A community-based participatory mixed-method approach on lived water, waste and health insecurity experiences in marginalised Roma communities in Eastern Slovakia

• Environment and health challenges of Roma communities often remain invisible in national statistics, but are well documented in Slovakia • Novel use of participatory visual methods in the context of environmental health in marginalised Roma communities to capture in-depth lived experiences • Unique combination of participatory visual methods with quantitative (HWISE, SanQoL-5) and qualitative data and syndromic surveillance in marginalised communities • Water, waste and environmental hygiene insecurities are main health challenges faced • Working with, and amplifying the voice of a population group at the margins of society With our study in Eastern Slovakia, we aimed to capture lived water, environment and health experiences, implement participatory visual methods in the context of environmental health, apply validated international water insecurity and sanitation related quality of life scales and syndromic surveillance, and uniquely combine participatory visual methods with quantitative (HWISE, SanQoL-5) and qualitative data and syndromic surveillance in marginalised Roma communities, amplifying community challenges and priorities. Data were collected during between October 2024 to May 2025 in three different villages and their included or adjacent Roma settlements from and with people of Roma nationality, and the majority population through survey questionnaire, in-depth interviews, group discussions and photovoice. Water, waste and environmental hygiene insecurities were the health challenges that Roma people addressed most. Water-related perceptions and experiences, and perceptions related to (in)equality differed in Roma and non-Roma respondents, across setllements, and by gender. Roma residents perceived health risks more strongly overall, and reportedly experienced more self-reported symptoms than non Roma residents. Photovoice and related discussions revealed that Roma residents had major concerns with solid waste and the absence of related management, living conditions overall, stray dogs and contaminated surface waters, and resulting health risks. Our direct participatory work with the target population provides a direct, unprecedented and intimate perspective on life within the communities, providing a nuanced, realistic understanding and amplifying everyday challenges faced. Our methodological approach offers opportunities and entry points for application in Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation similarly challenged and complex contexts in marginalised communities at the margins, beyond Roma communities, and beyond Slovakia