1RCSI medical student
Royal College of Surgeons in Ireland Student Medical Journal 2011;4(1):74-77.
Economic, political and cultural reform in 20th century Ireland brought a change from a state of emigration to one of immigration, with an associated change from monoculturalism to multiculturalism. Ireland was hesitant to join the multicultural arena, being the last western European country to do so.1 Today, despite the taming of the Celtic Tiger and the decline of vulnerable sectors in which many immigrants were employed, the country is still home to approximately half a million people who do not fall under the ethnic or cultural category of ‘white Irish’.2 It appears that multicultural Ireland has a more than transient nature. When we consider ideas from social identity theory about the tendency for even highly educated individuals to show inter-group prejudice,3,4 combined with strong competition for employment and cuts in public expenditure, it can be argued that the doors of cultural prejudice in Irish society are still wide open. In healthcare systems, barriers to equality of care include poor cultural competence, accessibility and prejudice. Culture affects how and where individuals approach and use health services. It also affects what people expect from service providers. Equality legislation, EU directives and health sector policies and strategies guide the Irish system towards a culturally competent, equal and accessible service.
Equal access to healthcare does not mean treating everyone the same. Rather, it means offering everyone the same opportunity to achieve comparable health outcomes, which in turn requires cultural competence.5 While cultural competence and awareness slowly grows in the different layers of the Irish healthcare system, individual healthcare providers can work on improving their own cultural awareness.
The purpose of this review is to highlight the need for cultural awareness, to introduce the Irish Traveller community, along with its specific healthcare needs, and to provide suggestions for further reading.
There are at least 25 minority groups in Ireland.6 The Irish Traveller community was chosen based on population size and its contrast to the background population. In September 2010, Mary Harney, the then Minister for Health and Children, published a report on a massive health study undertaken on the Irish Traveller community over the preceding three years. The study, called the All-Ireland Traveller Health Study (AITHS), which was largely based on self-report, included a survey of every identifiable Traveller family in the Republic of Ireland. It had a response rate of 80%, making it the most significant study of its kind.
An important caveat for even the most useful generalisations is that they should not be used as a basis for stereotyping. Individual patients may not fit into any one category, and it is unwise to presume patient characteristics.
The Irish Traveller community
The Irish Traveller community has a strong tradition and culture based on a nomadic existence. The vast majority are Roman Catholic, and religion has a strong, albeit waning, impact on the Traveller value system and beliefs.7 The most recent Irish census data suggest that the population of the Irish Traveller community is approximately 22,000 members. A 2010 survey revised that figure to more than 36,000.7 Irish Travellers have official recognition as a minority ethnic group in the United Kingdom. While the Irish Government recognises the distinct grounds for protection held by Travellers, the specific status of minority ethnic group has not yet been assigned. The implications of this lack of an ethnic identifier include a lack of robust data required for effective planning, provision and assessment of services. Travellers have a long history of suffering social exclusion and disadvantage in Ireland, which continues into the present day, and which has been recently addressed in Government policy and strategy formation.8 The Traveller community, with its traditional skills and culture, struggles to thrive in modern-day Ireland. Lack of employment and a dependency on social welfare payments heighten feelings of frustration and exclusion.7
Travellers and health
Levels of health in the Traveller community are significantly lower than those in the settled population, with current Traveller health comparable with the levels found in the settled population of the 1940s.8 Poor living conditions, social exclusion and low levels of education are some of the many factors that contribute to substandard health in the Traveller community. Compared with the settled population, Traveller men live approximately 15 years less, while life expectancy for Traveller women is approximately 12 years less. As shown in Table 1, life expectancy for Traveller males has not improved over the past 20 years, while males from the general population have widened the original gap of 10 years by a further five years. This is in contrast with Traveller females, who have had a five-year increase in life expectancy compared with 20 years ago, marginally closing the original gap between them and settled women.
The infant mortality rate (IMR) is a useful indicator of a population’s development and health. The Traveller IMR improved from 18.1 in 1987 to 14.1 in 2008 compared with figures of 7.4 in 1987 and 3.9 in 2008 for the general population. Traveller infants in 1987 were 2.4 times more likely to die than infants in the general population, and this gap had widened in 2008 to make Traveller infants 3.6 times more likely to die. It is clear that Traveller infants are not benefiting from advances in health compared to those in the non-Traveller population.
There are several important gender-specific issues in Traveller health. Relevant contrasting practices among Traveller women include a low usage of the oral contraceptive pill and low levels of breastfeeding.7 Irish Traveller women face hardship on many fronts – as women, as Travellers, and as Traveller women. Traveller women are almost four times more likely to be affected by depression than settled women, with one survey suggesting that up to one in three Traveller women are affected by long-term depression.9 Another stark reality highlighted in the recent study is the high level of non-accidental injuries occurring to Traveller women.7 The study found that compared with women of the settled population, injuries to Traveller women were three times more likely to be non-accidental. The exact nature of this violence was not revealed; however, domestic violence in the Traveller community is a known problem, which has yet to be successfully tackled.7 It appears that a traditional patriarchal culture persists in the Traveller community at the expense of female autonomy. This may have some bearing on the female-specific issues mentioned above. This may also become evident in the healthcare setting, when a male attempts to represent a female or family on health matters, requiring a culturally sensitive response from the healthcare worker. One aspect of poor health outcomes in the Traveller community is the availability of healthcare services to Travellers. Interestingly, recent data suggest that Irish Travellers have the same options in availing of healthcare services as the settled population.7 In addition, utilisation of general practitioner and emergency services is higher in the Traveller than in the settled population. Irish Traveller women’s health screening rates are higher than the general population.7 Again, this does not necessarily imply equal access, since Travellers are not denied specific services. Instead, this demonstrates that the challenges facing healthcare workers in providing equal care to Irish Travellers are more complex than just availability of services. Attitudes to health among the Traveller community include a predilection for avoidance, except in emergencies. Men present late for healthcare, while preventive care and outpatient services are under-utilised when compared to the background Irish population.7
Yet another factor that is a significant barrier to health is poor education. Census data from 2006 show that participation in higher education was less than 1% in the Traveller community compared with more than 30% of the settled population. The AITHS reported that Irish Travellers have great difficulty with articulation in the healthcare setting. Both Traveller men and women tend to internalise breakdown in communication as a personal failure associated with their inability to read or write, or to comprehend the healthcare worker. Feelings of embarrassment and shame can result, which may discourage them from seeking clarifications. Another plausible factor in communication breakdown can be the number of foreign medical staff working in Ireland, such that it may be difficult for non-Irish workers to understand the Irish Traveller accent and vice versa, leading to suboptimal consultations.
The main language used in the travelling community is English, in spite of the existence of a traditional language called ‘Cant’. Literacy is typically poor, with up to 80% of the adult community believed to be unable to read.6,8 A recent survey shows that approximately 50% of Travellers requiring prescription medications have reported difficulty reading the instructions, creating yet another barrier to health and health promotion.7 Special care must be taken to ensure that instructions and documents are understood, particularly those surrounding issues where consent is required.
Irish Travellers report lower satisfaction with Irish health services compared to the settled population. There is significantly less trust placed in healthcare professionals, along with increased perceptions of being treated with less respect and dignity.7 Out of the 1,324 Travellers surveyed, only 46% agreed that they had enough time to discuss their health problems with the health professionals, compared with 78% of the settled population. Traditional clinical training can lead to a tendency for the doctor to be neutral to race and culture, which in such circumstances may contribute to poor satisfaction due to a perceived lack of empathy and understanding.
With regard to other traditional practices in the Irish Traveller community, consanguinity resulting from endogamy often causes an increased prevalence of genetic disorders.10,11 Sensitive counselling in this regard may be required. It is also worthwhile to enquire about any traditional healing sought, since it is known that members of the Traveller community may seek traditional healing practices where direct hands-on contact with a wound site may be made by the healer.6 The AITHS shows that despite subjectively rating their health in a positive light, Irish Travellers have a significantly raised burden of chronic disease, along with higher rates of smoking, hypertension, hypercholesterolaemia and poor diet, compared to the general population. In addition, key areas to address to improve Traveller health include mother and child health, and respiratory and cardiovascular disease aetiology. Health attitudes, engagement in preventive practices and gender-specific issues, including mental health, are other areas that warrant improvement.
Culture affects many aspects of patient interaction with health services. Healthcare workers in multicultural societies often face additional challenges when caring for patients, be it a Muslim patient fasting during Ramadan,12,13 a Jehovah’s Witness who will not accept blood,14 or an Irish Traveller with a fatalistic attitude towards health. To provide equal access, a health service must offer all patients the same opportunity to achieve comparable health outcomes, which requires a culturally competent service. Ireland is home to people of 188 nationalities,15 practising at least 21 different religions, so it is a challenge for healthcare providers to become culturally competent. However, there are resources available to assist us in this challenge, including cultural mediation and a wealth of knowledge on the specific health service needs of different cultural and religious groups.
Cultural awareness resources available for healthcare professionals:
- National Health Services Intercultural Guide: Responding to the needs of diverse religious communities and cultures in healthcare settings.6
- Intercultural Health Strategy, 2007-2012.1
- Banks M. Modern Ireland: multinationals and multiculturalism. Information, Society and Justice. 2008;2(1):63-93.
- Central Statistics Office. Census 2006, Volume 5 – Ethnic or Cultural Background. Cited September 2010. Available from: http://www.cso.ie/census/Census2006_Volume5.htm.
- David CC. Intergroup attitudes and policy support: How prejudice against minority groups affects support for public policies. International Journal of Public Opinion Research. 2009;21(1):85-97.
- Brewer MB. The psychology of prejudice: ingroup love or outgroup hate? Journal of Social Issues. 1999;55(3):429-44.
- Minervino S, Martin MC. Cultural competence and cultural mediation: diversity strategies and practices in health care. Translocations. 2007;2(1):190-8.
- Health Service Executive. Health Services Intercultural Guide: Responding to the needs of diverse religious communities and cultures in healthcare settings. Cited September 2010. Available from: http://www.hse.ie/eng/services/Publications/services/ SocialInclusion/InterculturalGuide/interculturalguide.pdf.
- Department of Health and Children. All Ireland Traveller Health Study. Cited September 2010. Available from: http://www.dohc.ie/publications/aiths2010/ExecutiveSummary/ AITHS2010_SUMMARY_LR_All.pdf.
- Department of Health and Children. Traveller Health: A National Strategy 2002-2005. Cited September 2010. Available from: http://www.dohc.ie/publications/pdf/traveller_health.pdf.
- Pavee Point Travellers Centre. Traveller health press release 2005. Cited September 2010. Available from: http://www.paveepoint.ie/press_dec_05_3.html.
- Irish Health Independent Medical Reviewers. Health and the Travelling Community. Cited September 2010. Available from: http://www.irishhealth.com/article.html?id=1079.
- Pavee Point Travellers Centre. Travellers and consanguinity. Cited September 2010. Available from: http://www.paveepoint.ie/pav_consang.html.
- Felias-Christensen G, Corl D. Muslim religious observances and diabetes. Cited September 2010. Available from: http://ethnomed.org /clinical/diabetes/muslim-religious-observances-and-diabetes.
- Al-Arouj M et al. Recommendations for management of diabetes during Ramadan. Diabetes Care. 2005;28(9):2305-11.
- Royal College of Physicians of Ireland. An issue of patient informed consent: Jehovah’s Witnesses and blood transfusions. Cited September 2010. Available from: http://www.rcpi.ie/News/Pages/AnIssueofPatientInformedConsentJe hovahsWitnessesandBloodTransfusions.aspx.
- Central Statistics Office. Census 2006, Non-Irish Nationals Living in Ireland. Cited September 2010. Available from: http://www.cso.ie/census/Non-Irish%20Nationals.htm.
- Health Service Executive. National Intercultural Health Strategy, 2007-2012. Cited September 2010. Available from: http://www.hse.ie/eng/services/Publications/services/SocialInclusion/ National_Intercultural_Health_Strategy_2007_-_2012.pdf.