Gypsy, Roma and Travellers’ access
to and use of mental health services:
a nested case-control study
Hannah Walsh South London & Maudsley
Dr Eddie Chaplin South London & Maudsley
& London South Bank University
Acknowledgements
This project was carried out under the research mentor
scheme for nurses and allied health professionals
funded by the National Institute for Health Research
Maudsley Biomedical Research Centre and Dementia
Unit
The research mentor scheme initiative is designed to
enable frontline clinicians to develop their research skills
in carrying out small-scale projects
Overview
• Defining Gypsy, Roma, Travellers
• Background and context
• Aims and Objectives
• Methods
• Results
• Conclusions, limitations and recommendations
Background: History
Irish
Travellers
Roma Gypsy &
Romany
Celtic nomadic
Romanichals: India (Egypt); in Europe from 1400s
Richardson 2012; Travellers Aid Trust
Gypsy, Roma, Travellers
• History of nomadism, though many now live in
“settled” accommodation
• Close knit family life
• Self-employed
• Low literacy levels
• Mistrust of state institutions, state-sought
information
• Self-definition
• GRT – similarities and differences
Definitions for this study
•Irish Travellers: Originally from
Ireland
Gypsy, Romany: Born and brought
up in the UK
Roma: Born and brought up in Europe
NHS personal demographic service ethnic categories :
• White Irish Traveller
• White Traveller
• White Gypsy/Romany
2011 Census included
Gypsy/Romany, Irish Travellers for
first time
London population = 0.1%,
(8196); Southwark n= 263 ; UK
58000 (0.1%) (ONS)
“Hard to reach community” or “hard to reach services”? • Health outcomes worse than other minority groups
• Poor maternal health, high rate of infant mortality, lowered life
expectancy
• High levels of discrimination, low socio-economic status, loss of
nomadic lifestyle
• High rates of self-reported depression and anxiety, substance
misuse, problems in GP registration, high suicide rates (Ireland)
• Inverse relationship between use and need
• Poor ethnic monitoring –invisible in services
Carew 2013, Cemlyn 2009, Peters 2009, Richardson 2012, Van Cleemput 2007, 2012
Study aims and objectives
Aim: To explore GRT access to, and use of mental health services to identify differences in demography or service use in comparison to a control group
Objectives: • identify demographic characteristics of both case and
control groups • identify for both groups:
diagnoses services accessed use of Mental Health Act referral sources treatment outcomes
Method
Design:
Nested case-control design
Sample:
Case group: all Gypsy, Roma, Travellers accessing
services since 2007
Control group: equal number, other ethnicity
Analysis:
Descriptive statistics and odds ratios to highlight
differences between groups
Case Register Interactive Search: CRIS
• Anonymised database of former service user case notes;
all potentially identifying information is removed
• Requires ethical approval from CRIS committee
• Contains approximately 270,000 case notes, dated from
2007
• Produces information on what you’ve requested only –
no “fishing” is possible
Results: Case and control groups
•Case group n=275
• Coded ethnicity = 121 • Traveller = 23
• Gypsy/Romany = 56
• Irish Traveller = 41
• Free text reference = 203
• Duplicates removed = 49
• 155 male, 121 female
• 0.001% (0.1%) of SLaM population
Control group n=275
• 275 patients matched: by age within 6 months and gender
• Ethnicities unknown; not GRT
Age at first referral
Mean age: Case: 29.28 Control: 25.22
GP registration
GP registration: case
234
2417
Registered Unregistered Data missing
GP registration: control
249
1412
Registered Unregistered Data missing
OR of case being unregistered:
0.16
Inpatient & Mental Health Act use ever
Inpatient? Case Control
Yes 65 33
No 210 242
Odds ratio of being an inpatient if GRT = 2.21
MHA used? Case Control
Yes 41 16
No 24 17
Odds ratio of MHA use if GRT = 1.82
Diagnosis at first contact
0 5 10 15 20 25 30 35 40
F00 - 09 Organic
F10-19 Substance use
F 20-29 Schizophrenia/psychosis
F30-39 Mood disorders
F40-49 Neurotic/stress
F50-59 Physiological/physical
F60-69 Personality
F70-79 Learning disabilities
F80-89 Psychological development
F90-99 Childhood onset
Control Case
Missing data
Case: 128
(47%)
Control: 178
(65%)
OR of case
group
having an
SUD =
3.44
Conclusions
•Low rates of ethnic coding
•Roma not represented clearly
GP registration suggests little difference
Slightly older at first referral
Substance use disorder finding fits with previous research
Inpatient and MHA rates – more restrictive experience, or higher risk perceived?
Inverse relationship of service use and need
Further research required to explore use of services, including qualititative design
Limitations
•Method of identifying sample challenging
Unable to adequately stratify into Gypsy, Roma, Traveller; challenge of adequate classification of each
Unable to adjust for confounders with this design and database
Recording inaccuracies, bias, large number of missing data
Initial diagnosis gives only very limited picture
Next steps
Practice recommendations:
Address inadequate ethnic coding
Present findings to community group and Trust
Research recommendations:
In-depth research into service use
Qualitative design to elicit community views and
experiences
Consider potential for further discrimination
References
Carew AM, Cafferty S, Long J, Bellerose D, Lyons S (2013) Travellers
accessing addiction services of Ireland (2007-2010): Analysis of routine
surveillance data. Journal of Ethnicity in Substance Abuse, 12: 339-355.
Cemlyn S, Greenfields M, Burnett S, Matthews Z, Whitwell C. Inequalities
experienced by Gypsy and Traveller communities: a review. Equality and
Human Rights Commission.
Peters J, Parry G, Van Cleemput P, Moore J, Cooper CL, Walters SJ. (2009)
Health and use of health services: a comparison between Gypsies and
Travellers in other ethnic groups. Ethnicity and Health 14:4: 359-37
Richardson J, Ryder A. Setting the context: Gypsies and Travellers in British
society. In Richardson J, Ryder A, editors. Gypsies and Travellers:
Empowerment and inclusion in British society. Bristol: The Policy Press;
2012. pp3-21
Van Cleemput P, Parry G, Thomas K, Peters J, Cooper C (2007) Health-related
beliefs and experiences of Gypsies and Travellers: a qualitative study. J
Epidemiol Community Health. 61:205-210