Gypsy, Roma and Travellers: a review of healthcare engagement needs | Nursing Times

Introduction

Health visitors manage increasingly complex and large caseloads, a trend that is likely to continue (Institute of Health Visiting, 2024). Data sources, such as the census, that are used for policy and service planning may underestimate migration and the numbers of the Gypsy, Roma and Traveller (GRT) population, many of whom are Eastern European, as they are reliant on self-reporting.

The term ‘GRT’ refers to people from a range of ethnic groups living a nomadic lifestyle who are not from a specific ethnicity (UK Government, 2022). The UK government (2022) refers to the following:

• Gypsies (including English Gypsies, Scottish Gypsies or Travellers, Welsh Gypsies and other Romany people);
• Irish Travellers, who have specific Irish roots;
• Roma, who are from Central and Eastern Europe, and constitute more-recent migrants to the UK.

The GRT community faces health vulnerability due to existing health conditions and a poor understanding of UK health systems.

Policy context

UK inclusion law, as set out in the Equality Act 2010, safeguards the GRT population’s identity and culture, ensuring access to health services through reasonable adjustments. Nurses have a heightened duty to uphold respect, dignity and fairness, while confronting discrimination and advocating for vulnerable individuals. These commitments – supported by the Nursing and Midwifery Council’s (NMC’s) (2022) Standards of Proficiency for Specialist Community Public Health Nurses and the NMC’s (2018) Code – aim to eliminate inequality and enhance health outcomes universally.

Despite such policy and guidance, government reports have highlighted ongoing health and societal inequities for GRTs. The Equality and Human Rights Commission (2018) and Office for National Statistics (ONS) (2022) indicated poorer health among vulnerable groups, such as GRTs, compared with the general population. GRT populations often face barriers, such as restricted registration, due to their nomadic lifestyle, and lack of knowledge of the workings of the NHS (House of Commons Women and Equalities Committee, 2019).

The 2011 Census of England and Wales revealed that 14% of participating GRTs rated their health as “bad” or “very bad” – more than twice as many as the White British group (ONS, 2014). Key health concerns, such as neurodevelopmental delay, mental health issues, and high accident and emergency attendance rates are more prevalent among GRTs (Thompson et al, 2022; Maitre et al, 2021, Lynch et al, 2018).

Public policy highlights challenges in identifying and addressing GRT support and health needs because of insufficient knowledge about services on offer, and there is acknowledgment of the need for specialised interventions to enhance the health of members of the GRT community (Unwin et al, 2023). Reports reveal difficulties in accessing basic services, such as GPs, which impacts on broader engagement with the NHS, including with health visitor services (Bewick, 2018).

Health visitors deliver the Healthy Child Programme to all children in the UK. This screening programme offers developmental assessments, as well as health-promotion and health-protection information to promote the best start in life for children. Without knowledge of GRT children moving into an area, this service would not be offered, but a robust information-sharing system regarding the location of children could help overcome this.

Both the NMC’s (2022) proficiency standards for specialist community public health nurses and its (2018) Code emphasise the importance of cultural competence. Ethnographic research, though self-reporting, shows GRTs’ reported willingness to access postnatal services (Ellis et al, 2020). However, negative community perceptions affected engagement, prioritising lived experience over professional input. GRTs felt devalued and homogenised, as reported in the Welsh Government’s (2022) anti-racism plan, and often perceived greater marginalisation and racism compared with other ethnic populations in the UK (Thompson and Woodger, 2020).

Literature review

To identify existing challenges around GRTs’ marginalisation and their unequal health outcomes, and to look for potential solutions, we carried out a review of literature on the subject. Online databases (FINDit, Cumulated Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, Allied and Complementary Medicine Database, and Child Development & Adolescent Studies) were searched using the key search terms ‘gypsy’, ‘Roma traveller’, ‘engagement needs’, ‘specialist intervention’ and ‘experience’ in various combinations, as well as synonyms of these terms. Articles from before 2014 were discounted.

Summaries were read to select articles for relevance before evaluation using the Critical Appraisal Skills Programme tool. All relevant research – except that by James and Southern (2019) – used qualitative methods, which was appropriate as much research focused on understanding the lived experience of GRTs. All authors identified limitations in their study designs, and all sought ethical approval.

Our review of GRTs’ engagement needs revealed three transferable themes:

• Infrastructure barriers;
• Perceived support need and autonomy;
• Health professionals’ cultural competence.

Findings and discussion

Infrastructure barriers

Infrastructure barriers relate to both geographical and organisational barriers, including proximity of GRT sites to services and availability of services that enhance accessibility for the GRT population.

Geographical barriers
James and Southern (2019) found geographical disadvantages that hindered GRTs’ access to services and stated that policy oversight of their nomadic lifestyle aligned with non-health research on GRTs. Key areas noted were engagement challenges in a difficult financial and political climate, and other, more populist, issues often taking precedence over those facing the GRT community.

The Welsh Government (2023) revealed unsafe site locations due to mainstream hostility to this community, which affected health and wellbeing. With health visiting interventions taking place primarily at patients’ homes, non-attendance or non-engagement was an additional complexity linked to vulnerability triggers (McQueenie et al, 2019). Making accommodation or locations of services more local could alleviate engagement hurdles and enable the GRT population to engage with services. This would involve professional confidence and curiosity, as well as community cohesion, so good working relationships with GRT site managers could be established (Institute of Health Visiting, 2024).

McFadden et al (2018) found many predictors for engagement with health services, including location, timing and personnel. James and Southern (2019) highlighted political challenges, pointing out that GRTs are underrepresented politically and in key positions of influence. Overcoming such barriers needs time, understanding and interdisciplinary collaboration (West et al, 2015).

Language barriers
Language barriers pose challenges for GRTs, as many lack English proficiency, which affects health communication (Fernández Reino, 2019). The Equality Act 2010 emphasises the importance of reasonable adjustments. A viable adjustment is employing interpreting services, which is prevalent and cost effective in UK healthcare (Brandl et al, 2020). Use of interpreters improves healthcare access and enhances provision (Brandenberger et al, 2019).

The literature searched revealed inconsistent translator use, however, with missed opportunities for use of interpretation services, leading to incorrect care and reduced confidence in health services (Kang et al, 2019). Well-intentioned professionals may also provide materials in the wrong dialect (Fernández Reino, 2019), risking unclear communication. It is important to employ interpreters and understand how language barriers affect risk.

Perceived support need and autonomy

GRTs’ poor engagement with healthcare services has been observed, for example in universal screening and immunisation programmes (Kühlbrandt et al, 2023). Difficulties accessing such vital services stem from insensitive gatekeeping, needing proof of identification and address (Equality and Human Rights Commission, 2018; McFadden et al, 2018). This occurs despite there being no regulatory need for proof of identity, address or immigration status to access primary care. Kim (2020) highlighted the impact of limited primary care access, leading to delayed emergency care, with increased illness severity.

GRTs often express support needs to access health services (McFadden et al, 2018). Developing professional respect and increasing knowledge of needs among health visitors and community nurses could improve engagement. This could extend to engagement with online health information and services because, as the NHS expands digital services, vulnerable individuals, such as GRT communities, might struggle to access such resources. Policymakers must acknowledge limited access to information and communication technology among GRTs (Watts, 2020).

Perceived lack of support need and valuing experiential knowledge, highlighted in Smith and Newton (2017), also warrants consideration. Nurses should prioritise safety and wellbeing (NMC, 2018), which cannot be guaranteed when individuals can only access non-evidence-based information online or from members of the community. For nurses, non-judgmental, partnership-based approaches can foster enablement and health awareness. In-reach continuity can enhance engagement (Kühlbrandt et al, 2023), but time and effort is needed so trusting therapeutic working relationships can develop.

Health professionals’ cultural competence

Cultural competence can be defined as using a set of skills, knowledge and attitudes in the clinical setting in an intercultural context (Paric et al 2021; Garcimartín and Cerezo et al, 2014). Developing a therapeutic working relationship is crucial for nurses and health visitors to work towards reducing health inequalities. Cultural competence training could enhance empathy by raising awareness of the various GRT groups and their diverse history. Good practice for such training emphasises empathy and compassion through a focused programme that includes all members of the wider team (Gallagher and Polanin, 2015).

Dismissed individuality was a common theme in the literature – GRTs often felt pigeonholed as all the same when, in fact, they may share some characteristics but come from a diverse and rich heritage with different beliefs, customs and health needs (Dyson et al, 2020; Heaslip et al, 2019). In Dyson et al’s (2020) study, participants prioritised cultural competence training over specialist interventions – a salient finding given that another study (Heaslip et al, 2019) found that the next generation of nurses have developed negative views, which should be challenged, but these views were shared by the nurses who were supervising their practice.

Nurses and health visitors are well placed to promote a celebration of difference, challenging common stereotypes and thinking about GRTs on a human level. Box 1 features recommendations on how to improve engagement with members of the GRT community.

Conclusion

Health visitors and community nurses play a crucial role in addressing health disparities, notably for GRTs who experience worse outcomes and access to services than the general population. Our literature review reveals that they face barriers due to physical and attitudinal factors, necessitating improved cultural competence training. GRTs’ willingness to engage sometimes contrasts with professionals’ respect issues, which enhanced training could help to address. Overcoming physical barriers needs time, and inclusive policy and cultural competence programmes are crucial to support this group well.