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Roma in the Healthcare System: Experiences of Healthcare Professionals

1 Debora Levstik Jašarevič

1 Andrej Kočevar

1 Daša Petrič

2 Mirko Prosen

2 Sabina Ličen

1 Izola General Hospital, Izola, Slovenia

2 University of Primorska, Faculty of Health Science, Izola, Slovenia

Article received: 24. 05. 2025.

Article accepted: 11. 11. 2025.

DOI: 10.24141/2/10/1/2

Author for correspondence:

Debora Levstik Jašarevič

Izola General Hospital, Izola, Slovenia E-mail: levstik.debora@gmail.com

Keywords: Roma community, cultural differences, langua- ge barriers, healthcare workers, health literacy

Abstract

Introduction. The Roma community faces numerous challenges in accessing health services, including language barriers, discrimination, low health literacy, and social exclusion.

Aim. The aim of the research was to examine the experiences of health professionals in treating Roma

patients, with a focus on communication, cultural dif- ferences, and access to health services. Special em- phasis was also placed on the presence of antigypsy- ism in the healthcare system.

Methods. The research was based on a qualitative- descriptive design. The sample included 15 health- care workers with experience in treating Roma pa- tients, primarily from the Dolenjska region. Data were collected through semi-structured individual inter- views conducted between November and December 2024. The results were analyzed using thematic analysis.

Results. Thematic analysis identified four themes:

1. Cultural characteristics of the Roma community,

   (2) Healthcare of Roma, (3) Interpersonal relation- ships between healthcare workers and Roma, (4) Communication with Roma. The results show that language barriers, low health literacy, and cultural differences are the main challenges in the treatment of Roma patients. Healthcare workers highlighted the use of “Roma helpers” – cultural mediators, com- munication adaptations, and educational workshops as successful strategies.

   Conclusion. The research highlights the importance of intercultural competences for improving health- care for the Roma community. Healthcare profes- sionals identified key strategies for addressing anti- gypsyism, such as patience, building trust, involving Roma cultural mediators, and organising targeted workshops. These strategies align with current guidelines, as they are based on respect, inclusion, and co-design of services with the Roma community. The findings can contribute to the development of tailored programmes that promote inclusion and re- duce health inequalities.

   
   

   
   

   

   Introduction

   
   

   

   
   

   The Roma are an indigenous people originating from the northwestern part of India. They began arriv- ing in Europe in the 13th century and are today the largest ethnic minority, with around six million living in EU Member States, most of whom are citizens of these countries (1). In Slovenia, the Roma have set- tled mainly in three regions: Dolenjska, Gorenjska, and Prekmurje (2). According to the census, 3,246 people identified themselves as Roma, and 3,834 as speaking Roma as their mother tongue, although the actual number is estimated at 8,000–10,000. They live both autochthonously and in larger cities such as Maribor, Velenje, and Ljubljana (2). Almost half of the Roma population is under 18 years old, while the proportion over 65 is low, indicating a shorter life ex- pectancy. This is linked to lifestyle, frequent illness, and inadequate healthcare (2).

   The Roma have historically faced discrimination, high poverty rates, and limited access to healthcare, edu- cation, and employment. Roma women experience additional gender-based discrimination and violence (3), leading to further social exclusion. Key issues in- clude poor housing and informal settlements without access to electricity or water, which directly impacts health (4). These conditions, combined with limited healthcare access, contribute to poorer health out- comes. Discrimination within the healthcare system further worsens the situation. Roma children often lack access to education and frequently do not com- plete primary school. In some schools, performance among Roma pupils is particularly low, reflecting a lack of support and adapted programs. The Roma community also faces systemic discrimination, re- ferred to as antigypsyism, which hinders access to legal protections and social support (5).

   Specific research on Roma health is limited, geograph- ically narrow, and often based on small samples (1). A significant issue is the exclusion from health insur- ance: 55% of Roma are not covered by the national system (1). Research on risk factors for non-communi- cable diseases has shown significantly worse health indicators among the Roma, including high unemploy- ment, low physical activity, high obesity rates, and the influence of strong cultural factors combined with negative attitudes from the majority population (2).

   As societies become more culturally diverse, health- care systems must adapt to maintain quality and safety for all. This requires the development of inter- cultural competencies that enable professionals to work effectively in diverse environments (6). These competencies include basic cultural knowledge, in- tegration into everyday practice, and critical self-re- flection. Healthcare professionals are frequently ex- posed to cultural differences, and without adequate knowledge, this can result in ineffective care (6, 7). Health inequality refers to measurable, value-neutral differences in health between individuals or groups

   (8). Zaletel-Kragelj (9) identifies three main causes: unequal socio-economic conditions, unequal access to healthcare, and differences in the quality of the living environment.

   Although legally protected, the Roma community still faces significant practical barriers to accessing healthcare. These include socio-economic disadvan- tages, cultural differences, and stigmatization. The Strategy for Pomurje MoST – Analysis of vulnerability and health inequalities in local communities study identifies the Roma as a vulnerable group affected by socio-economic determinants (10, 11).

   Language barriers, cultural diversity, and lack of trust are frequently cited by healthcare professionals as key challenges (12). They report frequent misunder- standings, reliance on family members for interpret- ing, and a lack of professional interpreters (13). Cul- tural beliefs influence treatment acceptance. Some patients, for instance, refuse procedures like caesar- ean sections for religious reasons (14). Low health literacy leads to delayed care-seeking and poorer health outcomes (15). Healthcare professionals of- ten struggle to motivate Roma patients to adhere to long-term therapies (15).

   Many Roma also lack basic resources such as medica- tions, transportation, or proper nutrition (13). NIJZ data indicate that many Roma are unaware of basic proce- dures (e.g., how to book an appointment), which 47% of healthcare professionals perceive as a major barrier

   (16). There are also reports of discrimination and dis- trust in the healthcare system, which reduce its effec- tiveness (17). Roma patients may expect preferential treatment (e.g., walk-in visits without appointments), which clashes with established procedures (18).

   Improving the situation requires cultural competence training for healthcare workers (19), and customized preventive health programs (10).

   
   

   One of the goals of the National Health Literacy Strategy 2025–2035 is to empower the population of Slovenia by ensuring access to clear, understand- able, reliable, and culturally appropriate health infor- mation. Investing in the strengthening of health lit- eracy among vulnerable individuals can significantly contribute to reducing health inequalities. It is there- fore the responsibility of healthcare professionals to provide clear and comprehensible information, tai- lored to target audiences, with particular emphasis on vulnerable groups (20). Healthcare professionals possess valuable insights into the challenges faced by Roma patients, and their experiences are crucial for enhancing care quality. Although some barriers are already documented, there is a lack of in-depth research into the real-world experiences of health- care providers. This study aims to partially address that gap (21).

   
   

   

   Aim

   
   

   

   
   

   A preliminary review of the domestic and interna- tional literature revealed a limited number of stud- ies focusing on the experiences of healthcare pro- fessionals in treating Roma patients. Therefore, the purpose of this study was to gain an in-depth under- standing of these experiences. We aimed to explore how healthcare workers perceive the challenges they face and the strategies they employ to improve care for the Roma community. We specifically fo- cused on communication, cultural differences, and access to healthcare services. Special attention was also given to antigypsyism in the healthcare system, as perceived by healthcare professionals, and its ef- fect on the quality and fairness of care.

   
   

   Research Objectives

   1. To identify the experiences of healthcare pro- fessionals in treating Roma patients, particu- larly in terms of communication, cultural differ- ences, and access to healthcare services.

   2. To explore the challenges faced by healthcare workers and how they perceive and experi- ence these challenges.

   3. To examine the strategies used by healthcare professionals to improve the quality of health- care for Roma patients.

Central Research Question

What are the experiences of healthcare professionals in dealing with Roma patients regarding communica- tion, cultural differences, and access to healthcare services?

Methods

The research used a qualitative descriptive methodology.

Instrument

Data were collected using semi-structured individual interviews. The key feature of this method is that the researcher prepares guiding questions in advance, which serve as orientation during the interview but remain flexible. This approach allows for the devel- opment of a dialogical relationship between the in- terviewer and the interviewee, enabling an in-depth understanding of the participant (22).

The interview guide was based on a review of the relevant literature (George et al., 2018) and aligned with the research objectives. It consisted of fifteen open-ended questions divided into four sections: (1) experiences, (2) cultural differences, (3) challenges and obstacles, and (4) strategies for addressing challenges.

Sample Description

The study employed a purposive sample of 15 health- care workers with experience in providing care to the Roma population. Inclusion criteria included age and direct professional contact with Roma individuals. The sample consisted of 14 women and 1 man, aged 23 and 45 years.

Efforts were made to include various healthcare professional profiles to obtain a comprehensive view of their experiences in working with the Roma community.

Most participants held nursing degrees, with one having additional specialized qualifications. Partici- pants were employed across different healthcare in- stitutions in the Dolenjska, Primorska, and Prekmurje regions, with the majority coming from Dolenjska.

No participants from the Roma community were in- cluded in the sample.

Research Process and Statistics

The research was conducted between October 2024 and January 2025. Interview sessions were held in November and December 2024, either in quiet physi- cal locations or via the Zoom application. Open-end- ed questions and sub-questions had been prepared in advance.

Healthcare workers were contacted through profes- sional networks, colleagues, and acquaintances. A total of seven healthcare institutions and organi- zations in eastern Slovenia were approached. Par- ticipants were invited via email, where they were also informed about the purpose, process, and goals of the study. All participants provided informed consent, and signed consent forms were collected. Confidentiality and anonymity were assured for all participants.

Interviews were audio-recorded using a mobile phone or Zoom, and the recordings were stored in a pass- word-protected file. The interviews lasted between 15 and 45 minutes. Ethical considerations were strict- ly observed throughout the research process.

Audio recordings were transcribed using an unfocused transcription method and analyzed using thematic analysis (24). First, the transcripts were thorough- ly reviewed, and open coding was conducted. The codes were then grouped into broader subthemes, which were further categorized into larger thematic groups that formed the final thematic structure. The analysis followed an inductive approach. The study adhered to the principles of the Helsinki-Tokyo Dec- laration (25) and the Code of Ethics in Health Care in Slovenia (26).

Results

Through thematic analysis, we identified four themes:

(1) Cultural characteristics of the Roma community, (2) Health care of Roma, (3) Interpersonal relationships between health professionals and Roma, and (4) Com- munication with Roma (Table 1).

Cultural Characteristics of the Roma Community

The interviewed healthcare workers often empha- sized that Roma culture is deeply intertwined with daily life, which directly influences their attitudes toward health and healthcare services. As one par- ticipant noted: “I think it has a very strong influence. They have some of their own principles and beliefs, and you can hardly move them.” (MS8). These prin- ciples are sometimes expressed as superstitions or symbolic actions that hold particular significance. For instance, some Roma patients would place a scarf under the head of a hospitalized relative, believing it brings good luck. When the scarf was removed for practical reasons, family members felt offended: “… saying that this brings bad luck.” (MS8).

Family roles in the Roma community are clearly de- fined and often patriarchal, which also shapes com- munication in healthcare settings. One interviewee described a situation where, despite questions being addressed to a woman or child, the husband always responded: “In any case, the husband answers the questions.” (MS3).

Respect for Roma culture was identified as crucial for effective collaboration. Healthcare professionals who make an effort to understand and engage with their world are often met with appreciation: “If I am invited to an event, of course I will come. I think it is respect- ful of us to make an effort.” (MS13). Such gestures build trust and help to dismantle prejudice.

The interviews also revealed significant disparities in living conditions within the Roma community. While some live in well-maintained homes, others reside in makeshift shelters without basic infrastructure: “Some don’t even have drinking water, their bath- rooms are not well-maintained… they wash them- selves with purchased water or outside in streams.” (MS12). These conditions affect both hygiene and ac- cess to healthcare.

Unhealthy lifestyles are also common, particularly among the youth. Smoking begins at an early age, and diets often include fast food and sugary drinks: “They spend a lot of money on fast food, hamburg- ers… they drink a lot of sugary drinks.” (MS12).

Another important cultural aspect is the fear of healthcare services, especially dentists, as well as illness and pain in general. This fear is rooted in cul- tural narratives and past negative experiences: “It

seems that there is a fear of illness, even when they are very sick, they trust us and do not object.” (MS8).

One particularly notable feature of Roma culture is the prominent role of grandparents, who often raise the children due to very early parenthood. Young par- ents, often teenagers, are still developing their iden- tities and are not yet ready for full responsibility: “So I think what grandmothers and grandfathers say is that it is like a law for them.” (MS12). This genera- tional caregiving affects how children view authority and institutions.

Medical Treatment of Roma

Healthcare professionals frequently observe that Ro- ma patients are very receptive to medication. Many perceive treatment primarily as the receipt of medi- cine, while other forms of care, such as counselling or lifestyle changes, are less prioritized: “If we tell them that this is a medicine, that it will cure them, that’s great for them. They are very enthusiastic about drug treatment. Everything helps them.” (MS11).

Sometimes, medication is shared more widely than intended: “If they get Ventolin, for example, the whole family uses it.” (MS11). While some profes- sionals mention the use of alternative treatments like ointments and herbal remedies, others say Roma patients generally trust conventional medicine more: “They are very fond of asking for sprays, tablets, painkillers…” (MS12). This coexistence of traditional and official medicine reflects a desire for quick and practical solutions.

A major barrier to effective treatment is limited un- derstanding of medical instructions. Patients often return with the same issues due to unclear commu- nication or poor comprehension: “They come back for treatment several times for the same things.” (MS5). These issues often stem from a lack of Slovenian lan- guage skills and low literacy levels: “If I write them instructions on how to brush their teeth, they tell me that they have no one at home who can read them.” (MS12).

There are differing opinions about access to health- care. Some professionals cite systemic barriers such as lack of insurance and avoidance of preventive care: “Mothers don’t take their children to various clinics… they only bring their children if they are sick.” (MS1). Others note that despite obstacles, Roma families often find resourceful ways to access care: “Even if

they don’t have the language, a telephone or trans- port. They will come without anything. Or they will arrange for several Roma families to come in one van.” (MS11).

Prevention is often neglected in favor of curative treatment: “They don’t come to the parent school or the referral clinic.” (MS12). They usually respond to preventive measures only when a problem has already developed. This is not due to ignorance but results from a combination of low health literacy, mistrust, and life circumstances shaped by poverty.

Interpersonal Relationships Between Healthcare Professionals and Roma

Healthcare workers described mixed experiences with Roma patients. Some reported positive coop- eration: “I haven’t had any bad experiences so far. I feel like they have integrated into our system.” (MS6). Others mentioned challenges, often attributed to fear, cultural misunderstandings, and differing ex- pectations: “The experiences are quite difficult … but they are quite considerate, except for the instruc- tions regarding treatment.” (MS8).

Roma attitudes toward healthcare staff are often shaped by the quality of the relationship: “If I am nice to them… they behave nicely in return.” (MS1). Patience and respect were emphasized as key to fostering collaboration: “Patience. I have developed that.” (MS10). Effective strategies include informal outreach and direct community engagement, which help build trust: “They respect that we don’t invite them through official channels… when they see that, everything is a little easier.” (MS11).

Employing Roma assistants or cultural mediators was also noted as extremely helpful: “Now they have started to employ Roma in the day centre… it makes our work easier.” (MS12).

Family plays a central role in Roma healthcare experi- ences: “If someone gets sick, the whole family comes with them.” (MS12). “We work with grandmothers and grandfathers every day… even more than with parents.” (MS11).

Many healthcare workers admitted a lack of training on Roma culture and communication: “We have too little education when it comes to Roma.” (MS12). Although some expressed motivation to improve, they also re- ported burnout due to slow progress: “I tried really hard last year… over time, it wears off a little.” (MS13).

Other challenges included inconsistent documenta- tion and spontaneous behavior: “When they want something, they want it as soon as possible.” (MS11), “30, 40 people come to visit at the same time.” (MS1).

Despite these challenges, the interviews highlighted that mutual respect and adaptability lead to positive outcomes.

Communication with Roma

All interviewees agreed that communication is cen- tral to effective collaboration with the Roma commu- nity. Healthcare workers observed that Roma often have their own style of expression, which differs from standard Slovenian: “They have their own way of communicating… if you adapt to them, you get closer to them.” (MS1).

While communication typically takes place in Slo- venian, it is often dialectal or includes slang, which can lead to misunderstandings: “We communicate in Slovenian, without any problems.” (MS6). “When they don’t have a day off, they will communicate in their own language and will only understand what they want to hear.” (MS11).

Children and mothers in particular often struggle with language comprehension: “They have their own slang … mom doesn’t understand either.” (MS15). Healthcare workers often adapt their approach in real-time: “You develop a strategy, you adapt, on the fly.” (MS3). Creating a sense of acceptance is also seen as crucial: “It is a way to make them feel ac- cepted.” (MS4). “Roma assistants” or cultural media- tors play a vital role in facilitating communication and resolving misunderstandings: “If there is a problem or disagreement, we have a Roma assistant.” (MS12). These mediators translate not only language but also cultural context, making them indispensable to successful communication. Ultimately, healthcare workers find that communication with Roma is possi- ble, but it demands patience, cultural sensitivity, and flexibility.

Discussion

The research provides an in-depth examination of the experiences of healthcare professionals in treating Roma patients, highlighting key challenges related to communication, access to healthcare ser- vices, and cultural differences. The findings align with existing research that identifies similar issues and suggests solutions for improving healthcare for this socially marginalized group. Other authors (19, 21) report comparable challenges in working with Roma communities, namely, difficult communication, mistrust, and a poor understanding of the unique cul- tural needs of Roma families. Roma individuals face healthcare barriers at the level of service users, ser- vice providers, and institutions. A lack of access to interpreters or cultural mediators is also frequently noted. Roma are identified as a vulnerable popula- tion, particularly Roma children (22).

This culturally diverse ethnic minority has specific needs related to healthcare and requires targeted, culturally sensitive care to reduce health inequalities

(21). When healthcare is not culturally appropriate, it can lead to cultural distress and marginalization (19).

One of the most frequently reported challenges is communication. Healthcare professionals often cite the need for language adaptation, as some Roma individuals do not speak Slovenian fluently or use distinct slang. Similar observations are found in the work of Mustajbašić (13) and Lipovec Čebron (16), who argue that language barriers reinforce social exclusion and contribute to indirect antigypsyism within institutions. Interviewees pointed to the use of Roma assistants, community involvement, and in- dividualized approaches as effective strategies for improving communication. These strategies are con- sistent with Ušaja et al. (18), who emphasize the im- portance of intercultural communication. Such prac- tices represent an important step toward overcoming antigypsyism by involving Roma as active partners rather than passive recipients of healthcare services.

The research also found that Roma often have limit- ed access to health services due to lack of insurance, insufficient information, and mistrust of the system. Similar barriers are identified by Žagar et al. (1) and George et al. (12), who stress the systemic nature of Roma exclusion. Mistrust toward institutions, rooted

in historical abuses and neglect of Roma realities is a clear manifestation of antigypsyism in healthcare. Despite these challenges, interviewees also high- lighted the agency and resilience of many Roma in- dividuals who actively seek to access services. This resourcefulness, also documented by Hrženjak et al. (17), illustrates the strength of community and counters passive stereotypes often associated with antigypsyism.

Cultural differences play a significant role in the qual- ity of care. Interviewees mentioned varying beliefs about treatment, which are frequently misinter- preted as non-compliance. Komidar (7) warns that a lack of intercultural competence is not neutral, it can reinforce discrimination and deepen the divide between institutions and users. Additionally, the re- search revealed low levels of health literacy among Roma, posing another barrier to equitable and effec- tive care. This is supported by findings from Belovič et al. (2) and Bajraktarević et al. (15), who emphasize the influence of educational and social deprivation on health outcomes.

Healthcare professionals cited patience, building trust, the use of Roma cultural mediators, and organ- izing workshops as key strategies. These practices align with recommendations for combating antigyp- syism, as they are grounded in respect, inclusion, and co-creation of services with the Roma community. A key contribution of this research is its insight into how everyday practices of healthcare professionals can either reinforce or challenge antigypsyism. In this way, the study reinforces the notion that combating antigypsyism is not solely a political or educational issue, but a responsibility shared by every institution and individual within the system.

Despite the significance of these findings, the re- search has limitations that affect the generalizability and transferability of its results. The first limitation is the sample size, the study is based on interviews with only 15 healthcare workers, which limits broader generalization. The sample in this study was gender- imbalanced, with a significant predominance of fe- male participants. This imbalance represents a limita- tion, as it may influence the perspectives expressed in the findings. Future research should aim for a more balanced gender representation to ensure that both male and female viewpoints are adequately reflected. Moreover, the sample was geographically confined to the Dolenjska region, where healthcare professionals may have specific experiences that differ from those

in other parts of Slovenia. Another key limitation is the exclusive focus on the perspective of healthcare professionals, without including the voices of Roma as direct users of healthcare services. As a result, the study primarily reflects an institutional view of the barriers, while the lived experiences of Roma remain underrepresented. The qualitative nature of the re- search, while valuable for gaining deeper insight into individual experiences, does not allow for quantita- tive comparisons across groups or regions. Lastly, po- tential response bias must be considered, as partici- pants may have presented themselves or their work environments in a more favorable light.

The study highlights the importance of improving communication, addressing systemic barriers, and enhancing health literacy to ensure better health- care for Roma communities. It recommends addition- al training for healthcare workers in cultural compe- tence, the inclusion of Roma assistants in healthcare institutions, and the development of tailored pro- grams to expand access to services and promote health within Roma populations.

Conclusion

Research on healthcare professionals’ experiences treating Roma revealed that communication barriers, systemic exclusion, and cultural differences are key challenges that can lead to poorer quality health- care. Language barriers and low health literacy often hinder collaboration, reinforcing “antigypsy” patterns of inequality. However, some interviewees reported successful strategies such as the use of cultural me- diators (“Roma helpers”), building mutual trust, and educational activities, which suggest potential for improvement. These approaches go beyond technical solutions, they represent concrete measures against antigypsyism by building trust, eliminating prejudice, and bridging the gap between the community and the healthcare system.

For practical application, we propose the systematic inclusion of Roma cultural mediators in health institu- tions, mandatory training on cultural competence and recognition of antigypsyism for healthcare workers, the development of accessible and culturally adapted

health prevention programs, and the strengthening of health literacy in cooperation with the Roma com- munity. Future research should include Roma voices, assess the long-term effects of anti-discrimination strategies, and more comprehensively address the systemic roots of antigypsyism in Slovenia.

Through awareness, inclusion, and shared decision- making, we can together create a more equitable healthcare system for all - free from prejudice and discrimination.

Information about the origin of the article

The article was written for the course Transcultural Nursing and Global Health at the Master’s Degree in Nursing at the Faculty of Health Sciences Izola.

Author contributions

Conceptualization: (MP, DL, AK, DP); Data Curation: (DL, AK, DP); Formal Analysis: (DL, AK, DP); Investi- gation: (DL, AK, DP); Methodology: (AK); Project Ad- ministration: (DL); Resources: (DP); Supervision: (DL, MP, SB); Writing – Original Draft: (DL, AK, DP, MP, SB); Writing – Review & Editing: (DL, AK, DP, MP, SB). All authors have approved the final manuscript.

Conflict of interest

The authors declare no conflicts of interest.

Acknowledgements

We would like to thank all the healthcare profession- als who were willing to take part in the survey. We would also like to thank our mentor Mirko Prosen and our co-mentor Sabina Ličen.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not- for-profit sectors.

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