Objective: To provide the first valid and reliable estimate of the health status of Gypsies and Travellers in England by using standardised instruments to compare their health with that of a UK resident non-Traveller sample, drawn from different socioeconomic and ethnic groups, matched for age and sex. Design: Epidemiological survey, by structured interview, of quota sample and concurrent age-sex-matched comparators. Setting: The homes or alternative community settings of the participants at five study locations in England. Participants: Gypsies and Travellers of UK or Irish origin (n = 293) and an age-sex-matched comparison sample (n = 260); non-Gypsies or Travellers from rural communities, deprived inner-city White residents and ethnic minority populations. Results: Gypsies and Travellers reported poorer health status for the last year, were significantly more likely to have a long-term illness, health problem or disability, which limits daily activities or work, had more problems with mobility, self-care, usual activities, pain or discomfort and anxiety or depression as assessed using the EuroQol-5D health utility measure, and a higher overall prevalence of reported chest pain, respiratory problems, arthritis, miscarriage and premature death of offspring. No inequality was reported in diabetes, stroke and cancer. Conclusions: Significant health inequalities exist between the Gypsy and Traveller population in England and their non-Gypsy counterparts, even when compared with other socially deprived or excluded groups, and with other ethnic minorities.

Objective: To illuminate findings of the survey of the health status of Gypsies and Travellers by exploring their health-related beliefs and experiences. Design: Qualitative study of a purposive subsample from in-depth interviews using framework analysis. Setting: The homes or alternative community settings of the participants in five geographically dispersed study locations in England. Participants: 27 Gypsies and Travellers with an experience of ill health, purposively sampled from a larger population participating in an epidemiological survey of health status. Results: The experience of poor health and daily encounters of ill health among extended family members were normalised and accepted. Four major themes emerged relating to health beliefs and the effect of lifestyle on health for these respondents: the travelling way; low expectations of health; self-reliance and staying in control; fatalism and fear of death. These themes dominated accounts of health experience and were relevant to the experience. These themes add richness to the health status data and inform our understanding. Conclusions: Among Gypsies and Travellers, coherent cultural beliefs and attitudes underpin health-related behaviour, and health experiences must be understood in this context. In this group, ill health is seen as normal, an inevitable consequence of adverse social experiences, and is stoically and fatalistically accepted. The provision of effective healthcare and improvement of poor health in Gypsies and Travellers will require multi-agency awareness of these issues.

BackgroundCommunity-based peer support (CBPS) has been proposed as a potentially promising approach to improve health literacy (HL) and reduce health inequalities. Peer support, however, is described as a public health intervention in search of a theory, and as yet there are no systematic reviews exploring why or how peer support works to improve HL.ObjectiveTo undertake a participatory realist synthesis to develop a better understanding of the potential for CBPS to promote better HL and reduce health inequalities.Data sourcesQualitative evidence syntheses, conceptual reviews and primary studies evaluating peer-support programmes; related studies that informed theoretical or contextual elements of the studies of interest were included. We conducted searches covering 1975 to October 2011 across Scopus, Global Health (including MEDLINE), ProQuest Dissertations & Theses database (PQDT) [including the Education Resources Information Center (ERIC) and Social Work Abstracts], The King’s Fund Database and Web of Knowledge, and the Institute of Development Studies supplementary strategies were used for the identification of grey literature. We developed a new approach to searching called ‘cluster searching’, which uses a variety of search techniques to identify papers or other research outputs that relate to a single study.Study eligibility criteriaStudies written in English describing CBPS research/evaluation, and related papers describing theory, were included.Study appraisal and synthesis methodsStudies were selected on the basis of relevance in the first instance. We first analysed within-programme articulation of theory and appraised for coherence. Cross-programme analysis was used to configure relationships among context, mechanisms and outcomes. Patterns were then identified and compared with theories relevant to HL and health inequalities to produce a middle-range theory.ResultsThe synthesis indicated that organisations, researchers and health professionals that adopt an authoritarian design for peer-support programmes risk limiting the ability of peer supporters (PSs) to exercise autonomy and use their experiential knowledge to deliver culturally tailored support. Conversely, when organisations take a negotiated approach to codesigning programmes, PSs are enabled to establish meaningful relationships with people in socially vulnerable groups. CBPS is facilitated when organisations prioritise the importance of assessing community needs; investigate root causes of poor health and well-being; allow adequate time for development of relationships and connections; value experiential cultural knowledge; and share power and control during all stages of design and implementation. The theory now needs to be empirically tested via further primary research.LimitationsAnalysis and synthesis were challenged by a lack of explicit links between peer support for marginalised groups and health inequalities; explicitly stated programme theory; inconsistent reporting of context and mechanism; poor reporting of intermediate process outcomes; and the use of theories aimed at individual-level behaviour change for community-based interventions.ConclusionsPeer-support programmes have the potential to improve HL and reduce health inequalities but potential is dependent upon the surrounding equity context. More explicit empirical research is needed, which establishes clearer links between peer-supported HL and health inequalities.Study registrationThis study is registered as PROSPERO CRD42012002297.FundingThe National Institute for Health Research Public Health Research programme.

Being a Gypsy or Traveller is associated with even poorer health outcomes than those seen in two other ethnic minority groups resident in England, Pakistani Muslim and African Caribbean, and they in turn have poorer health outcomes than the White residents. More remains to be done to address the health and health service needs of such black and minority ethnic groups.

There are striking inequalities in the health of Gypsies and Travellers, even when compared with people from other ethnic minorities or from socio-economically deprived White UK groups. In this paper we explore the long-term health impact associated with a history of persecution, social pathologisation and social exclusion of Gypsies and Travellers. A society that has demonstrated entrenched and widespread hostility towards Gypsies and Travellers has contributed to wariness about trust in outsiders and contributes to the communication barriers with health staff that are implicated in their poor access to healthcare. Many of the problems identified by health staff mirrored those identified by Gypsies and Travellers, particularly with regards to mismatched expectations and resulting conflicts. Whilst the Department of Health has recognised the extreme health inequalities experienced by Gypsies and Travellers and the need for specific action to reduce them and improve access to health care, this paper emphasises the need for an associated improved effort at all levels to seriously tackle the wider determinants of health, including societal attitudes towards Gypsies and Travellers, as well as focusing on delivery of health services. Nurses are identified as needing to play a key part as role models in challenging prejudice and discrimination.