All 40 health mediators employed in the Program at the time of the interviews in the 4 GP clusters consented to be interviewed. Their demographic characteristics are shown in Table 1.
Table 1. Characteristics of the interviewees
Characteristics of the interviewees
Number of health mediators in the Program (persons)
Number of interviewees (persons)
Self-identified Roma (%)
High school graduates with maturity exam (GCSE) (%)
In-the-job vocational training (%)
Unemployed before entry into the Program (%)
Part-time position (%)
Three major themes emerged from the content analysis and coding of the interviews. The first related to the personal attributes of health mediators, including their motivation to join the program, their daily life, and the significance of their ethnic identity. The second theme focused on their work-related experiences: relationships with co-workers and clients, their work responsibilities, and their opinion about the operation of the Program. The third theme was related to their views on the future of the programme and their personal plans in the future. The graphical summary of findings is shown in Figure 1 presenting an overview of the model of work experiences including themes, subthemes with their background nodes and also their relationships.
Figure 1. Model of work experiences of health mediators in a primary care model program
[Figure 1 here]
Theme 1: Personal attributes
1.1 Motivation to join the program
Two-third, 25 out of the 40 health mediators had been unemployed before joining the Model Program even though all of them would have wanted to work. One who experienced a long period of unemployment put it this way:
“...it is not the only purpose of my existence to cook and bake at home like a domestic servant. I do want to work in a job, and then also do the housework on top of that.” (4.11.)
Nineteen persons emphasized that their knowledge of the communities and the possibility of helping people was a motivating factor for them.
“First, I like to interact with people, and those who don’t go to the doctor or don’t want to go, I can reach out to them.” (1.2.)
Ten persons mentioned that the local availability of the job and half-time employment allowed flexibility that they needed to also take care of their children.
“For me, it was very good that, I have two children, I need to work in my village, I didn’t have to go to another place.” (4.1.)
Interestingly, only a few of the interviewees mentioned earning income as a primary motivating factor.
1.2 Attitudes to health and self-esteem
All respondents stated that their lives changed for the better by joining the Program. Half of them said that their self-esteem increased since working here. They said they felt greater self-confidence and health-consciousness compared to the beginning of the Model Programme. More than two-third of the respondents considered themselves health-conscious:
“… my life changed a lot, I meet a lot of people, and I, even myself, became more health-conscious since I am working here.” (4.6.)
In one case, confidence even seemed a little stretched:
“...you know, it’s like a synonym, healthcare and I, we belong together.” (1.4.)
Increased knowledge in matters of health, disease and healthcare procedures was mentioned by several mediators who completed a vocational training in assistant health nurse training provided in the Program (20 persons).
“I learned new fields in healthcare … I have knowledge and I know things that I did not know before…” (1.6.)
One interviewee gave a concrete example of her skills that were commended the emergency crew:
“After I finished vocational training, it happened that I came across somebody on the street who was involved in an accident and he was bleeding and I quickly put together a pressure bandage and when the paramedics arrived, they asked who put it on, and they said “good job”. (3.10.)
In terms of their own health, they experienced improvements:
“My health has improved, my spirit is better, and I feel well among people. That fact that we help others makes me stronger too.” (1.4.)
They attributed a major importance to nutrition. Several had participated in nutrition counselling sessions provided by their dietitian co-workers and changed their own families’ diets accordingly. One of them reported to have lost 17 kg during the Program, personally helped by her dietitian co-worker. They considered setting an example and being authentic of outstanding importance.
“I have made up my mind that things cannot go like this at the age of forty that I cannot be locked into my own body, and at this point, I started a lifestyle change, so it was already worth it because of that.” (2.8.)
Several respondents reported that the local population’s trust in them had also increased, and that they had increased authority within the community. One health mediator explicitly said that she was proud to work along a doctor, and that it had an influence on how she and her family were seen by the community.
“We looked at the doctors as if they were gods, we respect them and all. And then we could also enter into their sphere.” (2.1.)
Some mediators expressed an understanding that increased status meant greater responsibility for being healthy and setting an example in order to be a role model to their peers and their children:
“I am not just a health mediator, but a doctor among the children. And the generations who have known me and I’ve grown up with, they look up to me. I am proud of this and the others are also proud of me.” (2.5.)
Some of them felt that people are proud of them, and they respect their person and their work. Their role within the family was also transformed. Their reputation improved in their families; family members supported their work, and their families overwhelmingly (39 out of 40) evaluated their work in a positive light. Some of them reported that they had become more talkative and self-assertive at home as well.
“I definitely speak more, that’s for sure, and I can explain things better also for the children at home. And then [the child] says, ‘Mum, you are not writing a report now, you don’t have to put it in such a fancy way.” (2.10.)
1.3 The significance of Roma ethnicity
Roma (or any) ethnicity was no requirement at recruitment but the job description stated that working with local Roma communities would be part of the job. 72% (29 out of 40) respondents identified themselves as being Roma, four persons identified as Hungarian, three stated to have a dual (Roma and Hungarian) ethnic identity, and four respondents were uncertain. One of the latter put it this way:
“The Roma or Gypsies are a separate ethnic group. But since we do not speak their language or follow their traditions, or do anything else that could be described as Roma, but I am not Hungarian either, at least not that kind of [majority] Hungarian, but ... however, I also do not, I would not consider myself to be Roma either.” (2.4.)
This respondent said she believed she had been chosen for the position because her family occupied a “prestigious” place in the community, and the GP and the locals had all known them and considered them to be reliable. Those who identified as Roma said that they considered their ethnicity important in their work, because Roma health mediators are more at ease in their communication with the local population, many of whom they personally know anyway.
“...Roma people are not easily accessible, and this had to be bridged between the doctor and the Roma, this connection.” (2.1.)
They had been well aware of the cultural differences in the local communities:
“If you want to help the Roma to catch up, then you do have to work with the problematic families. And you have to help them so that they can keep their pace in terms of hygiene and nutrition.” (2.1.)
63% of the respondents considered it important to employ Roma persons in healthcare in general, and all mediators agreed that the employment of Roma in the intervention area of the Model Program was indispensable due to their intimate knowledge and acceptance of Roma culture and behaviour.
“Someone once said that they were going to examine her neck. Because we told them it was a cervical screening [in Hungarian: cervix=neck], so she said, what do they want to look at on my neck?” (2.9.)
Theme 2: Work experience
2.1. Job responsibilities
Health mediators were responsible for getting in touch with those who were invited by letter but did not show up at the health status assessment:
“It is difficult to convince some people to come [to go to the health status assessment]” (1.2.)
They had to get in touch in person with the no-shows, and this gave rise to conflict situations that they made great efforts to resolve (see below). However, others from the community were willing to talk to the health mediators but not with their doctor:
“...the fact that we moved a lot of people who had not seen their doctor, or been to any screenings for years. There were a lot of people coming in to see us who were, let’s say, aware of having some kind of an illness, but not its consequences.” (4.5.)
In addition to recruiting for health status assessment, they also provided help – in accordance with the Rules of Procedures of the Program – to healthcare professionals in the GP clusters in terms of logistics and organization, under the supervision of the public health coordinator.
“…we take blood pressure in the waiting room, not in the GP’s office. But we also go out to the village to grab those who did not show up [for the health status assessment], because this is our main task.” (3.7.)
They also provided help – if requested – to the health visitors who were responsible for the monthly mother-baby clubs, attended by mothers and their babies as well as expectant mothers. Health mediators attended to the babies during the clubs so that the parents (mostly mothers) could pay attention to the presentations and discussions. They participated not only in the organization but also in the implementation of various lifestyle counselling and health promoting programs provided to local groups and communities.
“Afterall, they [local community members] got to know us, because we were present at all those events [for the communities] when anybody could come, and if they [the GP cluster] organized a screening for breast or lung cancer, we were there and we helped everyone.” (4.8.)
2.2 Conflict situations and work relationships
The main conflict situation emerged with local residents who were invited but did not show up at health status assessment. In such cases, mediators received the address of the person, had to get in touch with them in person, and convince the client to come to the assessment. One mediator illustrated the difficulties with one of her own encounters:
“I went to an old man’s house, rang the bell for a long time, and after a while, the man shouted out through the window: ‘I am not at home!” (1.7.)
Two of the mediators reported that they had cases where the person considered this invitation as harassment; in such cases they asked for the help of the physician.
“…[some] did not want to come [to health status assessment] at all. And we had to go next week and the week after, and they took this as harassment…” (2.11.)
Health mediators working with paediatricians frequently encountered problems when checking for lice. However, this has been resolved through their personal knowledge of the mothers and understanding communication. Intimate knowledge of the community and humour worked even in those few cases when the health mediator was male:
“...when we came to check the kids during the examination, and they would always say, look, here’s your mother coming again to check for the lice and everything. They teased him [the male health mediator] with this. But in the end, they got used to that. And they also really like it, they accept it, he’s so proud of me now, they’re so proud of me, I’ll say it like that, and that makes me feel good. Especially now that we have done this training ([in-the-job vocational training], it’s even better.” (2.9.)
Health mediators mostly worked in pairs. Stressful situations that they encountered were typically discussed on the same day with their immediate co-workers, immediate supervisor (the public health coordinator), or with family members. Mediators working with paediatricians consulted the health visitors in relation to problematic cases. Health mediators working in the same GP cluster had a monthly meeting with their supervisor, the public health coordinator during which conflicts could be discussed, and the experiences of mediators could be exchanged.
“If the recruitment didn’t go so well somewhere, and, for example, for those living in B* it always went better, then they would always say that this is the way they do it and we should try that as well. And, then, sometimes it actually worked like that. Or there were times when our way went better, and then we helped them.” (2.3.)
They found work-related administration adequate, and thought they received necessary information for their work, as well as recognition both in terms of their work and personally as well. The majority of the respondents (38 persons) mentioned that they had a good relationship with the public health coordinators (their supervisors), found them helpful, reliable, flexible and empathetic. They thought their supervisors, the public health coordinators treated them as equal partners though all the coordinators had been graduates and tended to be younger than most of the health mediators (hence the reference to them as ‘kids’).
“I think they are very fine kids.” (4.9.)
“They are helpful, because whenever there’s a problem or anything, they help with everything.” (1.6.)
However, 11 mediators thought there was too little communication with the head GP, the director of the entire GP cluster. 4 respondents specifically mentioned that they received the head GP’s approval late for some of their work-related requests. Sometimes they received tasks that were difficult to complete because of a tight deadline. For example, they only received the list of those who they had to invite personally for the health status assessment a few days before the due date. They all received the same-size of white gowns that did not fit all of them. There were instances when the lack of proper space became an issue when the mediators tried to help those who could not fill the health questionnaire themselves.
“They [management] can’t see it that we are put in the hallway for years, I guess just put out there. This was a big grievance for us, because when there was a lot of other patients around, we didn’t really like to read out the questions of a psychological test for everyone else to hear. We had to find somewhere a more private place so the other patients wouldn’t hear us.” (4.10.)
2.3 Opinions in general about the Programme
Respondents highlighted several strengths of the Program. They thought it was well-organised, they appreciated the teamwork and the equal treatment of workers, including the non-medical health professionals such as dietitian, physiotherapist, psychologist. They thought that the involvement of local partners such as the local governments and schools was important, and thought it useful that many programmes were organized in a wide range of settings like kindergartens, schools, retirement homes.
“So, we help to prepare health education lectures, and the organization of programmes. And it is very important, when we go to the kindergarten and school and the children listen to the presentations, and we help [the health professionals] to deliver the program.” (4.7.)
They thought the health status assessment for which all patients of the participating GPs were invited as very important. They cited a number of examples when patients with high blood pressure and diabetes were identified during health status assessment and sent for further examination in time; clients were reached who had not been seen by doctors for years; many persons got encouragement to participate in various extra services not previously provided by the GPs, and the number of children with lice decreased.
“Well, many people turned out to have diseases that they had for a long time but they did not care about. We found a lot of diabetics, those with narrowed [blood] vessels, many-many with high blood pressure.” (3.5.)
“I think the [health status] assessment was the best because people could learn about themselves, their health, and many problems came to light. We found many with high blood pressure.” (2.11.)
They had been aware of the fact that participation at the health status assessment at the time of the interviews had already been high. All health mediators mentioned in some form their own contribution towards this result, attributing an important part to themselves.
“The strength about this, as I said, is that we really reach those people and they go to the doctors, even though they haven’t seen them in years.” (2.1.)
Some put a high emphasis on the mediators’ work:
“I think the strength of this programme would be our work. We are the engines of this whole thing, that’s why I said that there is a need for us.” (1.6.)
Regarding conditions of their own work, they specifically mentioned that bicycles provided to them in the Fall of 2015 greatly helped their work, making their movement in the community much faster and freeing more time for the clients.
“Receiving the bikes was great because we all use it. Not only in our village but going from one village to the other.” (2.11.)
They thought their work eased the burden on the doctors and nurses; the community became more open toward doctors, and the Program set an example for other regions as well.
“Well, I think they became more open towards doctors, they come more often. They now believe more that it [going to the doctor] makes sense. They loved the [health status] assessment, many women came for that. So they are more open, and they think if they have a problem they are in good hands.” (2.10.)
Regarding shortcomings of the Program, they mentioned quite a few. Tools and equipment were not available at the beginning of the Program, and those ordered usually arrived after a very long time (e.g. bicycles and tablets) due to mandatory public procurement. Contracting of the health mediators was delayed, employment certificates for various purposes issued by the Program’s management were received slow and/or late (e.g. one of the health mediators’ child did not receive a scholarship as consequence). Their salaries sometimes arrived late, and twelve mediators had problems with the amount of family tax allowances but four of them could not decide if this was due to miscalculation by management or not; and eight persons had no insight about this at all.
“Shortcoming? I would say missing tools, like things that we would need to do our job, like we did not have bikes and had to walk everywhere … but we always find a solution, so at the end, there is no problem...” (1.6.)
The majority of health mediators expressed their wish to be employed six hours per day or full-time since they found their wages in half-time employment too low.
“Full time [work] would be much better because the money would be higher, and we could fill the hours working because we could do any tasks they [the supervisor] give us.” (2.9.)
“I would love to keep doing this but, let’s admit, the money is slim.” (4.11.)
Theme 3: Future prospects
3.1 Future of the Model Programme and suggestion for improvement
Regarding the continuation of the Program, 90% of the mediators responded that they would like to see the Program continue, including the work of health mediators.
“I believe we can improve this more, take this further, we can think of more things to add to it, we can expand it, I think there are a lot of opportunities in this.” (1.4.)
“I absolutely hope so. I think there’s a big need for this, our work also says that it would be important to have an occupation like this running for longer, either under this name or some other name, but there’s definitely reason for this to exist.” (1.6.)
27 of them said they hoped the Program including their work would continue:
“I don’t have such big plans, really, but I would definitely like to continue doing this work, I would like to continue doing it successfully, to the best of my abilities, I am open to any training or any new work, new areas also interest me, but I think I like this job and I would like to continue doing it.” (1.6.)
In terms of improvement, they suggested to have more community health promotion programmes; at-home screenings for the elderly; more specialist doctors such as dermatologist, rheumatologist; and a wider range of health assessment procedures including blood tests, abdominal ultrasound, screening for cervical cancer and mammography (the two latter were not part of health status assessment because these are organized according to a national protocol), and improved external communication, that is, greater publicity for the Program.
“More advertisement on TV maybe, in newspapers, on the news, on radio, maybe flyers.” (2.4.)
“I was in O*, in the hospital for an examination [escorting a patient], and the Head Physician asked, well, what do I need the blood test results for? Why did I need to have it done? And I told him, but he hadn’t heard about it [the Program]. And I told him, and I said this is great, well they could also have it, it would be good here in O*. And, and he was curious, but we need bigger publicity. We need to advertise [the Program] more.” (2.4.)
They also suggested more training for themselves, particularly improving communication skills; training in informal team building for non-medical workers, and they suggested further in-the-job vocational training:
“I would like to have [another] vocational training in the Program, let’s say social assistant…” (2.1.)
3.2 Personal plans for the future
Two-third of the interviewees (25 persons) had been unemployed before the Program, and twenty-two of them obtained in-the-job vocational qualification in the framework of the Program. Therefore, one of the items in the structured interview related to their plans to continue to work in healthcare after the end of the Program (scheduled for June 2016 at the time of the interviews that was later extended to May 2017). One did not want to continue, and three were uncertain, but the overwhelming majority of the mediators (36 persons) expressed their desire to work either in this position or some similar position in healthcare. They also expressed their willingness to learn new skills or vocation.
“I don’t have such big plans, but I would like to do this work in the future, to work successfully…I am fully open for anything, new training or new work, I’m interested in new fields but I like this work and would do it if I can…” (1.6.)
“I would add that I would like [the Program] to continue. It has been almost three years that I am working here and would like to keep doing it. After all, I signed up because I was interested. So I would like to do this or something similar in healthcare.” (4.3.)