irish traveller life expectancy

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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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The long road towards acceptance for Irish Travellers

The Irish Traveller community is fighting for official recognition of its ethnic identity and for a way of life.

Avila Park, Dublin, Ireland –   In a wooden shed in his back garden, James Collins sits on a low stool hammering out the final touches on a billy can. At 68, he is one of only two remaining traveller tinsmiths in Ireland.

Above the clutter of well-worn tools and scrap sheet metal hang a dozen or so other cans. Nowadays, he says, there’s precious little demand for his trade, and he largely continues it as a hobby, occasionally selling some of his work at vintage craft fairs.

Since the introduction of plastic homeware in the 1960s and 1970s, tinsmithing – traditionally dominated by the historically nomadic community known as Travellers – has effectively died out. Even the block tin, James originally used, is no longer available.

“It’s more difficult to work with,” he says, holding up a gleaming aluminium can. “You can’t make what you want to make out of it because you have to use solder and that won’t take solder.”

READ MORE: Ballinasloe Horse Fair – An ancient Irish tradition

James was raised on the road in the Irish midlands, a traditional upbringing unknown to most Travellers today. “I was bred, born and reared on the road,” he says, “but the young lads today wasn’t. They all grew up in houses and went to school and all this craic. I never got any education, never went to school in my life.”

Until his late 20s, when he settled in Avila Park, a housing estate for Travellers on the outskirts of Dublin, the Irish capital, James plied his trade for farmers, smithing and repairing buckets. “It never goes out of your mind; you’re always thinking, thinking the whole time about the road,” he says.

In comparison, younger generations have little interest in traditional crafts or the travelling lifestyle – James’ children and grandchildren don’t know how to harness a horse, for example. And anti-trespass legislation introduced in the early 2000s, which was used to disperse encampments by the side of roads or on council-owned land, made a nomadic existence increasingly difficult.

Yet, even as the distinct traditions of Irish Travellers seem to fade into the past, the battle for official recognition of their identity continues.

The search for recognition

Unlike the United Nations and the United Kingdom, Ireland does not recognise Travellers as a separate ethnicity from the non-Traveller community. For decades, human rights organisations and Traveller advocacy groups have been seeking this recognition, but to little avail.

However, on January 26, a parliamentary committee established to investigate the issue stated unequivocally that “Travellers are, de facto, a separate ethnic group”.

“This is not a gift to be bestowed upon them, but a fact the state ought to formally acknowledge,” it further said.

The committee report urged the Taoiseach, Ireland’s prime minister, or the minister for justice to give a statement to the Dail, the Irish parliament, acknowledging this at the earliest opportunity.

This development was welcomed by members of the Travelling community, although some remain cautious in their optimism. It would not be the first time an Irish government has reneged on such commitments – a 2014 parliamentary report made the same recommendation, which was never acted upon.

A history of deprivation and discrimination

An examination of the almost 30,000 Travellers in the Republic of Ireland shows a staggering level of deprivation completely at odds with the non-Traveller community. Another 4,000 to 5,000 Travellers live in Northern Ireland, in a similar situation.

Around half of Travellers have no secondary education and only 1 percent have attended university, according to Pavee Point, a group fighting for the rights of Travellers.

WATCH: Irish travellers facing discrimination

Some 84 percent of Travellers are unemployed, while suicide rates are almost seven times higher than among settled people. A 2010 study found that life expectancy was 15 years lower among men and 11 years lower among women when compared with their settled counterparts.

Discrimination against Travellers remains endemic at social and institutional levels. Being denied entry to businesses is a common occurrence and many try to hide their background when applying for jobs, fearing that potential employers will not hire them.

“Symbolically it would have a profound impact on our collective sense of identity, self-esteem and confidence as a people,” says Martin Collins, the co-director of Pavee Point, on the recognition of Traveller ethnicity.

“Some travellers have internalised [racism] and end up believing that they are of no value, they are of no worth … So that’s the impact. That’s the outcome of both racism and your identity being denied.”

A culture denied

It was a 1963 government report, the Commission on Itinerancy, that has set the tone for the state’s attitude towards Travellers ever since, says Sinn Fein Senator Padraig MacLochlainn, the first person from a Traveller background to be elected to the Irish parliament.

The Committee on Itinerancy ‘s terms of reference defined Travellers as a “problem”, whose social ills were “inherent in their way of life,” and outlined the goal of “promot[ing] their absorption into the general community”.

No Travellers were on the committee, nor were they consulted for its report.

“Our people and our state denied their history and decided that they were criminals and they needed to be immersed in with the rest of us,” says MacLochlainn.

This refusal to acknowledge the community’s rich cultural history – notably their own language, Cant, and significant contributions to Irish traditional music – persists today.

Traveller culture is frequently portrayed in the media as separate and distinct, MacLochlainn says, but almost always in negative terms, in exploitation TV shows   such as My Big Fat Gypsy Wedding and exposes on Traveller criminality.

“You clearly accept them as a distinct group – why are you making these programmes if you don’t? If they’re a distinct group, could you do it now in positive terms?

“When it comes to negative characterisations, the media, the establishment … in Ireland are more than happy for them to be characterised in negative terms,” the senator says.

Behind James’ shed in Avila Park, traditional and modern Traveller accommodation sit side by side. A wooden barreltop caravan, washed green with blue and red embellishments, sits between two mobile home units, where his younger relatives stay.

Only one has both electricity and running water, which were installed by the family. Power is provided from the house by a yellow cable, wound loosely around plastic drainpipes and holes in its pebbledash exterior.

An early morning fire in a nearby prefabricated unit just a few weeks before offered a bleak reminder of the danger these makeshift electrical fixtures pose. A neighbour raised the alarm and the young couple inside escaped before their home was reduced to a charred husk.

Children burned to death

This near disaster has reminded some people of a fire in the south Dublin suburb of Carrickmines more than a year ago, which continues to cast a shadow over relations between the Traveller and the settled communities.

In the early hours of October 10, 2015, a fire ripped through a halting site killing 10 people, including five children, from two families – the Lynch and Gilbert family and the Connors. The youngest victim was five months old. It was one of the deadliest fires in the history of the Republic of Ireland.

Social workers had raised concerns about the site’s substandard prefabricated units to authorities in the months before the fire, but no action was taken. The blaze and its aftermath would, for many, become an example of the pervasive discrimination Travellers face in Ireland today.

Three days after the fire, some locals blockaded land marked for temporary accommodation for the surviving members of the Connors family, preventing construction vehicles from entering. Though the obstruction was condemned by then Environment Minister Alan Kelly and several Traveller groups, the protesters were successful.

OPINION: Catholic Ireland’s saints and sinners

On October 21, one day before the last victims were buried, the county council announced that the Connors family would instead be resettled on a reclaimed dump on council land in a nearby suburb. At the time of writing, the family remain in that location.

Alongside many expressions of grief on social media after the fire were comments highlighting the discrimination towards travellers in Irish society.

On one popular news site, a comment simply wishing that the victims rest in peace received hundreds of thumbs down votes from other readers. “Hundreds of Irish people gave a thumbs down to an expression of sympathy for children who were burned to death,” says MacLochlainn. “That’s terrifying; that’s absolutely terrifying.”

In response to the tragedy, local authorities across the country conducted fire safety audits at Traveller accommodation sites. “All we got was a few fire alarms, a few fire blankets and some carbon monoxide alarms,” says Collins, of Pavee Point.

“That’s like re-arranging the chairs on the Titanic. That’s totally inadequate. These sites need to be completely redeveloped [and] refurbished, because the sites are just inherently dangerous. Getting a few fire alarms and a few hoses will not rectify the situation.”

For Collins, the long overdue recognition of Traveller ethnicity is an important milestone, but as the Carrickmines example shows, a commitment to materially improving the lives of Travellers is also necessary if they are to be truly equal in their own country.

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Article Contents

Introduction, acknowledgments.

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Social inequalities in health expectancy and the contribution of mortality and morbidity: the case of Irish Travellers

• Article contents
• Figures & tables
• Supplementary Data

Safa Abdalla, Cecily Kelleher, Brigid Quirke, Leslie Daly, on Behalf of the All-Ireland Traveller Health Study team, Fran Cronin, Anne Drummond, Patricia Fitzpatrick, Kate Frazier, Noor Aman Hamid, Claire Kelly, Jean Kilroe, Juzer Lotya, Catherine McGorrian, Ronnie G Moore, Sinead Murnane, Roisin Nic Carthaigh, Deirdre O'Mahony, Brid O'Shea, Anthony Staines, David Staines, Mary Rose Sweeney, Jill Turner, Aileen Ward, Jane Whelan, Social inequalities in health expectancy and the contribution of mortality and morbidity: the case of Irish Travellers, Journal of Public Health , Volume 35, Issue 4, December 2013, Pages 533–540, https://doi.org/10.1093/pubmed/fds106

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The health expectancy of Irish Travellers, a disadvantaged indigenous minority group in Ireland has not been previously estimated. This study aimed to examine health expectancy inequalities between Irish Travellers and the general population.

We used Sullivan's life table method to construct healthy life expectancy (HLE) and disability-free life expectancy (DFLE). The All-Ireland Traveller Health Study provided Irish Traveller population's mortality and health data. Vital registration, census and comparable national survey health data were used for the general population. We calculated the absolute and relative life expectancy, HLE and DFLE gaps between Irish Travellers and the general population and decomposed the HLE and DFLE gaps into mortality and morbidity contributions.

Irish Travellers had consistently lower HLE and DFLE than the general population. The health expectancy gap displayed notable age and gender variations and was wider than the life expectancy gap. Mortality contributed more than morbidity to the health expectancy gap in men but not in women.

This study illustrated the true extent of health inequalities experienced by an indigenous minority in Europe, clarifying the importance of reducing the burden of non-fatal disabling conditions for addressing these inequalities. The health expectancy measure used has application for other similar indigenous minorities elsewhere.

The poor health of disadvantaged indigenous minority groups has been documented in many countries, and is attributable to adverse socio-economic and environmental circumstances, marginalization and discrimination, unfavourable lifestyle factors and inadequate access to good quality health services. 1 , 2

Irish Travellers are one such indigenous minority group in Ireland, who share a distinctive history, value system, language and customs. They represent ∼1% of the population of Ireland and have the typical profile of a disadvantaged group, with lower employment and educational achievement. 3 Routine national data do not capture ethnic or cultural group status, but two major national studies in 1987 and again in 2010 showed that despite absolute improvements in their survivorship over two decades, Irish Travellers continue to fare poorly in terms of infant mortality and life expectancy, compared with the general population. 4 , 5

Commitment to reduce these inequalities is reflected in the national policy target of narrowing the life expectancy gap between Travellers and the general population. 6 However, using only life expectancy to track health inequalities overlooks inequalities in non-fatal health outcomes. Health expectancy, a measure widely used to assess health status and health inequalities in various settings, 7–10 adjusts life expectancy for time lived in less than perfect health, so that health expectancy at a particular age is the average time expected to be lived further in perfect health by an individual who reaches that age.

Studying the health expectancy of Irish Travellers presents a comprehensive yet concise baseline view of health inequalities related to this group. While health expectancy of the general population in Ireland is regularly measured by the European Health Expectancy Monitoring Unit, 11 the health expectancy of Irish Travellers has not been estimated before. This paper aimed to fill this gap by using health expectancy to examine health inequalities affecting Irish Travellers in the Republic of Ireland in 2007–2008. Specifically, we sought to answer the following questions:

What is the health expectancy of Irish Travellers in the Republic of Ireland?

What is the magnitude of inequalities in health expectancy between Irish Travellers and the general population and how does it compare with inequalities in life expectancy?

What is the contribution of mortality and morbidity to inequalities in health expectancy?

Health expectancy is a generic term encompassing a wide range of measures that vary by the underlying definition of health used in their construction. In this study, which was a secondary analysis and synthesis of existing mortality and cross-sectional survey data, we used Sullivan's prevalence-based life table method to construct healthy life expectancy (HLE) at age 15 and at age 65, based on poor self-reported perceived general health, and disability-free-life-expectancy (DFLE) at age 15 and at age 65, based on disability, for male and female Irish Travellers in the Republic of Ireland. A comparable set was constructed for the Irish general population. Life expectancy estimates were included for comparison. Using Sullivan's method required population data, mortality data and cross-sectional health data for each group. 12

Irish traveller data

Population and mortality data.

We used the Traveller population count by age and gender from the All-Ireland Traveller Health Study (AITHS). The study included a census of Irish Travellers and an assessment of their health status and mortality experience. The methodology of the study was published in a series of technical reports. 5 , 13 A Traveller was defined as a person identified by themselves and others as a member of the Traveller community, in keeping with the definition of the Traveller community in the Equal Status Act in Ireland. 14 The census interviews had a response rate of 78% of Traveller families in the Republic of Ireland. All families completed the core census section and a health status interview for a randomly selected child aged 5, 9 or 14 years, or in childless households, a health status or health service utilization interview for a randomly selected adult. AITHS received ethical approval from University College Dublin Research Ethics Committee. A written consent to participate was obtained from the respondents.

The mortality sub-study of AITHS provided the number of deaths over the year preceding the census. Traveller deaths were mainly reported by census respondents, with additional reports from Public Health Nurses. After the elimination of duplicate reports, a final list of Traveller deaths was matched with the official database of death records maintained by the General Registrar Office, using reported name, age, gender and place of death. 63% of the 166 identified deaths were successfully matched, and during the process, a researcher who was experienced in working with Travellers identified 22 further Traveller deaths that were not reported by the other sources, but had typical attributes of Travellers, e.g. trailer halting site for address or tinsmith for occupation. Those were confirmed by local study coordinators and Traveller peer researchers working with Travellers in the area where the deceased resided. More than 90% of the reported ages for those successfully matched were within a 5 years’ range of the ages in the official death record. Thus, for this study we included deaths identified from all sources, using the age and gender of the official record for the matched deaths and the reported age and gender for the unmatched deaths, excluding four males and two females lacking age data.

Perceived general health and disability data

We used perceived general health data and disability data from the health status survey of Irish Travellers aged 15 years and over in private households, conducted in 2008 as part of AITHS. 15 The survey had two components: a core component that included the perceived general health item, with a sample size of 5288 (2574 men and 2689 women) and a detailed component that included the disability item, with a sample size of 1663 (702 men and 961 women). These questions were selected from national instruments for comparability purposes, and conveyed to Traveller respondents in a culturally compatible manner (Table  1 ).

Perceived general health and disability questions used in the AITHS adult health status survey and in the SLAN 2007

a For the purpose of this study, poor health was taken as general health reported to be fair or poor in general.

b The culturally compatible harmonized form of the question administered to Traveller respondents was: ‘Have you any long-term medical problem or disability that stops you doing your daily work?’

General population data

For the general population, we used the number of deaths in 2007 by age and gender, 16 and the total population enumerated at census 2006. 17

The publicly available Survey of Lifestyle, Attitude and Nutrition (SLAN) 2007 data set included comparable perceived general health and disability questions (Table  1 ) for the general population in Ireland. 18 The survey included adults in private households aged 18 years and over and had a sample size of 10 364.

Calculation of health expectancy

Using the survey data from the Travellers and the general population, we estimated the age–gender specific prevalence of poor health and the age–gender specific prevalence of disability. As the Traveller survey was limited to those aged 15 years and over, and SLAN was limited to those aged 18 years and over, we used 5-year age groups starting from 15 years, assuming that the general population prevalence in those aged 18–19 years applied to those aged 15–19 years. SLAN data were available in 5-year age groups ending in the group 75 years and over, which was thus the final open-ended group for the analysis of both the SLAN and Traveller survey data.

For each gender, we constructed abridged life tables in 5-year age intervals, starting from the age of 15 and ending with an open-ended interval of 85 years and over. We used age-specific mortality rates to calculate the person-time contributed by a hypothetical cohort to each age interval, using Chiang's method. 19 Summing the person-time further to the age of 15 years and to the age of 65 years and dividing by the number of hypothetical survivors at the ages of 15 and 65 years, respectively, gave the life expectancy at those ages. For each gender group, and according to Sullivan's method, 12 we used the prevalence of poor health in each age interval to divide the person-time lived in that interval into person-time lived in poor health and person-time lived in good health. We constructed HLE at age 15 and at age 65, by summing the person-time in good health further to ages 15 and 65, respectively, and dividing by the number of hypothetical survivors at those ages. We applied the same approach to construct DFLE at age 15 and at age 65 using disability prevalence.

95% confidence intervals for life expectancy were computed using Chiang's method. 19 95% confidence intervals for HLE and DFLE were calculated according to Mathers (1991), 12 , 20 by quantifying and summing the variance resulting from mortality rates and the variance resulting from the prevalence of poor health and disability, respectively, to obtain the total variance and the standard error.

The gap between Travellers and the general population

We calculated absolute life expectancy, HLE and DFLE gaps as the difference between Traveller and the general population estimates. The standard error of the difference was the square root of the sum of the variance of Traveller and the general population estimates and was used to calculate 95% confidence intervals for the gap. The gap was statistically significant if the intervals did not include zero. To facilitate the comparisons of the gap across different indicators, ages and gender groups, it was also expressed in relative terms as a percentage of the general population estimates.

Mortality and morbidity contributions to the health expectancy gap

We performed a decomposition analysis to quantify the separate contribution of mortality and morbidity to the gap in HLE and DFLE at age 15 using the method described by Nusselder et al . 21 For HLE, the mortality contribution was the difference in person-years in good health due to the different mortality rates of the Travellers and the general population, assuming the same age-specific prevalence of poor health in both groups. The morbidity contribution was the difference in person-years in good health due to the difference in the prevalence of poor health, assuming the same age-specific mortality rates in both groups. The same applied for DFLE.

BM-SPSS statistics 18 (Release Version 18.0.2) was used for survey analysis, and Microsoft Excel (2007) spreadsheets were developed and used for health expectancy calculation and decomposition.

A comparison of the prevalence of poor health and disability between Irish Travellers and the general population is displayed in the online Supplementary data , appendix figure, and shows higher poor health and disability prevalence in Irish Travellers. Table  2 compares HLE and DFLE between Travellers and the general population. Traveller men at the age of 15 were expected to live 36.5 further years in good health and those at the age of 65 were expected to live 6.3 further years in good health, which was less than the HLE of the general population. Similar differentials were observed for women, with HLE at age 15 among Travellers of 41.1 years and at age 65 of 5.7 years. Likewise, Travellers' DFLE was lower than that of the general population. Travellers also had lower healthy proportions and disability-free proportions of their life expectancy than the general population (Fig.  1 ).

LE, HLE and DFLE at age 15 and at age 65 (in years) in Irish Travellers and the general population, together with the absolute and relative gaps, Republic of Ireland, 2007–2008

CI, confidence interval; DFLE, disability-free life expectancy; HLE, healthy life expectancy; LE, life expectancy.

a Absolute gap is in years and is based on subtracting the Irish Traveller estimate from the corresponding general population estimate. Figures differ slightly from differences calculated directly from the values in the table due to rounding.

b Statistically significant at the 0.05 level.

c Relative gap is the absolute gap expressed as a percentage of the general population estimate.

HLE and DFLE as a percentage of life expectancy, Republic of Ireland 2007–2008. The percentage of HLE and DFLE out of life expectancy is presented in horizontal bars, with the x -axis representing the percentage and the y -axis representing gender (men and women) and population group (Irish Travellers and the general population) categories. In both men and women, Travellers had lower percentage HLE at age 15 than that of the general population. Similar patterns were exhibited by HLE at age 65 and by DFLE at age 15 and at age 65.

The findings translated into statistically significant absolute gap between Irish Travellers and the general population in life expectancy, HLE and DFLE (Table  2 ). The gap was narrower at age 65 than at age 15. However, accounting for the lower health expectancy at age 65 revealed a wider relative gap in men (45 and 47% at age 65 compared with 32 and 31% at age 15 for HLE and DFLE, respectively) and women (59% and 51% at age 65 compared with 28% and 27% at age 15 for HLE and DFLE, respectively). The gap in HLE and DFLE at age 15 was wider in men than in women, but wider at age 65 in women than in men. The relative gaps were consistently wider with HLE and DFLE than with life expectancy where the latter showed gaps of 23% in men and 17% in women at the age of 15 and 37% in men and 38% in women at the age of 65.

Mortality made a larger contribution to the gap in HLE at age 15 and DFLE at age 15 (9.6 and 10.1 years, respectively) than poor health (7.2 and 6.9 years, respectively) in men (Fig.  2 ). In women, poor health contributed more to HLE at age 15 (9.1 years) than mortality (6.7 years), while disability also made a slightly higher contribution to DFLE at age 15 (8.2 years) than mortality (7.5 years).

Contribution of mortality and morbidity (in years) to the absolute gap in HLE and DFLE at age 15 between Irish Traveller and the general population, Ireland 2007–2008. Vertical bar charts display the contribution in years of the mortality and morbidity components of the gap in HLE and DFLE to the total absolute gap in men and women separately. The total absolute gap is based on subtracting the Irish Traveller estimates from the estimates for their general population counterparts. Mortality made a greater contribution to the gap in HLE and DFLE in men than morbidity, while in women, morbidity contributed more to the gap in HLE and slightly more to the gap in DFLE than mortality.

Main findings of this study

Irish Travellers had lower health expectancy than the general population and are expected to spend a higher proportion of their life expectancy in poor health and with disability. The health expectancy gap between Travellers and the general population was wider in women than in men in older ages. Its relative form was invariably wider than the life expectancy gap, with higher contribution of mortality among men at the age of 15 and significant contribution of morbidity particularly in women where it exceeded that of mortality.

What is already known on this topic

At a local level, Irish travellers have historically had an unfavourable mortality profile compared with the general population in Ireland. 4 , 15 Internationally, inequalities in health expectancy have previously been documented in the USA between African Americans and Whites, 22 , 23 in Belgium between the population of the Walloon region and the culturally distinct population of the Flemish region 24 and in New Zealand between the Maori and the Non-Maori population. 25 , 26 Almost all those studies reported wider gaps based on health expectancy compared with life expectancy, and a wider gap in older ages compared with younger ones was evident in health expectancy comparisons between Black and White ethnicities in the USA. 23 To the best of our knowledge, no other studies have so far reported on the contribution of mortality and morbidity to this gap, although a study in Belgium revealed a predominant contribution of disability to the socio-economic gap in DFLE in both men and women. 27

What this study adds

Our results extend beyond the previously published life expectancy findings for Irish Travellers, by incorporating non-fatal health outcomes. They present a health expectancy profile for Irish Travellers that is typical of disadvantaged indigenous minorities, with an even wider gap, although variations in the data collection methodologies and data completeness may partly explain the difference. Such profile is in line with the adverse patterns among Irish Travellers of the well-recognized array of social, structural and behavioural risk factors that influence their health, such as their high prevalence of diabetes, smoking and physical inactivity. 13 , 28 , 29

Our findings of age–gender variations in health expectancy offer a depiction of health inequalities that sums the effect of selective survivorship and cumulative effects of adverse life circumstances known to influence the magnitude of health inequalities in later life, 30 a picture that would not be as clear if only mortality was considered. Traveller women have always had better survival than Traveller men, 4 , 5 leaving space for life time disadvantage to manifest as a widening gap in poor health and disability in older surviving cohorts. Unhealthy Traveller men selectively die earlier, leaving relatively healthy older cohorts, with a narrower gap compared with women.

The finding of wider health expectancy gap than life expectancy gap confirms that health inequalities would be underestimated if based only on life expectancy. This implies that due attention needs to be paid to the contribution of non-fatal disabling conditions, which could require different interventions than those required for preventing primarily fatal conditions. Our decomposition results have further clarified that this is particularly important in women, where the contribution of morbidity exceeded that of mortality. The commonest reported morbidities among both Travellers and the general population, apart from acute infections, were back conditions and arthritis, 13 the former being considerably more common among Travellers, and both capable of significantly limiting their functional capacity and reducing their quality of life.

The results confirm the need for tailored policies and inter-sectoral action to interrupt the Travellers' life trajectories of disadvantage, in order to reduce the burden of both fatal and non-fatal conditions and improve Travellers' quality of life. Such efforts need to be coupled with the adoption of the health expectancy measure to effectively track progress in this regard, which is as relevant to other disadvantaged indigenous minorities where this is not yet the case. Our study has for the first time clearly illustrated the true extent and components of health inequalities in a disadvantaged indigenous minority group in Europe using novel methods, adding to the growing body of international evidence on health expectancy inequalities.

Limitations of this study

A number of limitations need to be noted regarding our findings. Basing the study on self-reported health status could have affected the comparability of the health expectancy measures between Travellers and the general population, as different groups tend to use different health status levels as cut-off points for the range of survey item responses available. This is due to different health expectations and different semantics attached to survey items and response levels. 31 Such reporting differences were illustrated in surveys utilizing anchoring vignettes. 32 Also Beam et al . 33 found that lack of adjustment for reporting differences led to the underestimation of racial/ethnic inequalities in self-reported health in the USA. A similar process could have biased the Travellers' prevalence of poor health and disability downwards, implying that the gap between Travellers and the general population could even be wider. Also, despite both SLAN and Traveller surveys being interview surveys, with the health status questions having more or less similar locations in the questionnaires, different sampling designs and non-response could have affected their comparability. Using harmonized survey items was the most we could do to maximize the comparability of the health expectancy estimates.

Retrospective identification of Traveller deaths could have led to under-reporting, although this would have been minimized by the use of multiple sources. Limitations associated with Sullivan's method include the use of the currently observed prevalence reflecting past morbidity patterns, and the implicit assumption that there is no recovery from morbidity. 34 However, as we used the same method for both comparison groups, and given the stark differentials in current mortality, we expect our estimates to correctly represent the direction of differentials in HLE and DFLE.

All-Ireland Traveller Health Study was funded by the Department of Health and Children (DoHC) in the Republic of Ireland and the Department of Social Services and Personal Safety of Northern Ireland (DSSPSNI) (grant no. V0350). Fieldwork funding support was received from the Irish Health Service Executive (HSE).

This work is based on the All-Ireland Traveller Health Study, funded by the Department of Health and Children (DoHC) in the Republic of Ireland and the Department of Social Services and Personal Safety of Northern Ireland (DSSPSNI) (grant no. V0350). The views expressed in this study are the authors' own and do not necessarily reflect the views and opinions of the Department of Health and Children or the Department of Health, Social Services and Public Safety. The authors wish to thank the Irish Travellers, Traveller peer researchers, study coordinators, Public Health Nurses, the General Registrar Office, Central Statistics Office and AITHS Technical Steering Group. Apart from the authors listed, the AITHS study team members were Ms Fran Cronin, Dr Anne Drummond, Dr Patricia Fitzpatrick, Dr Kate Frazier, Dr Noor Aman Hamid, Ms Claire Kelly, Ms Jean Kilroe, Mr Juzer Lotya, Dr Catherine McGorrian, Dr Ronnie G Moore, Ms Sinead Murnane, Ms Roisin Nic Carthaigh, Ms Deirdre O'Mahony, Ms Brid O'Shea, Prof Anthony Staines, Mr David Staines, Dr Mary Rose Sweeney, Dr Jill Turner, Ms Aileen Ward and Dr Jane Whelan.

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Social inequalities in health expectancy and the contribution of mortality and morbidity: the case of Irish Travellers

Collaborators.

• All-Ireland Traveller Health Study team : Fran Cronin ,  Anne Drummond ,  Patricia Fitzpatrick ,  Kate Frazier ,  Noor Aman Hamid ,  Claire Kelly ,  Jean Kilroe ,  Juzer Lotya ,  Catherine McGorrian ,  Ronnie G Moore ,  Sinead Murnane ,  Roisin Nic Carthaigh ,  Deirdre O'Mahony ,  Brid O'Shea ,  Anthony Staines ,  David Staines ,  Mary Rose Sweeney ,  Jill Turner ,  Aileen Ward ,  Jane Whelan

Affiliation

• 1 School of Public Health, Physiotherapy and Population Science, University College Dublin, Woodview House, Belfield, Dublin 4, Republic of Ireland.
• PMID: 23315684
• DOI: 10.1093/pubmed/fds106

Background: The health expectancy of Irish Travellers, a disadvantaged indigenous minority group in Ireland has not been previously estimated. This study aimed to examine health expectancy inequalities between Irish Travellers and the general population.

Methods: We used Sullivan's life table method to construct healthy life expectancy (HLE) and disability-free life expectancy (DFLE). The All-Ireland Traveller Health Study provided Irish Traveller population's mortality and health data. Vital registration, census and comparable national survey health data were used for the general population. We calculated the absolute and relative life expectancy, HLE and DFLE gaps between Irish Travellers and the general population and decomposed the HLE and DFLE gaps into mortality and morbidity contributions.

Results: Irish Travellers had consistently lower HLE and DFLE than the general population. The health expectancy gap displayed notable age and gender variations and was wider than the life expectancy gap. Mortality contributed more than morbidity to the health expectancy gap in men but not in women.

Conclusions: This study illustrated the true extent of health inequalities experienced by an indigenous minority in Europe, clarifying the importance of reducing the burden of non-fatal disabling conditions for addressing these inequalities. The health expectancy measure used has application for other similar indigenous minorities elsewhere.

Keywords: health intelligence; morbidity and mortality; social determinants.

Publication types

• Research Support, Non-U.S. Gov't
• Age Factors
• Health Status Disparities*
• Ireland / epidemiology
• Life Expectancy
• Middle Aged
• Minority Groups / statistics & numerical data
• Sex Factors
• Transients and Migrants / statistics & numerical data*
• Young Adult

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• Volume 13, Issue 8
• Scoping review on Physical Health Conditions in Irish Travellers (Mincéiri)
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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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• Watkinson RE ,
• Data collection in the Member States of the European Union
• Langohr K , et al
• Arce Arnáez A ,
• Cabello Ballesteros L ,
• Iñigo Martínez J
• Lizarralde E ,
• Muñoz P , et al
• McKeown P , et al
• Rodrigo SG ,
• Calatrava RG ,
• Vicenta Rigo Medrano M , et al
• Heathcock R , et al
• Concannon TW ,
• Meissner P ,
• Grunbaum JA , et al
• Pavee Point Traveller
• Department of Health, Ireland
• Deparment of Justice and Equality, Ireland
• Villani J ,
• Kuosmanen T ,
• McDonagh M , et al
• Williams DR ,
• Jackson JS , et al

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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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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Census of Population 2016 – Profile 8 Irish Travellers, Ethnicity and Religion

• Irish Travellers - Demographics

Comparison of Irish Traveller population to general population

The total number of usually resident Irish Travellers enumerated in April 2016 was 30,987 representing 0.7 per cent of the general population. This figure was an increase of 5.1 per cent on the 2011 figure of 29,495. (Note: all analysis is based on the usually resident population. The corresponding De Facto figures in 2016 and 2011 were 31,075 and 29,573 respectively).

The population pyramid below highlights how the structure of the Irish Traveller population is very different to that of the general population, with a broad base at the younger ages and reducing sharply at higher ages. Nearly 6 in 10 (58.1%) Irish Travellers were under 25 years of age (0-24) compared to just over 3 in 10 (33.4%) in the general population.

There were 451 Irish traveller males aged 65 or over representing just 2.9 per cent of the total, significantly lower than the general population (12.6%); the equivalent figures for females were 481 persons which represented just 3.1 per cent of the total, compared with 14.1 per cent for the general population.

Interactive table: StatBank Link E8001

It's a Fact

• 3% - The percentage of Irish Travellers who were aged 65 or over in 2016. The equivalent rate for the general population was 13.3%
• 39.7% - The percentage of Irish Travellers who were aged 14 or under in 2016. The equivalent rate for the general population was 21.4%

County analysis

There were significant differences in the size of the Irish Traveller community across the administrative counties.

As in 2011, Galway county had the highest number of Travellers with 2,647 persons, an increase of 6.7 per cent on the 2011 figure 2,481. This was followed by South Dublin with 2,208 persons, down 1.5 per cent on 2011.

Travellers were more urbanised than the general population with nearly 8 in 10 (78.6%) living in cities or towns (1,500 or more), compared with 62.4 per cent of the total population.

Irish Travellers in cities and towns

Dublin city and suburbs had the largest number of Irish Travellers with 5,089 persons. This was followed by Galway city and suburbs with 1,598 persons and Cork city and suburbs with 1,222.

Of the towns with 1,500 or more persons, Tuam had the highest number of Irish Travellers with 737 persons, followed by Longford with 730 persons.

Navan, Mullingar, Dundalk and Ballinasloe all had 500 or more Irish Travellers in 2016. 

Interactive table: StatBank Link E8002

• 78.6% - The percentage of Irish Travellers in urban areas. The comparable rate for the general population is 62.4%.

Irish Traveller marital status

Figure 1.3 presents marital status by age.  Among the general population 5.8 per cent of 15-29 year olds were married, compared with 3 in 10 (31.9%) of the Irish Traveller population. There were 201 married 15-19 year olds, down from 250 in 2011.

The divorce rate among Irish travellers was 2.2 per cent, compared with 4.7 per cent for the general population. The percentage of Irish travellers who were separated had fallen in 2016 to 10.4 per cent, down from 12.1 per cent in 2011.

Irish Traveller households

Nationally there was a 12.3 per cent increase in the number of Irish Traveller households (defined as households containing at least one Irish Traveller), rising from 7,765 in 2011 to 8,717 in 2016.

Of these 7,424 were classified as family households representing (85.2%) compared with 70.2 per cent of the general population.

Figure 1.4 illustrates other differences between Irish Traveller households and the general population. There were more than 3 times as many multiple family Traveller households (4.2% compared with 1.3%), more lone parents with children (17.9% compared with 11.7%) and fewer married couples without children (8.9% compared with 15.7%). Just over 1 in 10 (11%) Irish Travellers were living in one person households compared with almost 1 in 4 (23.5%) in the general population.

Household size

Irish traveller households comprising of a married couple with children had an average of 5.3 persons per household compared with 4.1 for the general population.

Figure 1.5 illustrates how there are proportionally fewer one and two person Irish Traveller households compared with the general population. More than 1 in 4 Irish Traveller households had 6 or more persons compared with less than 1 in 20 households in the State overall.

Interactive table: StatBank Link E8047

• 8,717 - The number of Irish Traveller households (containing at least one Irish Traveller)
• 31.9% - The percentage of 15-29 year old Irish Travellers who were married

Fertility among female population

Among Traveller women aged 40-49 (the age by which women have typically completed their fertility) 13.3 per cent had not given birth to a child - compared with 18.3 per cent of women generally. Nearly half had given birth to 5 or more children, in stark contrast to just under 1 in 20 (4.2%) of women overall in this age group.

Interactive table: StatBank Link E8044

• 4.2% - The percentage of Irish Traveller Households with 9 or more persons in 2016
• 0.1% - The percentage of General population Households with 9 or more persons in 2016
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The big fat truth about Gypsy life

M y Big Fat Gypsy Wedding, the television series that ended last week and attracted nine million viewers, was designed to "throw an overdue light on a secretive, marginalised and little-understood segment of our society", according to the blurb from Channel 4. But the show largely avoided the myriad of problems, such as discrimination, poor health and poverty faced by Travellers, except for what felt like a tokenistic final episode, and instead focused on over-the-top wedding dresses and other excesses.

MBFGW was about Gypsies and Travellers, but there was criticism from both communities that C4 failed to properly distinguish between the two. There are around 300,000 Gypsy Roma and Irish Travellers in the UK – Roma Gypsies are originally from northern India, whereas Travellers are of Irish origin – and both groups are nomadic. Since 2002, Travellers have been recognised as an ethnic group and are protected under the Race Relations Act. Last week C4 was accused by the Irish Traveller Movement in Britain of fuelling "hatred and suspicion" of their way of life and have demanded a right of reply. 

Kathleen, who lives with her six children in a three-bedroom trailer, is fairly typical of an Irish Traveller woman, except that she is separated from her husband. Along with many other Gypsy and Traveller women in the UK, Kathleen was a victim of domestic violence. Although there is no conclusive evidence about the prevalence of this abuse, a study in Wrexham, cited in a paper by the Equality and Human Rights Commission, 2007, found that 61% of married English Gypsy women and 81% of Irish Travellers had experienced domestic abuse. And a significant number of those women who had reported the abuse appeared to have suffered more severe and sustained violence than those within mainstream communities.

"I left him and went back to my mammy but he kept finding me, taking me home and getting me pregnant," Kathleen says. She now feels safe because she has male family members living on the same site. "With my brother close by, he wouldn't dare come here."

It is rare for women to call the police for help. "You would be seen as a grass and disowned by the whole community," says Bernie O'Roarke, outreach and resettlement worker for domestic violence charity Solas Anois (Gaelic for Comfort Now), which is based in London. The situation probably isn't helped by the fact that there is only one, 10-room refuge dedicated to Traveller women in the UK, also in London. But domestic violence is just one of the issues tackled by O'Roarke during her visits. The welfare needs, particularly those of the women and girls, of this community are vast. The women are three times more likely to miscarry or have a still-born child compared to the rest of the population, mainly, it is thought, as a result of reluctance to undergo routine gynaecological care, and infections linked to poor sanitation and lack of clean water. The rate of suicides among Traveller women is significantly higher than in the general population, and life expectancy is low for women and men, with one third of Travellers dying before the age of 59. And as many Traveller girls are taken out of education prior to secondary school to prevent them mixing with boys from other cultures, illiteracy rates are high.

O'Roarke is a familiar face on the sites around London, offering women and their children help with health care, education and finance. The men leave the women alone to deal with these issues, so if the women do want to talk about violence and abuse, they can do so without fear of the men overhearing.

I visit some trailers with O'Roarke at a site in London and am struck by how the women seem to manage, usually with large families, to keep everything so clean and tidy. There are colourful displays of Royal Crown Derby crockery, handed down from mother to daughter on her wedding day. There is certainly no sign of wealth or excessive spending. Many tell me they struggle to feed their children, and have no savings or bank account.

Things seem set to get worse for Traveller women. Only 19 days after the general election last year, £50m that had been allocated to building new sites across London was scrapped from the budget. O'Roarke is expecting to be the only Traveller liaison worker in the capital before long – her funding comes from the Irish government.

"Most of the women can't read or write. Who is supposed to help them if they get rid of the bit of support they have now?" asks O'Roarke. "We will be seeing Traveller women and their children on the streets because of these cuts. If they get a letter saying they are in danger of eviction but they can't read it, what are they supposed to do?"

Conditions on the site are as grim as the homes are spotless. The trailers are not connected to water pipes, and the toilets, bathrooms and cooking facilities are in a small, unheated shed across the yard. "In the snow and rain, the little ones are always getting colds," says Brigid, who lives in the next trailer to Kathleen. "And there are so many pot holes that the council haven't filled, you can go flying in the dark."

But living on a site is about being part of the community. When Traveller girls are growing up, they are only allowed to go out with other family members, and once married, her husband rules the roost. "The men would never allow a woman out with her friends," says Kathleen. "That's why we want to live on a site, for company." Kathleen, after spending time in a refuge after finally managing to escape her husband, was initially allocated a house, as opposed to a plot on a site. Almost immediately her children became depressed. "It's like putting a horse in a box. He would buck to get out," says Kathleen. "We can't live in houses; we need freedom and fresh air. I was on anti-depressives. The children couldn't go out because the neighbours would complain about the noise."  

Since moving to their site two years ago, Kathleen and her children have been far happier. Until MBFGW was screened, that is. "Now every week I go to the school and the parents are talking about that programme. They won't let our kids mix with theirs because they say we stink and don't talk properly. Settled kids won't even play sports with ours in case they touch them."

Mary, Kathleen's 15-year-old daughter, is upset by the series too, and says that she has faced further prejudice since it hit the screens. "That programme didn't show the real way we go on. All my friends are asking if it's true what they show on telly, and I think they've gone different [towards me] since it was shown."

In one episode the viewer was informed that young Traveller men at weddings and other social occasions use something known as "grabbing" to force a reluctant girl to kiss them. One newspaper report called it a "secret courting ritual".

"Grabbing has never happened to me or any of my friends and the first time I ever saw it was on the telly," says Mary. "I wouldn't put up with it, and I don't know why they made out we all do it. It's just one nasty boy they showed."

Brigid adds: "Grabbing has never happened to my kids. I have honestly never heard of it. It's all make-believe."

Helen, a Traveller in her 20s on the same site, is also furious about the portrayal of women in MBFGW. "The way us women come across in the programme is a disgrace," she said. "It shows us as nothing but slaves to the men, only good for cooking and cleaning, and always being available to open our legs to them. We don't want that for our daughters."

Helen is also worried that Traveller women are being portrayed as rich and spoilt when, in fact, life is a struggle for the majority. "I don't know anyone so rich that they can afford to splash out on wedding dresses like that. Mine was secondhand. They'll now be saying we are all criminals, or sponging off the state." I ask a number of Traveller women how representative of the Traveller and Gypsy communities those featured in MBFGW are, and they all come back with a similar answer: the programme focused on a small number of individuals from five sites (out of an estimated 300-plus across the UK), and in any community, there are a minority who have access to large amounts of cash.

I ask O'Roarke what she thinks the future holds for Travellers. She is worried. "That TV programme has put our work back 100 years. And if these women lose the little support they have, they literally will be left to rot."

She is concerned that problems affecting Traveller women and girls, such as lack of education, forced and early marriage, and abuse within the home, are not being taken seriously.

"These issues do not just affect certain Asian communities," says O'Roarke. "We have had Traveller women in the refuge who have been forced to marry someone who they have never met, and marrying cousins is not uncommon."

But some say that things are slowly improving. "I think it's changing an awful lot for the young ones," says Kathleen. "We don't want them to have no education and get married at 16, and have loads of kids and the same life as we did."

Would Kathleen ever marry again? It is out of the question, she tells me. These things are just not done. "You marry for life," she says. "If I was to have another man, my daughters would never be married because I would have brought shame on them."

O'Roarke would like to see changes that include: "Better support for the women to keep their daughters in education, and a serious commitment from the government to challenge the prejudice thrown at these people."

While people are being entertained by watching Katie Price-replica weddings on TV, and girls dressed in Beyoncé-style outfits dirty dancing, women such as Kathleen, Brigid and Helen are living in substandard conditions and facing daily prejudice while trying to give their children the best start in life. The reality is a far cry from the C4 depiction and is rarely aired. O'Roarke tells me that Traveller women are usually reluctant to allow outsiders into their homes, despite the impression given by MBFGW. "But we just want our side of the story put across," says Brigid, "so settled people know we are not like that."

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'Distinct identity': Irish Travellers celebrate day they were recognized as ethnic minority

This day six years ago, the Irish Traveller community was recognized by the Irish State as an ethnic group

• 16:45, 1 MAR 2023
• Updated 16:49, 1 MAR 2023

In Ireland, today marks Irish Traveller Ethnicity Day: a celebration of the moment Irish Travellers were officially recognized as an ethnic group in the Irish state.

On March 1, 2017, Taoiseach Enda Kenny made a statement in the Dáil formally recognizing the ethnic status of the Traveller community in Ireland. After a campaign spanning multiple decades, the date meant that the contributions made and challenges faced by the Traveller community would now be recognized at state level.

"The Traveller community has for many years campaigned to have their unique heritage, culture and identity formally recognized by the Irish state," the Taoiseach said at the time. "And in this state, they make their contribution as gardaí, doctors, members of the Defence Forces, prison officers."

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The Taoiseach continued: "So there should be no surprise that a person can identify as Irish and as Traveller. This is a deep and personal issue for many Travellers."

The Irish Traveller community has long faced discrimination in Ireland , with the group largely excluded from settled society over generations. The life expectancy of Irish Travellers is lower than their settled peers, and the community's suicide rate is six times the national average.

Being recognized as an ethnic minority means Irish Travellers (who are separate from but often confused with the Romani people due to similarities in their historically nomadic cultures) are now included in Ireland's anti-racism and integration policies. It also recognizes the unique culture and history of the Traveller community, who have, according to scientists, been genetically distinct from settled Irish people for at least 1,000 years.

The day doesn't just celebrate Irish Travellers based in Ireland, but their international diaspora. The community spans the UK, where they are also recognized as an ethnic minority, as well as Canada and the US .

It's difficult to guess how large the diaspora of the Irish Traveller community is in the US, as the US Census does not recognize them as an ethnic group. Estimations range their US population to be anywhere between 10,000 and 40,000.

The vast majority of this population is thought to have arrived in the US between 1845 and 1860 as a result of the Great Famine. Here, Irish Traveller communities mostly reside in Ohio, Georgia, Texas, Tennessee, Mississippi, and South Carolina. The largest is around 2,500 people, who live in Murphy Village, SC.

Like Irish Travellers in Ireland, Irish Travellers in the US have a unique cultural identity. This includes practicing devout Catholicism, a strong emphasis on family and community, and some usage of Cant, a language of mixed Irish and English origin spoken by Travellers.

"Our Traveller community is an integral part of our society for over a millennium, with their own distinct identity – a people within our people," the Taoiseach said this day six years ago. "...It is a historic day for our Travellers and a proud day for Ireland."

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• Republic of Ireland
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Irish residents continue to travel more, statistics show

People living here spent €3.1bn on overnight trips in 2023.

Kerry was among the most popular tourist destinations last year. Photograph: Bryan O Brien

Irish residents took 14.3 million domestic overnight trips last year 2023, spending €3.1 billion.

New data from the Central Statistics Office showed the figures continued to rise of the previous year, when there were 13.3 million overnight trips, with total expenditure of €2.9 billion. But overall nights were slightly lower, at 34 million last year compared with 34.2 million in 2022.

Some 45 per cent of travellers were on holiday, while visits to friends or relatives were in second place at 40 per cent.

The south of the country was the most popular destination for domestic overnight trips, including Clare, Tipperary, Limerick, Waterford, Kilkenny, Carlow, Wexford, Cork and Kerry.

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The next most popular regions were the east and midlands – Dublin, Wicklow, Kildare, Meath, Louth, Longford, Westmeath, Offaly, and Laois – at 36 per cent.

There were 12.6 million outbound overnight trips taken during the same period, with almost three million in the final three months of 2023. More than one-third – 38 per cent – were to a destination in the UK, including Northern Ireland.

“The number of domestic overnight trips taken in Q4 2023 was 11 per cent higher than in the same period in 2022, while the total number of outbound overnight trips rose by 27 per cent when compared with the same quarter in 2022. Expenditure also increased in Q4 2023, up 28 per cent for domestic overnight trips and 52 per cent for outbound overnight trips when compared with Q4 2022,” said Aaron Costello, statistician in the tourism and travel division.

“In 2023 Irish residents took 15.4 million domestic same-day visits and two million outbound same-day visits. Expenditure amounted to €717 million on domestic same-day visits in 2023 which was down from the 2022 figure of €856 million.”

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Ciara O'Brien

Ciara O'Brien is an Irish Times business and technology journalist

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