Unmet Health Need Among Roma: Visual Acuity and the Use of Vision Correcting Aids in the Hungarian Roma Population

Gergely Losonczy Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands Peter Piko MTA-DE Public Health Research Group, Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary. B. Jeroen Klevering Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands Zsigmond Kosa Department of Methodology for Health Visitors and Public Health, Faculty of Health, University of Debrecen, Nyiregyhaza, Hungary. Janos Sandor Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary. Roza Adany (  adany.roza@med.unideb.hu ) MTA-DE Public Health Research Group, Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.


Introduction
The European Roma population moved from South Asia into Europe between the 9th and 14th centuries.
Nowadays they from the largest transnational ethnic minority group in Europe with a population of about 10-12 million people 1 . Most of the European Union`s Roma population lives in Eastern-European countries including Romania, Bulgaria, Hungary and Slovakia where they make up between 5 and 10 per cent of the population, but there are also sizeable Roma minorities in the Western Balkan countries, as well as in Spain, Italy, France and the UK [2][3][4] . In comparison with the general populations, Roma populations have poorer health and high burden of both communicable and non-communicable diseases [5][6][7][8][9][10][11][12][13] , which can be attributed to social exclusion negatively in uencing their access to educational, social and health services 14,15 .
A diminished visual function can deeply affect quality of life, social participation and economic opportunity. Vision impairment also carries a high nancial cost for health care services. Vision and hearing impairment have been associated with a greater risk of injuries, loss of functional activity, anxiety and depression [16][17][18][19][20] . It has been shown, that minority ethnic groups such as Blacks and South Asians in England 21 and American Chinese people in the US have a higher prevalence of visual impairment compared to White people 22,23 , and have less access to appropriate health care services and treatments.
The only data available on the visual function of Roma people as compared to the general population comes from a study conducted in Spain. The Roma population was more likely to present with vision limitations for both far and near sights and showed a lower use of corrective aids than the general population. These ndings were associated with poor mental health and lower social participation 24 . The position of Roma on the labour market is very unfavourable 25 , and their integration is not only a moral, but also an economic imperative in the European Union with workforce shortages 26 . Among measures to overcome labour market barriers faced by Roma exploring and ful lling their unmet health needs is of crucial importance.
In the framework of a complex (behavior and health) survey as part of physical examination we investigated the visual acuity and spectacle dependence of the Hungarian Roma in comparison with the general population. The aim of the current study was to de ne uncorrected visual acuity and the use of glasses and/or contact lenses in Roma compared to the Hungarian population. We also investigated the effect of demographic, socioeconomic and health parameters on the visual acuity in these groups.

Materials And Methods
In 2018, we performed a cross-sectional survey in two North-East Hungarian counties (Hajdú-Bihar and Szabolcs-Szatmár-Bereg) where the majority of Roma live, frequently in segregated colonies 27 . This study had three main pillars as questionnaire-based, physical, and laboratory investigations involving adults aged 20-64 years from the Hungarian general (HG) and Hungarian Roma (HR) populations. Altogether, 832 participants were randomly selected including 417 HG (185 male and 232 female) and 415 HR (108 male and 307 female) subjects. Details of sampling, data collection and management are thoroughly described elsewhere 28 . In brief, segregated colonies exceeding 100 inhabitants were identi ed previously by Roma eld workers and ethnicity of the colony population was assessed by self-declaration. After veri cation of a previously created database, twenty colonies were randomly chosen, and twenty-ve households were randomly drawn from each colony. Individuals aged 20 to 64 years were identi ed in each Roma household and eventually one person was selected by random table. Individuals, aged 20 to 64 years, living in private households and registered by general practitioners in the same counties, were randomly chosen from the General Practitioners' Morbidity Sentinel Stations Program's registry (which has been working continuously since 1998) and served as reference sample 29 . In addition to anthropometric (among them waist circumference), demographic (age, sex), socioeconomic (among them educational level), and health-related data (as prevalence of hypertension, diabetes, antihypertensive, anti-diabetic and lipid-lowering treatments), fasting blood samples (native and EDTAanticoagulated) were also collected for routine laboratory tests including -among others -fasting glucose, high-density-lipoprotein-cholesterol (HDL-C), triglyceride (TG) measurements. As it is previously described in detail for the de nition of metabolic syndrome the following physical and laboratory parameters were considered as abnormal by adopting the International Diabetes Federation's cut-off values: waist circumference: ≥94 cm for males and ≥80 cm for females; systolic BP of ≥130 mmHg and/or diastolic BP of ≥85 mmHg; fasting glucose level: ≥5.6 mmol/L; fasting triglyceride level: ≥1.7 mmol/L; fasting high-density cholesterol (HDL-C) level: <1.03 mmol/L in males and <1.29 mmol/L in females 30 .
As part of the physical examination pillar of the survey, we measured the uncorrected visual acuity (UCVA) with the use of standard decimal visual acuity charts in general practitioners` o ces on Roma (n=314) individuals, and compared the ndings to data obtained on subjects representing the Hungarian general population (n=395). Decreased UCVA was de ned as below 0.5. The use of spectacles or contact lenses was recorded in the questionnaire-based pillar of the study.
Statistical analysis. All statistical tests were performed using IBM SPSS (version 26, IBM Company, Armonk, NY, USA) software. Prevalence data obtained in the survey were compared by χ2 test.
Multivariate linear and logistic regression analyses were applied to examine relationship between visual acuity and relevant demographic (education -in binary logistic model as education level is higher or not than primary one, sex) and health parameters (blood lipid levels, abdominal obesity, fasting glucose level and/or anti-diabetic treatment, blood pressure and/or anti-hypertensive treatment). In generally, the conventional p value of 0.05 was applied.

Results
Main characteristics of the study populations. Age and sex characteristics along with educational level of the study populations and prevalence of components of metabolic syndrome among them are summarized in Table 1. Only subjects with full records were considered in the analysis.   (Table 3A). These data indicate that the proportion of people in all age and sex groups making use of a visual aid is signi cantly less frequent in the Hungarian Roma sample as compared to that of the Hungarian general population. The difference in the use of visual aids was independent of the visual acuity. Both in the group of people with one or two eyes with a visual acuity at least 0.5 and in the group of people with a visual acuity below 0.5 on both eyes the number of people using glasses or contact lenses was signi cantly lower in the Hungarian Roma population as compared with the Hungarian general population. The most striking difference was found in the group with a visual acuity below 0.5 in both eyes (14.3% vs 77.1%, p<0.001) indicating a serious unmet health need in the Hungarian Roma population. (Table 3B.) The effect of different health parameters on visual acuity. We examined the effect of demographic and cardiometabolic risk factors on uncorrected visual acuity using linear regression analysis and found that Roma ethnicity was correlated with a slightly better visual acuity in the whole cohort, while age, abdominal obesity and elevated fasting glucose level and/or anti-diabetic treatment had a negative in uence on the visual acuity values in the entire cohort as well as in both populations apart. Female sex was a signi cant risk factor only among Roma. We could not nd any statistically signi cant correlation between visual acuity values and blood lipid parameters in any of the populations. (Table 4.)  Elevated blood pressure and/or anti-hypertensive treatment ** 1.332 0.441-4.021 0.611 *: average visual acuity for both eyes less than 0.5 or 0.5 and above **: binary covariate

Discussion
We have conducted a three pillars (questionnaire-based, physical, and laboratory investigations) crosssectional study in the Hungarian general and Roma populations in 2018 in North-East Hungary on samples of randomly selected adults aged 20-64 years. We de ned uncorrected visual acuity and the use of glasses and/or contact lenses as well as the effect of demographic, socioeconomic and health parameters on the visual acuity. The only data available on the visual function of Roma came from Spain and showed that this population was more likely to present with vision limitations and showed a lower use of corrective aids than the general population. Contrary to this study, we found that the Hungarian Roma population has a slightly, but signi cantly better average uncorrected visual acuity in every age and sex groups as compared to the Hungarian general population. However, this difference did not translate into a clinically signi cant difference, as the proportion of people with a visual acuity below 0.5 did not signi cantly differ in the two populations. It is noteworthy, that educational level was signi cantly lower in the Roma population in all age groups which could have a great role in their socioeconomic segregation and lower social opportunities. However, association between more years spent in education and myopia as suggested by a previous study 31 could not be con rmed in the present study as educational level had no statistically signi cant effect on the visual acuity. We cannot exclude the possibility that refractive parameters in the Roma population are closer to the normal emmetropy which could be a genetically determined characteristic 32,33 . Cultural and social isolation, as well as high level of genetic consanguinity throughout the centuries has led to a certain genetic segregation of Roma populations [34][35][36] . This is not only characterized by an overload of founder mutations, but also by the lack or decreased frequency of some other pathogenic mutations in these populations. These factors lead to a decreased genetic diversity in the Roma population, but the frequency of rare genetic variants and pathogenic alleles maybe both higher [37][38][39] and lower 16,40 as compared with the general population.
One of the strongest differences between the two populations was found in the use of vision correcting aids. The use of simple visual aids for distance vision, such as glasses or contact lenses, was signi cantly lower in members of the Hungarian Roma population. This difference was con rmed in all age and both sex groups. This difference could not be explained through the somewhat better visual acuity measured in the Roma population, because the proportion of eyes with a visual acuity below 0.5 did not signi cantly differ in the two groups. It is noteworthy, that the largest difference in wearing a vision correction aid was found in the group with a visual acuity below 0.5 with one or both eyes, indicating a serious unmet health need in the Hungarian Roma population. The lack of a proper visual correction in the Roma population may severely contribute to their lower education level, lower social opportunities and lower access to the labor market and nally to their social segregation.
We examined the association of demographic and certain health parameters with the visual acuity. Age, abdominal obesity and elevated fasting glucose level and/or anti-diabetic treatment had a statistically signi cant negative effect on the visual acuity as a continuous variable. However, when visual acuity was analysed as a binary covariate and decreased visual acuity was de ned as vision on both eyes less than 0.5, the only statistically signi cant association was found with the elevated fasting glucose level and/or anti-diabetic treatment in both populations. Elevated fasting glucose and/or anti-diabetic treatment was a stronger risk factor among the Roma population than in the Hungarian general population. This is in line with our previous ndings indicating that elevated plasma glucose or known type 2 diabetes are signi cantly more frequent in the Hungarian Roma than in the Hungarian general population and that the proportion of untreated diabetes is very high (53.3%) in the Roma population 41,42 . Also the proportion of missed glucose check-ups was signi cantly higher in the Roma than in de Hungarian population 43 . It is worth mentioning that in a comparative analysis the Hungarian general population carried a greater genetic risk for the development of type 2 diabetes mellitus than Roma, but in a combined population model the effect of ethnicity was relatively strong on the development of diabetes (OR: 2.484, p<0.001) 44 .
The prevalence of metabolic syndrome (HG: 39.8%, HR: 44.0%) and insulin resistance (HG: 42.3% and HR: 40.5%) was -almost equally -very unfavourable in both populations 28 . In our present study there was a trend for people with higher waist circumference to have lower visual acuity as seen in the linear regression analysis using vision acuity as a continuous variable. However, this association could not be veri ed when using a clinically signi cant cut-off value (UCVA lower than 0.5) and vision was considered as a binary variable. On the other hand, based on the present study one cannot exclude the in uence of central obesity on visual acuity in these populations. This should be further investigated, not only because very little is known about this association, but also because the prevalence of abdominal obesity is strongly increasing in the Hungarian Roma population 42 .
In the Roma population female sex was shown to be an independent risk factor for lower visual acuity, however this should be taken into consideration with precaution as the female sex was overrepresented in the Roma sample and this can be seen as a limitation of the study. This cross-sectional survey was based on randomly selected households, and as we described previously in many households, a proportionally higher number of women were at home during the day when most visits took place, and men at work at another location 28 . The Hungarian government quadrupled the budget for public works between 2010 and 2015 for all Hungarian municipalities. This is especially relevant for villages in the North-eastern region of Hungary, where segregated Roma settlements are concentrated and our study was carried out. The majority of workers participating in the programme are men from deprived Roma communities.
Our results suggest a slightly better average uncorrected visual acuity in the Hungarian Roma population but a much lower use of vision aids as well as a stronger negative effect of diabetes on uncorrected visual acuity in comparison with the Hungarian general population. These results call for public health actions for the improvement of poor primary care indicators on regular eye examination 45 , and a much more rigorous diabetes control within the Roma population 43 in Hungary. These measures could have an important impact on the social integration of Roma people in the Hungarian society.

Declarations
Data availability. The datasets used in the current study are not publicly available due to privacy/ethical restrictions, but are available from the corresponding senior author on reasonable request.