontario Public Health guidelines, testing is essential for this marginalized population within Flemingdon Park (June 14, 2020). What are the barriers for increasing testing in this group? Using the social ecological model of health, how can we understand the barriers for testing this Roma population for Covid-19, and what strategies can be employed to increase testing rates?
Using the Ecological Model for Health Promotion framework, the interactive characteristics of individuals and their environments can be explored to understand the complex health issues from different perspectives. Instead of focusing on a single factor, such as lifestyle, the multi-level framework helps bring the health issue into context (Golden, 2012). As per Stokols (1996), social, physical, and cultural aspects of an environment have a cumulative effect on health.
The benefit of a multi-level framework is the opportunity to ask questions beyond the analytical lens of an individual’s experience to recognize the different levels of influence that could theoretically shape the health of a particular population. When you understand the various multi-level elements or barriers, resources can go towards the correct level of influence, or correction of a barrier that would have the biggest impact on a particular group’s health (Galea, 2015).
The Ecological Model for Health Promotion framework (Figure 1) consists of five levels of analysis that include: intrapersonal factors, interpersonal processes and primary groups, institutional factors, community factors, and public policy (McLeroy et al., 1988). By gaining an understanding of the different factors at play and their impact from a multi-level approach, we can find a way to remove or change the right barriers to find success at increasing the testing levels of the Roma community within Flemingdon Park.
Figure 1
Ecological Model for Health Promotion
Intrapersonal Factors
As described by McLeroy (1988), these are the “self” factors, such as knowledge, attitude, behaviour, self-concept, skills, etc.
There is the strong individual and community belief that the rest of the world views the Romas as nothing more than fortune tellers, witches, and thieves (Csanyl-Robah, 2012). The community is so marginalized within their previous countries of origin that they were often unable to access health services. If they were able to access, it was often a racist experience (Csanyl-Robah, 2012). As a result, the Roma community has individuals with high and complex health needs with high rates of chronic illness, poor dental health, and often poor nutritional health as per Toronto Public Health (Canadian Public Health Association, n.d.). They also have higher rates of mental illness and auditory issues (Hune-Brown, 2018).
There is a lack of knowledge of English, which makes communication and employment difficult (Hune-Brown, 2018).
Interpersonal Processes and Primary Groups
These interpersonal processes and primary groups are the formal and informal social network and social support systems such as family, work group, and friendship networks (McLeroy, 1988).
The Roma community highly relies on each other and family for support given the discrimination that they faced in their country of origin and may experience now as refugees (Csanyl-Robah, 2012). The Roma community is relatively new to Flemingdon Park so they do not have a strong social network to support employment and accessing resources. When the most established Roma are still in poverty or do not have employment, they are unable to support newcomers with success (Hune-Brown, 2018).
The community is sometimes not trusting of authority figures, governmental services, even when the service is there to help people, there is a certain level of mistrust (Canadian Public Health Association, n.d.).
As a result of these factors, they require a leader to go first (Csanyl-Robah, 2012) and Roma families usually come to individual health appointments together and are reluctant to be separated (Canadian Public Health Association, n.d.). Health care providers find that their healthcare advice is ignored or appointments are missed because the Roma patients are dealing with other worries – such as refugee hearings or employment (Hune-Brown, 2018).
Institutional Factors
McLeroy (1988) refers to social institutions with organizational characteristics and formal (and informal) rules and regulations.
There are challenges with interpreter services for the Roma community. There is no formal way to certify the Roma language interpreters, since Romanes is not a written language and has multiple dialects. Often ethnic Hungarians are provided, who historically have discriminated against Roma, so they do not trust the interpretation services (Canadian Public Health Association, n.d.)(Hune-Brown, 2018).
Romas are not used to having social services from their home country (Hune-Brown, 2018), and have unusual patterns of accessing services such as attending one or two sessions on nutrition and then dropping off (Canadian Public Health Association, n.d.)
The Roma are wary with programs because they do not trust people who are not Roma (Hune-Brown, 2018). Successful service provision can only be achieved through respectful, equitable, long-term relationships between care providers and patients (Csanyl-Robah, 2012)(Canadian Public Health Association, n.d.)( Hune-Brown, 2018)
Community Factors
These are the relationships, as described by McLeroy (1988), among organizations, institutions, and informal networks within defined boundaries.
Flemingdon Park is a community of immigrants in Canada’s first completely planned “apartment city”, with low income, high social assistance, and low education rates (Statistics Canada, 2011). They have a 70% visible minority rate (Hune-Brown, 2018). Flemingdon Park is close to parks, health centres, transit, and has two community centres.
There are poor housing conditions (Leiberman, 2018) and multi-general apartments (Hune-Brown, 2018) that the Roma in Flemingdon Park primarily live in.
Public Policy
Public policies that make up the ecological model for health promotion are local, provincial, and national (McLeroy, 1988).
The Roma are able to access refugee assistance such as healthcare and schools. There was a notable change to refugee services a few years ago that altered transitional health services available, which lead to confusion (Canadian Public Health Association, n.d.). The Canadian Public Health Association recognizes that the knowledge of Romani culture and health needs are lacking and that targeted outreach efforts are required. Toronto Public Health has led a Roma Health Forum (Csanyl-Robah, 2012). (Canadian Public Health Association, n.d.)
Previously successful strategies to engage the Roma community is finding a community leader to advocate for health services. (Csanyl-Robah, 2012)(Hune-Brown, 2018) Modifications to existing health education services are provided in one session and are targeted to the Roma population (Canadian Public Health Association, n.d.)(Reliefweb, 2020). Suggestions by the United Nations Human Rights, Office of the High Commissioner (2020) to engage refugee and migrant workers with Covid-19 knowledge and best practice include:
- Disseminate this information through efficient channels including NGOs, refugee or migrant volunteers and respective communities
- Advocate for inclusion and non-discriminatory access of refugees and migrants to public health services
- Partner with refugee and migrant community network to monitor risks associated with human mobility in affected areas
- Tailor activities to the context, adjusting for community perceptions, beliefs and practices
- Diversify communication tools and format, and simplify messages; ensuring to test messages with target group
- Use continued feedback to adapt messages to the evolving situation
These recommendations are not specific to Romani, and based on the above framework analysis may not all be effective for the Roma community. A strategy that the Slovakians have used to promote Covid-19 testing is a Health Mediator that knows the population well and by name (United Nations Human Rights, 2020). Based on the framework analysis strategies that could be utilized in Flemingdon Park to increase testing rates in the Roma community are:
- Partner with existing Flemingdon health clinics who may have built up relationships in the community as locations for Covid-19 testing.
- Prepare to take families all at once to make it as efficient as possible since they are unlikely to come as individuals to be tested.
- Utilize leaders within the Roma community that do not have language barriers for support and promotion for symptomatic testing.
- User friendly ways for Roma to find out their results must be explored. Current practice is to direct patients to look up the result through an online portal. Given the poverty in the area, they are unlikely to have easy access to these results. A proposed alternative is to include the name of the family practice physician who can then access the results and follow up with the individual.
References
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