irish traveller health problems

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Traveller health 'not being prioritised' despite 'shocking' outcomes for children

“WE ARE WORKING with young women who are leaving maternity wards post-pregnancy onto the street, homeless.”

Mary Nevin, a community development worker with Longford Traveller Primary Healthcare Project, told Noteworthy “it’s important for our children to be healthy [and] to be safe” but for the Travellers she works with, this is often not the case.

Hidden homelessness is often to blame for health problems in children, said Nevin, with families living in inappropriate accommodation such as a caravan in a relative’s yard or sleeping on the floor in a sitting room.

“As a result of homelessness, women and their families will not engage with services. It has a huge impact physically, emotionally, and mentally.”

Nevin, a Traveller herself, said she regularly helps mothers who are coming home with a new baby to a “house packed with other family members” and “if someone gets sick, everyone’s going to get sick”.

This year more than any other, due to both the damning Children’s Ombudsman report on overcrowded and unsafe conditions at a Cork halting site as well as the terrible impact of Covid, issues with housing in the Traveller community have hit the headlines.

However, the health implications of living in poor conditions, often with no access to sanitation, electricity and running water, as well as issues including discrimination by health and education providers, have been known by authorities for decades.

These are revealed in the stark health statistics facing Traveller children in every study and piece of Census data available: almost four times higher infant mortality rates than the general population, increased levels of disability at all ages, poor mental health with six to seven times higher a rate of suicide in the Traveller community. The result – a decade lower life expectancy compared to the general population.

At Noteworthy , over the past number of months, we examined supports for Traveller children as part of our TOUGH START investigation. In this part of the series, we looked at health outcomes and spoke to Traveller health workers across the country.

We can today report that:

• The long-awaited Traveller Health Action Plan will be published “soon” but has taken years to develop
• Travellers have the highest rate of perinatal deaths – the number of stillbirths and deaths from 22 weeks’ gestation to seven days after birth – out of all ethnicities
• There was no documented internal discussion that mentions Travellers in relation to the National Maternity Strategy in the months leading up to its publication
• There is no mention of Travellers in HSE hospital staff induction training , in spite of a recommendation in the All-Ireland Traveller Health Study over a decade ago
• Ethnicity identifiers are not being recorded as part of numerous HSE reports, health statistics and, most recently, the Covid vaccine rollout
• Travellers are missing health appointments due to having no postal delivery service
• High rates of Covid in the Traveller community were the “tip of the iceberg and may not reflect all cases”, according to the National Social Inclusion Office
• Systemic issues with housing and education issues are impacting the health of Traveller children

In part one , Children’s Minister Roderic O’Gorman told Noteworthy that “there’s ingrained institutional racism against the Traveller community”. Over the next two weeks will also be investigating systemic issues facing Traveller children in education and housing. 

‘Not getting a start in life’

Travellers face an uphill battle even before birth as Ireland’s perinatal death figures reveal that they have the highest rate of perinatal deaths out of all ethnicities measured.

Perinatal mortality is the number of stillbirths and deaths from 22 weeks’ gestation to seven days after birth and is an important measure of maternity care, with the  World Health Organisation (WHO)  stating it can be used to “assess needs and develop programmes that will reduce avoidable child deaths more quickly”.

Mary-Brigid Collins works with a lot of young mothers through maternal health initiatives run by Pavee Point Traveller and Roma Centre. She is the assistant coordinator of the Primary Healthcare Project in the Dublin-based organisation. 

There’s a huge amount of young babies not even getting a start in life – as soon as they’re born, being taken away. 

The National Perinatal Epidemiology Centre produces a report on this each year – the most recent in 2017 – and each year since 2013 it stated: “While the numbers involved were small, Irish Traveller, Asian and Black ethnicities were overrepresented in the mothers who experienced perinatal deaths.”

Out of these ethnicities, Noteworthy analysis found that Irish Travellers are by far the most overrepresented for the years 2011 to 2017, with Travellers having an average of more than four times more perinatal deaths than expected for their population size.

This trend continued into recent years with seven deaths recorded in Travellers in 2018 and 10 in 2019, from unpublished HSE data obtained by  Noteworthy  through a freedom of information (FOI) and press request.

Other measures relating to maternal and neonatal health are also poor in Travellers, with Collins recently highlighting the low breastfeeding rate in the community – just 2% in comparison to the national average of 56% – at a Pavee Point event for National Breastfeeding Week.

The All-Ireland Traveller Health Study in 2010 – which compiled most of the statistics still used in relation to Traveller health, found that infant mortality – children who die under one year of age – was almost four times that of the general population. One of its key priority recommendations was that: 

All sectoral aspects of mother and child services merit top priority to reduce infant mortality, support positive parenting outcomes and break the cycle of lifelong disadvantage that starts so early for Traveller families.

More recent data show that Travellers are also experiencing more trauma around birth. Irish Travellers are overrepresented in experiencing  severe maternal morbidity  which measures unexpected outcomes of labour and delivery that result in significant short- or long-term consequences to a woman’s health.

Traveller babies are overrepresented in infants undergoing therapeutic hypothermia – a treatment for those exposed to reductions of oxygen or blood supply before birth. 

The latest report on planned home births reported no Traveller mothers were intending to have home births in 2016 or 2017 – both of the two years reported.  

Lack of actions in Maternity Strategy  

Despite all of this, Travellers received just one mention in the National Maternity Strategy 2016-2026 in relation to the “lower average age of mothers giving birth”. No mention of higher infant mortality, no mention of lower breastfeeding rates, not one other mention. 

Noteworthy  found, through FOI , that there were no memos or correspondence within the Department of Health that mentioned Travellers in relation to the strategy in the months leading up to its publication in 2016.

In addition, Irish Travellers didn’t get any mention in the  National Maternity Strategy Implementation Plan – a set of actions designed to implement the 10-year strategy.  

When asked about this lack of mentions, targeted actions and lack of internal discussion, a spokesperson for the Department of Health said that the pathways within the strategy “are designed to ensure that every woman can access the right level of care, from the right professional, at the right time and in the right place, based on her needs”. 

The Department spokesperson added that consultation, both online and in person, was conducted and as a result of this a number of “key recommendations” were made in the strategy “in the areas of targeted additional supports, tailored information and cultural sensitivity”.

The  consultation summary  reported that “specific groups, such as Travellers, reported feeling stigmatised, which made them reluctant to engage with services for future pregnancies” and also mentioned that “interpersonal skills of healthcare professionals is very important”, using the example of the label ‘Traveller’ and not the care requirement, being put on a cot to ensure appropriate feeding in the context of a metabolic disorder.

“It’s very important that we are included in all these pieces of research and strategies,” Collins told  Noteworthy , but added that Travellers should also be included in the resulting targets and plans. 

Lynsey Kavanagh, health researcher and policy analyst at Pavee Point, said that this type of “one-size-fits-all policy is developed for the mainstream” but “when groups aren’t equal, you need targeted measures to ensure equity of outcomes”. 

There was also no mention of Travellers in any of the following maternity-related reports : National Women and Infants Health Programme Report 2020, Development of Supported Care Pathway Irish Maternity Services 2020 or Irish Maternity Indicator System National Report 2020. 

When asked about this, the Department spokesperson said that these “deal with progress made or reports on specific metrics and were not designed to cover ethnicity issues”.

A spokesperson for the HSE also noted that ethnicity is not included in the Maternity Safety Statements which contain information on metrics covering a range of clinical activities and incidents, including perinatal deaths.

They added that these reports are “reviewed by the HSE’s National Women and Infant’s Health Programme and discussed with the six maternity networks at the regular meeting” and though ethnicity is not included, they “do focus discussion about challenges associated with perinatal mortality and actions that may be required”. 

‘Outcomes-focused approach’ is key

Lack of targeted actions or specific mentions across a range of Government strategies, policies and implementation plans was an issue highlighted by almost all Travellers that spoke to  Noteworthy  over the course of this investigation. 

When we asked Minister for Children, Equality, Disability, Integration and Youth Roderic O’Gorman about this, given many issues disproportionately impact the Traveller community, he said that with the review of the National Traveller and Roma Inclusion Strategy (NTRIS) happening this year, a “more outcomes-focused approach” is key. 

NTRIS is the Government policy framework for addressing the health and other needs of Travellers. In relation to health, it contains over 30 actions across four themes.

O’Gorman said that currently NTRIS is focused on actions such as “implement a policy” or “pass a law” but what people really want to see is “tangible outcomes” such as by a certain date, there will be a certain increase in Traveller-specific accommodation. 

These targeted and measurable actions with dedicated funding behind them are what Traveller advocates told us they will be hoping for when the long-awaiting Traveller Health Action Plan is published. 

This action plan was one of the main recommendations made by the All-Ireland Traveller Health Study over a decade ago and there is a commitment in the Programme for Government to implement it.

It is also a key NTRIS action and one that Pavee Point’s Kavanagh uses as an example of the lack of implementation of key parts of the Government’s inclusion strategy. “We’re 11 years trying to fight this battle,” waiting for this plan.

The Traveller health researcher welcomed the plan’s consultation process in 2018, but said Travellers on the ground and Traveller organisations are frustrated because they “just don’t see Traveller health being prioritised despite really shocking [health] statistics, which were exacerbated even more during Covid”.

Michelle Hayes, project manager at the HSE’s National Social Inclusion Office said they will be publishing the action plan “soon” and that it is her understanding that it “will be resourced and that there will be further resources for Traveller health in the coming years”.

A spokesperson for the Department of Health (DOH) said that “consideration of the plan and its resource implications has been delayed by the prioritisation of the rollout of the Covid-19 vaccination programme”. They continued: 

The Department is committed to providing the leadership and resources to ensure the implementation of the plan by the HSE.

Noteworthy  sought all DOH records from 2018 to the end of August in relation to the the action plan – including minutes of meetings and reports – but none were released as they contain “matter relating to the deliberative process”. 

However, the FOI response does reveal that over this 2.5-year period there were 23 records relating to the plan, mainly internal interactions or updates and emails between the HSE and DOH. All four in 2021 relate to the DOH seeking comments or sending observations on the draft plan.  

Though the HSE was a “key partner” during Covid, when it comes to Traveller health, Kavanagh feels “there is a block somewhere in the Department of Health” and a “lack of prioritisation”.

In addition to the slow development of the action plan, Kavanagh uses the example of  the National Traveller Advisory Committee not meeting since 2012.

When this was brought up in the Dáil in 2018 then Minister of State at the Department, Fine Gael’s Catherine Byrne, said that ”there is ongoing and extensive engagement with Traveller organisations” in regards to health inequality experienced by Travellers. 

However, Kavanagh said that the advisory committee was “was a mechanism to develop Traveller policy and work with the Department”. She added: “We see his as a huge gap because we don’t have a direct relationship with the Department.”

She also told  Noteworthy that Traveller health has received no new development funding since 2008, following austerity cuts – with the exception of some funding provided by initiatives through the Dormant Account Funds. 

Though this was raised in the Joint Committee on Key Issues affecting the Traveller Community in 2019 , when then Minister of State at the Department of Health, Fine Gael’s Jim Daly, stated the Department was “open to suggestions” for new development funding for Travellers, Kavanagh said there was no new funding was in recent budgets. 

When funding is provided, it does work, she added. The health researcher cited primary healthcare projects that targeted cervical smear and breast cancer screening, with uptake in Traveller women almost double that of the general population. 

Childhood trauma impacting health

In addition to stark outcomes facing Traveller babies, older children continue to have poorer health than the general population. For every disability documented in the 2016 Census, Traveller children have a higher proportion recorded than the general population. 

For under 15s, the percentage of Traveller children with a disability increased from 8.6% to 9.2% between the 2011 and 2016 Census, with boys being most impacted by all disabilities recorded. This is consistently higher than the level of disability in under 15s in the general population – 5.4% in 2011 and 5.9% in 2016.

The rate of disability worsens – with a growing gap between Traveller children and the general population – in older age groups. 

One issue that all Traveller healthcare workers brought up with  Noteworthy was poor mental health among all ages, which they said often go back to issues relating to childhood trauma.

The 2010 All-Ireland Traveller Health Study found that suicide represented 11% of all Traveller deaths. It was reported to be seven times higher in men – most commonly in young men aged 15-25 – and five times higher for Traveller women than the general population.

Over a decade later, suicide continues to be a problem in the Traveller community. The HSE gave  Noteworthy  initial findings of a study underway in the National Suicide Research Foundation examining emergency department presentations due to self-harm and suicide-related ideation.

Though still in progress, the study already found the highest rate of self-harm was observed among Traveller patients aged 50 or older, with Traveller men between 30 and 39 years having the highest risk of presenting with suicide-related ideation.

Patrick*, a Traveller community development worker from Cork City, said “you have to go back to the early days of school, children being segregated, people having childhood trauma, bringing that throughout their lives”.

Segregation policies were present in schools for Travellers throughout the last century, with activists saying that they continue today through the use of reduced school days. This will be the main focus of the next part of our TOUGH START series examining education – out next week.

Adverse Childhood Experiences (ACE) are potentially traumatic events that occur in childhood and are linked to chronic health problems, mental health conditions, and substance use problems in adulthood. Patrick said he often sees this in the Traveller community:

A lot of community I know of through a personal capacity and through my work would have had issues of childhood trauma and would have never engaged with a service to deal with that. 

He felt that not feeling valued by Irish society plays a huge part in this with “decades and decades of fallout” from the 1963 Report of the Commission on Itinerancy  which framed  Traveller culture and way of life as a ‘problem’. This “has had a generational impact on people’s mental health”, added Patrick.  

Children he works with often have a bleak outlook on life as “from a very young age, they are made feel very different and not wanted”.

Patrick spoke of one seven-year-old he worked with recently who was shocked to realise that Patrick was a working Traveller man as the boy felt he would not be able to get a job in the future. “Imagine all the issues that child will face going forward if that’s their outlook.”

He also said some were left isolated in council estates as “all the settled children were told not to play with the Traveller children”. 

When asked if the HSE has any tailored mental health programmes aimed at Traveller children and young people, a spokesperson listed services and mental health supports for Travellers that it, as well as NGOs, provide – including initiatives in collaboration with Traveller organisations around the country.

The spokesperson added that the HSE has recruited eight out of the nine mental health service coordinator posts “to support access to, and delivery of, mental health services for Travellers in each Community Healthcare area”.

A ‘ceiling full of black dots’

Poor accommodation was also listed by every Traveller advocate we spoke to for problems with mental health as well as other – often chronic – health conditions. 

In the recent Children’s Ombudsman report, it stated that one parent on the halting site “advised that their mental health team told them that their children’s poor mental wellbeing were linked to their living conditions”. 

Overcrowding – according to one of the Ombudsman’s findings – “has resulted in serious risks on the site which present a real and present danger to the safety and health of children”. 

Mary Nevin sees a “very high number of children with asthma and other types of chronic illnesses” in her work as a community development worker in Longford.

She was recently helping rehouse a woman with an asthmatic baby living in damp and cold private rented accommodation. She said that Travellers are looking for the basics and are not looking for luxury.

Missed health appointments

During the course of this investigation,  Noteworthy  uncovered an obstacle to healthcare that is very specific to the Traveller community – access to the postal service. 

Pavee Point’s Collins, who lives in a large Traveller group housing scheme, said that no post has been delivered to the over 60 families living there since 2018. She said there have been similar issues on a number of halting sites as well as temporary sites.

To pick up their post, Collins and her neighbours have to travel to their local sorting office which she said is a 35-minute walk, with no direct bus route. “A huge amount of people can’t even get to their post.”

This has resulted in people missing health appointments – something that can result in them or their children being removed from patient lists due to non-attendance policies in most hospitals. “That’s having a huge impact on people’s health,” explained Collins.

The reason the residents were given by An Post for ceasing delivery was that there were loose dogs in the area, the advocate said, but she felt frustrated that delivery was stopped to all houses – not just those with dogs. 

By law , on every working day, An Post must deliver to the home of every person in the State, except in such circumstances or geographical conditions deemed exceptional by ComReg.

Noteworthy asked An Post if they plan on resuming postal deliveries to this specific group housing scheme and also for figure on the number of Traveller housing units and halting sites they do not deliver to. However, at the time of publication, no response was provided.

We also asked ComReg is they were addressing this lack of service provision by An Post. A spokesperson said that it “is not aware of, nor has there been any complaint to ComReg from any addresses [in the specific Traveller group housing scheme], of disruptions to the provision of the universal postal service by An Post”.

Collins said they are currently trying to sort out the issue with An Post head office.

Literacy a barrier to children’s health

Even if Travellers do receive their health-related letters, low levels of literacy in the community can have an impact on care. 

“Female literacy is a strong determinant of child health and is recognised by WHO,” according to Dr Margaret Fitzgerald, public health lead for social inclusion and vulnerable groups at the HSE National Social Inclusion Office.

When it comes to health literacy, the All-Ireland Traveller Health Survey found that half of Travellers who take prescription medications have difficulty in reading the instructions.

In addition, better provision for those with literacy problems was one of the top actions that Travellers said would improve their health and wellbeing, alongside better accommodation, education and uptake of preventative care services. 

From her work with Travellers, Collins has seen the impact of this on maternal care and breastfeeding uptake. 

One woman who “wasn’t able to read” and “had literacy problems” was given a book with hundreds of pages of information on pregnancy. “She got the book and put it in the bin as it was no good to her.” 

To help with this, the Pavee Mothers initiative – which is funded by the HSE National Social Inclusion Office – published a book and an online resource that “was culturally appropriate and was by Travellers for Travellers”. This month, a new booklet was launched to promote breastfeeding in Traveller women.  

However, when it comes to health, Traveller health workers mentioned trust and fear frequently when they spoke to  Noteworthy . 

Nevin encounters this regularly in her work in Longford and said that “sometimes doctors can use very highfalutin’ words so language can be a barrier”. It can be difficult to build trust, she explained, as “Travellers have been let down so many times”. 

Mothers and families can also be fearful of health services for children “because they don’t have the appropriate accommodation” and worry about social worker involvement.

No mention in induction training

One way of addressing this is cultural training for healthcare staff. One of the recommendations of the All-Ireland Traveller Health Study was that a section on Travellers be included as part of routine staff inductions for hospitals with a significant Traveller catchment population. This was also recommended for GPs with a Traveller list.

Through FOI, Noteworthy asked a number of hospitals that treat children for staff induction training records such as reports, policy documents, presentations and information materials that related to Travellers.

This included CHI Temple Street, Crumlin and Tallaght as well as the paediatric section of the six hospitals in areas with a large Traveller catchment population – Cork, Limerick, Galway, Wexford and Drogheda.  

The response from all Children’s Health Ireland (CHI) hospitals stated that their induction content doesn’t include “any reference to the Traveller community”. All of the other hospitals provided a similar response.

The statement from Our Lady of Lourdes Hospital, Drogheda, added that guidelines on newborn screening in the Traveller community form part of midwifery education in the college curriculum and this is “supported with practical education during clinical placements”. 

When asked if any HSE hospitals include a section on Travellers as part of routine induction of staff, a HSE spokesperson said that “Traveller organisations and the Primary Health Care for Traveller projects around the country provide cultural awareness training on an ongoing basis in response to requests from health service providers”.

They added that with Covid, “they are recommending use of the eLearning module [Introduction to Traveller Health] until this can be complemented with face to face training post-Covid” and this is available to all staff through the HSE’s learning and development portal. 

Cultural awareness builds trust

All Traveller advocates we spoke to felt Traveller cultural awareness training was important in healthcare. Traveller community development worker, Patrick*, said people can “have stereotypical views based on negative media” and assumptions can be made.

This training “works to break down those stereotypes and educate people about who Travellers are and what the needs are in the community” which results in better engagement in services.

Training was also important to Nevin, but she said that alongside it, having Traveller-specific workers integrated across the health services is also needed. “A peer-led support available to a Traveller who may feel vulnerable and fearful to engage with health and nursing staff” would make it a lot easier for Travellers, she explained.

This is particularly needed in maternity wards, she added, where Traveller workers could not only support Travellers but also be able to support nursing staff and doctors. 

A HSE spokesperson said that “the National Social Inclusion office have provided funding for two Traveller specific maternity resources to support Traveller women’s engagement with the Maternity Hospitals”. They said this “is in response to the challenges identified by Traveller organisations on the ground”.

Dedicated healthcare workers for Travellers also enables greater trust, according to Nevin, who has seen this first hand when they had a public health nurse specifically for Travellers in Longford. 

Because of the bond the public health nurse had built with the community, more women were connecting with the nurse and if mothers with small babies had a problem, Nevin said that they felt “they could talk to that nurse about ailments”.

However, their last Traveller specific nurse left for another job in 2018 and wasn’t replaced since. Nevin said because of this young women are being left untreated, and this has been exacerbated more due to Covid. 

The community worker knows of one mother with a young baby who was hospitalised with postnatal depression, but Nevin felt she “wouldn’t have needed to go to hospital if she had been seen a little bit earlier”.

When asked if this public health nurse was going to be replaced, a spokesperson for the local HSE community healthcare organisation said that “the Longford Westmeath Travellers health post will be filled when transfers off the national panel are completed”. They did not give a timeline or date for when this would happen. 

The added strain of Covid

Pavee Point’s Collins also said that Covid has not helped the situation in terms of Traveller health, with isolating a huge problem within the Traveller community. She added: “You knew you had to do it, you wanted to do it, but it was very difficult to do it.”

Collins lives in a four-bedroom house but with eight others living there, when she had Covid she found it difficult to isolate from her children and grandchildren.

She, alongside other Traveller healthcare workers across the country, were on the ground throughout the pandemic helping with the response and distributing information on prevention measures, testing and the vaccine.

Having Traveller primary healthcare projects already running meant the HSE had somebody to bring materials “straight to the doors” by people who were Travellers themselves, according to Hayes from the National Social Inclusion Office.

There was also “huge cooperation” on sites, said Hayes. “Families themselves were brilliant in outbreak situations – before we even get to the point of engagement, they would already have reorganised themselves.”

Travellers were among the hardest hit by Covid, with over 5,200 cases between March 2020 and April 2021 . That was three times the rate of the general population. To put those case numbers in context, there were just over 30,000 Travellers recorded here in the last Census. 

The community was also sicker from the disease, with a hospitalisation rate (4.5%) nine times that of the general population (0.5%).

Outbreaks were a regular occurrence, with more notified in Irish Travellers than any other vulnerable group recorded by the Health Protection Surveillance Centre.  

‘Tip of the iceberg’

“At the beginning of Covid, we were very cognisant of the challenges and we knew that we were going to have problems with some of our vulnerable groups,” the HSE’s Fitzgerald told Noteworthy .

“We tried to put in place quite a significant amount of prevention, awareness and a response,” she explained. “Generally it worked very well. But what we feared did happen, and we saw particularly high rates of Covid in Travellers.”

Fitzgerald said the high rates in Travellers were “the tip of the iceberg and may not reflect all cases”. Though Travellers “weren’t that sick” during the first and second waves, she said that “by the third wave they were”. 

By the end of the latest wave, there were nearly 250 hospitalisations, 28 people in ICU and 15 deaths in the Traveller community, according to Fitzgerald. Those in ICU included young pregnant women. 

Many Travellers were presenting later and sicker in the second and third wave due to, Fitzgerald said, “a combination of culture and social isolation”, including finding it difficult to source medical attention because some “had disengaged from mainstream health services”. 

During the pandemic, the HSE “never had such an intense engagement with Traveller health units” and organisations, with “Travellers themselves looking for HSE involvement and health advice”, she added.

When asked if enough was done to address problems with social isolation and other issues encountered by Travellers during the pandemic, a spokesperson for the Department of Health said that there were “concerted efforts by departments and agencies to protect this group from Covid-19″. 

The spokesperson said that the Department of Housing “acknowledged the constraints facing people who live in halting sites in adhering to public health advice” and that additional accommodation and sanitary services were provided.  This will be covered more extensively as part of our article on Traveller accommodation – out later in this series.

The production of guidance of vulnerable groups, other HSE measures as well as work by the HSE Social Inclusion and Primary Care teams were also listed by the spokesperson, who continued: 

“Overall, the impact of Covid-19 was greatly minimised by an intensive and collaborative response from government, the HSE and civil society. Socially excluded groups were prioritised and received priority action in terms of detection, case management and contact tracing.”

Given the large number of cases that occurred, Pavee Point’s Collins is worried about the future impact of the disease and felt “the long-term effects of Covid are going to be showing up” across the community – one which already has a significant disease burden.

‘Not systematically recorded’

Though the Health Protection Surveillance Centre reported outbreaks in Irish Travellers, ethnic identifiers were not a standard part of the pandemic response and are not integrated into the health service – or many other State systems. 

For instance, it was recommended in the ‘HSE Vaccine Approach for Vulnerable Groups in Ireland’ report by the HSE National Social Inclusion Office in March 2021, that ethnicity be included in data capture to monitor progress. However, this was not implemented in the Covid vaccine rollout.

The HSE’s Fitzgerald said this was due to the “cyber attack and because of the difficulty with recording ethnicity” which she added is seen “across the whole government system” as it is “not something the State gathers, as a routine”. 

Noteworthy asked the HSE about this as well as the vaccine uptake in Travellers by age group but did not receive a response to this query before publication. 

Adding ethnicity to all datasets is something that the HSE National Social Inclusion Office has been advocating for many years, according to Hayes. She felt that once the health system is joined up with a unique identifier, that an ethnic identifier would be included. “It would be ridiculous if not,” she added.  

Lack of ethnicity data collection in Ireland contrasts with the UK  where over 90% of general practices have ethnicity data recorded. Over 80% of acute inpatient and day case records in Scotland also include this data. 

When asked about the use of ethnic identifiers, a HSE spokesperson said that “a number of hospitals and health services” are collecting data as per the ethnic categories in the Census, which includes Irish Traveller. These include the Rotunda Maternity Hospital, CHI Temple Street and other services include the Child and Adolescent Mental Health Service.

There is a commitment to incrementally roll out the Ethnic Identifier in the National Traveller Roma Inclusion Strategy as well as a commitment in the forthcoming National Traveller Health Action Plan (NTHAP) using the learning emerging from these programs to roll it out further in the health services.

The lack of an ethnic identifier means that much data and statistics relating to Traveller health come from academic research, Census data – now five years old – and the All-Ireland Traveller Health Study – over a decade old. 

When  Noteworthy asked the HSE for more up-to-date information on suicide in Travellers, a spokesperson said that the Central Statistics Office (CSO) is the source of official suicide data and its sources include findings and verdicts from Coroners.

However, the spokesperson added that ethnicity “is not systematically recorded” across the Coroner system. “Therefore official, complete data on suicide rates in the Traveller community is not available.”

Noteworthy was also unable to obtain records of Traveller complaints in the same eight hospitals we sent an FOI to in relation to induction training due to a lack of ethnic identifier in complaint data. 

A whole-of-government approach needed

Though the data may not always be recorded, inequity between the childhood facing Travellers and their peers in the settled community jumps out from every statistic that is available. So, what can be done to close this gap and improve Traveller children’s health? 

The HSE’s Fitzgerald said there “had to be greater investment in primary care and resourcing [of] Traveller community health workers”. She added that “Traveller children need wraparound care and support” with other sectors also needing to take action. 

Pavee Point’s Kavanagh said that “it’s not just the HSE’s role to address Traveller health inequalities, but a role for all government departments”.

Kavanagh added that “the fact that Travellers are a really young population is indicative of health status” which is in turn “indicative of institutional racism, appalling living circumstances [and] severe overcrowding”.

In 2016 , almost 60% of Travellers were under 25, almost double that of the general population (33%), with just 3% aged 65, less than a quarter that of the general population (13%) .

Community development worker Nevin also felt sorting out the bigger picture – including housing and education – is important to “improve the lives of all Travellers”.

“Our children are our future and it’s important they are treated with the respect and dignity, are able to get an education, go to further education and make an impact in hospitals, council offices, right across the board.”  

*Name has been changed. 

This article is part of our  TOUGH START  investigation being led  by  Maria Delaney  of Noteworthy and  Michelle Hennessy  of The Journal. Over the next two weeks will also reveal systemic issues facing  Traveller children in education and housing.  

This Noteworthy investigation was done in collaboration with The Journal. It was funded by you, our readers, with support from The Journal as well as the Noteworthy  general fund  to cover additional costs.

You may be interested in a proposed investigation which is almost funded –  BLIND JUSTICE  - where we want to look at the experience of Travellers in the justice system.

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Joint Committee on Key Issues facing the Traveller Community publishes final report

2 dec 2021, 10:50.

The Joint Committee on Key Issues affecting the Traveller Community has published its final report into inequalities faced by the Traveller Community, today Thursday December 02.

The report examines the stark inequalities of opportunity and outcome faced by the Traveller Community in the areas of health, education, employment and accommodation and recommends policy directions to mitigate the effects on the Traveller Community.

The Committee met with a large number of stakeholders including Ministers and Government department officials, state agencies, NGOs and advocacy groups and most importantly, representatives from Traveller organisations, both national and local.  

It is the Committee’s view that Traveller voices must be central in any examination of the issues faced by them, and that no solutions will be found for the serious inequalities faced by Travellers without the engagement and collaboration of the Traveller community themselves.

Launching the report, Committee Chairperson Senator Eileen Flynn said: “It gives me great pleasure, as someone who comes from Labre Park, to be able to chair this committee and open up those opportunities to many more Travellers. Travellers are one of the most studied groups in society. Over the years there have been numerous reports and studies produced which have highlighted the extreme difficulties and challenges faced by the Traveller community. Unfortunately, it is clear that these have not succeeded in improving conditions in Travellers’ lives.”

 “The Committee visited several Traveller accommodation sites around the country, to allow members to see for themselves the conditions Travellers are forced to endure, and to meet with residents and hear their experiences first-hand. Following the publication of the landmark No End in Site report into the Spring Lane halting site in Co Cork by the Ombudsman for Children’s Office – it is clear that such living conditions for Travellers can no longer endure.”

“Deficient and substandard living conditions precarious accommodation and homelessness have severely detrimental effects on both mental and physical health, and brutally impact Traveller children’s ability to thrive in education. Lower educational outcomes have a damaging impact on employment opportunities. Chronic unemployment causes stress and has negative consequences for mental health. These issues will not be solved in isolation and must be tackled through a whole of Government and a whole of society approach.” 

“Despite the dire conditions on the sites we visited, the Committee was particularly struck by the pride and care taken in the homes on site. The Committee offers a special thanks to the residents for welcoming them into their homes and sharing their stories and experiences.”  

“Travellers were particularly impacted by the pandemic due to their unsuitable living conditions. Living in overcrowded conditions prevented many Travellers from self-isolating when required to do so by public health guidelines. The lack of access to running water also made it difficult to comply with guidelines on hand hygiene. It took Covid-19 for some families to get water and portable toilets as a temporary emergency measure. There should be an immediate report prepared in relation to the effects of the Covid-19 pandemic on the Traveller community, and appropriate actions should be taken to address all concerns raised in this report.”

“I can’t stress this enough, the recommendations must be implemented. It is no exaggeration when I say that if these recommendations are implemented, they would create opportunities for Travellers that were not there before. This report will mean nothing if the recommendations are not implemented. Most importantly, it would mean a loss of hope for many Travellers who need those actions to be implemented as soon as possible.”

  The full report and its recommendations is available to read on the Committee’s webpage.  

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Irish Travellers suffer a disproportionate burden of physical health conditions, review finds

by Trinity College Dublin

In a review published in the open access journal BMJ Open Trinity researchers, led by Dr. Julie Broderick, head of discipline of physiotherapy, school of medicine, have presented findings showing that Irish Travellers suffer a disproportionate burden of physical health conditions with common conditions like metabolic syndrome, asthma, bronchitis, and tuberculosis 2–3 times more prevalent in Travellers compared to the general Irish population.

For the first time, all available evidence across published reports and peer-reviewed journals, along with gray literature was pooled, reporting physical health conditions of Mincéiri or Irish Travellers, up to 4 April 2023.

Eleven unique studies (20 reports) were included in this scoping review, including n=7,397 participants. One study took place in England and Wales, while the remaining studies took place in Ireland, North and South.

Dr. Broderick said, "Pooling the available evidence together really highlighted marked health disparities between Travellers and comparable figures from the general Irish population. The prevalence of a number of respiratory and cardiac conditions was two to three times higher in Travellers. Some rare conditions were described and there was a high injury profile in Travellers."

"We very much valued the input of a member of the Traveller community, Amy Ward who co-authored this work. Amy provided important direction, ensuring that the Traveller voice was integrated throughout the entire review process, which has enhanced the relevance and real-world impact of this work."

Amy Ward, member of the Traveller community, said, "I really see the value of collating this information which makes an important contribution to our knowledge of health in Travellers. I'm hopeful that this will be a springboard for a broader piece of work that could eventually see tangible improvements in the lives of the Traveller community."

Key findings

• Conditions like metabolic syndrome , asthma, bronchitis and tuberculosis were 2–3 times more prevalent in Irish Travellers compared with the background population.
• In Travellers under 65 years there was a higher rate of intentional injuries and a lower rate of unintentional injuries compared to the general population.
• Travellers over 65 years had higher rates of injury compared to the general population, highlighting their vulnerability.
• Unique health considerations of Travellers should be noted. Although numbers were small, some rare conditions were described within this review, such as type 2 hyperprolinemia and leukoencephalopathy with brain calcifications and cysts.
• Some findings suggested the possibility of health benefits associated with a distinct gut microbiome linked to the traditional Traveller way of life, although how this has changed with modernization is not fully known.
• Common conditions like cancer and arthritis were minimally reported within this review, so more data is needed on the prevalence of these in Travellers.

Implications of these findings

This review indicates a significant health disparity between Travellers and the general population.

Researchers suggest that providers of care for Travellers should be aware of the unique and disproportionate burden of physical health conditions experienced by this group.

Current health care provision needs to be more responsive to the needs of Travellers, and more broadly needs to address prevention strategies and address the social determinants of health such as housing, education, employment and income which are strongly associated with poor health.

Dr. Broderick concluded, "Providers of care for Travellers should be aware of the unique and disproportionate burden of physical health conditions experienced by this group."

"While it was outside the remit of this review to make specific recommendations, it would appear that current health care provision needs to be more responsive to the needs of Travelers. More broadly, the social determinants of health should be targeted such as housing, education, employment and income which are strongly associated with poor health ."

"We very much valued the input of a member of the Travelling community, Amy Ward who co-authored this work. Amy provided important direction, ensuring that the Traveller voice was integrated throughout the entire review process, which has enhanced the relevance and real-world impact of this work."

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Mental Health of Irish Travellers

An East London Perspective

• Reference work entry
• First Online: 18 September 2021
• Cite this reference work entry

• Finola Cullenbrooke 7 &
• Susham Gupta 8 , 9  

Part of the book series: Mental Health and Illness Worldwide ((MHIW))

1861 Accesses

Irish Travellers are a minority group who often move from place to place. Their patterns of migration are of interest. Although they originate from Eire, there are under-reported census figures. They have very strong patriarchy and family connections which affect help-seeking and it is crucial that families are engaged in a culturally appropriate and sensitive way to deliver services which will be acceptable. There is no doubt that Irish Travellers among other nomadic groups face high levels of social discrimination which can contribute to poor acceptance and rejection which in turn affects their help-seeking. The challenges faced by them are complex and often contribute to low socioeconomic status and poverty which affects their wellbeing. Additional factors like globalization, changing employment markets, financial insecurities, and altering gender roles can add to further stress in these groups thereby marginalizing them further. Lack of stable and reasonable accommodation can add to stress.

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Finola Cullenbrooke

Early Intervention of Psychosis, East London NHS Foundation Trust, London, UK

Susham Gupta

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Cullenbrooke, F., Gupta, S. (2021). Mental Health of Irish Travellers. In: Moussaoui, D., Bhugra, D., Tribe, R., Ventriglio, A. (eds) Mental Health, Mental Illness and Migration. Mental Health and Illness Worldwide. Springer, Singapore. https://doi.org/10.1007/978-981-10-2366-8_31

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Home > View All > Irish Traveller Health

Irish Traveller Health

• Written on 30/08/2022
• , Last updated 09/10/2022

Cite this article as:

You are on shift in your emergency department in London. You ask your registrar, who has recently moved from Ireland, to review one of your patients. He notices that the family are members of the Irish Traveller Community. You have never heard of this group of people and decide to quiz your registrar.

Who are the Irish Travellers?

The Irish Travellers are an Irish ethnic minority group with a proud history and culture. They have a value system, language, customs, and traditions, that make them an identifiable group, both to themselves and others. Nomadism and family are the core features of their identity. Early and arranged marriage, large families and consanguinity are cultural norms.

But I wouldn’t meet them in the UK, right?

Irish travellers don’t just live in Ireland. Travel and nomadism have resulted in Irish Travellers settling in many parts of the world. It is estimated that there are 40,000 living in Ireland, 15,000 in The UK , 6000 in mainland Europe and 7000 in America.

The importance of family in the community means that they will often live in close proximity to each other and form small neighbourhoods made up almost exclusively of Irish Travellers. This can result in some hospitals in the UK seeing many Irish Traveller patients and being familiar with their customs, and some hospitals seeing very few and, therefore, not having the insight required to provide them with the best treatment.

How would I recognize them?

There are many ways to ask. It is important to ask in a sensitive, non-judgmental and open-ended manner.

Questions such as “ Is there anything we should know about your culture or background that would help us look after your child? ” or “ Are you a member of any cultural or ethnic groups? ” are useful.

Alternatively, it may come up during your routine social history and may be volunteered by the family. If you ask about consanguinity the family may explain their background, where a large proportion of marriages are consanguineous.

Why is it important that I recognize Irish Travellers?

It is important to recognize that a patient is a member of the Irish Travelling Community because your understanding of their background, healthcare needs and potential risk factors may greatly influence your decision-making. Let’s look a little closer at factors that may affect their healthcare:

Demographics

The population pyramid for the Traveller population is similar to that of developing countries, with a high number of young people and very few older people. The All Ireland Traveller Health Study (AITHS) in 2010 found that 42% of Travellers were under 15 years of age, compared with 21% of the general population. The same study found that only 3% of Travellers were aged 65 years and over compared with 13% of the general population. The study only identified 8 travellers on the island of Ireland that were over 85 years of age.

Consanguinity accounts for approximately 71% of marriages. This is a first cousin in 39% , first cousin once removed in 11% and second cousin in 21% .

Life expectancy is significantly lower for Travellers than for the general population. For Traveller women it is 70.1 years, 11.5 years less than the general population. The life expectancy for Traveller men is 61.7 years, 15.1 years less than the general population.

The infant mortality rate is 3.6 times higher than the general population (14.1 deaths per hundred thousand compared with 3.9 per hundred thousand). Indeed, Irish Travellers have been found to have the highest infant mortality rate in Europe.

Accommodation

In recent years more and more Travellers have given up their nomadic past and settled in houses or trailer parks. It is estimated that 73% of Travellers live in a house with 18.2% living in a mobile home or caravan. These mobile home parks, or halting sites as they are known in Ireland, can have very poor conditions with inconsistent access to clean water, electricity, flushing toilets and safe, clean areas for children to play.

Relationship with healthcare

Irish Travellers face many barriers to healthcare and discrimination on a daily basis. The AITHS study found that the level of trust by Travellers in health professionals was only 41% , compared to 83% in the general population. Over 50% of Travellers had a concern about the quality of care they received when they engaged with services. Over 40% felt they were not treated with respect and dignity when accessing healthcare.

It is important to appreciate these barriers and make every effort to build a relationship and foster trust. This is particularly important when trying to obtain a family history. Travellers can be very private in relation to the health of their family and often will not disclose sensitive details in front of other family members. It is prudent to ask these sensitive questions alone, with the parents, and not in front of other relatives.

Many Travellers have a negative experience of the education system, with bullying and discrimination being widespread. Segregated education, with Traveller-only classes, has only been abandoned within the last 15-20 years. These factors have resulted in high drop-out rates in primary and secondary education.

Only 13% of Travellers complete secondary education, compared with 92% of the general population. Less than 1% of Travellers go on to tertiary level education. The 2016 Census only identified 167 Irish Travellers with a tertiary level qualification. Figures from the 2022 census are not yet available but it is likely they are much higher. Various support programs have greatly increased the accessibility of higher-level qualifications in recent years.

Literacy results can be very variable, with one large study estimating that 28.8% had difficulty reading and 50% had difficulty reading medication instructions.

Breastfeeding

Breastfeeding rates are generally quite low. Only 2.2% of Traveller women initiate breastfeeding, compared with approximately 50% in the general population. There are many factors responsible for this.

Formula feeding has historically been thought of as a status symbol within the Travelling Community and considered to be something that better-off women did. This fostered a stigma toward breastfeeding, resulting in generations of women who did not have the social support to breastfeed available because no one in their extended family may have breastfed. Breastfeeding mothers may also face negative reactions within their community if they feed in public.

The high incidence of galactosaemia in Ireland means newborns of Traveller parents are initially given soy milk while awaiting a screening test. This practice has helped create an image of breastfeeding as being “dangerous” within the community. It also makes things difficult for women hoping to establish breastfeeding. These factors may result in healthcare professionals being less inclined to discuss breastfeeding as there is an assumption that they will not want to breastfeed. This makes seeking support even more difficult.

Mental health and suicide

Mental health issues are three times higher in Travellers than in the general population. Suicide is six times more common in Travellers than in the general population and accounts for 11% of all Traveller deaths.

Positive aspects of culture

While it is important to be cognizant of the difficulties experienced by Irish Travellers we must also be aware of the positive aspects of their culture. Irish Travellers are immensely proud of their heritage. They have strong family bonds and support systems.

Most Irish Travellers are practising Catholics with the church providing a strong support structure. In a recent study, 89.4% of Irish Travellers rated religion as either ‘important’ or ‘very important’ in their lives.

There are also strong advocates within the Irish Travelling Community. The Pavee Point Organisation has long been a source of support and guidance for Travellers and has fought tirelessly for their rights, most notably by helping to achieve ethnic minority status for Irish Travellers in 2017.

What are the specific healthcare needs of their children?

It is important to remember that most Traveller children are healthy. Ninety per cent of Traveller children have no chronic health issue. Asthma accounts for 70% of those that do a have one. However, there is a range of genetic and metabolic disorders that are significantly more common in the Traveller population.

A study by Lynch et al in 2017 catalogued these disorders for the first time. Most clinicians working in Ireland are familiar with the increased incidence of these disorders in the community. The aim of the paper was to create a resource for clinicians who are less familiar and to ease forming a differential diagnosis and aid targeted testing. They identified 104 disorders, 90 of which are autosomal recessive. The 3 most common disorders and their carrier frequency are listed below.

The catalogue of disorders is available through the publication below:

Lynch SA, Crushell E, Lambert DM , et al Catalogue of inherited disorders found among the Irish Traveller population Journal of Medical Genetics   2018;55 : 233-239.

It is unlikely you will remember all of these conditions! Many of these disorders will present in the neonatal period. If you have a sick or septic baby from an Irish Traveller background you must consider metabolic and other rare diseases and investigate and manage appropriately.

These disorders are often incredibly rare, and challenging to diagnose and manage unless you are working in a centre familiar with them. Thankfully, help is at hand, an expert advisory network on the rare conditions affecting Irish Travellers is available on Orphanet .

How can I help them?

By having an understanding of the conditions that more commonly affect Irish Travellers you will be better prepared to diagnose and treat them. In particular, you should have a low threshold to perform metabolic investigations in an unwell neonate. If they have a rare disorder and you are seeing them in ED with an acute issue have a very low threshold to speak to their specialist directly.

Awareness of their culture and social situations will allow you to provide more empathetic, directed care and to put yourself in their shoes. Awareness of their home environment will help with discharge planning, particularly in children with complex needs .

A sensitive approach to literacy difficulties may help when providing patient information leaflets, discharge paperwork, prescriptions or when seeking consent.

Are there any specific differences in the provision of their healthcare in Ireland?

Paediatricians in Ireland will generally be familiar with many of the rare conditions above. Indeed, it is not unusual for a General Paediatrician to look after the only family in the country with a particular condition. The National Centre for Inherited Metabolic Disorders (NCIMD) and The National Clinical Genetics Services are located in Dublin and are the tertiary centres for the country. They look after many conditions that are rarely seen elsewhere in the world and would be a fantastic place for an international fellowship!

The newborn screening system in Ireland screens all newborns for 8 (relatively) common disorders, see below.

A major difference to other newborn screening programs is that there is targeted screening of children born to Irish Travellers for galactosaemia . These children are commenced on soy formula at birth until a Beutler Test can be performed to rapidly rule out galactosaemia. If negative, they can then commence normal infant formula .

The development of a genetic panel and carrier testing for Irish Travellers has been discussed for some time. Although technically feasible, there are complex issues surrounding this which have limited its progression to date. Irish Travellers can be very confidential about their family history and genetics, any future work in this area needs to be addressed sensitively.

You thank your registrar for their thorough and intriguing discussion on Irish Travellers and you resolve to use your new cultural awareness to improve your care of both Irish Travellers and other ethnic minorities in the future.

All Ireland Travel Health Study 2010

Education and Travellers [Internet]. [cited 2022 May 30]. Available from: https://www.paveepoint.ie/wp-content/uploads/2015/04/Factsheets-Pavee-Point-EDUCATION.pdf

Lynch SA, Crushell E, Lambert DM, Byrne N, Gorman K, King MD, et al. Catalogue of inherited disorders found among the Irish Traveller population. J Med Genet [Internet]. 2018 Apr 1 [cited 2022 May 30];55(4):233–9.

McGorrian C, Frazer K, Daly L, Moore RG, Turner J, Sweeney MR, et al. The health care experiences of Travellers compared to the general population: The All-Ireland Traveller Health Study. J Heal Serv Res Policy [Internet]. 2012 Jul 1 [cited 2022 May 20];17(3):173–80.

O’Reilly P, Jenkinson A, Martin T, Stone G, Power B, Murphy A. G294(P) Health and disease in children of the “ irish traveller” community. Arch Dis Child [Internet]. 2018 Mar 1 [cited 2022 May 20];103(Suppl 1):A120–A120.

Robinson L. BREASTFEEDING IN THE GYPSY, ROMA AND TRAVELLER COMMUNITY [Internet]. [cited 2022 May 30]. Available from: https://abm.me.uk/wp-content/uploads/Mag12-featured.pdf

Peter Tormey is an Irish Paediatric Emergency Medicine trainee with a keen interest in quality improvement and medical education. In his spare time he likes to cycle, drink coffee and swim in the sea

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All-Ireland Traveller Health Study

From Department of Health  

Published on 11 March 2010

Last updated on 26 October 2020

All Ireland Traveller Health Study: Our Geels - Summary of Findings

Alongside the executive summary above, this report is further broken into 3 technical reports and an appendix, which are available below. Because of their size, Technical Reports 2 and 3 are available in low-resolution format and are also broken into 4-part higher resolution versions.

Technical Report 1

Technical Report 1 features the findings of the Census of Traveller Population and a Quantitative Study of Health Status and Health Utilisation.

All Ireland Traveller Health Study: Our Geels - Technical Report 1: Health Survey Findings

Technical Report 2

Technical Report 2 reports on Demography and Vital Statistics including mortality and life expectancy data, an initial report of the Birth Cohort Study and a report on Travellers in Institutions. The Birth Cohort Study was a 1 year follow-up of all Traveller babies born on the island of Ireland between 14th October 2008 and 13th October 2009, with data collection up to 13th October 2010. Part D of Technical Report 2 is the Birth Cohort Study Follow Up and was published in September 2011.

All Ireland Traveller Health Study: Our Geels - Technical Report 2

All Ireland Traveller Health Study: Our Geels - Demography and Vital Statistics

All Ireland Traveller Health Study: Our Geels - The Birth Cohort Study

All Ireland Traveller Health Study: Our Geels - Travellers in Institutions

All Ireland Traveller Health Study: Our Geels - Bibliography

All Ireland Traveller Health Study: Our Geels - The Birth Cohort Study Follow Up

Technical Report 3

Technical Report 3 reports on Consultative Studies including qualitative studies based on focus groups and semi-structured interviews with Travellers and key discussants, and a survey of Health Service Providers.

All Ireland Traveller Health Study: Our Geels - Technical Report 3

All Ireland Traveller Health Study: Our Geels - Qualitative Studies

All Ireland Traveller Health Study: Our Geels - Health Service Provider Study

All Ireland Traveller Health Study: Our Geels - Discussion and Recommendations

Appendix (Questionnaires)

Preamble Health Service Providers Questionnaire for Ireland and Northern Ireland

‘OURGEELS’ AITHS QUESTIONNAIRE 2008

‘OUR GEELS’: FINAL AITHS QUESTIONNAIRE NORTHERN IRELAND

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A qualitative study of the perceptions of mental health among the Traveller community in Ireland

Affiliations.

• 1 Mental Health Services, Health Service Executive, 2-3 Sherwood House, Sherwood Avenue, H91 TR22, Galway, Ireland.
• 2 World Health Organization Collaborating Centre for Health Promotion Research, National University of Ireland Galway, Galway, Ireland.
• PMID: 33582793
• DOI: 10.1093/heapro/daab009

Irish Travellers are a minority ethnic group who experience a high prevalence of mental health problems and a rate of suicide six times higher compared to the general Irish population. This study explores Travellers' perceptions of mental health and its determinants. It also identifies the most relevant factors for promoting positive mental health and wellbeing among this socially excluded group. A descriptive qualitative approach was employed to explore participants' perceptions of mental health and mental health needs. Four focus groups were conducted with a total of 25 adult members of the Travelling community. Inductive thematic analysis was undertaken to identify and interpret the main themes emerging from the participants' responses. Travellers conceptualize mental health mostly in negative terms and showed a lack of awareness of the concept of positive mental health. Travellers showed a strong awareness of the social determinants of mental health identifying employment, better education, suitable accommodation, a reduction of discrimination and improved trust and social cohesion as important determinants that need to be addressed to improve their mental health status. The centrality of cultural identity and social-emotional skills emerged as key factors in promoting positive mental health among Travellers. The findings suggest that Travellers' mental health is multidimensional and requires a socio-ecological approach that addresses the wider determinants of health. Community mental health promotion initiatives should focus on reducing discrimination, enhancing social and emotional wellbeing and self-esteem, improvement of living conditions, reduced mental health stigma, and the promotion of Traveller culture and positive self-identity.

Keywords: Irish Travellers; ethnic minorities; mental health; qualitative methods; social determinants of mental health.

© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please email: [email protected].

• Mental Health*
• Minority Groups*
• Qualitative Research

Irish Travellers 'mental health crisis' driven by discrimination and deprivation

• Published 18 April 2022

Members of the community say discrimination is causing a mental health crisis in their home country

Irish Travellers suffer some of the worst discrimination and poverty of any ethnic group in Europe, according to European Union research , external .

Members of the community have said it is causing a mental health crisis in their home country.

In 2021, an Irish parliamentary committee reported that 11% of Travellers in Ireland die by suicide , external .

It also said that life expectancy among men in the community is up to 15 years shorter than the wider population.

Rose Marie Maughan works with the Irish Travellers Movement, a national network of over 40 organisations.

"Our suicide rate is seven times higher than non-travellers," she said.

"Only 3% of us live past the age of 65 and 80% of us are unemployed.

"If that was any other community in Ireland, there would be international attention."

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Irish Traveller Mags Casey lost 28 family members to suicide

Mags Casey is the chair of the Irish Travellers National Mental Health Network.

Nearly 30 members of her extended family have died by suicide in the last 10 years.

Her sister-in-law died in January 2012, followed two years later by her brother, who, Mags said, never recovered from the grief of losing his wife.

"The first suicide in our family, I thought the world ended," she said.

"I didn't know how to sit with four children and tell them your mother's dead, your mother's gone.

"The devastating effects it has on a family - addiction, family breakdown, a spiral of grief, young people not knowing how to deal with that grief."

'You're living two lives'

David Friel, a 24-year-old from County Donegal, is the first Traveller in the north-west of Ireland to achieve a masters degree.

Only 1% of Irish Travellers reach third-level education compared to over half of the general population.

David said that young Irish Travellers are struggling to balance their sense of identity with the demands of belonging in Irish society.

"It's trying to pass as a member of the settled population," he added.

David's grandfather kept 100 horses but now he said the family are struggling to maintain one horse

"So, you're not being your true authentic self. That mentally is very, very difficult.

"You're living two lives, and no-one can maintain that."

Irish Travellers have a long history of nomadism, but activists have said laws have seen them forced to assimilate into the "settled" population and abandon traditions like living in caravans, keeping horses and specialist trades.

They have said their culture is being eroded.

David's grandfather kept 100 horses, but now, he said, the family is struggling to maintain one horse.

"The traditional means of employment have been obliterated - tinsmithing, or hawking, or gathering whelks or scrap," he explained.

"If you don't have employment, it's very difficult to sustain animals."

'Out of sight and out of mind'

Mags Casey highlighted the halting site where she grew up in Limerick.

A large wall has been built around the site separating it from the nearby housing estates.

"They deliberately put that wall around us to fence Travellers in completely," said Mags.

"Away from society. Out of sight and out of mind."

A large wall has been built around a halting site in Limerick, separating it from the nearby housing estates

Campaigners say Travellers have a distinct identity and that their culture is often misconstrued because they are not represented in many aspects of everyday life.

They claim that prejudice against Travellers has become socially acceptable and isn't challenged in the same way other forms of discrimination are.

"It is totally embedded in Irish society to accept racism against Travellers," said David.

"If we look at the media, if we look at the gardaí (Irish police), we look at teachers, we look at politics - we're not represented.

"It's about having Travellers at the table, having meaningful dialogue and having the narratives from within the community."

Prof Verene Shepherd is the chair of the UN Committee on the Elimination of Racial Discrimination, which published its most recent major report on Ireland in 2019 , external .

Travellers say they need more action and support to address the discrimination

"Travellers are 10 times more likely to experience discrimination in seeking work," said Prof Shepherd.

"Travellers are more than 22 times more likely than white Irish to experience discrimination in shops, pubs and restaurants."

The Irish government has said it has a range of policies to encourage the inclusion of Travellers in areas like education, employment, health and accommodation.

But Irish Travellers have said they need more action and support to address the discrimination creating a mental health crisis in their community.

Specific spending on Traveller mental health is €250,000 (£207,013) a year, and €12m (£9.9m) went towards Traveller accommodation in 2021.

"We're proud and we're dignified people," said Mags.

"We have solutions and we want you to listen to us. We aren't in it for money.

"We're in it to stay alive and keep our young kids alive."

You can watch Travellers: A Culture In Crisis on the BBC iPlayer and listen on BBC Sounds .

If you have been affected by any of the issues raised in this video, please visit the BBC Action Line here .

This article was updated on 26 July 2022 to link to the research referred to in it.

Related Topics

• Republic of Ireland
• Mental health

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• Volume 13, Issue 8
• Scoping review on Physical Health Conditions in Irish Travellers (Mincéiri)
• Article Text
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• Fiona Kennedy 1 ,
• Amy Ward 2 ,
• David Mockler 3 ,
• Jacopo Villani 4 ,
• http://orcid.org/0000-0002-2572-6479 Julie Broderick 1
• 1 School of Medicine , Trinity College Dublin , Dublin , Ireland
• 2 Independent Public and Patient Expert , Belfast , UK
• 3 John Stearne Library , Trinity College Dublin , Dublin , Ireland
• 4 Mental Health Services , Health Service Executive , Galway , Ireland
• Correspondence to Dr Julie Broderick; broderju{at}tcd.ie

Objective The objective of this scoping review was to collate physical health conditions in Mincéiri—Irish Travellers.

Design Scoping review.

Search strategy and charting method MEDLINE/PubMed, EMBASE, PEDro, AMED, CINAHL, PsycINFO, SCOPUS as well as reports and grey literature were searched for primary data reporting physical health conditions of Irish Travellers up to 4 April 2023. Data was extracted, described and organised meaningfully into tables according to reported physical health conditions.

Eligibility criteria The population was Travellers. The concept referred to physical health conditions. The context was Irish Travellers based in any location or setting. Exclusion criteria was data/research other than primary data relating to physical health conditions of Irish Travellers.

Results From 198 citations generated from the database search, 11 unique studies (20 reports) were included in this scoping review, including n=7397 participants. Driven by the data, physical health conditions were categorised into cardiovascular diseases, respiratory diseases, injuries/musculoskeletal/arthritic disorders, genetic disorders and gut/bowel conditions. This review showed that the metabolic syndrome, asthma, bronchitis, tuberculosis and intentional injuries were 2–3 times more prevalent in Irish Travellers compared with the background population. Genetic conditions were also described in a proportion of Travellers.

Conclusions Overall, Irish Travellers experience a disproportionate burden of physical health conditions compared with background populations. Healthcare providers need to be aware of the unique physical health burden experienced by many Irish Travellers. Multifaceted strategies are needed to improve the health profile of this vulnerable and marginalised group.

• public health
• primary care
• coronary heart disease

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study. Data are available upon reasonable request. All data are available within the article and online supplemental files.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2022-068876

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STRENGTHS AND LIMITATIONS OF THIS STUDY

The methods for this scoping review were informed by the scoping review guidance from the Joanna Briggs Institute and it was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist.

Screening and data extraction processes were performed in duplicate.

Stakeholder involvement was integral to this review, as a member of the Travelling community was one of the coauthors of this work.

This was the first time all studies, reports and grey literature were comprehensively reviewed and collated to provide a broad picture of physical health conditions of Irish Travellers.

As is the convention in scoping reviews, quality assessment was not undertaken—results must be interpreted in light of this.

Introduction

Irish Travellers or ‘Mincéiri’, as known in their language of Shelta, 1 2 are a traditionally nomadic minority group primarily based on the island of Ireland. 3 They also reside in the UK with smaller populations in Europe and the USA. The term ‘Travellers’ is used as a generic term to refer to people who have a historical and cultural tradition based on a mobile lifestyle and includes English and Welsh Gypsies, Irish Travellers and Scottish Travellers. Each of these groups has a separate ethnic identity that is particularly evident from their different languages but they share many aspects of a common cultural identity as traditional Travellers or Romani people. 3 4 In this review, we specifically included ‘Irish Travellers’ only. As Irish Travellers in Ireland are known as ‘Travellers’ rather than ‘Irish Travellers, the term ‘Travellers’ is used hereafter, recognising that the authors are referring to Travellers of Irish descent.

The number of Travellers recorded in the Irish Census of 2016 was reported to be 30,987 accounting for 0.7% of the general population. 5 In the 2011 Census for England and Wales, 58,000 people identified as Gypsy or Traveller (Irish origin) which may be an underestimation of the actual number. 4

Travellers have been recognised formally as a distinct indigenous ethnic group in Ireland since 2017, which should have marked a positive step towards an inclusive society. 6 Yet, Travellers are 22 times more likely to experience discrimination than the general population 7 and they remain a severely marginalised group. 8 9 Consequently, Travellers face poor health and experience a higher burden of mortality and morbidity than the general population. 8

Traveller life expectancy has been reported to be 66 years, 11.5–15.1 years less than that of the general population. 8 The infant mortality rate is 3.6 times higher than the general population 8 and 10% of Travellers do not reach their second birthday. 10 The disproportionate mortality may be due to poor health as well as other factors such as inadequate housing, education and literacy levels. 8 Mental health disorders are prevalent, with reported suicide rates sixfold to sevenfold higher than the general population. 8 Physical health appears to be poorer 8 but the scale and range of physical health conditions experienced by Travellers is not well known. The aim of this review was to summarise available data and categorise physical health conditions in Travellers. Due to the exploratory nature and lack of delineation of this area identified by an initial test review, a scoping review methodology was chosen.

The objectives of this review were:

To explore the extent, breadth and nature of the literature with regard to physical health conditions experienced by Travellers.

To categorise the evidence about physical health in Travellers.

To compare physical health conditions of Travellers to the background population where possible.

Methodology

The protocol for this review was published on Open Science Framework ( https://osf.io/v6etg/ ). This review followed the Joanna Briggs Institute’s (JBI) methodology for scoping reviews 11 and was also informed by the original framework of Arksey, 12 and enhancements proposed by Levac. 13 It was checked against the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews Checklist. 14 The six stage framework developed by Arksey and O’ Malley 12 was used to structure this review.

Stage 1 refers to identifying the research question. The primary research question was; what is known about the physical health of Travellers. The secondary research question was; how does the physical health of Travellers compare to the background population, and where this information was available.

Stage 2 refers to identifying relevant studies. A comprehensive search strategy was developed collaboratively with a skilled research librarian (DM). The following electronic databases were searched: MEDLINE/PubMed, EMBASE, PEDro, AMED, CINAHL, PsycINFO, SCOPUS (see extended data). The original search was performed on 9 March 2021 (rerun on 2 November 2021 and 4 April 2023). The search strategy was generated from a combination of free text search terms, text words, Medical Subject Headings terms and keywords with Boolean operators. The full search details are outlined in online supplemental box 1 . Authors of abstracts included in this review were contacted to ascertain if full text versions were available. Reference lists of included studies were examined for relevant studies. Grey literature was searched using the CADTH Grey Matters tool and the following websites were checked: Lenus, ProQuest E-Thesis Portal and RIAN. For each of these sources, the terms ‘Travellers’ and ‘Health’ were searched. For each, the website was ‘hand searched’ for potentially relevant documents. The first 10 pages of each search’s hits were reviewed for potentially relevant material. A targeted search of Google Scholar and WorldCat search engines was also performed.

Supplemental material

Stage 3 refers to study selection. This was based on the population, concept and context mnemonic. 11 The population was Travellers. The concept referred to physical health conditions. There is no single definition of physical health conditions. We took this to mean any condition, including a disease or event (eg, injury) that impacts the physical health system. The context was quite broad and included Irish Travellers based in any location or setting. It was originally envisaged that this review would encompass ‘health’ in a more holistic way including mental and physical health conditions. Given the large scope of a review including both dimensions of health, a pragmatic decision was taken to consider physical health conditions only in this review and refine the search strategy accordingly. 12 13 15 This included primary data documenting prevalence of physical health conditions as well as perceptions of Travellers regarding physical health conditions experienced. Only English language sources were searched as it was expected the literature would be concentrated mainly in Ireland and the UK/other English-speaking jurisdictions. No date restriction was applied to generate a purposefully broad scope of the available literature. Both quantitative and qualitative study designs were included, although it was expected data would be primarily quantitative in nature. Studies that examined physical health conditions of Travellers (>18 years) as a primary or secondary outcome measure were included. If intervention studies were included, only baseline data was extracted. Exclusion criteria were data which did not relate to physical health conditions of Irish Travellers.

Duplications were removed and studies were imported into Covidence for title and abstract screening which took place independently by two reviewers (JB and FK). Both authors then conducted a full-text evaluation. If necessary, discrepancies were resolved by consensus by including a third author.

Stage 4 refers to charting the data. Relevant data pertaining to physical health conditions of Travellers were retrieved. Two reviewers (JB and FK) independently extracted data using a bespoke data extraction instrument. 11 The data extraction process took place from October 2021 to March 2022. The data extraction instrument was designed by review authors (JB and FK) based on the JBI template source of evidence details, characteristics and results. Two review authors (JB and FK) independently extracted data from the first ten studies using the initially developed data extraction form and met to ascertain its suitability. Minor changes to the data extraction tool were made at this stage. The data extraction instrument collected the following data relating to included studies (author, title, year of publication, study aims/objectives, research design, living arrangements, location of participants, inclusion/exclusion criteria, data collection method, number of participants, age (mean and SD), biological sex, details of physical health condition reported and physical health conditions in the background comparison population). Any differences were resolved by consensus discussion. A third author (DM) was available if disparities emerged between reviewers.

Stage 5 refers to collating, summarising and reporting of results. Data were reported for each selected study within each category as agreed in the previous stage. Findings were mapped to summarise the range of evidence to present the breadth and depth of the field. 13 Tables were also presented to outline the research findings as defined in stage 4. According to scoping review methodological enhancements proposed by Levac et al , 13 results were presented numerically and in a data driven approach were categorised meaningfully into the following subcategories of physical health conditions; cardiovascular disease (CVD), respiratory, genetic, injuries/musculoskeletal/arthritic disorders and gut/bowel conditions. Where available, data were compared with the background population. Implications for policy, practice and research were identified. Entries were independently checked by two authors (JB and FK).

Patient and public involvement

Stage 6 refers to patient and public involvement. Stakeholder/public involvement was integral to this review. The initial research question was generated by the principal author who has an interest broadly in the physical health of marginalised groups. In the planning phase, the research question evolved and was refined by engaging informally with the research team and a member of the Travelling community (AW) about this topic. In conversation, AW identified the poor physical health and prevalence of physical health conditions among many Travellers which consolidated the purpose of conducting this review. AW was then personally invited to join the review team. Her involvement began after the initial database search and continued throughout the data synthesis and write-up phases. A number of online meetings took place during which AW shared her perspectives verbally and in written form on early results, drafts and conclusions of the review as they emerged.

Studies identified

After removal of duplicates, 197 studies were identified. After excluding irrelevant studies, a total of 11 studies and 20 reports were deemed eligible for inclusion. Quantitative studies predominated (n=8), with 2 qualitative studies 16 17 and 1 mixed methods study. 18 Three were reports generated from the grey literature search, 9 17 18 while the remaining were generated from the systematic database search. The PRISMA flow chart summarises the search strategy ( figure 1 ).

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Preferred Reporting Items for Systematic Reviews and Meta-Analysesflowchart describing the process of study selection.* The following databases were searched: MEDLINE/PubMed, EMBASE, PEDro, AMED, CINAHL, PsycINFO, SCOPUS and Grey Literature.

Study characteristics are shown in online supplemental table 1 . A total of 7397 participants were included with more than half (n=4141) from the All Ireland Traveller Health Study (AITHS). 8 One study took part in 18 England and Wales and the remaining studies were based in Ireland. Living arrangements of participants were reported in three studies. 9 18 19 In one study, a quarter (n=515) lived in a caravan, a trailer or a chalet 19 and in another, participants’ accommodation included encampments, halting sites and social housing. 20 All (Traveller) participants in Mac Gabhann’s study (n=296) resided in prisons in England and Wales. 18

Participants’ characteristics are shown in online supplemental table 2 . The majority of studies included males and females with overall 61% of participants were female. The UK based study included mostly male participants (93.6% male), 18 while one study included females only. 16 The age profile of participants was predominantly young, with the majority in their second, third and fourth decades. Tables 1–4 summarise physical health conditions from included primary studies.

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Cardiovascular diseases

Respiratory diseases

Injuries/musculoskeletal/arthritic disorders

Genetic diseases, other conditions and self-rated health

Three studies reported CVDs ( table 1 ). Tan et al 21 reported the following CVD risk factors among study participants (n=47): high triglyceride levels (23%), low HDL cholesterol levels (62%), impaired fasting glucose levels (19%) and hypertension (systolic blood pressure (BP)≥130 mm Hg 43% and diastolic BP≥85 mm Hg 38%). The prevalence of diabetes, pre-diabetes and the metabolic syndrome evaluated in a series of pilot studies was higher than the general population. 22 The incidence of metabolic disease was over two times higher among Travellers (53.2%) compared with the background population (21%). 22 Self-reported CVD was approximately 5%, compared with a self-reported CVD rate of 16.1% in the general population. 8

Two studies explored respiratory conditions ( table 2 ). 23 24 One study reported a 5 year tuberculosis (TB) cumulative crude incidence rate of 81.4/100 000 in Travellers compared with 45.5/100 000 and 27.3/100 000 in the general population and white Irish-born population, respectively. 23 The rates of TB were therefore threefold higher in Travellers than in the white Irish-born population. 23 Nolan et al reported that 41% of Travellers were smokers and 86% of these smokers reported respiratory symptoms including cough, wheeze and shortness of breath, while 23% had an obstructive respiratory disease pattern. 24 Respiratory conditions (bronchitis and asthma) were rated as the second most common physical health condition, with a prevalence of 24.5% among Travellers in Ireland and 35.1% in Northern Ireland. 8 This is considerably higher than available comparison data of 3% with chronic bronchitis in the Irish background population. 25

Abdalla et al evaluated injuries 26 ( table 3 ). They demonstrated that the prevalence of unintentional non-fatal injury in Travellers<65 years was lower (standardised incidence ratio (SIR)=40), while the prevalence of intentional injury was higher (SIR=213) than the general population. Travellers > 65 years had higher injury rates for both unintentional (SIR=137) and intentional injuries (SIR=517). Common physical health problems reported by a population of 281 Travellers in prison in the UK were asthma (n=12), ‘back’ problems (n=10), epilepsy (n=9) and arthritis (n=7). 18

Two studies ( table 4 ) examined genetic disorders both inherited in an autosomal recessive manner. One was a case report of a 32 year-old woman who inherited a rare leucoencephalopathy and severe central nervous system (CNS) impairment was reported. 27 Flynn et al also reported CNS dysfunction in Travellers due to the presence of type 2 hyperprolinaemia. 28

One study examined the effects of lifestyle changes on the microbiome and its associated risks for chronic disease. 20 The results demonstrated that Travellers retained a microbiota similar to that of non-industrialised populations due to halting site dwelling, number of siblings and animal ownership. Another study evaluating the prevalence of inflammatory bowel disease found no records of idiopathic bowel disease in the Traveller population.

Most Travellers described their health as very good (59%) or good (28%). 8 Comparable figures among the general population are similar at 62% and 29%, respectively. 25 Overall, 12% of Travellers described their health as fair, bad or very bad. 8 The corresponding figure for non-Travellers was 9%. 25 Breaking this down to 34–54 year age group, 31% of Travellers 8 categorised their health as ‘very good’ compared with 57% among non-Travellers. 25 In this age group, 29% of Travellers 8 had health categorised as ‘fair’, ‘bad’ or ‘very bad’ while the comparable figure in non-Travellers was 8%. 25

Three studies conducted qualitative or mixed methods research. In the Mac Gabhann’s study, which explored experiences of Travellers in prison in the UK, 18 prison staff completed 296 surveys, while 57 Travellers (of Irish origin), predominantly male (93.6%), participated in focus groups and semistructured interviews. Almost a quarter (24.6%) of prisoners reported physical health problems and Travellers reflected negatively on the use of healthcare prison facilities to manage their health condition.

''I’ll never go back to them, they’ve done nothing for me''.

Murphy 17 explored the experiences of homelessness for Travellers through qualitative interviews of 14 Travellers in one county in Ireland. They vividly described the negative impact of homelessness had on their physical health.

''I never had blood pressure in my life. Now, the last year and a half, ever since the time we had to leave (the rented house), I’m taking blood pressure tablets''.

Collateral relevant to family members was also reported.

''My mother is on a breathing machine because she has a sleeping disorder so in the, in the night time if she would knock it off, she goes into her, what’s it a coma. And with the sleeping disorder it cut’s your oxygen from your throat to your brain, so that leads to a heart attack or a stroke''.

Murphy also described health problems that participants directly attributed to their homeless state or living conditions (on a site with no toilet) such as chronic kidney infections. Limited access to electricity was a problem identified which resulted in a lack of refrigeration to store medication such as insulin. 17

Hodgins et al explored, through focus groups, perceptions of illness causation and health inequalities in 41 Traveller women in two regions in Ireland. 16 Themes of poor living conditions, discrimination, stress, anxiety, depression and violence described their perceptions of the cause of their poor health. Traveller women attributed other health conditions such as heart disease to the stresses of their life and considered risk factors such as smoking as less important factors and often beneficial to health status.

''People have a lot of worry, a lot of stresses and can develop heart disease and heart attacks….''.

The interaction of poor accommodation and health was also noted.

''An awful lot of it comes from bad accommodation and discrimination. I keep sayin’ those two words an’ I know well it’s those that are causing’ the most problems, causin’ heart problems and depression''.

This scoping review appears to be the first time that data relating to physical health conditions of Travellers has been synthesised. Pooling the evidence together underlines two key findings. Firstly, the disproportionately high burden of physical health conditions such as the metabolic syndrome, asthma, bronchitis, TB and intentional injuries which were 2–3 times higher in Travellers compared with the background Irish population. Secondly, the unique health considerations such as rare genetic diseases experienced by a proportion of Travellers and the possibility of health benefits associated with their distinct gut microbiome linked to the traditional Traveller way of life.

Over 7000 Travellers were included in this review with the largest source of data from the AITHS. 8 One study took place in England and Wales, while the rest of the studies were based in Ireland. Living conditions were not specified in the majority of studies. This is important to note as living conditions are a key driver of health 29 which is rated higher by Travellers when living conditions are better. 20

There was a higher representation of females (61%) within this review. This may be explained by findings from the AITHS highlighting that female Travellers were more likely to engage in research studies. 8 The majority of participants were in their second to fourth decades, which concurs with Central Statistics Office (2016) data 5 demonstrating that Travellers are a young population. The paucity of older participants means that the effects of ageing and extent of geriatric syndromes in this population are not fully known.

This review showed high rates of the metabolic syndrome, CVD risk factors and established CVD disease compared with the background population, yet lower self-reported CVD of approximately 5.6% 30 vs 16.1% for the general population. 25 This likely underestimation of CVD among Travellers may be due to a reluctance to divulge information and/or a lack of disease awareness, fewer attendances for preventive services as well as late presentation and higher case fatality rates of CVD. 8 Evidently, improved targeted primary and secondary care strategies for Travellers are required.

Respiratory conditions (bronchitis and asthma) were rated as the second most common physical health condition, with a prevalence of 24.5% among Travellers in Ireland and 35.1% in Northern Ireland. 8 This is markedly higher than the comparison background population of 3% with chronic bronchitis 25 in Ireland. The rates of TB were threefold higher in Travellers than in the white Irish-born population. 23 Proposed risk factors were cited as higher house occupancy, smoking and the presence of diabetes or pre-diabetes.

Travellers suffer a greater burden of injuries and a higher risk of dying from injuries than the general population. 26 Notably, a higher rate of intentional injuries, and a lower rate of unintentional injuries were reported, compared with the general population. The high rate of intentional injuries likely links to mental health crises among Travellers with a suicide rate of six times than the general population. 8 The true intentional injury rates may be in fact higher as Travellers may not present themselves to care settings for minor injuries and may be more inclined to self-treat or present late for care. 8 Conversely, there may be actually a lower unintentional injury rate due to lower participation in sport and recreational activities in young Travellers. Travellers over 65 years, however, were two times as likely to be injured, highlighting their vulnerability. The AITHS cited the home as the most likely location for an injury, which may be due to poor living environments. 8 This is in accordance with a recent report, which highlighted grossly inadequate living conditions among Travellers. 31

This review highlighted genetic conditions such as type 2 hyperprolinaemia 28 and leucoencephalopathy. 27 These represent an important factor affecting physical health in Travellers as autosomal recessive conditions are commonly reported. 32 Of note, some studies (n=5) examining inherited disorders such as congenital atrichia, a rare autosomal recessive disorder, were excluded from this review as they did not meet the age eligibility criteria. Given that genetic conditions are prevalent in Travellers, consideration of ‘grown up’ genetic conditions should be an area of emerging focus.

Positive physical health factors, linked to the gut, were discussed in two studies. 20 33 McCormick and Manning noted the absence of consultant-diagnosed inflammatory bowel disease possibly due to exposure to enteric bacteria and infection in early life. 33 Keohane et al suggested the ‘non-industrialised microbiome’ of Travellers may be due to living conditions and animal ownership. 20 How the gut microbiome changes with modernisation should be evaluated in future studies.

When comparing Travellers to non-Travellers (35–54 age group), Travellers are approximately three times as likely to have poor health or some type of difficulty or disability, with the health gap rapidly increasing with age, which mirrors the pattern in other ethnic minority groups. 34 A UK based study found that compared with white British people and 17 different ethnic minority groups, Gypsy and Irish Travellers (with the exception of younger and older age groups) had markedly high levels of multiple long-term conditions. 35 Another study found that inequalities in health-related quality of life were widest for Gypsy or Irish Travellers, Pakistani and Bangladeshi women. 36

In a similar way to Travellers experiencing a high burden of physical health conditions compared with the background population, poorer health is experienced by Roma people compared with non-Roma people across Europe. 37 For instance, a high prevalence of TB has been detected in the Roma population. 38 Other diseases have been described in Roma people, such as hepatitis A 39 and hepatitis C virus and HIV. 40 An outbreak of hepatitis A in Travellers was described in the literature, 41 but was not included in the current review due to the high proportion of participants under 18 years. A high prevalence of measles was documented in Roma people, 42 a number of papers also described measles outbreaks in Irish Travellers 43 but similarly were also excluded from the present review due to the proportion of children in these papers.

A strength of this review is the synthesis of data relating to physical health conditions of Travellers based in England and Wales, Ireland and Northern Ireland. A further strength was the active stakeholder involvement by the inclusion of a member of the Travelling community as an integral and valued member of the review team. This ensured the real-world relevance of this research and is likely to increase the chances of implementation of research findings into real-life settings. 44

There were a number of limitations. As is the general convention in scoping reviews, a formal quality assessment of included studies 11 12 was not conducted therefore, the robustness of evidence 12 could not be judged. We acknowledge that definitive recommendations are not possible and the review must be interpreted in light of this. 11 12 We therefore see this work as a useful accessible summary of the evidence base regarding physical health conditions in Travellers. 11 45 As previously stated, the initial intention was to perform a review encompassing physical and mental health conditions; however, a pragmatic decision was taken to include physical health conditions only which we acknowledge is somewhat unidimensional as physical and mental health conditions are inter-related and multimorbidity can straddle both.

The AITHS which is over 10 years old remains the most comprehensive report of Traveller health and is quoted widely in subsequent reports. It highlighted four priority areas for intervention: mother and child services; men’s health; cause-specific issues for respiratory and cardiovascular disease; and a new model of primary care delivery. The importance of using a ‘social determinants’ approach linking inequalities in healthcare, accommodation and other factors such as racism and discrimination to poor health was also advocated. 8 With a stark 39% of Travellers estimated to be homeless, this negatively affects overall health and well-being and compounds health inequalities. 46 The long awaited recently published National Traveller Health Action Plan (2022), 47 relevant to Ireland, contained 45 key actions around resourcing, identifying, reinstating and expanding Primary Health Care for Travellers Project and engaging with public health. It also echoed a social determinants approach with targeted and mainstream strategies to overcome inequalities. This was also advocated in the National Traveller and Roma Inclusion Strategy 2017–2021. 48 Another important approach of the National Traveller Health Action Plan is a ‘whole-of-government approach’ with integrated cross-sectoral working. All of these approaches, if implemented, should impact the burden of physical health conditions in Travellers but there is a sense of policy conflict, 49 policy fatigue and policy failure in the absence of tangible action on previous recommendations.

More is known about physical health conditions in Irish-based Travellers and policies described are relevant to this setting. Less is known specifically about the physical health conditions of UK based Irish Travellers. Some research collectively pooled data from gypsies and Irish Travellers as well as other Traveller groups. Although all these groups experience discrimination, poor living conditions and health inequalities, how these groups vary in relation to physical health conditions is not well known.

Ethnic identifiers would enable physical health conditions to be more accurately tracked but this would need to be conducted sensitively. This is in line with a key recommendation of the National Traveller Health Action Plan (2022–2027), 47 which recommends systematic ethnic equality monitoring, including the introduction of ethnic identifiers on health data sets. Due to the inter-relationship between living conditions and health, living conditions need to be radically improved and studies including Travellers should include data on living arrangements.

It should also be considered that the extent of physical health conditions may be underestimated due to Travellers not presenting or presenting late for care as well as a mistrust of healthcare professionals. 8 The co-development of trust-building mechanisms and improved co-operation between Travellers and healthcare professionals has been recognised as important strategies to improve Travellers’ access and engagement with mainstream health services. 50 Non-communicable diseases such as cancer and arthritis in Travellers featured minimally within this review. The health of older Travellers was not specifically explored, which may be partly due to the mortality gap. Further work is needed on how best to build confidence and empower Travellers to self-manage their health without ‘talking at them’. Functional literacy and health literacy levels need to be optimised while also reducing the stigma associated with accessing healthcare. 8 Supporting Traveller groups to co-design culturally appropriate health literacy resources has been identified as crucial to improve understanding of pathways to access services and signs and symptoms of different health conditions. 50 Healthcare staff can be discriminatory in their attitudes 51 which also needs attention. At a broader level, healthcare service design needs to be culturally appropriate. A recent study exploring Travellers’ views about how existing healthcare provision could be more responsive to their needs found that employing members of the community within the health service, embedding an ethos of cultural safety and humility and delivering Traveller Cultural Awareness Training to healthcare staff would improve the cultural appropriateness of mainstream health services. 50

Ultimately, inequalities in health, relevant to Travellers and other ethnic minority groups, are closely linked to racism and discrimination as well as the social determinants of health such as housing, education, employment and income which are strongly associated with poor health. 52 These underlying factors therefore need to be tackled to impact health.

This scoping review highlights marked inequalities in the burden of physical health conditions experienced by Mincéiri. Many common physical health conditions were 2–3 times more prevalent in Travellers compared with the background population. Multifaceted and tangible action is required including better targeted approaches and accommodations within mainstream healthcare, underpinned by a social determinants approach, to bridge the gap in physical health conditions experienced by this marginalised group.

Ethics statements

Patient consent for publication.

Not applicable.

Acknowledgments

We would like to thank Dr John Gilmore, University College Dublin, who provided useful comments on this work. We would also like to thank the excellent second year medical students of the School of Medicine, Trinity College Dublin, who performed a test review in 2021, which preceded this work (Sinead Cummins, Cliona Sheehy, Eva Perdue, Laura Mc Kenna).

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• ↵ Census 2016 profile 8 - Irish travellers, Ethnicity and religion 2016 . 2016 . Available : https://www.cso.ie/en/csolatestnews/presspages/2017/census2016profile8-irishtravellersethnicityandreligion
• ↵ Statement by an Taoiseach Enda Kenny TD on the recognition of travellers as an ethnic group, Dáil Éireann, Department of an Taoiseach . 2018 . Available : https://www.gov.ie/en/speech/d29014-statement-by-an-taoiseach-enda-kenny-td-on-the-recognition-of-travel
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Contributors FK: independent data screening, data extraction, data synthesis and drafting of manuscript. AW: contribution to the development of the design and drafting of manuscript. JV: drafting of manuscript. DM: generation and refinement of search strategy. JB: conception of original idea and deigning the study, refinement of search strategy, independent data screening, data extraction, data synthesis and drafting of manuscript and guarantor of this work. All authors provided important intellectual contribution and guidance throughout the development of the manuscript. All authors contributed, edited and approved the final version of this manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methodology section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• National Social Inclusion Office
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Irish Travellers

Taoiseach Enda Kenny announced formal recognition for Travellers as a distinct ethnic group within the State on 1st March 2017, thus giving formal recognition to Travellers unique heritage, culture and identity.

Travellers are particularly disadvantaged in terms of health status and access to health services. Further information and resources can be found below:

Traveller Projects and Resources

The National Traveller Mental Health Service

Health Inequality

The health inequalities that lead to such poor health status are highlighted in the findings of the All Ireland Traveller Health Study (2010) . These include:

• Traveller women live on average 11.5 years less than women in the general population;
• Traveller men live on average 15 years less; and
• the number of deaths among Traveller infants is estimated at 14.1 for every 1,000 live births compared to 3.9 for every 1,000 live births among the general population;
• The study also showed that deaths from respiratory and cardiovascular diseases and suicides increased in Travellers compared to the general population. 

The strategic direction of Traveller health care is outlined in the National Traveller and Roma Inclusion Strategy .                                              

Primary Health Care Projects

We provide support to a range of primary care projects and other initiatives for Travellers. This includes the ongoing work of the HSE Traveller Health Units. The Traveller Health Units work to:

• enhance Traveller health status;
• improve the capacity of mainstream health services to respond to Traveller needs; and
• respond to the social determinants that impact Traveller health.

Primary Health Care for Travellers Projects (PHCTPs) established a model for how Travellers could take part in developing health services. Travellers work as community health workers, and this allows primary health care to be developed based on the Traveller community’s own values and perceptions. This helps to achieve positive outcomes with long-term effects.

For information about the National Social Inclusion Office call: 01 778 5168, or Email: [email protected].

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Article Contents

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A qualitative study of the perceptions of mental health among the Traveller community in Ireland

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Jacopo Villani, Margaret M Barry, A qualitative study of the perceptions of mental health among the Traveller community in Ireland, Health Promotion International , Volume 36, Issue 5, October 2021, Pages 1450–1462, https://doi.org/10.1093/heapro/daab009

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Irish Travellers are a minority ethnic group who experience a high prevalence of mental health problems and a rate of suicide six times higher compared to the general Irish population. This study explores Travellers’ perceptions of mental health and its determinants. It also identifies the most relevant factors for promoting positive mental health and wellbeing among this socially excluded group. A descriptive qualitative approach was employed to explore participants’ perceptions of mental health and mental health needs. Four focus groups were conducted with a total of 25 adult members of the Travelling community. Inductive thematic analysis was undertaken to identify and interpret the main themes emerging from the participants’ responses. Travellers conceptualize mental health mostly in negative terms and showed a lack of awareness of the concept of positive mental health. Travellers showed a strong awareness of the social determinants of mental health identifying employment, better education, suitable accommodation, a reduction of discrimination and improved trust and social cohesion as important determinants that need to be addressed to improve their mental health status. The centrality of cultural identity and social–emotional skills emerged as key factors in promoting positive mental health among Travellers. The findings suggest that Travellers’ mental health is multidimensional and requires a socio-ecological approach that addresses the wider determinants of health. Community mental health promotion initiatives should focus on reducing discrimination, enhancing social and emotional wellbeing and self-esteem, improvement of living conditions, reduced mental health stigma, and the promotion of Traveller culture and positive self-identity.

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Housing, racism, and jobs are biggest issues facing Travellers, forum hears

Impact of intergenerational exclusion on the community’s young people discusssed.

Members of the Travelling community protesting over accommodation in 2014. Photograph: Dara Mac Dónaill/The Irish Times

Inadequate housing, racism and a dearth of job prospects are the greatest challenges facing young Travellers, a forum to increase their involvement in discussions on such issues heard on Wednesday.

The event, hosted by the Irish Traveller Movement (ITM) to mark publication of its first Traveller Youth Participation and Leadership Strategy, heard from a number of Traveller youth workers.

Bernard Joyce, director of ITM, pointing out 58 per cent of Travellers are under 25, said: "Young Travellers need to be heard on issues of importance to them, but there are few spaces where this happens, or where their views are sought. We need to encourage their engagement and ensure that's valued in the wider context of Irish life, and visible in national conversations."

The strategy, to run from 2021 to 2015, aims to bring young Travellers together on a regular basis to discuss and make recommendations on the issues important to them. It is hoped this will “empower” them and build their capacity to “become leaders in their own communities”.

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Census 2016 found just 8 per cent of working-age Travellers, compared with 73 per cent nationally had reached leaving certificate at second level.

Traveller youth workers who participated in drawing up the strategy stressed the impact of intergenerational exclusion on the community’s young people.

Michael Collins, youth worker from Finglas, Dublin, and a Traveller, said many young people had negative experiences when trying to get work, while others who wanted to get into training or apprenticeships did not know how. He called for a dedicated Traveller employment service.

“Travellers don’t have the social capital or the connections other young people would have to gain employment. There are agencies that could help. It’s about getting information out to the young people.”

Sally Flynn, a Dublin-based Traveller woman, said she had been "very lucky" with the support she received at her secondary school in Ballyfermot.

She said many Traveller children and teenagers, however, felt belittled and unwelcome at school. Reduced timetables was mentioned as a means schools use to exclude Traveller children.

One of the biggest issues Ms Flynn saw for Traveller children was “overcrowding” in housing and halting sites.

“It has a huge impact on the young people’s mental health. We see it every day. People still do not have their basic needs being met.”

Leanna Ward, a young Traveller based in Galway, said while it was important to encourage young Travellers to participate in strategies, and to stay on in education, there had to be the prospect of employment in adulthood.

“Having the strategy is brilliant but it’s about having opportunities afterwards. Is there an opportunity for employment?” Citing the example of Bounceback recycling in Galway, which is employs 12 Travellers, she said “it should be mandatory for employers to have one Traveller employed”.

Minister for Children and Equality, Roderic O’Gorman, sent his support for the strategy though Mr Joyce, in answer to a question, said there had been no financial support from the Department for it.

Kitty Holland

Kitty Holland is Social Affairs Correspondent of The Irish Times

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• Allianz Travel Insurance
• Seven Corners

Buying travel insurance is a smart move for any type of trip, but you may not need a policy that covers everything under the sun. If you don't need coverage for trip cancellations or delays because you're relying on your travel credit card to offer these protections, for example, you may find you only need emergency medical coverage that works away from home.

Still, travel medical coverage varies widely based on included benefits, policy limits and more. If you're comparing travel insurance plans and hoping to find the best option for unexpected medical expenses, read on to learn which policies we recommend.

Frequently Asked Questions

The term travel insurance usually describes a comprehensive travel insurance policy that includes coverage for medical expenses as well as trip cancellations and interruptions, trip delays, lost baggage, and more. Meanwhile, travel medical insurance is coverage that focuses on paying for emergency medical expenses and other related care.

Travelers need international health insurance if they're visiting a place where their own health coverage will not apply. This typically includes all international trips away from home since U.S. health plans limit coverage to care required in the United States.

Note that if you don't have travel health insurance and you become sick or injured abroad, you'll be responsible for paying back any health care costs you incur.

Many travel insurance policies cover emergency medical expenses you incur during a covered trip. However, the included benefits of each policy can vary widely, and so can the policy limits that apply.

If you're looking for a travel insurance policy that offers sufficient protection for unexpected medical expenses, you'll typically want to choose a plan with at least $100,000 in coverage for emergency medical care and at least that much in protection for emergency medical evacuation and transportation.

However, higher limits can provide even more protection from overseas medical bills, which can become pricey depending on the type of care you need. As just one example, Allianz says the average cost of emergency medical evacuation can easily reach up to $200,000 or more depending on where you’re traveling.

Your U.S. health insurance policy almost never covers medical expenses incurred abroad. The same is true for most people on Medicare and especially Medicaid. If you want to ensure you have travel medical coverage that applies overseas, you should purchase a travel insurance plan with adequate limits for every trip. Read the U.S. News article on this topic for more information.

The cost of travel medical insurance can vary depending on the age of the travelers, the type of coverage purchased, the length of the trip and other factors. You can use a comparison site like TravelInsurance.com to explore different travel medical insurance plans and their cost.

• Allianz Travel Insurance: Best Overall
• Seven Corners: Best for Families
• GeoBlue: Best for Expats
• WorldTrips: Best Cost

Coverage for preexisting conditions is available as an add-on

Easy to purchase as needed for individual trips

Relatively low limits for medical expenses

No coverage for trip cancellations or trip interruption

• Up to $50,000 in emergency medical coverage
• Up to $250,000 in emergency medical evacuation coverage
• Up to $2,000 in coverage for baggage loss and damage
• Up to $600 in baggage delay insurance
• Up to $1,000 for travel delays
• Up to $10,000 in travel accident insurance
• 24-hour hotline assistance
• Concierge services

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Purchase comprehensive medical coverage worth up to $5 million

Coverage for families with up to 10 people

Low coverage amounts for trip interruption

Medical coverage options vary by age

• Up to $5 million in comprehensive medical coverage
• Up to $500,000 in emergency evacuation coverage
• Up to $10,000 in coverage for incidental trips to home country
• Up to $25,000 in coverage for terrorist activity
• Up to $500 in accidental dental emergency coverage
• Up to $100 per occurrence in coverage for emergency eye exams
• $50,000 in coverage for local burial or cremation
• 24/7 travel assistance
• Up to $25,000 in coverage for accidental death and dismemberment per traveler
• Up to $500 for loss of checked baggage
• Up to $5,000 for trip interruptions
• Up to $100 per day for trip delays
• Up to $50,000 for personal liability

Qualify for international health insurance with no annual or lifetime caps

Use coverage within the U.S. with select providers

Deductible from $500 to $10,000 can apply

Doesn't come with any nonmedical travel insurance benefits

• Up to $250,000 in coverage for emergency medical evacuation
• Up to $25,000 for repatriation of mortal remains
• $50,000 in coverage for accidental death and dismemberment

High limits for medical insurance and emergency medical evacuation

Covers multiple trips over a period of up to 364 days

Deductible of $250 required for each covered trip

Copays required for medical care received in the U.S.

• Up to $1,000,000 of maximum coverage
• Up to $1,000,000 for emergency medical evacuation
• Up to $10,000 for trip interruptions
• Up to $1,000 for lost checked luggage
• Up to $100 per day for travel delays
• Up to $25,000 in personal liability coverage
• Medical coverage for eligible expenses related to COVID-19
• Ability to add coverage for your spouse and/or child(ren)
• Repatriation of remains coverage up to overall limit
• Up to $5,000 for local burial or cremation 
• $10,000 to $50,000 for common carrier accidental death

Why Trust U.S. News Travel

Holly Johnson is an award-winning content creator who has been writing about travel insurance and travel for more than a decade. She has researched travel insurance options for her own vacations and family trips to more than 50 countries around the world and has experience navigating the claims and reimbursement process. In fact, she has successfully filed several travel insurance claims for trip delays and trip cancellations over the years. Johnson also works alongside her husband, Greg, who has been licensed to sell travel insurance in 50 states, in their family media business.

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