Situation analysis
vulnerability sometimes refers simply to a lack of physical and/or mental resilience among individual people, but here the context is broader – vulnerability to both social adversity and ill health. This results from exclusionary processes that operate differentially across the whole of society and give rise to the social gradient in health. Although social exclusion is a dynamic and gradual phenomenon and actions should focus on addressing exclusionary processes, identifying individuals or groups who are socially excluded and considering them in both research and policy-making are equally important.
Two specific groups are highlighted, migrants and Roma, to illustrate many of the issues faced by vulnerable groups in general
Migrants migration in Europe today involves a diverse group of people, including regular and irregular migrants, victims of human trafficking, asylum-seekers, refugees, displaced people and returnees. many migrate for economic reasons. Overall, 75 million migrants live in the WHO European Region, amounting to 8% of
About 12–15 million Roma live in the European Region, and an estimated 10 million live in the Eu alone. Roma are estimated to account for 10% of the population of Bulgaria, 9% in Slovakia and 8% in Romania, and these proportions are likely to increase (126,131).
There are indications that life expectancy among Roma communities is 10–15 years lower than average, the rates of infant mortality are increased and the levels of maternal and child mortality and morbidity are alarmingly high (131–
133).
Higher rates of illness have been reported among Roma populations than among majority populations, with higher rates of type 2 diabetes, coronary artery disease and obesity among adults and of nutritional deficiencies and malnutrition among children. For example, many Roma women in settlements in Serbia are undernourished (51%) and smoke tobacco (almost all), and a united nations Development Programme survey of vulnerability found that 50% of Roma children face malnutrition risks more than twice monthly, in contrast to 6% of majority children (134–136).
A disproportionate number of Roma have low income in many countries, and evidence suggests that this leads to a concentration of Roma among the people with the lowest incomes. Exclusion linked to discrimination against Roma may be an independent risk factor for poverty (132,137).
Evidence indicates significant inequity in health system access and health status between Roma and majority populations. For instance, data on antenatal care coverage, low birth weight, prevalence of breastfeeding, maternal smoking, the total population and 39% of all migrants worldwide (78). most migrants in the European Region are young adults. Women comprise half of all migrants and are often overrepresented in vulnerable groups, such as victims of human trafficking for sexual exploitation (125).
There are substantial variations between groups, countries and health conditions. nevertheless, the burden of ill health among excluded migrant groups is often unacceptably large (126). Where figures exist, they generally indicate lower life expectancy for migrants, and some communities also show increased rates of infant mortality. migrants’ illnesses are largely similar to those of the rest of the population, although some groups may have a higher prevalence of health problems, including communicable diseases; poor nutrition; high rates of alcohol and drug abuse; reproductive and sexual ill health; occupational health problems; and mental disorders (127–129).
The vulnerability of most migrants leaves them exposed to hazardous working environments, poor housing, labour exploitation and inadequate access to health care. Occupational accident rates are about twice as high for migrant workers as for native workers in the European Region (126).
The health conditions and environment at the migrants’ place of origin, such as a high prevalence of tuberculosis or HIv infection, determine many baseline health characteristics, with health risks increasing during the migratory journey, for example owing to traumatic experiences (130). After arrival, poverty and social exclusion exert the greatest influence on health outcomes, with the availability, accessibility, acceptability and quality of services in the host environment influencing the health of migrants (126). On arrival, a variety of factors may increase psychosocial vulnerability and hinder successful integration. migrants may experience obstacles in accessing services because of stigmatization, lack of information about services and lack of information in other than the predominant languages of host countries.
Roma
nutritional status and vaccination rates reveal marked inequities between the Roma and the majority population, including (in some contexts) when Roma are compared with the poorest quintile of the general population (138,139).
Solutions that work
Since the health problems of migrants and others who are vulnerable can result from or be worsened by their disadvantageous social position, measures that combat socially exclusionary processes are likely to have the most fundamental effect on their health. Furthermore, policies should address inequities in the state of health of migrants, Roma and others made vulnerable through exclusionary processes, and in the accessibility and quality of health and social services available to them. many of the strategies for achieving this are not specific to such groups as the Roma, but are similar to those needed for ethnic minorities and others subject to multiple exclusionary processes in general. They include training health care workers in working with minority and marginalized populations, involving those populations in designing, implementing and evaluating health programmes, and improving health information systems so that data are collected and presented in an ethnically disaggregated format. Integrated policy approaches designed to tackle the multiple causes of social exclusion are the most successful (140).
many of the health and socioeconomic challenges associated with migration are the product of global inequity, and action that focuses solely on host countries will be less effective than integrated global programmes designed to mitigate the factors in the country and region both of origin and of destination.
migrants also frequently confront gender-specific challenges, particularly in the context of maternal, newborn and child health, sexual and reproductive health, and violence. migrants should have early access to reproductive health services, preventive health services and health promotion, screening and diagnostic care, as well as prenatal and obstetric services. Special attention should be paid to women and girls who have been trafficked, as many have been exposed to gender-based violence.
WHO resolutions adopted at global and regional levels relating to social inclusion and poverty and health are relevant to vulnerable people. These include the World Health Assembly resolution on reducing health inequities through action on the social determinants of health (47) and work following up Regional Committee resolution EuR/RC52/R7 on poverty and health (141), such as that addressing health inequities linked to migration and ethnicity (126).
Specifically on the health of migrants, a World Health Assembly resolution in 2008 (142) was followed up by a WHO/International Organization for migration global consultation on an operational framework during the Spanish Eu Presidency in 2010 (143). The need for coordinated and sustained international action is being picked up through various policy processes and conferences, with outcome documents, such as the Bratislava Declaration on Health, Human Rights and migration signed by Council of Europe member countries in 2007 (144) and recommendations on mobility, migration and access to health care adopted by the Council of Europe Committee of ministers in 2011 (145). The International Convention on the Protection of the Rights of All migrant Workers and members of their Families (146) provides a broader framework for the universal human right to health without discrimination.
The Decade of Roma Inclusion 2005–2015 is a political commitment by European governments to improve the socioeconomic status and social inclusion of Roma, and health is a priority area of focus together with education,
employment and housing. In 2011, the European Commission launched an Eu Framework for national Roma Integration Strategies by 2020, which requests that all Eu countries develop and implement targeted strategies for promoting integration in health, housing, education and employment (131). Other relevant work includes the European Council communication on solidarity in health and the European Council’s conclusions on Roma (147).
A gender approach is needed to understand and tackle socioeconomic and health inequities. gender equity refers to fairness and justice in the distribution of benefits, power, resources and responsibilities between women and men to allow them to attain their full health potential. The concept recognizes that women and men have different needs and opportunities that impact on their health status, their access to services and their contributions to the health workforce. It acknowledges that these differences should be identified and addressed in a manner that rectifies the imbalance between the sexes.
Differences in mortality and morbidity rates between men and women are well established; however, the scale of these varies widely across the WHO European Region. It is important to look at differences in health beyond life expectancy and to consider the health that individuals experience during their lifetimes. Where healthy life years are measured, women’s mortality advantage contributes to more healthy life years but their higher prevalence of disability reduces the difference. There are also documented differences between women and men in terms of the use of health care resources, exposure to risk, vulnerability and responses from the health systems (148).
men’s ill health is influenced by gender roles and norms: greater levels of occupational exposure to physical and chemical hazards, risk behaviours associated with male lifestyle, and health behaviour paradigms related to masculinity (men are less likely to visit a doctor when they are ill and are less likely to report on the symptoms of disease or illness).
gender norms and roles shape the way adolescents view sexuality and play an important role in attitudes towards risk-taking and access to and use of information and services. Women’s access to sexual and reproductive health services may be limited by gender stereotypes and socioeconomic barriers to services (91).
The importance of early childhood care and education is based on the assumption of a universal, high-quality, free primary and secondary education system. most countries in the European Region have well-established systems, but in some countries girls are not equally enrolled in secondary education or have higher drop-out rates. This not only has lifelong impact on gender inequality, it also reduces countries’ potential for economic development and growth.
Women are a group at risk among older people with a low socioeconomic position. Special attention should be paid to older women who, owing to a longer life and a different life-course, have more health problems in old age;
in addition, they are more likely to need and not to be able to access health services.
Situation analysis