“mental health issues experienced by gypsies, traveller and roma communities": margaret...
TRANSCRIPT
“Mental Health Issues experienced by Gypsies, Traveller and Roma Communities":
Margaret Greenfields: Professor of Social Policy/Community Engagement &Director of IDRICS [email protected]
Presentation Outline
• Summary of Background Literature• Case studies drawn from series of health and
social inclusion projects undertaken by IDRICS
• Barriers to Service Access• Gypsy, Traveller and Roma mental health
initiatives
CAUTIONARY NOTE• Examples indicative of (calculated/estimated)
disproportionality of MH stressors amongst GTR communities + significant anecdotal evidence from practitioners/NGO workers.
• Overall GTR communities display widespread ‘resilience’ in the face of hardship.
• Limited data available – predominantly drawn from small-scale studies re limitations on administrative data-sets/exclusion from NHS data dictionary.
Background – GRT health status• Estimated 250,000-300,000 Gypsies and Travellers in Britain equivalent in
size to the Sikh community (CRE 2006; EHRC/Cemlyn et. al 2009) nb: 3-4% p.a compound natural population growth = 390,000-430,000 in 2014-15. (Figures exclude estimates of Roma migrant populations).
• Figures for migrant Roma vary from between 50,000-200,000 (2008-2013 reports - e.g. Salford University RomaMATRIX; 2013; Craig, 2011; MigRom, 2014).
• Average life expectancy of G/T populations in the UK has been estimated variously as 10-12 years below that of ‘other’ White British citizens (Parry et al, 2004). Baker/Leeds REC (2006) estimated an average life expectancy of 50 years, Bedfordshire NHS Health Trust (2010) around 65 years. Anecdotally (see evidence from Smith & Greenfields, 2013; Parry et. al. 2004; Greenfields & Brindley, 2015 forthcoming, and Rogers, 2015) all suggest high levels of anxiety/depression + link to multiple traumatic bereavements.
• No comparable data exists on Roma populations in the UK although based on European reports e.g EPHA, 2014; FRA, 2012 it is anticipated that higher morbidity and early morbidity exist and that significant variations in health status may be found when Roma are compared to other ‘mainstream’ populations.
• 2/3rds of Gypsies/Travellers now resident in housing. Of those in caravans approximately 21% have nowhere to live/statutory homeless (Smith & Greenfields, 2013; Greenfields & Smith 2010-2011 re enforced sedentarisation and socio-cultural impacts)
• Roma overwhelming living in housing – anecdotally often severely overcrowded and poorly maintained (Craig, 2011). Greenfields et al on-going research confirms this picture. Relatively high rates of undiagnosed/treated infectious disease (anecdotal and limited research evidence) e.g. TB, Hepatitis C, etc. see further: http://bucks.ac.uk/content/documents/Research/INSTAL/Bridging_the_Gap_Health_and_Social_Care_Report.pdf
• Parry et. al. 2004; Cemlyn et. al., 2009; Greenfields, (various dates) have all found abundant evidence of premature mortality and morbidity (including child bereavement/maternal mortality); high rates of cardio-vascular disease; over-representation in Type II diabetes; arthritis; asthma and obesity; increasing reports of problematic substance misuse and high rates of anxiety and depression.
• Craig, 2011 suggests that the limited research findings pertaining to Roma migrants offer a similar picture. See too NFGLG, 2014 – report on NRIS in the UK, health review and recommendations.
Specific Evidence in relation to MH• Parry et. al. (2004) higher rates of anxiety/depression than ‘mainstream’
populations – ‘travelling’ as protective factor.
• Goward et. al. (2006) premature parental loss significant, many women felt unable to seek help within community.
• Greenfields (2008) significant barriers to help-seeking/stigma (for GRT staff and service user) http://www.better-health.org.uk/resources/research/good-job-traveller-exploring-gypsy-and-travellers-perceptions-health-and-social-c
• Cemlyn et. al. (2009) summarised state of knowledge re health including MH evidence.
• Mind (Bristol) (2008) assertive outreach/ support service/small scale study (9 participants) http://www.bristolmind.org.uk/files/docs/research/gypsy-traveller-research-summary.pdf
• Lau & Ridge (2010) impact of social exclusion on mental health in Gypsy, Roma, and Traveller (GRT) communities (small case study based on 2 x cases)
• Smith & Greenfields/Greenfields & Smith (2010-13) – impacts of enforced sedentarism on MH of formerly nomadic participants.
• Greenfields & Brindley (forthcoming) commissioned DH ‘Inclusion Health’ report – evidence that most significant health concern reported by respondents = anxiety/depression associated with insecure accommodation.
• Roma Support Group (limited report) small scale trial study wellbeing support/advocacy programme (with East London Foundation MH Trust) DH Pacesetters GTR stream funded. Predominantly anxiety/depression – mirroring post-migration stressors and undiagnosed existing MH conditions.
• Irish evidence (anecdotally replicated in the UK) high rates of suicide. In Ireland second highest cause of death working age Travellers (Brack & Monaghan, 2007; Walker, 2008).
• Rogers (2015) multiple traumatic bereavements including suicide/infant mortality associated with depression/anxiety para-suicide etc.
Case StudyIrish Traveller family on unauthorised encampment/repeated evictions – pregnant 41 year old (5 older children), limited ante-natal care, no screening for foetal abnormalities “feeling unwell”. Late miscarriage approx. 24 weeks. Discharged from hospital 4/7 to ‘car park’ – midwife follow up care.
Temporary registration arranged with GP. Prescribed anti-depressants 8/52 as unable to cope with loss. No counselling offered, family mobile/repeat evictions.
When researcher interviewed family in relation to homelessness 5 years later, woman still taking anti-depressants, did not believe had had review.
Clear evidence of on-going psychological trauma, shaking, anxious, panting. 16 year old daughter caring for family as mother ‘unable to cope’.
Registered when possible as temporary patient in local areas and presented medication bottle/prescription sheet. Support volunteer (Catholic Chaplaincy) reported GP simply “scribbling out the prescription couldn’t get us out of there fast enough and had initially refused to accept the woman until I went with her. No blood pressure or history taken.”
Family functionally illiterate, no awareness of risk of long-term medication use reported 2/3 attempts to register with GPs turned away as no vacancies, outside area or don’t deal with Travellers site.
Case Study 2• Czech Roma woman migrant (limited English). 8 Children,
living in extreme poverty/overcrowding.• Husband re-migration for family/work purposes• Income reduced and housing related debts. Concerns
reported re neglect of children.• Social Services interventions (cultural conflict/poor
communication within case). • Mother ‘highly uncooperative’ – younger children became
looked after. Mother exhibiting ‘florid’ symptoms of psychosis including threatening behaviour to social workers/suicide threats. MH issues overlooked initially and interpreted as culturally specific reaction/ ‘anger’. Support staff at point of intervention then sought MH assessment.
Case Study 3• English Romany woman – residence in housing
following repeated evictions from roadside sites following failure to obtain planning permission for ‘self-owned site’.
• Anxiety/Depression associated with isolation ‘loss of culture’
• Hospitalisation following suicide attempts, children became looked after.
• On return to residence on site (family land) mental health stabilised. Children returned to care.
Housing Transitions and MH
• Administrative and practical concerns pertaining to enforced sedentarism compounded by unfamiliar physical layout and design of housing (Greenfields/Smith; Smith/Greenfields 2010-2013).
• ‘only using one room and a kitchen like – there’s too much space in a big house and no real space outside so it’s topsy turvy’.
• Feelings of claustrophobia commonly reported across all study areas
• ‘It’s just staring at the four walls does my head in. It’s terrible really terrible. I know in a trailer it’s smaller but you’ve got windows all around you and you can see out in all directions who’s coming and what’s going on so it just feels bigger.’
• ‘It’s depressing when you have these 4 walls all round you. In your trailer you can look out every side. You think a house is bigger than a trailer but it makes no difference at all ’cos when you have the windows you can look out but when you have those solid walls all around you, it does your head in…. like being in prison’
• Mental health issues (particularly depression and anxiety) among housed Gypsies/Travellers identified in previous studies (Parry et al, 2004; Van Cleemput, 2008)
• ‘Mental illness is big in the housed Gypsies. I’ve seen it. It’s massive and I see it all through the country. They put them in substandard housing because they think that’s what they are substandard people.’
• Compounded by isolation when housed away from community members
• ‘…you’d go literally three months and you might just say good morning to someone outside because they lived their own lives never spoke to each other. I didn’t want people in my house but you didn’t visit people and it got to the stage when I had the children and post natal depression kicked in.’ (Greenfields/Smith & Smith/Greenfields 2010-2013)
Barriers to Service Access - Key Findings across all GRT groups
• Problems over registration – gatekeeping by front-line staff/receptionists• Limited understanding of current DH rules on access to health care (Roma) • Documentation/literacy issues/Internal community stigma re MH concerns • Cultural misunderstandings/gender issues – barriers to reporting DV etc.• Attendance for primary care/emergency treatment when MH condition often
deteriorated considerably• Lack of screening/difficulties engaging with the ‘system’ = late diagnosis• Low levels of health literacy/awareness of treatment options• Stigma impacting on care/adverse stereotypes enacted by health care
professionals• Disrupted treatment regimes occasioned by frequent movement or non-
compliance with medication (cf: external factors including lack of access to electricity/phones/literacy barriers etc. etc)
• Emergent evidence – Roma – pre-existing health conditions leading to public agency/social work engagement re children – exacerbating fear/anxiety symptoms and post-migration stress for some.
GRT Service Users’ identification of barriers to health care
• Getting through gatekeepers • Lack of awareness of how system works/rights -
language barriers (R)• Short and inflexible appointments • Lack of cultural competence/stereotyping/hostility nb
lack of awareness of ‘minorities amongst minorities eg LGBT GRT service users.
• Practical barriers – child care, distance travelled; lack of post, literacy, etc
• Stigma “you’d not want anyone to know – the shame of it would be terrible”
Costs of Poor Quality Care• Human cost (pain, suffering, avoidable mortality)• Impact of diminished trust in services resulting from
‘word of mouth’ transmission of poor care experience • Excess cost to the NHS resulting from late treatment of
preventable condition (see further http://www.leedsgate.co.uk/wp-content/uploads/2013/06/Cost-Benefit-Analysis-report-Gypsy-and-Traveller-Health-Pathways.pdf) [estimated cost over 1 year – non-specialist health pathways > £20,000 per client]
• Impact on staff skills/trajectories/empathy
Good Practice/Gypsy, Traveller and Roma mental health initiatives
• Recruitment of specialist trained GTR staff members – advocates/wellbeing specialists – e.g in Kent
• Traveller Movement DVD on seeking mental health support (aimed at Gypsies and Travellers).
• FFT – publications on depression/anxiety, wellbeing consultation (publications for service users and staff)
• MIND – (Bristol) targeted service – now closed.• BANES – CCG specialist services including MH awareness• RSG Mental Health Advocacy project with migrant Roma summary
report – now recruiting advocate for follow-up work. see: http://romasupportgroup.org.uk/wp/wp-content/uploads/2011/08/Roma-Mental-Health-Advocacy-Project-Evaluation-Report.pdf
Transferable and Comparable Good Practice Recommendations
• Work on culturally specific outreach activities in partnership with specialist NGOs – employment of community members as advocates nb: “Good Job for a Traveller” Greenfields, 2008 re: perceptions of some MH posts…
• Embed cultural competence into training of staff pre and post-qualification (e.g. CPD points as incentives)
• Ensure Key staff with specific experiences/ competences are identified in within teams and across localities (community staff) + resource library
• Engage with CCGs/ in relation to joint commissioning – and across areas to save on resources
• Specialist outreach services/direct access by pt. and ‘one stop shops’ for vulnerable groups staffed by ‘experts’ with internships/rotations for other clinical staff.
