Target communities: Marginalized Roma communities

Vaccine(s): Human Papilomavirus (HPV)

Description of the target community

Roma are the largest and one of the most disadvantaged ethnic minority in Europe as well as in Slovakia 1European Union: European Agency for Fundamental Rights (FRA). Fundamental Rights Report 2019. Publications Offce of the European Union, Luxembourg, 20192Ministry of Interior of the Slovak republic. Atlas rómskych komunít 2019. [Atlas of Roma communities 2019]. 2019. Available online: Out of approximately 440 000 Roma in Slovakia, more than half live in marginalized Roma communities 3Ministry of Interior of the Slovak republic. Atlas rómskych komunít 2019. [Atlas of Roma communities 2019]. 2019. Available online: characterized by spatial and social distance from the majority population. Roma living in marginalized communities often experience discrimination, generational poverty, limited access to education, employment, housing, and various types of services including health care 4Ministry of Interior of the Slovak republic. Atlas rómskych komunít 2019. [Atlas of Roma communities 2019]. 2019. Available online: European Commission. Civil Society Monitoring Report on Implementation of the National Roma Integration Strategy in Slovakia: Focusing on structural and horizontal preconditions for successful implementation of the strategy. Directorate-General for Justice and Consumers. European Commission, Brussels, 201864. Jarcuska, P., Bobakova, D., Uhrin, J., Bobak, L., Babinska, I., Kolarcik, P., … & Geckova, A. M. (2013). Are barriers in accessing health services in the Roma population associated with worse health status among Roma?. International journal of public health, 58(3), 427-434.. These circumstances are reflected in health inequities between Roma and the majority population 7Ministry of Interior of the Slovak republic. Atlas rómskych komunít 2019. [Atlas of Roma communities 2019]. 2019. Available online:, K.; van Dijk, J. P. Roma Health: An Overview of Communicable Diseases in Eastern and Central Europe. Int. J. Environ. Res. Public Health. 2020, 17(20), 7632.

Vaccine uptake

Specific data on HPV vaccine uptake in the Roma community is lacking. In the Slovakian general population, the uptake of HPV vaccination in 12-year olds in 2019 was 23%. Given the low HPV vaccination uptake in the general population and the lower uptake of other vaccinations like DPT, Polio, MMR and BCG in the Roma community, it can be assumed that HPV vaccination rates among Roma are very low.9Laetitia Duval, François-Charles Wolff, Martin Mckee, Bayard Roberts. The Roma vaccination gap: Evidence from twelve countries in Central and South-East Europe. Vaccine, Elsevier, 2016, 34 (46), pp.5524 – 5530. ff10.1016/j.vaccine.2016.10.003ff. ffhal-01385007f

Contextual factors:

Approximately 260,000 Roma live in more than 1,000 registered concentrations characterized by the spatial and social distance between Roma and the majority population of Slovakia. Another approximately 75,000 Roma live in more or less confined communities within municipalities with a share of the Roma population over 30%, while in many villages Roma are even in the majority.10Ministry of the Interior of the Slovak Republic. (2019). Atlas of Roma Communities 2019. Available from: The population living in marginalized Roma communities is on average younger than the majority population in Slovakia. Roma living in these marginalized communities have worse access to proper housing, education, health care, job opportunities, and basic services. Their use of health care is 36% lower than in the national population, which points to barriers in access to health care.30 Among these barriers are lower health literacy, lack of funding for transport and medication, fear, mistrust, and bad experience with discriminatory practices of health professionals.11Jarčuška, P., Bobáková, D., Uhrín, J., Bobák, L., Babinská, I., Kolarčík, P., Veselská, Z., Madarasová Gecková, A., HepaMeta Team. (2013). Are barriers in accessing health services in the Roma population associated with worse health status among Roma? International Journal of Public Health, 58, 427-434.12Belák A., Fiľakovská Bobáková D., Madarasová Gecková A., van Dijk J.P., Reijneveld S.A.: Why don´t health care frontline professionals do more for segregated Roma? Exploring mechanisms supporting unequal care practices. Social Science & Medicine 2020, 246:112739.

Health system barriers:

Due to migration between settlements and abroad there is a lack of vaccination data which leads to a suboptimal health information system, which is necessary to understand, act if necessary and compare data. The Roma community in Slovakia often are unaware of the importance of immunization. Secondly, they experience challenges in accessing vaccination services. The Roma community in Slovakia use health services less frequently compared to majority of the population; they only tend to use health care in acute cases. Limited use of vaccination services is partly explained by significant information barriers, discrimination and the absence of a doctor to approach when needed. In addition, limited language and cultural understanding of healthcare professionals often result in the indirect unavailability of vaccination services. Finally, the lack of governmental financial resources lead to disruption of programmes focusing on the improvement of Roma health, including vaccine preventable diseases. Transport and medical costs are additional barriers to accessing healthcare services among the Slovak Roma community, 9.2% could not afford or did not want to pay a fee for immunization.

Addressing health system barriers to HPV vaccine uptake

Marginalised Roma communities in Slovakia encounter multiple barriers when it comes to Human papillomavirus (HPV) vaccine uptake. Identified by local stakeholders (community members, healthcare professionals, public health authorities and policymakers), the most significant and feasible to address ones include: insufficient information delivery, linguistic barriers, limited access to the healthcare system, lack of awareness raising initiatives, and inadequate healthcare professional training. To effectively respond to the community’s needs, we have based our piloting interventions in Eastern Slovakia, Kosice on these barriers and have devised a multicomponent approach. The main component will be recruiting and training Roma health mediators along with healthcare professionals to conduct educational sessions for parents and their children.

Component 1: health promoters
Engaging Roma health mediators and healthcare professionals

The position of “Roma health mediator” is well-established in Slovakia under the national project “Healthy Communities”. These mediators, of Roma origin, reside and work within the communities that RIVER-EU aims to reach, enjoying the trust of their peers. Utilising their network, they are ideal candidates for recruiting participants.

When enlisting healthcare professionals, the outreach extends to those working in primary care, gynaecologists, vaccinologists, and medical students. Priority is given to candidates with a Roma background, ensuring to include both genders.

Health promoters’ training

This pilot intervention offers education on HPV-related infections, vaccination, and practical information about the Slovak Immunisation Programme to Roma health mediators, empowering them to promote HPV immunisation and bridge the gap between healthcare systems and communities. Building on their previous experience, they will additionally participate in training sessions that aim to refresh their presentation and communication skills.

Healthcare professionals will undergo more in-depth training through online courses, covering similar topics. By the end of the training, both groups will become familiar with context-specific barriers, beliefs, and attitudes towards HPV vaccination, and will be equipped with culturally appropriate communication skills and strategies for using easy to understand language.

Component 2: educational programmes in the community
Defining target groups for educational sessions

Following the training, health promoters will organise HPV educational sessions for parents/legal guardians and their vaccine-eligible children (boys and girls aged between 12 and 14 and 364 days) who haven’t received vaccination, along with 11-year-old children who will turn 12 during the intervention’s duration. This focus on the specified age group aligns with the project’s aim to promote HPV vaccinations that are accessible and free of charge.

Educational content and settings

Our focus lies on marginalised Roma communities in Kosice, Eastern Slovakia, where vaccination rates are notably low. Sessions for parents and legal guardians will convene in neighbourhoods and familiar venues such as community centres, schools, health centres, and religious establishments. Separate sessions for boys and girls, conducted during school hours, ensure a safe environment for questions, with no teachers present.

These sessions provide factual information on HPV, HPV vaccination, how to access additional information, and arrange a vaccination appointment, with the aid of audiovisual content, brochures with simple wording and graphics. They are delivered in Slovak and Romani languages by Roma health mediators and supported by health professionals to address technical inquiries. Common community beliefs and understandings are openly discussed as well.

After the sessions, Roma health mediators extend their support indefinitely, ensuring continuity beyond the project’s duration. They provide vaccine reminders and guidance in navigating the healthcare system. On-demand appointments with healthcare professionals are available for personalised assistance.

Roma health mediators extend their support indefinitely, ensuring continuity beyond the project’s duration.

Quality assurance

Both training and educational sessions will undergo evaluation using pre- and post-knowledge and attitude questionnaires. Participants will be surveyed about their vaccination intentions post-session and six months later. Continuous evaluation and updates based on feedback will ensure content relevance and effectiveness.

More about the HPV vaccination programme in Slovakia