HEALTH BELIEFS AND PRACTICES AMONG SLOVENIAN ROMA AND THEIR RESPONSE TO FEBRILE ILLNESSES: A
QUALITATIVE STUDY
STALIŠČA IN RAVNANJE ROMOV V SLOVENIJI V ZVEZI Z VROČINSKIMI STANJI: KVALITATIVNA ŠTUDIJA
Danica Rotar Pavlič1, Erika Zelko2, Janko Kersnik12, Verica Lolič3
Prispelo: 4. 11. 2010 - Sprejeto: 6. 1. 2011
Original scientific article UDC 397(497.4):612.57
Abstract
Introduction: When the Roma fell ill in the past, they used herbal home i^emedies to ti^eat diseases. If the i^emedy failed to cui^e the illness, they called the local healei^. Today, most Roma visit physicians. This study investigates health beliefs and pf^actices held by the Roma people in Slovenia and theii i^esponse to febi^ile illnesses. Methods: Field interviews using a semi-structured questionnaire were conducted in the vicinity of Kočevje. Socio-demogt^aphic data wei^e gathei^ed and i^ecoided manually, and the int^ivie^s wei^e tape i^ecoi^ded. Qualitative analysis wa^s pe^oi^med by thiee researchers. Special attention wa^s paid to data validation.
Results: The majority of Roma are not acquainted with thermometers and therefore do not use them. About one-third of the interviewees knew what the normal body temperature should be. Only 15% of the Roma population take their body temper^atui^e when they ai^e feeling unwell. One-half visit their physicians. More than half of the population take par^acetamol or aspii^in when they feel fevei^ish. Moi^e often, they resort to tea and emphasize the healing effect of sweating.
Conclusion: The Roma beliefs and pr^actices regar^ding health and fever are insti^uctive and show how impovei^ished a narrow biomedical approach can be. Failure to use technical devices, such as thermometers, and lack of familiai^ity with the numerical values defining the border between normal and elevated body temperature, nonetheless do not mean that the Roma take inappropriate measures in response to illness. Illnesses (including fever) can also be recognized without these tools and can be appropriately responded to by drinking teas, using compresses, and taking fever-reducing medications.
Key words: Roma, illness, thermometer, fever, activity, doctor
Izvirni znanstveni članek UDK 397(497.4):612.57.2
Izvleček
Uvod: V preteklosti so Romi za zdravljenje uporabljali domače zeliščne pripravke. Kadar ta zdravila niso bila učinkovita, so poklicali lokalnega zdravilca. Danes večina Romov obišče zdravnika. V prispevku ugotavljamo, kakšno je prepričanje in ravnanje slovenskih Romov v zvezi z zdravjem in kako ukrepajo pri vročinskih stanjih. Metode: V okolici Kočevja smo na terenu izvedli intervjuje na osnovi polstrukturiranih vprašalnikov. Zbrane sociodemografske podatke smo ročno zapisovali, pogovore pa smo posneli. Kvalitativno analizo podatkov so izvedli ti^ije r^aziskovalci. Posebno pokornost smo namenili validaciji podatkov.
Rezultati: Večina Romov ne pozna termometra in ga zato tudi ne uporablja. Približno ena tretjina vprašanih je vedela, kakšna naj bi bila normalna telesna temperatura. Ob slabem počutju si le 15 odstotkov romskega prebivalstva meri telesno temperaturo. Polovica jih obišče zdravnika. Več kot polovica romskih prebivalcev vzame paracetamol ali aspirin, kadar ima vročino. Pogosteje se zatečejo k pitju čaja in poudarjajo zdravilne učinke potenja.
1University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana, Slovenia
2University of Maribor, Faculty of Medicine, Department of Family Medicine, Slomškov trg 15, 2000 Maribor, Slovenia
3Private General Practice, Roška cesta 18, 1330 Kočevje, Slovenia Correspondence to: e-mail: danica.rotar@guest.arnes.si
Zaključek: Prepričanja in ravnanje Romov v zvezi z zdravjem in povišano telesno temperaturo so poučna in nam k^ažejo, k^ak^o osiromašen je lahko ozko usm^rj^ni t^iomedicinsk^i pr^istop. Dejstvo, da Romi ne upor^ab^ljajo tehničnih pilpomočk^ov, npr^. tei^mometra, in ne poznajo številčne vi^ednosti, ki loči med normalno in povišano telesno temperaturo, še ne pomeni, da ob bolezni ravnajo neustrezno. Bolezenska stanja, tudi povišano telesno temperaturo, lah^o pr^epozn^mo tudi br^ez t^h orodij in se jim ustr^ezno postavimo po r^obu s pitjem čaja, z upor^^bo ob^kl^dkov in z jemanjem zdi^avil proti vročini.
Ključne besede: Romi, bolezni, termometer, povišana telesna temperatura, aktivnosti, zdravljenje
1 Introduction
This study focuses on Roma beliefs regarding elevated body temperature and on ther dealing with fever. Although the Roma have been living in Europe and the Balkans since the fifteenth century, they still maintain some ancient beliefs (1). Superstitions and responses that are no longer common today—but have been preserved in the Roma communities—are believed to result from the stigmatization they have been subjected to in Europe over the past centuries and that forced them into isolation (2). Fever was selected because it is a clear and easily identifiable sign there is something wrong. It can be explained as a malfunction or maladaptation of biological and physiological processes under the Western medical paradigm. It could also be examined in the light of personal, interpersonal, and cultural changes and reactions that go far beyond a narrow »medicocentric« view (3, 4). Scientists and laypeople are becoming increasingly aware of the need to understand cultural variation in medical beliefs and practices. They state that transcultural medicine, medicine of minorities and migrants must receive much more attention. The more we know about how health and disease are managed in different cultures, the easier it is to recognize the "culture bound" elements in our own medical beliefs and practices. Nonetheless, few papers have thus far dealt with this issue, primarily because of the obstacles and mistrust that researchers encounter when they try to interact with a Roma community. This may originate from the historical circumstances mentioned above. Little concrete information is available on the contemporary health status of the Roma in Europe (5). Demographic statistics and field research prove that Roma community members generally have a lower life expectancy and that they are more often affected by conditions such as tuberculosis, asthma, diabetes, and anaemia (6). The genetic structure of the Roma in Slovenia was studied by Marij Avčin in 1969 (7). According to data provided by social work centres in 2003, Slovenia was home to 6,264 Roma, whereas the
2004 statistics provided by municipalities in which Roma have settled historically, showed that 6,448 members of the Roma ethnic community resided there (8). The Roma community in Slovenia is heterogeneous, similar to the pattern in other European countries. Roma are subjected to marginalization and stigmatization by members of the majority population and other ethnic minorities (9).
The Slovenian Roma are divided into the following three groups: the Lower Carniola or "Croatian" Roma; the Prekmurje or "Hungarian" Roma; and the Upper Carniola or "German" Roma. Each of these groups speaks its own Romani dialect. There is even less information available on the Roma living near Kočevje— the area included in this study—than on the Slovenian Roma in general. Slovenian authors dealing with the Roma classify Roma from Kočevje in the Lower Carniolan group and do not make further distinctions. The Lower Carniola Roma are referred to as "Croatian" gypsies by other Roma in Slovenia. They are most numerous around Novo mesto (10). They speak a Romani dialect that contains a number of Slovenian words and many Croatian ones. Upon their arrival in the Kočevje region, the Roma first settled in Karst caves in the settlement of Željne near Kočevje (11). The Romas from Kočevje have appointed their own leader or "king," a successful entrepreneur. His wealth is comparable to that of other entrepreneurs from Kočevje. Some Roma shun him out of envy (12). When assessing the Roma attitude to health and illness, one must bear in mind how their culture and lifestyle are different from that of other Slovenians.
When a Roma fell ill in the past, his/her family waited for the illness to resolve itself and resorted to treatment with home herbal remedies only after a couple of days (13). If the remedy did not cure the illness, they called the local healer; if he determined that the patient could not be helped, he was left to die. Those who sought professional medical help were rare, and they were usually forced to do so because of injury or infection. Today, most Roma do visit a physician, but some of them, mostly the elderly, still practice home treatment.
In comparison to other Slovenians, Roma are more likely to request a house call; however, in the majority of cases the reasons for house calls are non-medical. When it comes to house calls, the Roma community leaders' trust has to be gained (14). The literature provides no information on how the Roma react to fever and when they decide to visit a doctor. Very little data have been gathered on the Roma community living in the Kočevje area. In studying this unexplored area, we used fieldwork and qualitative research in order not to lose specific cultural features, convictions, and beliefs, which may happen with quantitative research.
2 Participants and methods
2.1	Patients
We are aware that the term gypsy is not favoured by the Roma people, to whom the term is applied by non-Roma, and so we have exclusively used the term Roma. VL, who meets with Roma patients on a daily basis, first explained the study concept to their leader or "king," who approved of the research. Home care nurses, who know the field well, also helped with the sampling. We used the purposive sampling method.
2.2	Instruments
The data were obtained through a Slovenian language semi-structured questionnaire which included close-ended and open-ended questions. If the interviewee did not understand the question, VL explained it using dialect. The following socio-demographic data were gathered : sex, age, living environment (water and electricity supply, use of radio and television), education and employment. Furthermore, the questionnaire enquired about the marital status of the interviewees, i.e. single, married, living in a partnership, or widow(er). The question on health was open-ended ("What does it mean to be healthy?"). We obtained information on whether the interviewee was a welfare recipient. The questions related to fever and feeling unwell were as follows:
•	What is the first thing you do when you feel sick and tired, when you sweat and have a headache?
•	What is the normal body temperature?
•	You have noticed that you were very hot and sweaty. Would you take your temperature with a thermometer?
•	How do you usually lower body temperature?
•	When do you feel that you are healthy again?
2.3 Methods
The Roma were interviewed in the field with the assistance of a physician (VL) working in their environment. VL took notes on interviews by hand and showed her notes to the interviewees at the end. She also tape recorded the interviews. DRP verified whether the notes agreed with the audio material. The data were analysed using descriptive statistics and qualitative data analysis (15). Qualitative text analysis was carried out by three researchers (DRP, EZ, VL). Special attention was paid to data validation. The consistency of the coding was evaluated based on all the interviews transcribed. No major discrepancies were found. After completing the analysis, DRP visited the Roma community twice to verify the validity of the interpreted data. She conducted interviews with the doctors responsible for the community.
3 Results
We intervewed 136 Roma from the town of Kočevje and the vicinity. There were 88 women and 48 men, aged 15 to 65 years. Four interviews were excluded because the interviewees said they had changed their minds concerning participation; in some cases most of the questions were left unanswered. One hundred thirty-two interviews were included in the analysis. The majority of the Roma interviewed had not finished primary school: 43% of them had never attended primary school; 21% had completed two years of primary school, 24% had completed four years, and 11% had completed eight years of primary school. Only 1% had taken a vocational degree. Eighty-three percent of the Roma interviewees were unemployed, 15% were employed, and 2% were occasionally employed. Seventy-three percent of the interviewees were married or living in a non-marital partnership, 18% were widowed, and 9% were single. All women were unemployed, and the majority of men worked as manual labourers. Sixty-two percent of the Roma interviewees were receiving welfare. They mostly lived in wooden one-room shanties constructed from scrap wood and tin. Seventy-nine percent of the Roma interviewees had access to drinking water; 76% lived in homes with electricity, and 64% had a TV set and a radio. The answers to the question about what health meant to them most often included a good diet, and the listing of frequently consumed foods. Health is also associated with sound sleep, normal breathing and lung function, and with the absence of pain, shaking limbs, and tingling.
Table 1. Key statements on what it means to be healthy obtained from individual interviews with the Roma. Tabela 1. Ključne izjave Romov o pomenu besedne zveze 'biti zdrav'.
Being healthy means	Comments (transcripts)
Well-being	That I eat and sleep well.
	I'm healthy when I feel good and happy.
Breathing	I'm healthy when I can breathe.
	Being healthy means I can smoke and not cough.
Pain	I'm healthy when nothing hurts.
	It means my back doesn't hurt.
	I'm healthy when I can get out of bed.
	I'm healthy when my stomach doesn't hurt.
	That I don't feel pain in my heart.
Sensation	It means that I'm not shaking.
	When I don't feel tingling over the left side of my body.
The majority of the Roma do not take their body temperature when they feel ill because most of them do not have a thermometer available. Fifty-two percent of the Roma interviewees said they do not own a thermometer; 15% do own one, but fail to take their temperature when it is elevated and they are sweating; and 33% take their temperature when it is elevated and they are sweating. Only 28% of the Roma knew that the normal body temperature is less than 37 °C. The majority of Roma rely on tea or grated potatoes and cooling compresses when they feel feverish:
•	"I make myself tea with lemon, or, even better, with schnapps. With a bit of schnapps in it, I drink three cups a day." (HK, male, 63)
•	"I make hot tea, any kind. I drink it hot and cover myself with a blanket so I start sweating." (KV, male, 65)
•	"I make chamomile tea with honey. I pour whiskey on my hands and snort it through my nose." (KZ, female, 44)
•	"I make my own tea from herbs that I pick during the summer. I make all herbal teas. I'm not well until I sweat it out. I have to relax to sweat, and then the disease comes out." (BM, female, 65)
•	"I have homemade tea and I drink it. If the tea doesn't help, I see a doctor. I believe in tea because it's my homemade tea." (RE, female, 58)
•	"I roast some sugar. If I see it's not helping, I go to the doctor's. If I still have a fever, I put beet on my arms and legs, or potatoes. I wouldn't know of any other cures." (ŠE, female, 58)
•	"First I make various teas. If my temperature doesn't drop for more than three days, I see a doctor." (ŠŠ, male, 49)
•	"I use sage and chamomile. I drink linden tea. If I get a fever, I put on cold compresses." (F, female, 41)
•	"I drink tea and rub my chest with ointments. Fever can be cured with potatoes you put on your legs, so the temperature drops. I grate potatoes and put them around my feet. Or I put on cold cloths. If nothing helps, I go to the doctor. But potatoes help. That's what my mom told me, and what her mom told her." (BD, female, 35)
•	"I also use potatoes with fever. I slice the potatoes and put them on the soles of my feet, wrap them in a diaper or a handkerchief and then tie them around my feet and also put them on my forehead. This definitely breaks a fever, and so does beet juice. And for colds I also use onion. You peel the onion, fry it a little, wrap it in a diaper, and then lay it on your chest, which also helps knock out a cold. I've tried this on my kids, myself, and my grandkids, and know that this is a sure cure from natural herbs." (SS, male, 59)
•	Some are concerned about pollution and no longer collect herbs.
"How should I put it . . . all these chemicals and cars, you can't collect that many herbs anymore." (F, female) Fifty-eight percent of the Roma interviewees were aware of the benefits of aspirin (acetylsalicylic acid) and paracetamol; 24% still opt for cold compresses for a high fever, and 18% choose herbs. Talking to the
Roma and observing them in the field revealed that young Roma girls pick healing herbs, but do not know what to use them for. Older Roma women know the healing properties of herbs, but prefer to send seriously ill Roma to a physician. They primarily pick linden blossoms, lemon balm, elder, chamomile, wormwood, plantain, and centaury.
4 Discussion
The study showed that the majority of the Roma studied do not take their temperature when they feel ill. They focus on "staying healthy," which for them means they sleep well, feel well, breathe normally, do not cough, do not feel any pain, and do not have a fever. The majority do not own a thermometer and even those who have one only rarely take their temperature. They do not have thermometers in their houses, but they do have televisions and radios. The Roma are not really interested in what normal and elevated temperatures are. Even though we expected the majority to use the traditional methods of drinking tea and using cold compresses to treat fever, in fact less than half of the interviewees were found to use them. Fifty-eight percent of the Roma interviewees were aware of the benefits of aspirin (acetylsalicylic acid) and paracetamol. When they fall ill, the Roma visit their doctor promptly. One hundred thirty-two Roma from Kočevje and the vicinity participated in the study. This is a highly representative sample considering that demographic data on Roma collected in 1982 showed that there were 321 Roma residents in Kočevje, i.e. 1.76% of the local population (13). The advantage of this study is the fact that it was conducted in their home environment and that they were not included in the study on the basis of medical documents of clinics or hospitals. There are few studies on the health status of the Roma; and even fewer focusing on a particular health issue (5, 16, 17). Fieldwork has shown that it is difficult to obtain access to local Roma communities. Despite the fact that the nurses and local physician had obtained the authorization from the Roma leader, the Roma interviewees asked with incredulity why it was necessary to note down their statements and why the researcher was using a tape recorder. As early as the Middle Ages, the Roma were known as healers. Miraculous powers were attributed to Roma women: it was said they could heal men and animals, and that they were searching for a medicine for this life and the next. There is little data on measures taken by the Roma upon the occurrence of a particular medical
problem, such as fever. According to Jože Zadravec (13), a physician and researcher, a Roma woman treated her children's fevers by wrapping them in cold cloths. She used grated raw potatoes and placed them on her children's chests and soles. Some Roma women used beets or turnips. If the temperature did not drop, they rubbed the child with spirits. Similar answers were yielded by this study, which was in turn extended to enquire about medicines that the Roma from Kočevje take to treat fever. Our study has shown that as many as 58% of the Roma interviewees are familiar with the effects of aspirin (acetylsalicylic acid) and paracetamol. Perhaps this is a result of the impact of radio and television, which were present in 64% of the Roma homes. Zadravec established that the Roma like medicines because they often asked him for tablets. He stated that Roma girls bring along several health insurance cards and demand analgesics, antiasthmatics, cough medicine, vitamins, and antipyretics. This list, provided by Zadravec, indirectly confirms the results of the study: according to the Roma, health is defined as feeling good and the absence of breathing problems, pain, and tremors (13). This study—like the one by Jože Zadravec—falls into the area of medical folklore. The Roma beliefs and practices regarding health and fever are instructive in how impoverished a narrow biomedical approach can be. Failure to use technical devices, such as thermometers, and lack of familiarity with the numerical values defining the border between normal and elevated body temperature do not mean that the Roma take inappropriate measures in response to illness. Illness (including fever) can also be recognized without these tools and can be appropriately responded to by drinking teas, using compresses, and taking fever-reducing medications.
Our study reveals a number of accompanying elements of the experience and treatment of illnesses that can only be studied using an anthropological method (19). Approaches used in treating elevated body temperature can be traced in the actions taken by healers. A good knowledge of the cultural and historical background provides a better understanding of individual patients' decisions and makes it possible to overcome obstacles in communicating with and treating, not only the Roma, but all patients (20).
5 Conclusions
The Roma are an important ethnic minority in Eastern and Central Europe. In Slovenia, Zadravec conducted
the largest number of studies on the Roma attitudes towards health by observing Roma communities in northeastern Slovenia. This study includes Roma from the southern Slovenian town of Kočevje and the vicinity. The Roma generally do not use a thermometer, but instead define health or illness according to their general wellbeing. However, more than one half are aware of the benefits of antipyretics. The Roma frequently use traditional folk medicines (teas, compresses) to treat fever. They only see the doctor if their health problems last more than three days.
There is a need for further research in the health of the Roma population with a particular emphasis on non-communicable diseases and interventions that could improve their health.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
DRP and VL designed the original study, VL collected the data, and DRP, VL, and EZ analyzed the data collected JK commented on the analysis, DRP and EZ drafted the paper and DRP revised subsequent drafts based on co-authors' comments.
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