Title: Enhancing Gypsy/Travellers’ trust: using maternity and early years’ health services and dental health services as exemplars of mainstream service provision.
Funder: Department of Health and Social Care

Abstract: Gypsy/Travellers have poor health compared to the general population and other disadvantaged groups, evidenced by increased infant mortality, poor child and dental health and underuse of health services. Increasing uptake of MEYHS and CDHS for Gypsy/Travellers could improve health outcomes, and reduce lifetime health inequalities and costs of delayed treatment. Widespread discrimination, alongside structural and cultural barriers experienced by Gypsy/Travellers when accessing healthcare, result in mistrust of services and lack of awareness of their needs by healthcare providers. Trust is associated with utilisation of healthcare and care quality. Community engagement (e.g. information provision and exchange, peer-delivered interventions) can enhance trust and ensure services are tailored to the needs of specific populations. Evidence is lacking on how to enhance Gypsy/Travellers trust in mainstream services. Aim Examine which approaches to community engagement best enhance Gypsy/Travellers trust in services. Research questions What activities/methods are used to engage Gypsy/Travellers in health services and to what extent do they focus on negotiating trust? How do different engagement activities of health services enhance trust and increase uptake of MEYHS and CDHS by Gypsy/Travellers? What are the knowledge, beliefs and experiences of Gypsy/Travellers of MEYHS and CDHS? What different approaches are used to enhanced Gypsy/Travellers trust in MEYHS and CDHS and what are the implications for policy and practice? What are the likely costs of different approaches to community engagement? Are community engagement approaches that work to enhance Gypsy/Travellers trust in MEYHS and CDHS applicable to other health services/vulnerable communities? This multi-method study comprises four linked stages. Three related reviews, each including economic evaluations: a) systematic review of Gypsy/Travellers access to health services; b) systematic review of reviews exploring trust; c) Realist Synthesis testing four hypotheses of community engagement approaches to enhance trust and increase Gypsy/Travellers participation in health services (RQ1-3,5); Online consultation gathering information on community engagement activities including barriers and good practice (RQ1,2,5). In-depth case studies (three in England, one in Scotland) of different Gypsy/Travellers communities exploring views of 48 mothers of pre-school children, 40 healthcare providers and 12 informants from third sector organisations and contextual documentary analysis. (RQ2,3,5) Two stakeholder workshops evaluating whether policy options are realistic, sustainable and replicable. (RQ4,5,6) The multidisciplinary research team has strong policy and practice links (AM, KA, CJ, NI, HJ) and expertise in conducting culturally appropriate research in diverse settings (AM, KA, CJ, NI), using a range of methods (AM, KA, CJ, SM, NI) including health economics (KB); working with vulnerable populations (AM, KA, CJ, NI, HJ), including Gypsy/Travellers (HJ, CJ), in maternity and early years settings (AM, KA, CJ, KB) and children s dental services (NI). We have expertise in PPI (AM, KA, CJ). Our team includes the Chief Executive (HJ) of a community-led organisation that aims to improve the quality of life for Gypsies and Irish Travellers. We will collaborate with an information specialist to design sensitive and precise searches. The study will provide policymakers with options and recommendations for how to enhance trust among Gypsy/Travellers in MEYHS and CDHS. Importantly these recommendations and policy options will be informed by the views of users and stakeholders on feasibility, sustainability, replicability and possible costs. This information will provide guidance for health service commissioners and healthcare providers on how to increase uptake of health services, thereby potentially improving health and reducing lifetime inequalities for Gypsy/Travellers. In addition, the research will explore how the recommendations might work for other mainstream health services and other vulnerable populations, thus widening the impact. The findings will also provide relevant information for third sector organisations on how to engage effectively with health services.

Lay abstract: Gypsy/Travellers have poorer health than the general UK population and other disadvantaged populations, but use health services less. Increasing uptake of Maternity and Early Years Health Services (MEYHS) and Children s Dental Health Services (CDHS) can reduce lifetime inequalities. However, Gypsy/Travellers face many barriers to accessing services including mistrust of health services. Community engagement, such as information provision and exchange or peer-delivered interventions, is one approach to increasing trust in mainstream services. However, there are no studies examining which community engagement approaches work best for Gypsy/Travellers. We will work with Gypsy/Travellers, healthcare providers and third sector organisations to explore which community engagement approaches are best at enhancing Gypsy/Travellers trust. We will use Maternity and Early Years Health Services and Children s Dental Health Services as examples of service provision. We propose a four-stage study: (1) reviews of existing literature on trust and engagement; (2) a wide-scale consultation with community groups and health services in England and Scotland to identify barriers and successful approaches to engaging Gypsy/Travellers; (3) in-depth interviews with mothers of pre-school children from Gypsy/Traveller backgrounds, healthcare providers, and third sector organisations in four locations to understand experiences of provision (3 in England,1 in Scotland); (4) two workshops to assess whether policy recommendations based on our findings are practical and if they would work for other health services and in other vulnerable populations. The outcomes of our research will be: a) a framework to explain how Gypsy/Travellers do or do not engage with services; b) recommendations for policy and practice on how to enhance trust and improve the acceptability of health services to Gypsy/Travellers; c) sound evidence, including potential costs, upon which to base future action and research. An ethical issue will be obtaining informed consent from participants with low literacy. Ethics approvals will be sought from the NHS and participating universities. Our multidisciplinary team has strong policy and practice links and expertise in conducting culturally sensitive health services research. We have worked in diverse settings using multiple methods with vulnerable populations. Our expertise includes community engagement, maternity and early years provision and children s dental health services.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH;ORAL AND GASTROINTESTINAL