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A methodological review of recent studies on traveller's health
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Given the lack of routine data collection on Travellers’ health, policy makers and practitioners are forced to rely on the results of one-off studies. In recent years these have been reviewed by a number of commentators, all of whom have pointed to their limitations. The aim of the survey of research presented was to move the debate one step further through focussing not on the substantive results of these studies but on their methods. The intention is to highlight some of the underlying reasons for the unsatisfactory nature of much of the existing literature.
Box 1: Databases included in the search strategy
The
MEDLINE
database is produced by the U.S. National Library of Medicine. It encompasses information from
Index Medicus
,
Index to Dental Literature
and
International Nursing
, as well as other sources of coverage in the areas of allied health, biological and physical sciences, humanities and information science as they relate to medicine and health care, communication disorders, population biology and reproductive biology.
PubMed
, a service of the National Library of Medicine, provides access to over 11 million MEDLINE citations back to the mid-1960s and additional life science journals. PubMed includes links to many sites providing full text articles and other related resources.
Over 90 commercial databases are available through Ovid. They include the definitive bibliographic resources in many research areas. For research in medicine and allied health, Ovid offers
MEDLINE®
and
EMBASE
; in nursing,
CINAHL
; in bioscience, the
BIOSIS
databases; for general reference,
Current Contents®
,
Newspaper Abstracts
and
Wilson Reader's Guide Abstracts
; and so on in business, humanities, engineering, agriculture, science & technology, and social sciences.
HealthPromis
(HEA
)
National health promotion database for England, which contains references and links to a range of sources. These include official publications, surveys, reports, books, journal articles and resources. Previously maintained by the Health Education Authority (HEA).
CINAHL
The Cumulative Index to Nursing & Allied Health (CINAHL) database provides authoritative coverage of the literature related to nursing and allied health. Virtually all English-language publications are indexed along with the publications of the American Nurses Association and the National League for Nursing.
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In order to carry out this review, searches were conducted on five computerised data bases: Medline, PubMed, Ovid, CINHAL and the HEA (see Box 1). Search terms included Gyps*, Traveller*, health* and Roma* and searches were limited to articles published in English since 1980. In addition,
Internet search engines were used to find local organizations involved with Traveller and Gypsy issues in the UK. This was followed up by contacting people at the Traveller Law Research Unit at Cardiff University, who provided further information on the ‘grey’ literature. The regular newsletter "Travellers’ Times" was also searched. These various search strategies, as well as hand searches,
yielded a range of relevant articles and a total of 105 were put into a Reference Manager database. The research team then read all of these articles and completed data extraction sheets which included a review of sources of evidence.
Those articles which made little use of empirical evidence were set aside and the rest were classified into those which had collected primary data (32) and those which relied on secondary data (26). The team then reviewed the methods used for primary data collection as well as examining the ways in which earlier data were cited by later commentators. The 58 articles reviewed are summarised in
Appendix 1
, which includes the findings and the recommendations (if any) of each study, as well as a range of methodological details.
Overall the review indicated that studies in this field were largely small scale and anecdotal. Many had been carried out by heath care workers directly involved with Travellers. Health visitors in particular have been very active in documenting the needs of this group (Anderson, 1997; Batstone, 1993; Kargar, 1992; Lawrie, 1983; Ormandy, 1993; Rose, 1993; Sadler, 1993; Taylor, 1991; Tylor, 1993; Vernon, 1994). These authors are highly motivated but unfortunately rarely have either the research training or the resources to undertake robust studies which would stand up to wider scrutiny.
Studies which focus on health status or social determinants of health are mostly concerned with infectious diseases or with the condition of mothers and babies (Cornwell, 1984; Feder
et al
., 1989; Feder and Hussey, 1990; Feder and Vaclavik, 1991; Feder
et al
., 1993; Durward, 1990; McKenzie, 1990; Save the Children, 1983; Webb, 1996 and 1998). Some interest has been shown in dietary issues and in dental health (Edwards and Watt, 1997a and 1997b). However very few studies have explored major non-communicable diseases such as cancer and heart disease and no studies on the topic of occupational hazards were found (Hajioff and McKee 2000).
As a result of this relatively narrow focus, there is very little evidence on the main health problems experienced by men. Women’s problems have received more attention but only those associated with their role as mothers. Very few references are made in the literature to ‘hidden’ problems such as gender violence and child abuse. Mental health has also been largely ignored except for very general references to the negative impact on Travellers of discriminatory behaviour by the wider society.
The impact of poor quality sites on both physical and mental health has received attention in a few studies but, surprisingly, there has been no detailed examination of potential links (Chartered Institute of Environmental Health, 1995). Many studies refer to the damaging effects of the 1994 Criminal Justice and Public Order Act which increased the power of local authorities to evict Travellers (Niner
et al
., 1998; Morris and Clements, 1999; Webster, 1995). At the same time there are a number of references to the harm done to those Travellers who cannot move around and are forced to live in houses (van Cleemput, 2000). These complex relationships between travelling
per se
and health require further investigation if their interactions and implications are to be properly understood.
Very few studies have attempted any systematic comparison of the health status of Travellers with the wider population. The only real exception to this is an important pilot study carried out in Sheffield in 1995 (van Cleemput, 1995).
In this
investigation 87 Travellers were matched for age and sex with working class members of a socially deprived area. The results showed statistically significant differences between the two groups in certain dimensions of wellbeing and significant associations between frequency of travelling, smoking and health status. A larger study based on this pilot is now underway and should provide valuable information on the socio-demographic correlates of Traveller health compared with other materially disadvantaged groups in the population.
Moving on from health status to health services, most studies have concentrated on issues relating to primary care (Feder, 1989; Hussey, 1988; Hennink
et al
., 1993). Reflecting current moves towards joint working, several comprehensive studies have examined Traveller use of local community health services as well as their use of social care (Cemlyn, 1994; Cemlyn, 2000a and 2000b; Harvey
et al
., 1999; Hawes, 1996; Hawes and Perez, 1996; Morris and Clements, 1999). While these are clearly important areas for investigation, they leave a number of other health care arenas largely unexplored. Very little indeed is known about Traveller use of accident and emergency services or in-patient care, for example (Beach, 1999). A few studies have examined the links between Travellers and public/environmental health services but these are very few in number despite the obvious significance of such initiatives for mobile populations (Chartered Institute of Environmental Health, 1995; Hussey, 1998; Redondo and Guisasola, 1995).
Most importantly, the literature does not include examples of interventions which have been evaluated with any degree of rigour. There are many cases of projects which have been documented by the health workers involved. These reports usually focus on the positive aspects of their interventions and offer useful suggestions for those wishing to do similar work. However, they are rarely well designed and tend to use process rather that outcome measures as indicators of success. Such accounts can give important indications of ways of avoiding culturally inappropriate approaches to service delivery. However, they cannot provide concrete evidence of improvements in the health status of Travellers.
Despite the weak methodological foundations of the data reported in many of these studies, they are frequently cited in subsequent articles with little or no recognition of their limitations. In a number of cases it was evident that the informal and anecdotal observations of individuals had a tendency to be transmuted into empirical ‘truths’ over the course of repeated publication. This may be understandable in the context of a desire to improve the circumstances of a group which has been largely ignored. However, it is of little value in building a scientific foundation for evidence-based practice. Since very few of these findings can be directly compared with those concerning other groups, they remain outside broader public health debates. According to one recent commentator, the available literature “does not represent a picture of ‘evidence piling up’ so much as a patchy and ill-understood phenomenon whose complexity is matched by its marginality to the mainstream health structure” (Hawes 1997: 17).
The overall conclusion from these reviews of national data sources and of recent studies was that they could contribute relatively little to the search for better sources of information on Travellers in the South West region. The DETR/DLTR Count measures the numbers of caravans and their location across the region but does not give any indication of the needs of individuals. The findings of one-off studies from other parts of the country give some indication of topics needing further investigation but offer little in the way of new data sources or innovative approaches for developing a more robust evidence base.
