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Family Practice
© Oxford University Press 2001
Vol. 18, No. 4
Printed in Great Britain
Health, attitude to care and pattern of attendance
among gypsy women—a general practice perspective
Arja Lehti and Bengt Mattsona
Lehti A and Mattson B. Health, attitude to care and pattern of attendance among gypsy
women—a general practice perspective. Family Practice 2001; 18: 445–448.
Background. There is a lack of knowledge about health and attitude to care among gypsies.
Objectives. The aim of this study was to explore the reasons for and patterns of attendance
among gypsy women in primary health care and to shed light on health problems of gypsies.
Methods. Four gypsy women, frequently attending a primary health care centre, were interviewed in depth. Data were analysed according to grounded theory. Additional facts were received
from record files.
Results and Conclusions. The gypsy women seldom approached the health centre alone but
paid a visit together with relatives or friends. The women usually presented the same type of
symptoms, often pain, headache and depression, and obtained the same type of diagnosis and
treatment. The symptoms had an acute character and the women wanted immediate access.
A collective pattern, a hierarchical order and a strict rule system characterized the gypsy life and
coloured the relation to health and illness. Young women were especially vulnerable and could
easily end up outside the collective and display symptoms.
Keywords. Attitude to care, collective pattern, gypsy, health, primary care.
sterilizations have taken place.4 Today, 12 million
gypsies live throughout the world.
Background
In literature, opera and film, gypsies are often linked to
freedom and a mysterious way of living, and they are
supposed to be some kind of masters of romance. At
the same time, gypsies are often labelled as causing
social problems. The gypsy people are associated with a
high rate of criminality, and they constitute one of the
few ethnic groups which has not adapted to society in
general.1,2
A number of countries of origin have been attributed
to gypsies.3 By the 19th century, the theory of an Indian
origin emerged. Their language ‘Romany’ is similar to
Sanskrit, and genetic similarities exist between gypsies
and Indians from the Punjab. About 1000 years ago,
gypsies moved westward from India, and in the 14th
century they inhabited several countries in the Balkans.
In the 16th century, the first gypsies came to Sweden.
The gypsies usually move a lot and over the years
they have been subject to different restrictions. Thus
they were prohibited from immigrating to Sweden for
almost half a century from 1914 to 1954, and compulsory
Health status of gypsies
Health and illness are interpreted in different ways.
The dominating perspective is a biomedical view of
the human being. Other explanatory models reflect an
attitude more in accordance with folk tradition and do
not focus primarily on the physical body.5 Gypsies are
said to interpret well-being and illness more from the
latter perspective where fate, rituals and purification
rules influence life and health.6 Health problems among
gypsies are reported rarely, as gypsies are isolated and
often on the move.7–13
In the mid-1970s, a Swedish study on gypsies’ health
and living conditions showed that they were more ill than
other Swedes but they used medical services less. The
prevalence of asthma and chronic bronchitis was higher
among gypsy people than in a control group.14 High
frequencies of diabetes and heart disease, obesity and
smoking among gypsies have been documented in studies
from the USA and UK.15,16 Marriage between cousins is
more frequent among gypsies, and comparatively high
numbers of genetic disorders have been reported.17
Received 19 April 2000; Revised 17 November 2000; Accepted
12 March 2001.
Mariehems Health Centre, Morkullevagen 9, 90651 Umeå and
aDepartment of Primary Health Care, Göteborg University
Vasa Hospital, 4133 Göteborg, Sweden.
Health centre perspective
As a Finnish-speaking doctor, one of us (AL) has met
several Finnish-speaking gypsy women for |7 years at
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Mariehems Health Centre in Umeå, Sweden. Umeå is a
university town in northern Sweden and the catchment
area of the health centre is characterized by people
of various ages and social conditions. Within the area,
social mobility is high and the community provides
apartments for people with a low income in new blocks
of buildings.
The women paid visits to the health centre in unconventional ways and, over the years, the problems of the
women and their ways of attending the service grew
more and more interesting.
The aims of the study were 2-fold. Of prime interest
was to learn more about the reasons for and patterns
of attendance of the women. Furthermore, we wanted
to know more about their health problems and related
conditions of life.
Methods
The four gypsy women most frequently attending during
a 2-year period (attendance rate between three and 13
times) were invited to an in-depth interview. They came
from four different core families. All the women were
informed about the study and it was initially stressed that
participation was voluntary.
The women were between 31 and 40 years of age
and all had been or were married. They had 19 children
all together and were born in Finland. They had lived
in Sweden for 5–20 years and had moved several times.
One of the women was assaulted and maltreated for
many years by her former husband. The women had
attended school periodically; one of them had been at a
Bible school and another had participated in a sewing
course. None had any formal vocational training and, at
the time of the interviews, none was employed. For a
couple of months, one of the women had earlier worked
as a cleaner and another as a trainee receptionist. All of
the women were interested in needlework, which might
be used in possible employment in the future.
The aim of the interviews was to let the participant
explain her situation in her own words. Open questions
concerning health, illness and attendance at the health
centre were asked and the interviews that were performed
at the health centre lasted for 1 to 2.5 hours. The conversations were audiotaped and transcribed verbatim.
The data analysis was based on grounded theory.18 The
transcripts were first read several times and examined
separately using open coding. Keywords and codes were
then discussed and sorted into categories. Afterwards,
the data were re-read by using selective coding. The
categories derived from the open coding were examined
systematically, and concepts summarizing the material
were searched for. Each interview was analysed preliminarily at once.
Another source of data were the medical records of
the women and of available relatives and friends during
2 years, as well as the observations made by one of us
(AL) in clinical practice. This information was shared
and discussed together and used to increase the understanding and to validate the interview data.
Results
All the women agreed to participate initially but they
occasionally displayed a kind of suspicion. They did
not always attend when planned, and unexpected local
events in the gypsy group prevented some of the women
from leaving their homes for certain periods. The process of making appointments for the interviews lasted
for many months.
Attending the health centre
A gypsy woman approached the health centre in ways
different from the majority of patients. They seldom
attended alone; they were accompanied by one or more
relatives or friends, sometimes just as a companion or to
see a doctor as well.
The symptoms had an acute character, and women
often insisted on immediate access, causing irritation and
anger among other patients and staff. Their pattern of
attendance also had a recurrent character. For periods
they attended very frequently (2–3 times a week) and
then for months were not seen.
The women also attended when they were upset by
something extraordinary that had occurred in the gypsy
collective, for example conflicts among the men, including
fighting with knives, or a noticeable contravention of collective rules. Troublesome contacts with authorities, such
as the social welfare, often caused tension, pain and depression, resulting in an immediate visit to the health centre.
Another striking feature was the tendency among
the women and their relatives and friends to attend
the health centre chronologically, closely following each
other. They then displayed the same kind of symptoms
and often were given the same diagnosis and treatment.
Daily life of the women
Hierarchical order and traditional rules. There was a
marked ranking order in the gypsy families. The dominating variables were gender and age; women and youths
were low ranking. Elderly members were shown honour
and respect, and the younger ones took care of their
older relatives. The life of the families included many
rules, which also were hierarchical, and the gypsy women
had more rules to follow than the men.
The limit between what is pure and what is dirty was
often commented on. The demarcation was sharp, and to
be regarded as dirty was a disgrace and influenced their
whole life. Purification rituals were common.
“A woman is dirty because she menstruates and
bears children. After childbirth a woman cannot
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Attitudes of gypsy women to health care
touch anything at home and to dress herself in front
of an older person is disrespectful.”
Intimate relationships. A close relationship and daily
contact with relatives and friends was very common.
Wedding ceremonies and funerals are participated in
and, if a relative was in hospital it was necessary for at
least one of the family to be there. Their lives are characterized by unplanned events by constantly being on the
move.
“It just happens that someone gets sick for (X) in
Finland. Then you must travel there and take your
children with you.”
Collective punishment. If the rules were broken, it
was easy to be rejected by the collective and vendettas
actually existed. According to Swedish law, it is the guilty
party that is punished but among gypsies not even
relatives go free.
One event during the time between interviews led to
the immediate removal of all the ‘guilty’ relatives.
“Things happen that restrict my life. There are lots
of things like that.”
Women’s health
The women attended mostly because of pain in their
neck and shoulders. They suffered from headaches and
even depression. One of the women had been given the
diagnosis ‘collagenosis’ by a rheumatologist but she had
few symptoms due to that, and laboratory tests were
normal. Several doctors had examined the other women
and no organic failure was found. All of the women felt
quite healthy. They thought that one’s way of living
(smoking, alcoholism, physical exercise) and events
around them, and indeed even fate, influenced health
and illness.
Collective view of health. An obvious group view
characterized the women’s attitude to health and illness.
They came together and often had similar symptoms.
A recommended treatment for one was often asked for
by others even if symptoms were mild. A study of the
records afterwards sometimes showed that the treatment by a physiotherapist was most successful if the
woman and her companions got individual treatment
on the same day and as many times as each other. An
obvious group mentality dominated when attending
the health centre as well as in other activities of daily
life.
Discussion
These observations are based on a few interviews with
gypsy women who came from different families. They
knew each other however, and it is obvious that the
way of living, cultural values and their attitude to health
447
and illness were similar among these women and their
families.
Actual literature about gypsy culture confirms many
of the interview observations. The hierarchical order,
the strict rule system, the obvious intimate relationship
with respect for the elderly and the collective pattern are
characteristic for this group.1,2 This pattern has existed
for many years. The women said that today all gypsies
have modern houses in Sweden. This was the one big difference in gypsy living and the only one to have changed
over the years.
The women’s position and the body
The most remarkable discovery from our contact
with these women in the health centre was the young
gypsy woman’s low-ranking hierarchical position. She has
many children and is supposed to take care of the elderly
as well as the children and the home. They do not have
babysitters. The young woman’s life is obviously influenced by the collective control and all its demands, but at
the same time she has a close network and many people
with whom to share troubles and happiness.
The collective control includes most things but not
your own physical body. To take care of one’s body and
its functions is private. A woman’s body from the waist
down is unclean, ‘marime’, because she menstruates, and
it is dishonourable for a woman to show her body or talk
about illness to men or elderly women.
After childbirth, a gypsy woman is also outside the
collective. She is only allowed to be at home for ~30–40
days, but not in the kitchen. While fertile, she is low
ranking and has a more strict rule system to follow. If
she breaks traditions or rules, it is easy to end up outside
the collective. To be outside and separated from the
collective seems to bring on ill health. The tension, body
pain and depression, which were the most common reasons
for attending the health centre, could often be explained
and understood as the collective influence. During the
study, several revenge actions occurred followed by immediate attendance.
Collective pattern and health promotion
The collective pattern of attendance dominated. The
women practically always attended in pairs or in threes,
and similar symptoms were often presented at the same
time. If the collective restricted the individual arena, the
common network was a support for the women. Our
experience is that a gypsy woman with support and
protection from her sisters managed her problems better
and had better possibilities for successful treatment. In
Figure 1, a model of the gypsy woman in her context is
shown.
The collective has a health promotion potential
(intimate relationship, collective view of health) and
means security for the individual. The hierarchical unchallenged order, a traditional system of rules and collective
punishment, has an ill health promotion potential. If you
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References
1
2
3
4
5
6
FIGURE 1 The inner circle of the figure represents the gypsy
collective and its sharp border with the world around.
Hierarchical order, with age and gender as decisive themes,
rules inside the collective. Contravention of rules with risk for
collective punishment will easily lead to being outside the
collective. The young gypsy women are low ranking and run a
large risk of ending up outside
7
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16
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