Prejudices of Nurses Towards Roma as Patients in the Healthcare System of the Republic of Croatia

1,2Biserka Sedić 1,3Aleksandar Racz 1,3Jadranka Pavić

4 Ljerka Armano

5 Suzana Kunac

6 Filip Škiljan

7 Petra Rodik

1 Melita Rukavina

1 University of Applied Health Sciences, Zagreb, Croatia

2 University of Josip Juraj Strossmayer, Faculty of Dental Medicine and Health, Osijek, Croatia

3 Faculty of Health Studies, University of Rijeka, Rijeka, Croatia

4 Sestre milosrdnice University Hospital Center, Zagreb, Croatia

5 Roma Association in the Republic of Croatia “Kali Sara“, Zagreb, Croatia

6 Institute for Migration and Ethnic Studies, Zagreb, Croatia

7 Dotplot, a business for data processing and other services, Zagreb, Croatia

Article received: 20.09.2024.

Article accepted: 19.11.2024.

https://doi.org/10.24141/2/8/2/8

Author for correspondence:

Aleksandar Racz

University of Applied Health Sciences Mlinarska 38, Zagreb, Croatia

E-mail: aracz@zvu.hr

Keywords: Roma, prejudices, nurses, discrimination, he- althcare system

Abstract

Due to deeply rooted prejudices, the Roma are the most vulnerable and multiply discriminated ethnic group and national minority, facing discriminatory challenges in various spheres of society, including our healthcare system. These challenges limit the quality of healthcare, potentially increasing the risk of disease progression and premature death. The study aimed to analyze the prejudices of nurses and medical technicians towards members of the Roma national minority and to assess their correlation with certain socio-demographic characteristics and beliefs of the respondents.

The study included 536 nurses employed in the healthcare system across all three levels, working di- rectly with patients. Based on the opinions collected on 29 provided statements about the status and treatment of Roma as patients, 19 statements were isolated through exploratory factor analysis and clas- sified into four detected and interpretable reliable factors. These factors were named: “Roma within the healthcare system”, “Protecting Roma from the consequences of discrimination”, “General prejudices against Roma”, and “Attitudes of nurses and medical technicians towards Roma patients”, which together explain 60.7% of the total variance.

The analysis showed that some nurses share the same general prejudices towards Roma as the gener- al population. Respondents with a higher level of ed- ucation, older age, and those living in the Međimurje County and Northern Croatia expressed statistically significantly more negative attitudes toward Roma than younger, less educated individuals and those living in other parts of Croatia. Additionally, belong-

ing to the majority population resulted in more nega- tive attitudes towards Roma compared to respond- ents from national minorities.

Respondents who had personal and professional con- tact with Roma on some factors exhibited less nega- tive attitudes than those who had no such contact. Respondents from the right-wing political spectrum expressed more negative attitudes towards Roma, while religiosity did not show statistical significance.

Introduction

The Roma national minority (hereinafter: RNM) is a group characterized, as in most European countries and the Republic of Croatia, by deeply rooted nega- tive perceptions and discrimination that manifest across various societal domains, including healthcare

(1). This is substantiated by long-term reports from the public defender, which document attitudes, lev- els of awareness, and forms of discrimination, show- ing that the Roma are the group facing the most prej- udice in Croatia (2). Specifically, as a result of cultural, ethnic, and racial prejudices prevalent among the majority population, the RNM experiences significant limitations in daily life, including access to high-qual- ity medical care. This is particularly concerning given the RNM’s multiple vulnerabilities, high prevalence of chronic non-communicable diseases, injuries, preg- nancy and childbirth complications, and infant mor- tality rates exceeding the national average. Conse- quently, the RNM has a significantly shorter average life expectancy than the majority population – over 10 years shorter in Croatia compared to the general population, and even more significant discrepancies across most EU countries (3).

The relationship between healthcare workers and the RNM is further complicated by the specifics of Roma culture and their unique perspectives on health, ill- ness, and treatment. Roma are often perceived as a distinct group that resists collaboration during medi- cal care, with interactions frequently seen as prob- lematic, time-consuming, and resource-draining (4).

Although healthcare systems emphasize the need for an individualized approach to every patient, gen-

eralized attitudes towards the Roma fail to account for individual differences. Such attitudes often arise without objective data about the subject of the at- titude (5) or prior to or independently of personal experience (6).

Prejudice can be defined as a “logically unfounded, persistently held attitude toward various objects, accompanied by different emotions” (7). Ethnic prejudice, as part of the cognitive and emotional components of attitudes towards specific groups, is characterized by a relatively simplistic and rigid un- derstanding of the characteristics of the RNM. This oversimplification reflects an inherent human ten- dency to reduce complexity for easier comprehen- sion (7).

Prejudice is deeply ingrained in socialization process- es, from primary family influences to secondary ex- periences in school, during formal education, through media, or from other sources (8). Healthcare profes- sionals, including nurses, are not exempt from the influence prejudices and stereotypes have on their behavior towards patients in professional settings.

Studies on prejudice towards the RNM, particularly among nurses as the most prominent healthcare pro- fessionals within the healthcare system, are scarce globally and have yet to be conducted in Croatia. This research, therefore, represents a contribution to illu- minating this issue (9).

Aim

To analyze the prejudices of nurses and nursing tech- nicians toward members of the Roma National Minor- ity (RNM). The secondary objective was to examine the relationship between specific sociodemographic characteristics, personal religious and political be- liefs, and the presence of personal and profession- al contacts with members of the RNM and the ex- pressed prejudices towards this group.

Methods

Participants

The study included 536 nurses and nursing techni- cians employed within the Croatian healthcare sys- tem at all three levels of healthcare provision. Of the total number of participants, 83.2% were women, and 16.8% were men.

The average age of the participants was 30.9 years (SD=10.181), with the youngest being 20 and the oldest 64. The most significant representation was within the 23–27 age group (40.1%), while 36 par- ticipants (8.7%) were aged 52 years or older.

Regarding place of residence, 59.7% of participants reported living in urban areas, while 40.3% resided in rural areas.

The majority of participants, 56.5%, were from Za- greb and its surrounding area, followed by partici- pants from Slavonia (16.4%), Dalmatia (7.8%), North- ern Croatia (8.4%), and Međimurje (4.3%), with the latter two regions being home to significant RNM populations. Fewer participants were from Lika, Kor- dun, and Banija (4.9%), with the lowest representa- tion from Istria, Primorje, and Gorski Kotar (1.7%).

Most participants (95.3%) identified as members of the majority population, while 4.7% identified as belonging to other national minorities, though none identified as RNM.

In terms of work experience, the largest group had 2–5 years of service (35.3%), followed by 6–10 years (18.5%) and less than one year (14.6%). Participants with 11–15 years (6.9%), 16–20 years (6.3%), and 21–25 years of experience (6.7%) were similarly dis- tributed, with a slightly higher proportion reporting 26 or more years of service (11.7%).

Regarding educational background, 75.2% of par- ticipants held secondary-level nursing qualifications, 16.8% had higher vocational qualifications, and 6.9% had university degrees. A small proportion (1.1%) had additional non-nursing qualifications, though this group was excluded from further analysis due to its size.

Political and Religious Beliefs

In terms of political orientation, 5.6% identified as left-leaning, either “slightly left of center” (3.7%) or “strongly left of center” (1.9%). Conversely, 13.2% identified as right-leaning, including 8.2% who “clearly supported center-right parties” and 5.0% who were “slightly right of center”. The major- ity (52.4%) considered themselves “apolitical”, while 25.2% chose not to disclose their political beliefs.

Regarding religious beliefs, 65.1% identified as re- ligious, with 40.7% stating they were “religious but do not accept all teachings of their faith” and 24.4% fully adhering to their faith’s teachings. Additionally, 12.5% identified as “non-religious but not opposed to religion”, 5.2% were “indifferent to religion”, and 3.7% stated they were “unsure about their beliefs”. A mi- nority (0.6%) identified as “non-religious and opposed to religion”, while 12.9% did not answer this question. For clarity in analysis, religiosity was categorized into three groups: religious, non-religious, and other (those unsure, indifferent, or who did not respond).

Contact with the RNM

Personal and professional contact with the RNM was another critical area of inquiry. Among participants, 42.7% reported having acquaintances or friends who are members of the RNM, while 57.3% did not. Ad- ditionally, 75.6% had direct professional contact with the RNM, whereas 24.4% did not.

Instruments

The survey was conducted using questionnaires pre- viously employed in published studies, with minimal modifications to address the specific characteristics of participants working in biomedicine and health- care (10–14).

The first section of the questionnaire collected data on participants’ sociodemographic characteristics, including gender, age, healthcare profession, length of professional experience, type of residence (urban/ rural), and county of residence.

The second section asked participants to indicate whether they identified as members of a national minority. It also explored self-assessed political ori- entation and personal religiosity.

The third section focused on prejudices towards the RNM. Based on a literature review and findings on

typical prejudices against the Roma, 29 statements were developed, tailored to the specific context of participants employed in biomedicine and health- care (10–14). Participants rated their agreement with each statement using a five-point Likert scale, ranging from 1 (“strongly disagree”) to 5 (“strongly agree”).

Procedure

The study was conducted online using Google Forms between April 1 and May 1, 2023, as a cross-section- al study conducted simultaneously. The sample was non-probabilistic, representing a limitation due to the inability to generalize findings to the entire popula- tion of nurses in Croatia. Data collection employed the snowball sampling method, initiated by public invitations to participate via Alumni clubs, the offi- cial websites of higher education institutions train- ing nurses, and the official websites of professional chambers.

Statistics

Descriptive and inferential statistical methods were used to process the data. Given statistically signifi- cant deviations from normal distribution (as verified by the Kolmogorov-Smirnov test), non-parametric methods were applied to analyze differences and as- sess associations. These included the Kruskal-Wallis H test for differences across two or more groups (15), post hoc Dunn’s test, and Spearman’s rho correlation coefficient.

Results

The core theme of this study centers on prejudices regarding the Roma National Minority (RNM) ‘s posi- tion and relationship with the society they live in and their role as users of the Croatian healthcare system. Before analyzing the collected attitudes and examin- ing the relationship between sociodemographic char- acteristics and prejudices, the factorial structure of the questionnaire was assessed.

An exploratory factor analysis (EFA) was conducted to reduce the initial set of 29 items to a smaller num- ber of latent dimensions. This analysis aimed to iden- tify the underlying structure of the relatively large number of variables (16). The analysis yielded a fac- tor solution with Promax rotation, explaining 60.7% of the total variance. Four interpretable and reliable factors were identified, with Cronbach’s alpha coeffi- cients ranging from 0.77 to 0.92. A total of 19 items were retained from the original 29 statements.

Specifically:

• The first factor accounted for 38.7% of the explained variance and included items related to attitudes about how the healthcare sys- tem should interact with the RNM (see Table 1). This factor was labeled “Roma within the Healthcare System” (Extracted Factor 1).

• Items with the highest correlations with this latent dimension pertained to the treat- ment of RNM in hospitals or clinics within the healthcare system.

The table below presents the arithmetic means for the statements grouped under Factor 1, which re- flects attitudes towards the treatment and integra- tion of the Roma National Minority within the health- care system.

The analysis of results from Table 2 shows that nurs- es/technicians generally disagree with the given statements. The least accepted statement among all those provided was “During abortion procedures or gynecological surgeries, it is reasonable to discreetly perform sterilization to reduce the number of chil- dren born to Romani women” (M=1.94) and “Special clinics or restricted visiting hours for Roma should be established to avoid their mixing with other pa- tients” (M=2.10).

On the other hand, a moderate agreement was reached for the statement, “Roma individuals do not earn income or pay taxes and contributions, so it is unfair for them to have access to the same level of healthcare as those who contribute to the health- care system through their earnings.” (M=2.73), which may indicate that some believe RNM members should have a different approach in the healthcare system.

The next five items shown in Table 3 share a com- mon theme: statements related to attitudes toward “Protecting Roma from the Consequences of Discrim- ination” (Extracted Factor 2).

This component accounts for 11.5% of the variance (Table 3). On the one hand, the factor is homogene- ous as it gathers all statements formulated affirma- tively and is also entirely consistent in content.

The table below presents the average values for the statements categorized under Factor 2, which reflects attitudes towards protecting the Roma Na- tional Minority from the effects of discrimination.

The highest average value, indicating moderate agreement among nurses/technicians, is expressed for the statement “It is shameful that Roma in our country live up to 10 years less than the majority population” (M=3.16), followed by “ Roma individu- als are more exposed to discrimination by healthcare professionals than any other national minority group “ (M=2.93).

The third extracted component accounts for 8.0% of the variance, and the statements comprising it can best be characterized as general prejudices against the Roma National Minority. Therefore, this factor is called “General Prejudices Against Roma” (Extracted Factor 3) (Table 5).

These are four items related to negative character- istics that are often attributed to all members of the Roma National Minority, namely that they do not have a positive attitude towards work and that they have many children whom they do not take proper care of.

The highest level of agreement was obtained for the statement “Roma individuals usually have many chil- dren, for whom they do not provide adequate care “ (M=3.55), where it is evident that, on average, nurses generally agree with this statement (Table 6). Addition- ally, moderate agreement was found with the statement that “Roma individuals do not have a positive attitude towards work” (M=3.1) and that “There are very few re- sponsible and reasonable Roma individuals “ (M=3.08).

The next three statements, which represent three items of factor component 4, all concern prejudices about Roma’s behavior in direct communication with the healthcare team and as patients. This component explains only 2.8% of the variance (Table 7). Given the common theme of these three statements, this factor was named “Healthcare Workers’ Attitude To- wards RNM Members as Patients.”

Like the first component, this one also relates ex- plicitly to Roma in the context of healthcare. Unlike the first component, which relates to the healthcare system, the fourth component pertains to the inter- personal level of the relationship between Roma and healthcare workers, including issues related to exam- inations and therapy, as well as difficulties that may arise in communication with them and some specific behaviors within healthcare interventions.

As shown in Table 8, the highest average agreement for this factor is with the statement, “Roma individu- als do not listen to what healthcare professionals tell them, either because they do not understand or do not wish to understand the advice given, and instead act according to their own preferences” (M=3.17). However, the other two statements also indicate moderate agreement from healthcare workers re- garding potential communication difficulties with RNM members (M=2.96) and questionable adher- ence to the instructions they receive from healthcare professionals (M=2.96).

Additional analyses were conducted to examine the relationship between the factors obtained and spe- cific sociodemographic variables, and the results are presented in Table 9.

The analyses showed no statistically significant dif- ferences based on gender and the size of the settle- ment (city/village) where nurses/technicians live for all four extracted factors (Table 9). Furthermore, it was shown that respondents with an undergraduate professional or university nursing degree have more negative attitudes (except for Factor 2) than those with a high school or higher education.

For Factor 2, “General Prejudices towards Roma” the analysis of differences showed no statistically significant differences regarding religiosity or per- sonal and professional contact with Roma (Table 9). However, it was found that those who are not mem- bers of a national minority and those positioned on the right side of the political spectrum (compared to those who positioned themselves on the left, as well as those who are apolitical or did not answer this question) have more negative attitudes, while the difference compared to those in the center was not statistically significant. Similar results regarding political orientation were obtained for the remaining factors. Respondents on the right side of the political spectrum have more negative attitudes.

Regarding other sociodemographic characteristics, it was found that for Factor 1, respondents from Međimurje and Northern Croatia had statistically sig- nificantly more negative attitudes (higher score on this factor) than all others. In contrast, respondents from Zagreb and its surroundings had more negative attitudes than respondents from all other regions (except for Međimurje and Northern Croatia, with re- spondents from Međimurje having the most negative attitudes). Factors 3 and 4 also found that respond-

Education

K-W=15.371

df=2

Settlement

K-W=0.0466

df=1

p=0.829

K-W=0.0195

df=1

p=0.8889

K-W=0.737

df=1

p=0.3906

K-W=1.554

df=1

p=0.2125

p=0.0004

K-W=4.9887

df=2

p=0.08255

K-W=15.536

df=2

p=0.0004

K-W=29.721

df=2

p=0.000

Region - aggregated

K-W=23.434

df=2

Ethnic Minority Affiliation

K-W=12.135

df=1

p=0.0005

K-W=5.2598

df=1

p=0.0218

K-W=8.695

df=1

p=0.0032

K-W=1.501

df=1

p=0.2205

p=0.0000

K-W=2.529

df=2

p=0.2824

K-W=24.962

df=2

p=0.0000

K-W=18.548

df=2

p=0.0000

Religiosity - aggregated

K-W=13.319

df=2

Political Engagement

K-W=64.611

df=6

p=0.0000

K-W=30.645

df=6

p=0.0000

K-W=69.07

df=6

p=0.0000

K-W=58.142

df=6

p=0.0000

p=0.0013

K-W=0.31211

df=2

p=0.8555

K-W=0.57406

df=2

p=0.7505

K-W=4.7408

df=2

p=0.0934

Friendship with Ethnic Minority Members

K-W=30.46

df=1

K-W – Kruskal-Wallis H test

K-W=5.361

df=1

p=0.02059

K-W=1.305

df=1

p=0.2533

K-W=3.2247

df=1

p=0.07254

K-W=16.401

df=1

p=0.000

Personal Contact with Ethnic Minority Members

p=0.000

K-W=0.687

df=1

p=0.4073

K-W=18.472

df=1

p=0.000

K-W=28.349

df=1

p=0.000

ents from Međimurje or the northern part of Croatia have more negative attitudes (compared to all other regions). In contrast, the differences among other re- gions were not statistically significant.

Looking at the religiosity of the respondents, statisti- cally significant differences were found only for Factor 1, “Roma within the healthcare system”, in the direc- tion that those who are religious or non-religious have more positive attitudes (lower average factor score) on this factor compared to those who defined their relationship to religion in other ways (“I am indiffer- ent to religion”, “I think about it a lot, but I am not sure whether I believe or not”, and “I do not wish to answer this question”). No statistically significant differences were found for the remaining three extracted factors.

Considering personal and professional contacts with Roma and belonging to a national minority, for Fac-

tors 1, 3, and 4, respondents who have no personal contact with Roma have more negative attitudes. In contrast, professional contact showed statistically significant results only for Factors 1 and 4. Negative attitudes were expressed by respondents who do not belong to a national minority (except for Factor 4).

Table 10 presents the results of additional analyses that examined the correlation between age and work experience with the four extracted factors. These analyses reveal how demographic factors such as age and years of work experience influence attitudes toward the different factors related to prejudices and perceptions of Roma within the healthcare system.

Regarding the relationship between age and work experience, statistically significant correlations were not found only for the 2nd factor (Table 10). Older respondents and those with more work experience

p= 0.000

Work experience ρ=0.2005

ρ=0.03477

p= 0.4218

ρ=0.1647

p= 0.0001

ρ=0.2115

p= 0.000

show a more negative attitude towards the Roma National Minority (RNM) in terms of the remaining three factors. It is important to note that this correla- tion is very weak in both cases.

Discussion

This study aimed to explore the prejudices nurses have towards members of the Roma National Minor- ity (RNM). To investigate these prejudices, a newly constructed questionnaire for assessing nurses’ at- titudes towards the Roma minority was used. After conducting exploratory factor analysis, four inter- pretable and reliable factors were identified, named “Roma within the healthcare system”, “Protecting Ro- ma from the consequences of discrimination”, “Gen- eral prejudices towards Roma”, and “Nurses’ attitudes towards members of the RNM as patients”.

Roma are an ethnically, linguistically, and culturally diverse group with a long history of severe discrimi- nation and marginalization (17, 18), which may pre- sent a challenge for healthcare professionals. The results indicate that nurses also exhibit prejudices in some aspects of their thinking about members of the RNM in the healthcare system. Although some statements point to slightly negative attitudes (e.g., “It is justified to place RNM in separate ‘Roma rooms’ in hospitals”, M=2.03, or “ During abortion proce- dures or gynecological surgeries, it is reasonable to discreetly perform sterilization to reduce the num- ber of children born to Romani women”, M=1.94), it is concerning that some respondents gave higher ratings. Separation of Roma during hospitalization was a practice in many European countries until re- cently (19). The statement regarding the sterilization

of Romani women describes a criminal, eugenics- inspired shameful practice that was systematically carried out in some countries, such as Slovakia and the Czech Republic, against the RNM in the 20th cen- tury (20), and such treatment of Romani women was also conducted in concentration camps (21). This is also the statement with the least agreement in our sample. The highest degree of agreement was found for the statement that Roma, on average, have more children than members of the majority population and that they do not take adequate care of them (M=3.55). Although a large number of children is a fact for most Romani families, especially those living in segregated Romani settlements, it does not nec- essarily mean that the parents do not care for their children. However, those Romani families assimilated into larger urban areas tend to have fewer children than “traditional” Romani families (22). Moderate agreement with certain statements likely reflects the general societal attitude towards the RNM, such as “Roma do not have a positive attitude towards work” (M=3.1) and “There are very few responsible and reasonable Roma” (M=3.08).

Regarding Roma as a patient in the healthcare sys- tem, nurses recognize the difficulties that may arise in communication due to the language barrier. They also moderately agree that Roma do not listen to healthcare workers’ advice, either because they do not understand the instructions or because they pre- fer to act according to their own will. What is posi- tive is that they find it shameful that Roma have a shorter life expectancy than the majority population. However, due to the formulation of the statement, it remains to be explored whether they consider this a shame for society or the Roma themselves.

Research on beliefs and prejudices in this population is rare, so the results of this study can only be tenta- tively viewed in light of the findings on the percep- tion of Roma published in just a few studies. Heaslip et al. conducted a qualitative study involving nursing

students from four European countries (UK, Spain, Belgium, and Turkey), who articulated a broader soci- etal stigma associated with the RNM in all four coun- tries. Negative attributes were expressed through prejudices about the RNM as a group focused on crime, aggressive, violent behavior, or the choices these communities made regarding how they chose to live their lives. The study showed that the atti- tudes expressed were influenced by broader societal perceptions and personal and professional lived ex- periences (23).

Additionally, a study conducted in the Greek public health sector indicated that a significant portion of employees tended to exhibit prejudices towards Roma, which negatively affected their treatment of Roma when they tried to access necessary health- care services (24). In our study, however, only 8.8% of respondents believe that “spending public money on treating Roma is an unnecessary expense and a waste of money”. In comparison, more than half of the respondents (56.9%) disagree or largely disagree with this statement.

Previous research has shown that both adults and chil- dren and adolescents in our society express high lev- els of prejudice towards the Roma National Minority (RNM) (25,26). In many European countries, prejudices against Roma are widespread and severe on personal, institutional, and national levels, especially in Eastern Europe, where Roma represents a significant ethnic minority. This is confirmed by studies showing that unfavorable views of the Roma population are wide- spread in Central and Eastern Europe (worst rated in Italy, best in Sweden, with Poland in the middle) (27). Reports from Italy (28), Spain (29), Hungary, Slovakia (11), and the UK (30) also support this.

Research from Hungary and Slovakia reveals a gener- ally high level of prejudice towards the RNM among the general population (31,32), specific ideological groups (33) such as the extreme right (34), and even professional groups like the police (35) and health- care workers (36).

A particular goal of this study was to analyze the re- lationship between prejudice towards the RNM and some socio-demographic characteristics of the re- spondents, as well as the existence of personal and professional contacts with members of the RNM, af- filiation with the majority nation or national minority, and self-assessment of the respondent’s position on the political spectrum and religiosity.

Gender and place of residence (city/village) were not statistically significant, but a significant, though very weak, correlation was found with age (older re- spondents had more negative attitudes). Likewise, for most factors, no differences were found based on religiosity, except for the factor where there was no difference between religious and non-religious re- spondents. However, both groups had more positive attitudes compared to those who defined their rela- tionship with religion in other ways (“I am indifferent to religion”, “I think about it a lot, but I am unsure whether I believe or not”, and “I do not want to an- swer this question”). Regarding political orientation, all factors showed that respondents who positioned themselves on the right side of the political spec- trum had more negative attitudes.

The results can be partially compared with results from similar studies conducted among nurses, such as the one in Poland, which showed that the level of distance towards the RNM did not significantly correlate with age, work experience, life in another country, nursing specialization, working in another country, participation in cultural events, gender, or religion (37).

Research has shown that positive contact between members of different groups is one of the most ef- fective ways to reduce prejudice (38). According to Allport’s contact hypothesis, contact with an out- group should lead to better intergroup relations and reduced social distance (39). This was only partially confirmed in our study. On the “General prejudices to- wards Roma” factor (F2), there were no differences in assessments based on prior personal or professional experience with the RNM. On the other hand, on fac- tors 1, 3, and 4, respondents with no personal/friend- ship contact with members of the RNM had more negative attitudes. In contrast, professional contact was statistically significant only for factors 1 and 4. More hostile attitudes were expressed by respond- ents who were not members of national minorities (except on factor 3, where no statistically significant differences were found).

Positive intergroup contact generally leads to posi- tive experiences with the out-group, exposing group members to information that challenges their exist- ing stereotypes, which further leads to changes in beliefs, attitudes, and behavior towards the out- group (40). However, we found more negative atti- tudes in regions of Croatia where more members of the RNM live. Consequently, there is a higher likeli-

hood that healthcare workers will have more person- al and professional contact with Roma. Statistically, significantly more negative attitudes were found in respondents from Međimurje and Northern Croatia compared to all other regions. It also appeared that belonging to the majority nation was associated with more negative attitudes on most factors (except for factor 4, “Nurses’ attitudes towards members of the RNM as patients”), which we can, among other things, link to fewer contacts with members of na- tional minorities. The issue of attitudes and preju- dices towards Roma is complex and requires further research.

Some studies have indicated a connection between religiosity and ethnic distance and intolerance, with prejudices expressed stronger towards national and ethnic groups arising from higher religiosity (41), which was not confirmed in this study.

Additionally, the results of this study do not fully align with the findings of studies that have estab- lished that as the level of education rises, the level of intergroup anxiety decreases (24). Nurses with bachelor’s degrees showed more negative attitudes towards the RNM than those with a secondary edu- cation. This may suggest that under the influence of dominant societal attitudes, educated healthcare workers risk becoming carriers of the same anti-Ro- ma prejudices and negative attitudes as the general population. However, it is positive that nurses with higher levels of education showed more positive at- titudes. Since nurses with higher education also tend to have more extended work experience, be older, and show more negative attitudes towards the RNM than those with lower education and younger age, future analyses should investigate the interconnec- tion between these three characteristics.

It was also confirmed that there is a significant rela- tionship between political orientation (42) and preju- dice towards certain marginalized groups in society. The results of this study showed that respondents who positioned themselves on the right side of the political spectrum expressed more negative attitudes toward the RNM across all four extracted factors.

The unacceptability or unwillingness of society to address the growing prejudices towards the Roma National Minority (RNM) in order to ensure equal op- portunities for them, especially in the healthcare sys- tem (43), is unacceptable. Given the developments in Europe, including Croatia, where more members of

other national minorities are entering the workforce and long-term becoming users of the healthcare sys- tem, the more negative attitudes we found on some statements should be viewed in a broader social con- text and the current climate toward people who are not members of the majority nation.

Roma, who have been subjected to multiple forms of discrimination for centuries due to prejudice, still of- ten cannot enjoy the same rights and opportunities or the same level of protection that EU legal achieve- ments provide to other EU citizens. To achieve this, intercultural awareness and dialogue need to be en- couraged through training healthcare workers about the specific health needs of Roma.

Furthermore, it is necessary to confront negative ste- reotypes about the RNM, including those in the me- dia and online platforms such as social media, where scientific research and publications can significantly contribute (44,45).

Only through targeted work can intercultural differ- ences be overcome. This can be achieved by provid- ing continuous training to healthcare workers on the health needs of the RNM while not forgetting past tragedies and immoral practices. This can be achieved by supporting scholarships and other incen- tives to attract more Roma into the healthcare sector while being mindful of the sensitivities of Roma men and women (22,46,47).

The limitations of this research include the conveni- ence sample, which is reflected in the younger age structure of the sample, and the relatively small num- ber of nurses from different regions of Croatia, which led to a small number of respondents in some cat- egories. One reason might be the online data collec- tion, which likely attracted those with higher digital literacy. Additionally, better operationalizing certain variables such as religiosity and political orientation should be considered.

Conclusion

Considering that nurses are often the first point of contact with patients and the largest subgroup within the healthcare worker population, it is crucial

nate prejudice among healthcare workers at all levels toward the RNM. This is essential to correct these prejudices and ensure full equality for all RNMs who have access to the same healthcare rights available to the majority population.

to identify their prejudices towards members of the           RNM in the healthcare system.

A questionnaire on nurses’ prejudices towards the Roma National Minority was applied, and through exploratory factor analysis, four interpretable and reliable factors were identified, named “Roma within the healthcare system”, “Protecting Roma from the consequences of discrimination”, “General prejudices towards Roma”, and “Nurses’ attitudes towards RNM members as patients”. The results show that some nurses share the same general prejudices towards the RNM as the general population. Given that they are healthcare workers who encounter Roma both as patients and in the healthcare system, the existence of prejudices could result in inadequate care for RNM patients and lead to worse health outcomes.

The analysis of the relationship between specific so- cio-demographic indicators and beliefs and prejudices towards the RNM revealed that gender and the size of the settlement where respondents live were in- significant. Statistically significant differences were found based on the level of education and the region of residence, with respondents with higher educa- tion levels and those living in Međimurje County and Northern Croatia exhibiting more negative attitudes towards the RNM than those with lower education or living in other parts of Croatia. Additionally, belong- ing to the majority population was associated with more negative attitudes than those expressed by members of national minorities included in this study. Statistically significant differences in attitudes were also found between respondents who had personal and professional contacts with members of the RNM compared to those who did not, with such contacts contributing to less negative attitudes. Respondents from the right-wing political spectrum and those from the majority population expressed statistically significantly more negative attitudes, while religios- ity did not show statistical significance.

To improve Roma’s position in realizing their funda- mental right to universal and free healthcare guaran- teed by the Constitution, it is necessary to first elimi-

Reference

1. Bagić D, Burić I, Potočnik D, Dobrotić I. Romska svakod- nevnica u Hrvatskoj: prepreke i mogućnosti za promje- nu = Everyday life of Roma in Croatia: challenges and potentials for transformation. Zagreb: UNDP; UNHCR; UNICEF, 2014. Croatian.

2. Rašić N, Lucić D, Galić B, Karajić N. Roma inclusion in Croatian society: Identity, social distance and the expe- rience of discrimination. Zagreb: Office for Human Rights and the Rights of National Minorities of the Government of the Republic of Croatia 2020. Croatian.

3. Gruskin S, Daniels N. Process is the point: justice and human rights: priority setting and fair deliberative process. Am J Public Health. 2008;98(9):1573-7. doi: 10.2105/AJPH.2007.

4. European Public Health Alliance (EPHA). Closing the life expectancy gap of Roma in Europe [Internet]. Eu- ropean Public Health Alliance (EPHA) AISBL; 2021. Available from: https://www.reyn.eu/wp-content/ uploads/2019/03/closing-the-life-expectancy-gap- of-roma-in-europe-study.pdf

5. Petz B. Predrasude. In: Petz B, editor. Psihologijski rječnik Zagreb: Prosvjeta; 1992. Croatian.

6. Atkinson RL, Hilgard E. Uvod u psihologiju. Jastrebar- sko: Naklada Slap; 2007. Croatian.

7. Rot N. Osnove socijalne psihologije [Foundations of social psychology]. Beograd: Zavod za udžbenike i nastavna sredstva SR Srbije; 1975. Serbian.

8. Škiljan F, Babić D. Romi u Podravini i Međimurju i uključenost u hrvatsko društvo: od predrasuda i stig- matizacije do socijalne distance i diskriminacije. Po- dravina. 2014;13(25):141-59. Croatian.

9. Kunac S, Racz A. Health status and access to the healthcare system of members of the Roma national minority in the Republic of Croatia. In: Equal Access to Healthcare in Socially Diverse Societies. Verlag Karl Al- ber; 2023. p. 193–212. Available from: https://www.no- mos-elibrary.de/10.5771/9783495997895-193.pdf

10. Kende A, Krekó P. Xenophobia, prejudice, and right-wing populism in East-Central Europe. Curr Opin Behav Sci. 2020;34:29–33. doi.10.1016/j.cobeha.2019.11.011.

11. Kende A, Hadarics M, Lášticová B. Anti-Roma attitudes as expressions of dominant social norms in Eastern

    
    

    Europe. Int J Intercult Relat. 2017;60:12–27. doi. org/10.1016/j.ijintrel.2017.06.002.

12. Kende A, Hadarics M, Bigazzi S, Boza M, Kunst JR, Lan- tos NA, et al. The last acceptable prejudice in Europe? Anti-gypsyism as the obstacle to Roma inclusion. Group Process Intergroup Relat. 2020;24(3):388–410. doi.org/10.1177/1368430220907701.

13. Bilać M. Stereotipi i socijalna distanca studenata Sveučilišta u Zadru prema Romima [Graduate thesis]. Zadar: University of Zadar, Department of Sociology; 2017. Croatian.

14. Grgić D. Multikulturalni stavovi i socijalna distanca studenata Sveučilišta u Zadru prema manjinama [Graduate thesis]. Zadar: University of Zadar, Depart- ment of Sociology; 2017. Croatian.

15. Tabachnick BG, Fidell LS, Ullman JB. Using multivariate statistics. 6th ed. Pearson; 2013.

16. Duthie BA. Fundamental statistical concepts and techniques in the biological and environmental sci- ences: With jamovi. CRC Press; 2024. Available from: https://bradduthie.github.io/stats/

17. Feischmidt M, Szombati K, Szuhay P. Collective crimi- nalization of the Roma in Central and Eastern Europe. In: Routledge Handbook of European Criminology. Routledge; 2013. p. 168–87. Available from: https:// www.researchgate.net/publication/335716144_Col- lective_criminalization_of_the_Roma_in_Central_ and_Eastern_Europe_Social_causes_circumstances_ consequences

18. Pogány I. Pariah peoples: Roma and the mul- tiple failures of law in Central and Eastern Eu- rope. Soc Leg Stud. 2012;21(3):375–93. doi. org/10.1177/0964663911429152.

19. Ciaian P, Kancs DA. Causes of the social and eco- nomic marginalisation: The role of social mobil- ity barriers for Roma. EERI Res Pap Ser [Internet]. 2016. Available from: https://www.econstor.eu/han- dle/10419/179382

20. Albert G, Szilvasi M. Intersectional Discrimination of Romani Women Forcibly Sterilized in the Former Czechoslovakia and Czech Republic. Health Hum Rights. 2017;19(2):23-34.

21. Wisely A. War against “Internal Enemies”: Dr. Franz Lu- cas’s SterilizationofSinti and Roma in Ravensbrück Men’s Camp in January 1945. Cent Eur Hist. 2019;52(4):650–

    71. doi:10.1017/S0008938919000852.

22. Klasnić K, Kunac S, Rodik P. Uključivanje Roma u hrvats- ko društvo: žene, mladi i djeca. Zagreb: Office for Hu- man Rights and the Rights of National Minorities of the Government of the Republic of Croatia 2020. Croatian.

23. Heaslip V, Vanceulebroeck V, Kalkan I, Kömürcü N, Sola- nas IA. Student nurse perceptions of Gypsy Roma Trav- ellers; A European qualitative study. Nurse Educ Today. 2019;82:1-7. doi: 10.1016/j.nedt.2019.07.011.

24. Asimopoulos C, Martinaki S, Kompoti D, Kontogianni E, Gouga G. Anti-Roma prejudice in Greece: A challenge for social work. Comunitania. 2019;(18):85–100.

25. Hrvatić N. Romi u Hrvatskoj: Od migracija do in- terkulturalnih odnosa. Migracijske i etničke teme. 2004;20(4):367–85. Croatian.

26. Maričić J, Kamenov Ž, Horvat K. Predrasude u dječjoj dobi: Provjera dviju skala socijalne distance. Društve- na istraživanja. 2012;1(115):137–58. Croatian.

27. Pew Research Center. Unfavorable views of Roma are widespread in Central, Eastern Europe [Internet]. 2019. Available from: https://www.pewresearch. org/global/2019/10/14/minority-groups/pg_10- 15-19-europe-values-06-04

28. Fontanella L, Villano P, Di Donato M. Attitudes towar- ds Roma people and migrants: A comparison through a Bayesian multidimensional IRT model. Qual Quant. 2016;50(2):471–90. doi.org/10.1007/s11135-014-

    0158-9.

29. Villano P, Fontanella L, Fontanella S, Di Donato M. Stereotyping Roma people in Italy: IRT models for ambivalent prejudice measurement. Int J Intercult Relat. 2017;57:30–41. https://doi.org/10.1016/j.ijin- trel.2017.01.003

30. Hutchison P, Chihade R, Puiu AA. Predictors of “the last acceptable racism”: Group threats and public attitudes toward Gypsies and Travellers. J Appl Soc Psychol. 2018;48(5):237–47. https://doi.org/10.1111/ jasp.12508

31. Csepeli G. Gypsies and gadje: The perception of Ro- ma in Hungarian society. Cent Eur Polit Sci Rev. 2010;11(40):62–78.

32. Enyedi Z, Fábián Z, Sik E. Is prejudice growing in Hun- gary? Changes in anti-Semitism, anti-Roma feeling and xenophobia over the last decade. In Kolosi T, Tóth IG, Vukovich G, editors, Social Report 2004. Bu- dapest: TÁRKI Társadalomkutatási Intézet Zrt. 2004. Available from: https://openresearch.ceu.edu/han- dle/20.500.14018/9261

33. Aluaș M. Slovakia forced sterilization on Rroma women practices. an ethical case analyze. Stud Univ Babes-Bolyai Bioeth. 2015;60(2):103–13. Available from: https:// www.ceeol.com/search/article-detail?id=343241

34. Bernát A, Juhász A, Krekó P, Molnár C. The roots of ra- dicalism and anti-Roma attitudes on the far right [In- ternet]. 2013. Available from: http://www.tarki.hu/en/ news/2013/items/20130305_bernat_juhasz_kreko_ molnar.pdf

35. Székelyi M, Csepeli G, Orkeny A. Ambitious education: The role of family, school and friends in the deve- lopment of successful Romany life courses. Romani Stud. 2003;13(1):53–73.

36. Babusik F. Roma vállalkozások, vállalkozó romák [In- ternet]. 2005. Available from: http://www.esely.org/ kiadvanyok/2005_5/babusik.pdf

37. Zalewska-Puchała J, Majda A, Bodys-Cupak I. Attitudes of Polish nurses in the example of Lesser Poland Voi- vodeship towards representatives of Roma society. Med Stud/Studia Med. 2020;36(4):257–64.

    
    

38. Pettigrew TF. Future directions for intergroup contact the- ory and research. Int J Intercult Relat. 2008;32:187–99.

39. Allport GW. The Nature of Prejudice. Cambridge, MA: Addison-Wesley; 1954.

40. Zervoulis K, Lyons E. Predicting ingroup favouritism and outgroup derogation in a multicultural context: The effects of history representations, group identification, collective self-esteem and intergroup contact. In: British Psychological Society’s Social Psychology Section Confe- rence, Book of Abstracts. Huddersfield, UK; 2002. p. 82.

41. Rutland A, Cameron L, Milne A, McGeorge P. Social norms and self-presentation: children’s implicit and explicit intergroup attitudes. Child Dev. 2005;76(2):451-66. doi: 10.1111/j.1467-8624.2005.00856.x.

42. Banovac B, Boneta Ž. Etnička distanca i socijalna (dez) integracija lokalnih zajednica. Revija za sociologiju. 2006;37(1-2):21–46. Croatian.

43. Medlobi M, Čepo D. Stavovi korisnika društvenih mre- ža o izbjeglicama i tražiteljima azila: post festum tzv. izbjegličke krize. Političke perspektive. 2018;8(1- 2):41-69. Croatian.

44. Kunac S, Klasnić K, Lalić S. Uključivanje Roma u hr- vatsko društvo: Istraživanje baznih podataka. Zagreb: Centar za mirovne studije; 2018. Croatian.

45. Kapralski S. Between mneme and anamnesis: On the memory and forgetting of the Roma Holocaust. J Bal- tic Stud. 2023;54(1):7–26. https://doi.org/10.1080/0 1629778.2023.2156565

46. Asimopoulos C, Martinaki S, Kontogianni H, Kompoti D, Pachi K, Tzaneti P. Attitudes of public hospital staff towards Roma people in Attica, Greece: A comparative study. Arch Hellenic Med. 2019;36(2):202–11.

47. Stanciu A, Cohrs JC, Hanke K, Gavreliuc A. Within-culture variation in the content of stereotypes: Application and development of the stereotype content model in an Ea- stern European culture. J Soc Psychol. 2017;157(5):611- 628. doi: 10.1080/00224545.2016.1262812.

48. Vives-Cases C, Espinar-Ruiz E, Castellanos-Torres E, Coe AB. Multiple struggles in fighting violence against women: implications among Romani women leaders in Spain. Glob Health Action. 2017;10(sup2):1317084. doi: 10.1080/16549716.2017.1317084.

PREDRASUDE MEDICINSKIH SESTARA O ROMIMA KAO PACIJENTIMA U SUSTAVU ZDRAVSTVA REPUBLIKE HRVATSKE

Sažetak

Zbog duboko ukorijenjenih predrasuda, Romi su naj- ranjivija, višestruko diskriminirana etnička skupina i nacionalna manjina koja se u raznim sferama društva, pa tako i u našem zdravstvenom sustavu, suočava s diskriminacijskim izazovima koji ograničavaju kvalite- tu zdravstvene skrbi, uslijed čega se može povećavati rizik od progresije bolesti i prerane smrti. Cilj istraži- vanja bio je analizirati predrasude medicinskih sesta- ra prema pripadnicima romske nacionalne manjine, te analizirati njihovu povezanost s određenim sociode- mografskim obilježjima i uvjerenjima ispitanika. Istra- živanjem je bilo obuhvaćeno 536 medicinskih sestara zaposlenih u sustavu zdravstvene zaštite na sve tri razine, koje neposredno rade s pacijentima. Iz priku- pljenih stavova o 29 ponuđenih tvrdnji o položaju i odnosu prema Romima kao pacijentima, eksplorator- nom faktorskom analizom izdvojeno je 19 tvrdnji raz- vrstanih u četiri detektirana i interpretabilna pouzda- na faktora koji su nazvani „Romi unutar zdravstvenog sustava”, „Zaštita Roma od posljedica diskriminacije”,

„Opće predrasude prema Romima” i „Odnos medicin- skih sestara prema pripadnicima romske nacional- ne manjine kao pacijentima”, kojima se objašnjava 60,7 % ukupne varijance. Analiza je pokazala da dio medicinskih sestra dijeli iste opće predrasude prema Romima kao i opća populacija, pri čemu ispitanici s vi- šom razinom završenog obrazovanja i starije životne dobi te oni koji žive na području Međimurske županije i/ili sjeverne Hrvatske iskazuju statistički značajno negativnije stavove prema Romima od mlađih, niže obrazovanih i onih koji žive u drugim dijelovima Hr-

vatske. Također, pripadnost većinskom stanovništvu donosi negativnije stavove prema Romima nego što ih iskazuju pripadnici nacionalnih manjina. Oni ispita- nici koji su imali privatne i profesionalne kontakte s pripadnicima romske nacionalne manjine u dijelu fak- tora iskazuju manje negativne stavove od onih koji su ih nisu imali. Negativnije stavove prema Romima iskazuju ispitanici s desnog političkog spektra, dok se religioznost nije pokazala statistički značajnom.

Ključne riječi: Romi, predrasude, medicinske sestre, diskri- minacija, zdravstveni sustav