South West Public Health Observatory
The Health of Travellers in the South West Region: a review of data sources and a strategy for change
 

 

 

Improving the knowledge base for Traveller health: conceptual challenges

 

Any attempt to improve the knowledge base on the health needs of Travellers will need to be preceded by a conceptual as well as technical debate about the most appropriate methods to be deployed. Discussion is needed about the definitions to be used and also about the best ways of investigating the social determinants of Travellers’ health.  In particular, much more thought is needed regarding how Travellers can most appropriately be placed within current discourses on inequality and social exclusion. Both have been used to frame the health problems of Travellers but as we shall see, neither is entirely appropriate.

 

The first problem to be tackled is that of definitions and classifications. Who should be included in the group to be investigated? Work in this area is strewn with debates about categorisation and naming, many of which are essentially political rather than scientific in nature. Travellers themselves, and those concerned with their interests, have highlighted the importance of allowing individuals and groups to name themselves as part of the process by which they shape their own identity (Acton, 1997; Feder, 1990; Hancock, 1996; Turner, 2000). This is entirely understandable from a political point of view, but self-definition can lead to confusion if it is used as the basis on which to design a study. 

 

Much of the literature refers to the fact that Travellers (or more specifically Romani Gypsies) have been granted ‘ethnic minority’ status for the purposes of the Race Relations Act 1976 [1] . Indeed it is this legal judgement which is frequently brought forward as an argument for capitalising the terms ‘Gypsy’ and ‘Traveller’. This decision was clearly an important tool in the campaigns waged by both Travellers and their supporters to protect these groups from discrimination [2] . However, it does not follow that ethnic minority status is also useful as an analytic category in either epidemiological studies or needs assessments.

 

There is now an extensive debate on the problems of using ethnicity as a variable in health and health services research (Bhopal and White, 1993; Bhopal, 1997; Bhopal and Donaldson, 1998; Smaje, 1995). In many cases the term is used incorrectly as a euphemism for ‘race’, raising all the problems associated with the deployment of biological categories to explain social phenomena. More appropriately, the term ‘ethnic group’ is sometimes used to refer to “a group of people that belong together because of shared characteristics including ancestral and geographic origins, cultural tradition and language” (Bhopal 1997:1751). This can be a valuable tool in the planning of sensitive and effective services. However, its utility depends on a clear definition of who is included in the group and the rationale for their inclusion as well as criteria for the exclusion of others.

 

This issue of defining group membership has been a continuing problem in the context of Traveller research. Should traditional and ‘New’ Travellers be regarded as members of the same research population, for example? Both are nomadic in similar ways but their cultures are very different. Even amongst traditional Gypsies/Travellers there are cultural differences which need to be taken seriously. Should those who define themselves as Romani, English or Welsh Gypsies be included in the same study as those who define themselves as Scottish Travellers or Irish Travellers? Similarly, should those Gypsies and/or Travellers who travel, those who remain in one place and those who travel occasionally be grouped together despite the fact that the material and environmental influences on their health may be very different? Gypsies/Travellers are a very diverse group of people characterised by a ‘continuity rather that community of culture’ (Hawes 1997) and this has major implications for the development of sensitive and appropriate research designs.

 

The issue of definitions and boundaries is especially difficult in the context of epidemiological studies exploring the causes of health and illness. Bhopal and others have used the term ‘black box’ to apply to the many studies which use ethnicity as a key variable (Bhopal, 1997; Bhopal and Donaldson, 1998). Too frequently such studies are entirely descriptive, with no attempts to produce causal explanations. This is characteristic of much of the current literature on Travellers. A range of potential influences on health are identified and described but no attempt is made to elucidate their relative importance or the links between them. This amounts to a serious methodological constraint on the creation of an appropriate evidence base for practice.

 

The first set of influences referred to in the literature are what could be called behavioural or cultural factors. Here studies have identified a diverse group of factors that are assumed to have an impact on Travellers’ health. These include high fat diets, what are referred to as ‘alternative’ hygiene practices (Acton et al ., 1994; Okley, 1983), young age at marriage and large family size, lack of education and low levels of literacy especially among women, risk taking behaviours including smoking and drinking among men, and an ‘innate’ reluctance to use health services. These are clearly important areas for investigation but they need to be much more clearly delineated and understood. In particular we need to know how important each of these are, how they relate to each other and how they impact differently on men and women and on older and younger people within Traveller populations.

 

At the same time it is also important to be able to separate these cultural/behavioural factors from the more material ones. How far are Travellers’ health problems related to their low socio-economic position, how much to the poor quality of the sites they often inhabit and how much to travelling itself? And how far do these problems reflect their experiences of discrimination and rejection? There is now a growing literature on migrant health from different parts of the world which poses very similar challenges. Many studies have emphasised the need to disentangle the effects of poverty and low socio-economic position from the effects of a highly mobile lifestyle, from the effects of marginalisation from mainstream society. Yet very few insights from such wider studies have been incorporated into work on Traveller health. Cross fertilisation of this kind could play an important part in bringing these issues into the wider public health arena.

 

There are therefore serious problems involved in any attempt to draw firmer conclusions about the determinants of health among Travellers. If the gaps in current knowledge are to be filled, much more thought will need to be given to the ways in which the different groups are defined and to the different elements of the causal model to be deployed in explaining their health status and in planning for change.

 

[1] CRE v Dutton (1989) 1 All ER 306. This was extended to Irish Travellers in an unreported court case in London in August 2000 (for details visit www.cre.gov.uk ).

[2] More details of these various campaigns can be found in Turner (2000) and in Morris and Clements (1999).