Illustration 4. Project H ealth W orker with Irish Traveller in the ‘health bus’
5.3.4.1 Service p ro vid ers9 perspective o f PHW
The Project Health Worker has a background as a trained Health Visitor and had worked with the Wrexham Gypsies and Travellers several years prior to joining the project team. This proved to be advantageous, as a large proportion of the community remembered her from her previous role. She had built up relationships with several of the Gypsy and Traveller families in the area and therefore, was accepted more readily than if she had been a stranger. The families that knew the Project Health Worker were able to ‘vouch’ for her to other Gypsies and Travellers who did not know her. On several occasions, when new Travellers arrived, rumours had circulated that the project workers were informants either to the police or social services. It was the Gypsies and Travellers who knew the Project Health Worker who dispelled these rumours.
The Project Health Worker’s role has, however, changed with time. At first, the role was one of ‘nurse’, attempting to meet the immediate health needs of the community. The reason for this was twofold, first, due to the high level of unmet need in the community and second, to help to gain the trust of the community.
The hope was that Gypsies and Travellers would feel that the initiative was theirs and that there was some benefit to visiting the ‘health bus’ initially. Later, the role broadened and shifted in emphasis to health promotion and coronary health status collection, as well as advocacy work which often involved bridging the gap between health and social care.
“At the beginning I think I would have done any nursing
task....just to get them on board and then when they gained confidence in me, we then really focused on the heart disease stuff.. .but I don’t think we could have done that straight away, there were people who had major issues that needed to be dealt with first. ”
(Project Health Worker)
The advocacy role has grown as more people in the community trust the Project Health Worker and more problems are disclosed. Often health is not seen as the most pressing issue to Gypsies and Travellers, immediate life problems such as immediate accommodation needs and site provision, take precedence over long term health goals, and the Project Health Worker is trusted as a person who can liaise with other professionals. This difference in priorities between the project workers and the Gypsy and Traveller communities was not fully expected by those in the project team. Feder (1994) evaluated a dedicated Traveller’s Health Visitor in East London and also found the role to be much wider than anticipated. He found that in the absence of input from other professionals, the Traveller Health Visitor adopted responsibility for medical, welfare and social advice.
“ The big issues are about accommodation, about site provision and those major issues. They don’t seem to think about
their health the same.”
(Steering Group Member)
“/ think the current bulk o f the work has been advocacy and I think the reason for the change is the nature o f the client group who in terms o f thinking of their immediacy and needs, and felt needs, are not the same as our perceived needs, not sure we could have anticipated that.."
(Steering Group Member)
The role of the Project Health Worker has now developed as a signposter and co-ordinator to other services by forging strong links with other health and social agencies. Pathways to enable improved access to health and social care have been established (see figure 5.3). Gypsies and Travellers engage with the service in several ways. The majority will make contact with the community health initiative by using the drop-in mobile health service. Referrals to the service also occur through relatives of a person either suggesting they contact the service or by asking the Project Health Worker to contact a relative, if they have a particular unmet health need. Other ways of referral are through Primary and Secondary care professionals contacting the Project Health Worker or through contact with the site warden who will notify the Project Health Worker of any new arrivals on the council run site.
On first contact with a new Gypsy or Traveller, the Project Health Worker carries out a health needs assessment. This includes assessing whether the person or family has any particular unmet health or social needs and whether they are registered with a GP. If they are not registered with a GP and are experiencing difficulties or have any unmet health or social needs then the Project Health Worker will assist in meeting these needs. Due to the high levels of poor literacy skills in Gypsies and Travellers, help is often required to register with a GP and to contact other agencies.
Many of the Gypsies and Travellers that have contact with the community health initiative have chronic health complaints that have resulted from
travelling. These have not been addressed, or have been partially dealt with by other health and social care agencies in other parts of the country. One job of the Project Health Worker is to ‘unravel the maze’ of partial care by attempting to trace past diagnosis, treatment, and assessments of health needs from the information given by the clients. Once the health needs are established, the
Project Health Worker assists the Gypsy/Travellers to arrange appointments with GPs and other health professionals if this is required.
Gypsy/Travellers often miss appointments with health professionals because they have difficulty remembering future dates, if they are unable to read or write.
Also, they are often required to travel to visit a sick relative or attend a funeral at short notice. This often results in a breakdown of contact with health
professionals and therefore, a break in treatment, often resulting in
Gypsy/Travellers having to start again with new referrals. The Project Health Worker will remind those Gypsy/Travellers that have difficulty, that an
appointment is due and if they miss an appointment, will liaise with health professionals to commence treatment rather than removing them from
treatment/consultant lists. She has also introduced calendars to those who are able, to record their appointments, but with limited success as possessions in the trailer are often discarded due to a lack of space.
For Gypsies and Travellers who experience problems with treatment or communication problems with other health professionals, the Project Health Worker liaises on their behalf. She also accompanies those Gypsies and Travellers who express a wish for her to do so, to consultations, where she often acts as an interpreter between the client and the health professional, providing support to both parties.
Gypsy/Traveller Access to Health Care Pathway
Liaison with GPs and other health professionals
Provide medical advice to Gypsy/T ravellers Triage & research past
health need, diagnosis, treatment, assessments unravelling the m aze’
5.3.4.2 Service users' perspective ofPH W role
To the Gypsies and Travellers involved with this project, the role of the Project Health Worker is seen as wide, encompassing a range of health and social care needs.
“She (Health Worker) does everything, she helps us with things we can’t do, she takes our blood pressures and does all sorts o f things. If we don’t feel well, we’ll tell her and she
advises us and tells us where to go, to the hospital or the doctors”
(Resp.5, female, 37yrs, Irish Traveller)
She is the Health Visitor that looks after them by sorting out their problems.
When asked what the Project Health Worker does, four main themes emerged, adult general health, access to healthcare, social support and children’s health.
Adult general health was seen by most Gypsies and Travellers as the type of work that the Project Health Worker was most involved with. This involves such things as providing general health checks including blood pressure, weight and blood tests, giving general health advice, helping people with their health problems and first line assessment of health problems.
“I know she’s the health lady ain’t she. Taking blood tests from people like that, I know. I knows her a long time, The tests are to see if anythings wrong with yer. She helps people on the site, helps them with their health problems. ”
(Resp.3, female, 65yrs, Irish Traveller)
“We call her the Health Visitor. She looks after our health.
People here have respect for her. If they have a problem or something is worrying them, then they go to her. ”
(Resp.10, male, 16yrs, Irish Traveller) Providing a listening ear was seen as an important role of the Project Health Worker. To many, this is the first time a close relationship has developed
between themselves and a Health Worker, or anyone from outside the Gypsy or Traveller community. Being able to talk your worries through is seen as
valuable.
“She’s more like, how can I say to yer, she’s more like a friend than a Health Visitor because she’ll sit and talk to yer.
It’s like she’s not frightened to talk to yer, she’s not frightened to touch yer. ..She’s a person you can sit to and you can tell what you need to say.. .and she’ll ju st sit there and listen. ”
(Resp.2, female,22yrs, English Gypsy)
Access to Primary Care was an area that was mentioned frequently by the Gypsies and Travellers interviewed, many said they had been helped to register or re-register with GPs.
Communication was also mentioned. The Project Health Worker has assisted in communication between the GP or other health professionals and the Gypsy and Traveller communities as mentioned above. The Health Worker has accompanied people on visits to see their GP when they felt that they were having problems with communication. This may take the form of the patient needing to have what the doctor is saying explained or reinforced or it may be the other way around, with the Project Health Worker explaining the patient’s viewpoint or culture. The Project Health Worker also liaises with GPs through writing letters of explanation concerning a person’s worries.
“She can help you get a GP and she has helped me by writing a letter to the doctor once explaining what I was worried about.’’
(Resp.7, female, 23yrs, Irish Traveller)
“She, when I needed to get to hospital now, I couldn’t get there, I needed someone to come and explain things and she come.”
(Resp. 13, female, 21 yrs, Irish Traveller)
Social support was also seen as a role of the Project Health Worker. This
includes liaison with other agencies on behalf of Gypsies and Travellers, as well as providing advice about entitlements and help with filling out forms.
Finally, the Gypsies and Travellers interviewed saw the Project Health Worker’s role as one including preventative health care for children in the form of
vaccinations. One woman said she would not go to the surgery, to the Health Visitor, she preferred the children to be vaccinated by the Project Health
Worker, having been influenced by her mother’s belief that the Health Visitor (in general practice) is an authority figure who might take your children away.
“Like m y son with his injections. I ‘a v e n ’t taken him anywhere else, I ’m waiting for h e r (Project Health W orker) to com e and do
' e m. .. W ell I d o n ’t understand what a Health Visitor does to be honest with yer, I ’ve always seen the b ad side o f a Health Visitor to be honest with yer, because m e m a m ’s alw ays said 'Oh, the Health
Visitor’s coming, I ’m gonna ‘ave m e children took off m e ’.”
(Resp.2, fem ale, 22yrs, English Gypsy)