Gypsies and Travellers accessing primary health care : interactions with health staff and requirements for 'culturally safe' services

摘要

This thesis explores the barriers to accessing primary care health service provision for Gypsies and Travellers in England. Research took place 'in two phases. The first was a qualitative study of Gypsies' and Travellers' cultural beliefs, attitudes, perceptions of and access to health care. Findings included low expectations and poor experience of services, as well as many examples of communication barriers between Gypsies and Travellers and health staff. The second phase built on these findings, by adopting participatory action research (PAR) methods, to explore communication processes from both staff and Gypsy and Traveller perspectives. The aim was to elicit understanding with a view to exploring how barriers might be overcome. Both phases ofresearch show how Gypsy and Traveller experiences of discrimination and racism contribute to a sense ofdevalued identity, characterised by feelings of shame and humiliation. Shame and attempts to ward off shame are central features of relationships and encounters with health staff as personal reactions to these experiences can produce mutual mistrust and poor relations between staff and the Gypsy and Traveller patients. At the same time, health staff reactions are shaped by pressures related to role, status and setting. By focusing on processes of coconstructed communication, I identify specific patterns of tension and mistrust. In conclusion, I argue that a reflective and collaborative staff approach in primary care, based on effective leadership and a shared team ethos, can provide the empathic focus needed as a starting-point for trust and effective communication. I also argue that acquisition of good communication skills and development of experiential cultural awareness, whilst essential, are insufficient to guarantee cultural competence. A reflexive approach, focussing on personal qualities, values, beliefs and attitudes, is also essential for cultural safety. I outline the specific staff training implications of these findings, in terms of ensuring culturally safe health care for Gypsies and Travellers.