Traveller Cultural AwarenessTraining Programme EvaluationReport prepared by Waterford Institute of TechnologyIn collaboration with the Traveller Health UnitSouth East Community Healthcare

Report prepared by: Waterford Institute of Technology

December 2017

Waterford Institute of Technology Research Team:Dr Suzanne Denieffe Dr Mary ReidyDr Deidre Byrne Dr Michael BerginMs Majella McCarthy Professor John SG Wells

In collaboration with:Traveller Health Unit SouthEast Community Healthcare

For:Traveller Health UnitSouth East Community HealthcareHealth Service ExecutiveSocial Inclusion Department

Foreword

As General Manager of Social Inclusion Services and Chairperson of the South East Traveller Health Unit, it gives me great pleasure to introduce the Traveller Cultural Awareness Training Programme Evaluation, undertaken by Waterford Institute of Technology in the South East Community Healthcare (SECH) area.

Travellers experience poorer health than the general populations. Irish Travellers have a reduced life expectancy: Traveller men’s life expectancy is 62 years which is 15 years less than men in the general population and Traveller women’s life expectancy is 70, 11 years less than women in the general population, All Ireland Traveller Health Study 2010, (AITHS). The AITHS informs us that heart disease and stroke accounted for 25% of Traveller Deaths, cancer 19%, lung disease 13% and suicide 11%. Of those tested in the 12 months of the (AITHS) 25% were diagnosed with having high cholesterol and 33% with high blood pressure. This study also highlighted that Travellers have a 15% higher rate of smoking compared to the general population.

It is incumbent on the health services to tackle these inequalities in health outcomes. However, it is recognised that they are multifaceted in origin and influenced by the social determinants of health, but they are certainly linked to the challenges of discrimination and prejudice which are very real problems facing the Traveller Community today.

There is an increasing awareness that public services need to respect the cultural and ethnic identity of Travellers when they access services. This has been reflected in more recent Traveller Cultural Awareness training programmes which have been attended by front line staff from across the public services.

I welcome the Traveller Cultural Awareness Training Programme Evaluation and its recommendations. It provides the South East Traveller Health Unit (SE THU) with a blueprint to plan and develop the Traveller Cultural Awareness Training Programme going forward to enable us to reach out to health services front line staff and indeed other public service front line staff in the South East Healthcare Area, to develop and raise their awareness of the cultural sensitivities of Travellers attending our services and provide culturally competent service delivery.

I would like to thank Waterford Institute of Technology Research Staff for their professionalism and ethical approach to undertaking this evaluation. Their ability to understand from the beginning how important it was for the THU SE that Travellers needed to be central players in this evaluation, facilitating Travellers to be on the interview panel for the research assistant, and participating on the WIT Ethics Committee being a couple initiatives worthy of note.

I would also like to thank the Traveller Health Unit staff, the Coordinators, the Traveller Health Workers the HSE staff and the Steering Group who participated on and engaged with the Evaluation Team and contributed significantly to the evaluation process.

Jeanne HendrickGeneral ManagerSocial Inclusion, South East Community Healthcare

Acknowledgments

The Research Team would like to acknowledge the support of all involved in the study without whom the study could not have been undertaken: the Steering Group for their advice and support; the Traveller Health Project Coordinators for their willingness to help and assist in organising the data collection; the Traveller Community Health Workers/ Programme Facilitators for sharing their experiences; and to the Travellers and Interdisciplinary Workers who took part so willingly in the focus groups.

The Wheel of Culture was created by the Wexford Traveller Community Health Programme in April 2012

i

Foreword i Acknowledgments i Index of Figures 1 List of Tables 1 Executive Summary 2 Chapter 1. Introduction to Report 8 Chapter 2. Background and Context 9 2.1 Travellers in Ireland 9 2.2 Public Sector Duty and Travellers 11 2.3 Travellers and accommodation 11 2.4 Travellers and discrimination 11 2.5 Travellers and education 12 2.6 Travellers and health 12 2.7 HSE strategy and initiatives for Traveller health 14 2.8 Cultural awareness and competence training 15 2.9 Other Culture Awareness Training Initiatives 16 2.10 Traveller Culture Awareness Training SECH 17 2.11 Rationale for the Study 18 Chapter 3. Study Methodology and Methods 19 3.1 Introduction 19 3.2 Study aim and objectives 19 3.3 Study design 19 3.4 Data collection tools 19 3.4.1 Health Promotion Officers Questionnaire 20 3.4.2 THP Coordinators Questionnaire 20 3.4.3 TCAT Past Participants Questionnaire 20 3.4.4 TCAT Workshop Evaluations 20 3.4.5 TCAT Facilitators Focus Groups 21 3.4.6 Travellers Focus Groups 21 3.5 Population and sample 21 3.6 Data analysis methods 21 3.6.1 Quantitative data 21 3.6.2 Qualitative data 22 3.7 Ethical approval 22 Chapter 4. Study Results 23 4.1 Sample accrual 23 4.2 TCAT Programme evaluation questionnaire 23 4.3 Health Promotion Officers Questionnaire 26 4.3.1 Views of the TCAT Programme 27 4.3.2 Usefulness / benefits of the TCAT Programme 27 4.3.3 Changes made to the TCAT Programme 27 4.3.4 Key training needs of TCAT facilitators 27 4.3.5 Training needs of new TCAT facilitators 27 4.3.6 Support needs of new TCAT facilitators 27 4.4 THP Coordinators Questionnaire 28 4.4.1 Views on the programme 28 4.4.2 Usefulness / benefits of the programme 28 4.4.3 Training required for Travellers’ facilitating the programme 28 4.4.4 Supports provided for the programme 28 4.4.5 Other supports that might be required for Traveller facilitators 29 4.4.6 Suggestions for improvements to the programme 29 4.4.7 Changes made to the programme over time 29 4.4.8 Impact of the Changes 29 4.4.9 Suggestions for the future roll out of the programme 29 4.5 TCAT Facilitators Focus Group 29 4.5.1 Introduction 29

Contents

ii

4.5.2 TCAT operational delivery 30 4.5.3 Programme content 30 4.5.4 Targeted training programme 30 4.5.5 Training and characteristics required to facilitate TCAT 30 4.5.6 Mandatory TCAT training for front line staff 31 4.5.7 Perceived advantages of TCAT 31 4.5.8 Challenges and opportunities encountered in delivering TCAT 32 4.5.9 Discrimination against Travellers and the impact on TCAT delivery 34 4.6 Travellers Focus Groups 35 4.6.1 Introduction 35 4.6.2 Views on cultural awareness training programmes 35 4.6.3 Lack of awareness of Traveller culture, norms and beliefs 35 4.6.4 Benefits of cultural awareness training programmes 36 4.6.5 The need for a targeted approach to TCAT delivery 36 4.7 Past Participants Questionnaire 37 4.7.1 Length of time since programme completion 37 4.7.2 Area of work 37 4.7.3 Views of the TCAT programme 37 4.7.4 Usefulness or benefits of the TCAT programme 38 4.7.5 Impact has the programme on interactions with Travellers 38 4.7.6 Work style / behaviour changed since undertaking the programme 38 4.6.7 Other content that should have been included in the programme 38 4.8 Summary of Results 38 4.8.1 Evaluation questionnaire summary 38 4.8.2 Health Promotion Officer questionnaire summary 39 4.8.3 Coordinators questionnaire summary 39 4.8.4 Facilitators Focus Groups 39 4.8.5 Travellers Focus Groups summary 39 4.8.6 Past Participants Questionnaire summary 40 Chapter 5. Discussion and Recommendations 41 5.1 The organisational structure of the programme 41 5.2 Common understanding and shared beliefs of key stakeholders 42 5.3 The adaptations made to the originally designed programme; 42 5.5 Informing the development of a Traveller Cultural Competence Pack 43 5.6 Study Limitations 43 5.7 Conclusions and Recommendations 43 References 48 Appendices 51 Appendix 1 Evaluation Questionnaire 51 Appendix 2 Health Promotion Officers Questionnaire 52 Appendix 3 Traveller Health Project Coordinators Questionnaire 53 Appendix 4 TCAT Past Participants Questionnaire 54 Appendix 5 Evaluation Questionnaire Code book 55 Appendix 6 TCAT Focus Group Consent Form 56 Appendix 7 Travellers Focus Group Consent Form 57 Appendix 8 Information Health Promotion Officers 58 Appendix 9 Information Traveller Health Project Coordinators 59 Appendix 10 Information TCAT Focus Groups 60 Appendix 11 Information Travellers Focus Group 61 Appendix 12 TCAT Programme Facilitators Manual 62 Appendix 13 TCAT Marketing Leaflet 86 Appendix 14 TCAT Completion Certificate 86

iii

Index of Abbreviations

AITHS All Ireland Traveller Health Study CERD Committee on the Elimination of Racial Discrimination COI Commission on Itinerancy CSO Central Statistics Office DoHC Department of Health and Children HPO Health Promotion Officer NCCRI National Consultative Committee on Racism and Interculturalism HSE Health Service Executive ITM Irish Traveller Movement SECH South East Community Healthcare (Carlow, Kilkenny, Waterford, Wexford and South Tipperary)

SETHU South East Travellers Health Unit SLAN Survey of Lifestyle and Nutrition in Ireland SPSS Statistical Package for Social Sciences STEP Survey of Traveller Education Provision in Irish Schools TCAT Traveller Cultural Awareness Training THP Traveller Health Projects THU Traveller Health Unit TPRB Travelling People Review Body WLD Wexford Local Development WIT Waterford Institute of Technology

Index of Figures

Figure 1: HSE SEHC: Carlow, Kilkenny, Tipperary South, Waterford, Wexford 15 Figure 2: Daily activities limited by illness, health problems or disability. 26 Figure 3: Sequential mixed methods design 37 Figure 4: Overall workshop rating 44 Figure 5: Pace of the workshop 44 Figure 6: What I found most helpful 46 Figure 7: Least helpful aspects of workshop 47 Figure 8: Rating the Facilitator’s style of delivery 48 Figure 9: Professional background of past participant 70

List of Tables

Table 1: Stakeholders Data Collection tools 39 Table 2: Sample Details 42 Table 3: Gains from the Workshop 44 Table 4: Other comments regarding workshops 47 Table 5: Overall findings summary 75

1

Executive SummaryBackgroundWhite Irish Travellers are an Irish ethnic group, making up almost 1% of the Irish population. Travellers have their own unique culture which was based on travelling around the country. As a society Ireland needs to work in partnership with Travellers to address the issues that face the Traveller community, such as discrimination in education, housing and health. There is a need for public services to respect the cultural and ethnic identity of Travellers when they access services.

Traveller Cultural Awareness Training Programme The Regional Traveller Health Network in association with the Health Promotion Department of the HSE developed, using a co-production approach, the Traveller Cultural Awareness Training (TCAT) Programme on behalf of Traveller Health Unit. The programme is delivered by Traveller Community Health Workers who have been trained in facilitation skills to deliver the programme by the Health Promotion Department, South East Community Healthcare (SECH), Health Service Executive.

The TCAT programme aims to improve Travellers’ health though the provision of education on Traveller culture to health service staff and other public service staff so to make their services more accessible and thus have an impact on Traveller health outcomes.

The aims of the TCAT programme are:

• To raise awareness of Traveller health issues• To provide information on Traveller culture and how this impacts on use of services• To identify the main barriers experienced by Travellers in accessing services• To identify ways of moving forward to improve access and uptake of services

Waterford Institute of Technology (WIT) were commissioned by the Social Inclusion Department SECH to evaluate the TCAT programme.

Aim of the studyThe aims of the study were to evaluate and analyse the programme by obtaining the views of key stakeholders regarding the TCAT programme and how it was achieving the programme aims. The analysis was used to make evidence based recommendations for the future development and implementation of the programme regarding how the training should continue to be delivered with the aim of ensuring the maximum effectiveness of the programme.

In line with the principles of community development work, Travellers, as key stakeholders, were integral to the study including advising on methods of communication, consultation, and participation in the overall evaluation. There was Traveller involvement in the Steering Group who directed and advised the research team. Traveller consultations in relation to data collection were vital in ensuring that the data collected included all key stakeholders, the programme facilitators and the Travellers who are users of health services. There was also Traveller representation on the Ethics Committee who reviewed the project in WIT.

Study designThe study design used an explanatory sequential mixed methods design. The key people who were involved in the study were the Traveller Community Health Workers Programme Facilitators, Traveller Community Health Project Coordinators (hereafter referred to as Coordinators, the Health Promotion Officers, Travellers and the programme participants. The study used a mixed methods approach and examined: programme evaluation forms; surveys with the Coordinators, Health Promotion Officers and people who attended the TCAT programme; Focus groups with Traveller Community Health Workers Programme Facilitators and Coordinators, Travellers and Interdisciplinary Team members.

The study consisted of three key stages.

• Stage 1: an examination of completed programme evaluation forms. • Stage 2: survey questionnaires for the coordinators, the health promotion officers and the TCAT

programme attendees designed using open ended questions.• Stage 3: focus groups with TCAT programme Facilitators and Coordinators, Travellers and Interdisciplinary

Workers.

2

The findings from all stages of this evaluation clearly identify that the participants in the study recognised the value of the TCAT programme and the need to continue to offer training in this area.

The evaluation questionnaires analysed (n= 580, 48% of total programme participants) identified that the TCAT programme raised awareness of Traveller culture and issues for Travellers accessing services for those that attend. They showed that the participants were provided with information on Traveller culture and how culture can affect the use of services and the main barriers experienced by Travellers in accessing services. The evaluation surveys also identified that one of the TCAT programmes greatest strengths are the Traveller Community Health Workers who deliver the training, i.e. meeting and listening to Travellers.

The evaluation survey did not ask for ways of moving forward to improve access and uptake of services for Travellers but some of the participants did comment on the need for change of attitudes and their own attitudes changing because of the training.

The Health Promotion Officers were in agreement that a full day training was appropriate for the TCAT programme, that the content was fit for purpose and that the programme being delivered by members of the Travelling community was vital. They also referred to the personal benefits for the Traveller Community Health Workers who facilitate the programme in terms of developing transferable skills in facilitation, communication and increased self-confidence.

The Health Promotion Officers were not involved in the ongoing delivery of the programme and therefore not involved in the modifications made by the individual groups. The Health Promotion Officer who was aware of changes thought that tailoring the content to suit specific groups would be beneficial and more relevant to the particular service. As far as the training needs required for Traveller Community Health Workers to deliver the programme they suggest as a prerequisite the Traveller Community Health Workers would need to have a high degree of maturity as well as good literacy. They identified the essential key training needs as: facilitation skills, confidence building, personal development training as well as training in the ability to deal with resistance and to learn how to respond objectively to challenging questions or opinions during the workshops.

Their opinions on the amount of time required to train Traveller Community Health Workers to facilitate on the TCAT programme ranged from 6 to 10 sessions suggested that facilitator training is best done over time as it allows for reflection on learning and time to develop confidence, competence and self-awareness. The level of support needed for new and experienced Traveller Community Health Workers facilitators is high as the TCAT programme is challenging for the facilitators and the participants.

The Coordinators were in agreement that a degree of fluidity needs to inbuilt into the TCAT programme that is dependent on the range of service providers attending and their available timeframes. There was consensus that the content of the programme was effective in raising awareness of Traveller culture but the content needed to updated and refreshed, for example with regard to Traveller ethnic minority status.

There was agreement that the Traveller Community Health Workers need a specific skill set to deliver the programme that consists not only the ability to develop facilitation skills but also the desire and confidence to deliver the programme. The coordinators were explicit that their role is to support the delivery of the TCAT programme. They are responsible for the coordination and administration of the programme and are there in a supporting role on the day. It is the Traveller Community Health Workers who facilitate the training and in agreement with the findings from the evaluations they point to benefits of service providers getting the opportunity to meet with and talk to Travellers, to raise concerns and to build links.

Suggestions for improvement to the TCAT programme from Coordinators included addressing the allocation of hours to deliver the training as this interferes with and puts extra demands on the limited part time hours undertaken by the Traveller Community Health Workers. It was also suggested to expand the potential audience by introducing mandatory TCAT for all public service workers and stressed the need for updated information, additional resources and training for the facilitators.

From the Travellers and Co-ordinators it was evident that the facilitators were satisfied with the programme, in particular, the tailored TCAT package and the advantages to the fluidity of TCAT programme delivery were deemed significant. Confident, experienced group facilitators were reported to be amongst the key characteristics required to deliver training. Facilitators called for and welcomed mandatory TCAT training for all front line staff. Despite the fact that the facilitators reported that the advantages of TCAT outweighed any disadvantages associated in

3

delivering the programme, it was very clear that a lack of time, TCAT programmes not being recognised as a key performance indicator (KPI) and lack of skills and resources hindered facilitator’s delivery of the TCAT programmes and calls were made to strengthen the scope and breadth of the programme. The Traveller focus groups findings included the suggestion that the current TCAT programme needs to be targeted more broadly at service providers. The need to encompass the education sector and in particular the need to target primary schools was highlighted as an area warranting further attention. However, in general all sectors were reported to potentially benefit from increased TCAT delivery, including Travellers themselves. It was evident that discrimination and prejudice is still perceived as a very real problem facing the Travelling community today and more work needs to be attributed to this area when developing future TCAT programmes. The findings from the questionnaire of past participants suggest that for the respondents who found the TCAT training a positive experience on the day their opinion had not altered over the passage of time. The majority of respondents felt that the training had impacted on their interactions with Travellers and that their work style / behaviour had changed to some degree since undertaking the TCAT programme. Unfortunately the sample was too small to be representative and further research needs to done in this area but the findings indicate that an inbuilt follow-up survey of past participants could be beneficial to the future roll out of the TCAT programme.

Report Recommendations are as follows:

R1. The HSE should continue to offer Traveller Culture Awareness Training through the Traveller Health Projects

In relation to programme content, this evaluation recommends TCAT continue to be delivered utilising a ‘module by module’ format. Specific short training modules should be developed on topics relevant to specific key target groups.

R2. Continue to use the modular approach to delivery of the awareness training and build on these modules

The evaluation findings identify the need to develop the scope of the current programme and in particular the need to target more front line health care staff and public health sector employees. This evaluation estimated that approximately 1,200 service providers across the HSE SECH region had previously participated in TCAT (since programme commencement in 2007) but no data was available to the evaluation team to determine the breakdown in the numbers of previous participants of TCAT per sector.

Therefore, it could be the situation that key front line healthcare professionals may not in fact be receiving this important training. This evaluation therefore recommends offering this training to more front line staff, those that have regular contact with Travellers. Health professionals identified for such training from the focus groups included: maternity services, paediatric services, primary care and public health services and all those working directly with Travellers. Priority groups identified in the SE THU Strategic Plan 2015-2020 were health services/ social work services, local authority/public representative, schools and training institutes/ media/ business/ Chamber of Commerce/ Gardaí, social services. In terms of offering, consideration also needs to be taken of the need to ‘market’ the programme, making it more visible to staff who may interested in undertaking the programme, perhaps creating a webpage and distributing flyers on the programme to key settings.

R3. HSE should identify the priority staff who require this training and target these for programme delivery

The evaluation team are aware that it can be a challenge to get staff to engage with this training. Consideration needs to be taken therefore as to how best to get this engagement. An issue which could be causing reluctance to attend could be the difficulty with release. The THU need to consider how best to deal with this challenge. It has been identified in the findings that the programme is delivered in a modular format wherein depending on

4

the target audience programme elements are included or omitted. To address the difficulty with staff release, preparation of key modules which could be delivered in on- line mode could provide greater coverage to a wider range of participants and address key elements of Traveller culture awareness. It should be stressed however that the success of the programme to date has been in the Traveller facilitator interactions with the programme participants and the question and answer sessions. Undertaking an on-line programme could be used as a preparation for a face to face delivered programme, shortening the duration that would be required for delivery but retain the very valuable element of Traveller- Participant interaction.

The on-line programme would need to be developed in a full and genuine collaboration with Travellers to ensure that their voice is heard in this programme development. The modules which could be delivered in an online modality would need to be identified and then expertise in the preparation of online programmes would need to be resourced. The format could include videos, voice overs, online exercises and mini quizzes built in to encourage engagement and enhance learning of the participants. A certificate of completion could then be printed out by the participant and displayed in the workplace. A focus group item raised was to include cultural awareness training as part of the training for new health and social care professionals and the Gardaí. An online programme would enable the easier inclusion of such content in other educational programmes.

R4. Consider development of an online programme on Traveller Culture and Issues to support the current programme delivery model

R5. Allow for a completion certificate from the online programme as for the current programme

R6. Ensure full Traveller involvement in the development of this programme

R7. Promote the inclusion of the online programme in educational programmes for health and social care professionals and the Gardaí

The SE THU Strategic Plan 2015-2020 outlines a proposal for the development of Cultural Competency Training for Service Champions. As this has not yet commenced in the region, the evaluation team did not specifically address this. The proposal for service champions and the role they would play within services to promote Traveller Culture awareness is undoubtably important but would seem to be not yet operational. A pilot of such a champion programme would seem warranted to test the feasibility and operational issues that may arise.

R8. Pilot the Service Champion Model within a service and evaluate

The ideal would be to build up a critical mass within prioritised services of those with Traveller culture awareness undertaken. However it would seem in order to attain a cohort of trained personnel, value must be placed by services and staff on receiving this training. Inclusion of culture awareness training as a requirement for staff in prioritised services and putting in place a key performance indicator (KPI) on the number of staff trained and monitoring of this indicator would seem to be means of developing this critical mass. Development of service champions could then also be put as a KPI for services but perhaps this is a later stage development.

R9. HSE need to include Traveller Culture Awareness Training as a KPI for target groups

Another strategy which could be considered to encourage the engagement of key priority staff in this training could be development of the programme so as to obtain Continuing Education Units (CEUs) for health and social care professionals. The various registration boards either have such a continuous professional development requirement currently or are moving towards such a requirement. These registration boards have mechanisms in place where training programme can be awarded CEUs. The THU may consider obtaining such accreditation for the training as a means of incentivising health and social care staff to participate in the programme.

5

R10. Consider obtaining CEU points for the Traveller Culture Awareness Training Programme

With the new Ethnicity recognition and as new data on Traveller health issues becomes available, there may be a requirement for follow up training. However, until a substantial cohort of front line staff have received training, consideration of upskilling/ re-training is a more long term issue. The SE THU Strategic Plan 2015-2020 identified the possibility of sharing of programmes/ resources, that is those which have been trialled and found to be successful. Certainly the Traveller Culture Awareness Programme has been shown in this evaluation to be successful in raising awareness of those attending. There is substantial expertise available now within the THU in terms of trained and experienced programme facilitators. The evaluation team are of the view that this cohort can be used to develop and support more programme facilitators. If the programme is to reach its full target audience, there will be more programme facilitators required. Currently only Traveller Community Health Workers act as facilitators, the evaluation team suggest that other Travellers could also become involved in delivery of the programme, with of course the proviso of requiring full training and ongoing support.

It seems that there is only one male Traveller Community Health Workers at present in SECH, but he is not a programme facilitator. It is important therefore to consider involving more Traveller men as programme facilitators.

R11. Train more Travellers, either Traveller Community Health Workers or non-Traveller Community Health Workers, to be programme facilitators

Facilitators participating in this evaluation were credited for their confidence, communication, motivation to deliver programme, facilitation, leadership and management skills and these were largely attributed to having previously participated in facilitation skills training. This evaluation highlights the need to build on current training (facilitation skills training) and recommends that all facilitators’ delivering TCAT receive validated and certified training. The evaluation previously conducted on training for delivery of Traveller culture awareness identified that having a validated programme was valued by the Travellers who received the award. This training should be considered mandatory for any new Facilitators. It was felt by the current facilitators that further training was required on dealing objectively with challenging and difficult questions/ people.

R12. Consider providing a NQF validated programme to new and existing trainers

Resources to support the programme were also raised in the evaluation. These resource issues include equipment, administration and delivery requirements.

A barrier linked to programme delivery was the lack of equipment resources to effectively deliver TCAT programmes, for example over-head projectors and videos were still used by some facilitators delivering the programmes. The need for increased resources, i.e. laptops and equipment required to assist with more interactive training delivery modes are required to present a professional programme. Common sharing of training resources should be encouraged and required materials provided to all programmes across SECH regions. Additionally, facilitators will need to be trained to confidently deliver interactive training materials, ICT, PowerPoints etc.

R13. Ensure that there is suitable ICT and other equipment to enable effective programme delivery, perhaps sharing this from a central location

Programme delivery could perhaps be co-ordinated from a central unit. This could assist in part to reduce resource demands. A central administrator / co-ordinator could promote/ market the programme, organise delivery teams, book venues, maintain a database and ongoing evaluation of the programme. If the programme is to be delivered more widely, the need for such administrative/ organisational support will become more of a demand. The maintenance of a central database is an important point, it would allow for monitoring of programme delivery, informing the achievement or not of KPIs should they be introduced and enable follow up of programme participants, perhaps in terms of upskilling or future research.

6

R 14. Create a centralised administration/ co-ordination system for organising the delivery of the training

One of the key barriers to programme delivery highlighted amongst all groups participating in this evaluation was in relation to the time required to prepare, refresh and deliver TCAT programmes. Part time working hours of facilitators, in addition to current projects running to capacity, were all linked to the decline in the number of TCAT programmes delivered across all the HSE SECH region in recent times.

It seemed therefore that there is a lack of trained facilitators available to deliver the programme. Creation of a bank of trained facilitators (both THU and non THU Travellers) who could work across the region could in part help in ensure that the programme is delivered across the region and can continue to be delivered into the future.

R15. Create a bank of facilitators who can deliver the programme across the region

Another key resource issue is that facilitators only work part time hours. While it is acknowledged that there are a number of reasons for this, it reduces the facilitators availability for their regular work for that week and also reduces the number of programmes that can be run. Indeed, lack of facilitator time was a reason given in one region for the non-running of the programme for a number of years. If the programme is to be more frequently and widely delivered, the issue of resourcing of facilitators must be addressed, and should include the time for programme preparation, delivery and team evaluation post programme.

R16. Consider how the facilitators can be resourced to allow for increased numbers of programmes to be delivered.

It was evident from both the evaluation forms and the past participant forms received that the programme is effective in terms of raising awareness and developing knowledge among the participants of Traveller culture and the issues they face for those who attend the training. The Traveller focus group findings identified however that substantial lack of knowledge on Traveller culture still exists. It was not possible to ascertain the actual impact of the training conducted to date. Should a critical mass of staff receive the training, it is likely that there would be more positive benefits for Travellers receiving such services. However, without such a base of trained staff, it was not possible for the evaluation team to examine the effectiveness and impact of the training to date. The creation and maintenance of a database of past programme participants would allow for ease of follow up for future evaluations and examination of programme impacts.

R17. Maintain a central database of training provided

In order to address the recommendations above, there will be cost implications. It is beyond the scope of this evaluation to address these costs. However possible costs identified include programme delivery equipment, centralised programme co-ordination, additional Facilitators training and work hours, additional work hours for current Traveller Community Health Workers and costs associated with the development of an online modules(s) from the training programme.

7

Chapter 1. Introduction to Report

A Traveller Culture Awareness Training Programme [TCATP] was developed by the Regional Traveller Health Network, a subgroup of the South East Traveller Health Unit with the support of the Health Service Executive [HSE] Community Health Organisation Area 5 Health Promotion Department and launched in 2013. The need for a Traveller Culture Training Pack was first identified by the South East Traveller Health Unit and was developed by the Clonmel Traveller Community Health Project for the region. The Clonmel Traveller Community Health Workers supported by their Traveller Health Project Coordinator facilitated their first Traveller Culture Workshop in October 2005. The aim of the programme was to contribute to improving the health status of Travellers by improving their uptake of health services and other public services which that influence health outcomes.

Figure 1:HSE SEHC: Carlow, Kilkenny, Tipperary South, Waterford, Wexford

Original source: Mahmoud and Molloy (2016)

The programme was rolled out across HSE South East Community Healthcare (SECH) region and is delivered by trained facilitators, who also work as Traveller Community Health Workers. The programme was originally designed to be delivered to HSE frontline staff and has been delivered to a variety of HSE staff including Social Workers, Speech and Language Therapists, Dental staff, Nurses and Psychologists. The programme is also suitable for use with any service provider and has been delivered to county council employees, housing agencies and in schools to transition year students. The programme provided an opportunity to look at issues arising in service provision, to identify barriers to access and to explore possible solutions.

The objectives of the programme were to:

• To raise awareness of Traveller health issues • To provide information on Traveller culture and how this impacts on use of services• To identify the main barriers experienced by Travellers in accessing services • To identify ways of moving forward to improve access and uptake of services

In 2017, the South East Traveller Health Unit made a decision to evaluate the programme and Waterford Institute of Technology have undertaken this study in collaboration with the Traveller Heath Unit.

The aim of the study was to evaluate and analyse the programme and its impact and to undertake this evaluation in line with Community Development principles. Based on the work of Pawson and Tilley (1997) a realist evaluation seeks to identify the underlying assumptions about how the programme is supposed to work and then use that to guide the evaluation (Gerrish and Lathlean, 2015).

The report is structured as follows. Chapter 2 provides the background to the study, exploring Traveller culture and key issues that they face. This chapter also examines past and current Government and HSE strategies which address Traveller health issues. The chapter considers culture awareness training and competence and how this can be developed. The Traveller Culture Awareness Training Programme as delivered in SECH is outlined along with other programmes identified. Chapter 3 then details the study design, methodology and methods. The study results are contained in Chapter 4. Finally Chapter 5 provides a discussion of the findings and recommendations.

8

Chapter 2. Background and Context

A background will first be given to set the context and rationale for the study. Travellers and their distinction as an ethnic group in Ireland will be discussed (section 2.1). Public Sector Duty in service provision for Travellers will be discussed in section 2.2. This will be followed by an exploration of key challenges which face Travellers in Ireland, namely accommodation (section 2.3), discrimination (section 2.4), education (section 2.5) and health (section 2.6). HSE strategies and initiatives regarding Traveller health will then be discussed (section 2.7), followed by exploration of the key principles of cultural awareness and competence training (section 2.8-2.9). Cultural awareness training programmes that have been delivered will then be outlined (section 2.10), concluding with the rationale for the current study (section 2.11).

2.1 Travellers in IrelandIrish Travellers or Minciers as they call themselves are a small indigenous ethnic minority group who have been part of Irish society for centuries. They have a distinctive lifestyle and culture, based on a nomadic tradition, which sets them apart from the general population. Travellers represent less than 1% of the population of Ireland: Of the 4,689,921 persons resident in the State at the time of Census 2016, 30,987 were White – Irish Travellers (0.7%). In the HSE SECH region there were approximately 4,000 Travellers recorded in the region on the night of the 2016 census (CSO, 2016).

The majority of Travellers are Roman Catholics and religion is very important in the life of Travellers. Traveller family life is often organised along traditional gender divisions and women are the primary carers. Travellers tend to marry younger than the general population with young women marrying around the age of 17 years and young men around the age of 19 years. Strong connection to the extended family is of cultural significance within the Traveller community.

Traveller Ethnicity is the collective set of beliefs, attitudes, values, norms and language that Travellers share that make them Travellers. Everyone is part of an ethnic group which shapes their identify. Defining someone’s ethnicity is difficult, as every culture changes over time. There are some things that define what ethnicity is:

• To be part of a specific ethnic group, you must be born into the group. For instance, some Travellers may hide their identity and chose not to be recognised as Travellers, but no one can ever become a Traveller unless they are born into it.

• Travellers have a shared history, culture and language.• Travellers acknowledge themselves as being of a group different to settled people and settled people

acknowledge them as being a separate group.

“We may not be able to describe easily and for all Travellers what makes us Travellers but we know in our hearts we are. We feel it. It really is in our soul”

Brigid Quilligan, Traveller Activist

Ethnicity and culture are very important for Travellers. Culture is a series of values and norms that is acquired by learning (mostly non-consciously) at an early age and is adapted differently by each individual within the group over their lifetime, and is then passed on in, perhaps in a changing process, from generation to generation. Culture has a profound influence on how people think, feel, act and process information. Culture is more than traditions, music, language and religious beliefs. It also provides a series of frameworks for how the world is viewed, shapes values and how information is we interpreted and boundaries defined.

Culture is transmitted from members of the same cultural group, usually by young children from parents, their peers and their social group, with the basic components of culture acquired at early ages (with children internalising key cultural values and norms). Culture is learned by hearing, seeing and unconsciously adopting or copying the actions of others in their cultural group. Culture is actively generated and created, in attempts to modify or protect or expand existing norms and in the face of internal and external challenges. Culture is not static and solely based in the past, but an interplay between tradition and emerging new ideas.

Traveller culture and identity are constantly changing and adapting. Some aspects of change happen as society changes globally. Other changes are forced upon the community - for example, legislative changes have had huge

9

negative impacts on Traveller culture: nomadism was effectively criminalised through the Trespass legislation, changing laws governing market trading and laws covering horse ownership. These laws have meant that traditional aspects of Traveller culture are almost impossible to express. Despite these policies, which have had serious impacts on the community, Travellers continue to see themselves as Travellers and show pride in their identity and heritage.

Traveller ethnicity recognition is at the heart of the question of how Travellers might become less unequal in Irish Society and is extremely important for Travellers. The report of the Task Force on the Traveller Community highlighted the importance of recognition of Traveller culture: “The recognition of Travellers’ culture and identity has an importance for Travellers and their status in Irish society. Identity and belonging is vital to everybody and is equal to physical wants and needs. Identity and sense of community cannot be ignored because identity is fiercely cherished by everyone and community is vital for everyone’s sense of belonging.”

In addition, the publication of the Equality Authority report Traveller Ethnicity in 2006 established a clear case for the acknowledgment of Traveller ethnicity: “An understanding and recognition of Traveller ethnicity is central to the effective promotion of equality of opportunity for the Traveller community.”

The recognition of Traveller ethnicity is a matter of huge significance for Travellers.

“We all know of Travellers who are struggling with their identity. We see the effects this has on people. Some people look as if they are thriving, they are principals, doctors, lawyers, teachers, guards, but how must it be for them to live and work in a society where Travellers are openly spoken about in degrading terms? How must it be for them if they feel someone they teach or a client of theirs recognises they are Travellers? Could their whole world fall apart if their identity is revealed? The unfortunate answer is yes. So while we have some really positive role models who are open about their identity, we have many more that conceal it”

Brigid Quilligan, Traveller Activist 2012

Equality encompasses a range of different objectives. These include:

• Equality in the distribution of resources in society, resources such as incomes, jobs, health, education and accommodation. Travellers experience serious inequalities in this regard with high levels of unemployment, a low presence in third level education, low life expectancy and many families still living on the side of the road with basic facilities.

• Equality in relation to who holds power or has influence in Irish society. There are no Travellers in the Dáil, Seanad, or judiciary for example. Traveller organizations are represented in social partnership but express increasing frustration at their lack of influence within social partnership.

• Equality in access to relationships of care, respect and solidarity with the wider society. Travellers’ experience is one of relationships characterized by tension, disrespect, abuse and conflict with the wider settled society.

• Equality in the status and standing afforded to different groups in society. The denial of Traveller ethnicity until 2017 undermined any status and standing for Travellers in Irish society.

It is important to understand that these different equality objectives are interlinked. Where a group does not have status or standing it will not enjoy relationships of respect with the wider society, it will find it hard to exercise any influence over decisions and it will experience barriers in seeking to access resources. The recognition of Traveller ethnicity won’t necessarily secure equality for Travellers. However it provides a new and solid foundation from which to pursue equality for Travellers.

The Irish Traveller Movement formed a campaign for Traveller ethnicity recognition. Analysis of what ethnicity meant, what recognition would mean, lobbying nationally and internationally for that recognition has been part of all their work. After a motion at their AGM in 2008 by Blanchardstown Traveller Development Group, a specific petition and campaign began. Launched on the 10th December 2008 (as part of ITM Celebration of UN International Human Rights Day) Traveller organisations began conversations among the community on ethnicity, identity and getting Travellers to sign petitions calling for their ethnicity to be recognised.

Based on this, they began a specific lobbying campaign, and in conjunction with other Traveller groups, built political allies to the point where in 2014 a joint party Oireachtas Committee agreed that Traveller ethnicity should be recognised

10

and set out steps for how this should happen. The Irish Traveller Movement and other national Traveller groups continued to work with Government Departments to strengthen this call, including ensuring a second Joint Oireachtas Committee report at the end of 2016 generated further momentum. The Irish Traveller Movement and others ensured that the Council of Europe and European Commission were lobbied to add their voices for ethnicity recognition.

The work of thousands of Travellers, locally, regionally, nationally and internationally was finally successful on Wednesday 1st March 2017 as Traveller ethnicity was formally recognised by the Irish State. This event was historic and notable for the all-party consensus on the issue. The key argument for recognition of Traveller ethnicity was that recognition of the unique cultural identity of Travellers and this recognition of their special place in Irish society is important to their pride and self-esteem and also to overcome the legacy of economic marginalisation and discrimination. Travellers now have a new platform for positive engagement and dialogue with Government in seeking sustainable solutions to their issues. In announcing the decision the Government stressed that it is without prejudice to Travellers being (and self-identifying as) part of the Irish nation.

Recognition of Traveller ethnicity created an opportunity for a sustainable relationship between Travellers and non-Travellers and the institutions of the State. It constituted a new beginning for the work that Ireland needs to do as a society, in partnership with Travellers, to address the issues that face the Traveller community. It is anticipated that this official recognition can be of significant ‘benefit in ensuring respect for the cultural identity of Travellers in the context of targeted services’ (Watson et al., 2017: x).

2.2 Public Sector Duty and Travellers Public Sector Duty is a positive duty in mainstreaming equality and human rights on a statutory basis in Ireland (Pavee Point Traveller and Roma Centre, 2015). Since 2003 public bodies have to consider compliance with public sector duty under the European Convention on Human Rights Act (Government of Ireland, 2003). The Irish Human Rights and Equality Commission Act 2014 introduced a public sector equality and human rights duty in Ireland (Government of Ireland, 2014). Public bodies have to try embed equality and human rights considerations in their policies to eliminate discrimination, promote equality of opportunity and protect human rights (Walsh, 2015).

In order to realise public duty it is crucial for public bodies to gather information on the experiences, situations and needs of groups across the nine grounds of the Equal Status Acts 2000-2015 (Government of Ireland, 2000-2015, Crowley, 2015, Walsh, 2015). There is a need to examine the impact of policies on ethnic groups help overcome the invisibility of these groups in society (Crowley, 2015). A structured participatory approach to public sector duty implementation which engages public authorities and civil society groups and takes into account power dynamics and competencies is needed (Collins, 2015). Ultimately a focus on the key policy issues of health, education and accommodation in a coordinated, inclusive and collective way will lead to a reduction in inequalities and the advancement of the human rights of Travellers (Irish Human Rights and Equality Commission, 2017, Pavee Point Traveller and Roma Centre, 2017).

2.3 Travellers and accommodation Traditionally, Travellers practised a nomadic way of life. At present, the majority of Travellers are more sedentary due to a number of reasons, including the introduction of the Housing (Miscellaneous Provisions) Act 2002, the increase in school attendance and reduced opportunities to practice traditional forms of employment. However, ‘it is important to note that whilst many Travellers may live in one place they tend to have a nomadic perspective, which differs from sedentary ways of viewing the world’ (Cavaliero, 2016: 11). O’Mahony (2017) found, based on a study of Travellers (n =481) that 45% had never travelled and only 1 in 10 still travel compared to 1 in 3 who reported still travelling in the year 2000.

According to the Irish Traveller Movement [ITM] many Travellers, (but not all) would prefer to live in ‘culturally appropriate’ or ‘Traveller specific’ accommodation - halting sites or group housing schemes, ‘where large extended families live together based on Traveller’s shared identity’ (ITM 2017). Travellers today live in a variety of accommodation that include: official halting sites, unofficial halting sites, group housing schemes, local authority housing, private rented accommodation, and their own private property (Cavaliero 2016). The majority of Travellers according to AITHS (2010) live in houses (73.3%), while 18.2% live in trailers/mobile homes or caravans. The AITHS (2010) showed that 7.6% of Travellers (n=2,753) are living in conditions where they do not have access to basic services such as running water.

2.4 Travellers and discrimination It is very evident that Travellers experience disadvantage in terms of education, employment, housing and health (Nolan and Maître, 2008; All Ireland Traveller Health Study [AITHS], 2010; Watson et al., 2011; 2017; McGinnity et al., 2017). It is

11

also known that Travellers are a marginalised community in Irish society who experience high levels of prejudice and discrimination (Nolan and Maître, 2008; AITHS, 2010; MacGréil, 2011; Pavee Point, 2011; Cavaliero, 2016; O’Mahony 2017; Watson et al., 2017). The AITHS (2010) reported that just under half of Travellers experienced discrimination.

Box 1 highlights some key findings of that report relating to discrimination

• 40% of Travellers have experienced discrimination in accessing health services.• 62% of Travellers have experienced discrimination at school.• 55% of Travellers have experienced discrimination at work.• 61% of Travellers have experienced discrimination in a shop/restaurant/pub. • 77% of Travellers have experienced discrimination in the ‘past year’ • 43% of Travellers indicate they have encountered discrimination while accessing employment • 40% of Travellers indicate they or their children have been bullied at school due to their identity

(AITHS, 2010; O’ Mahony, 2017)

Pavee Point is a voluntary non-governmental organisation which is committed to the attainment of human rights for Irish Travellers. The group is a partnership of Travellers and the majority population working together to address the racism and exclusion that Travellers experience in society. It has been involved in direct work with Travellers since 1985. According to Pavee Point (2011: 36) Traveller women are more easily recognizable than Traveller men and this leads to increased opportunities to experience discrimination. Women, as the primary carers in the family (Cavaliero, 2016), are also more likely to come into contact with service providers such as schools, social welfare, health care providers and consequently experience significantly more direct discrimination. AITHS (2010) found that 71% of Traveller women had experienced verbal abuse because they were Travellers. Travellers have low levels of satisfaction with health service care and less trust in health professionals than the general population (HSE, 2008).

Observations of the Committee on the Elimination of Racial Discrimination [CERD] - Ireland (2017) ,while noting the efforts made so far by the State to understand the issues affecting Travellers through the Survey of Traveller Education Provision in Irish Schools [STEP] and the AITHS, identified that efforts made to improve the welfare of Travellers have not substantially improved their situation. The Committee noted the poor outcomes in the fields of health, education, housing, employment for Travellers as compared to the general population (art. 5(e)) and recommended that the State strengthen its’ efforts to implement the policy advice offered by the National Traveller Monitoring and Advisory Committee. Concrete measures are needed to improve the livelihoods of the Traveller community by focusing on improving students’ enrolment and retention in schools, employment and access to health care, housing and transient sites.

2.5 Travellers and educationResearch shows that there is a large distinction between Travellers and non-Travellers in the levels of education attained. Watson et al. (2017: 4) suggest that ‘the labour market disadvantage of Travellers is largely linked to this educational disadvantage:

• Only 8% of Travellers complete 2nd level education compared to 73% of non-Travellers. • Just 1% of Travellers have a 3rd level degree compared to 30% of the general population.• 28% of Travellers leave school before they are 13 years old compared to 1% of non-Travellers.

O’Mahony (2017) found that educational attainment had improved for younger Travellers, 39% had completed the Junior/ Inter Certificate in 2017 compared to 9% in 2000 and 16% had completed the Leaving Certificate in 2017 compared to 2% in 2000. Watson et al. (2017) also found that patterns across age groups suggest that levels of education have improved for younger Travellers. However, educational attainment has also improved for non-Travellers over this time but the improvements have happened more slowly for Travellers and as a result the educational gap has increased over time (Watson et al., 2017: 70).

2.6 Travellers and health Knowledge of the poor health status of Travellers has been in the public domain since the early 1960s. The Commission on Itinerancy [COI] noted that infant mortality was considerably higher and life expectancy was significantly lower for Travellers than it was for the settled population at that time. They also noted : ‘Travellers were generally healthier than one would expect of people suffering from the hardship and rigours of their way of life’ (COI, 1963: 43).

12

Twenty years later the Travelling People Review Body [TPRB] proposed the need for regular collection of data on the health status of Travellers: ‘There is an urgent need to establish the reasons for apparent low life expectancy of Travellers and the number of infant and child deaths’ (TPRB 1983: 95).

That 1983 review also recommended that ‘an element of positive discrimination by health boards’ towards Travellers would be needed because of the difficult conditions in which many of them lived. The publications of the Travellers’ Health Status Study - Census of Travelling People 1986 and The Travellers’ Health Status Study - Vital Statistics of the Travelling People’ 1987 gave rise to significant concern about the health status of Travellers (Pavee Point, 2005).

The All Ireland Traveller Health Survey (AITHS, 2010) found Travellers continue to experience significant health inequalities compared to the general population. From this study it was identified that the life expectancy of a Traveller man was 61.7 years, 15.1 years less than men in the general population and equivalent to the life expectancy of the general population in the 1940s. Similarly life expectancy of a Traveller woman at 70.1 years is 11.5 years less than a woman in the general population. The infant mortality rate is almost four times that of the general public.

The mental health of Travellers is also worse than the non-Traveller population. According to the Department of Health and Children (2002) information about the uptake and use of mental health services by the Traveller Community is poorly documented perhaps pointing to services that do not meet their needs in terms of cultural congruence and access. While the determinants of mental health for Travellers are the same as for settled people, it could be argued that Travellers face additional challenges that heighten their vulnerability to mental health problems and suicide. The AITHS survey found that the suicide rate among Traveller men is 7 times higher than the general population (2010). A National Travellers Survey conducted on behalf of the Community Foundation of Ireland in 2017 found that mental health problems are common in the Travelling community and reports that 82% have been affected by suicide and 44% of those affected in their immediate family have also experienced suicide in their wider family (O’Mahony, 2017).

Watson et al. (2017) drew on relevant data on Travellers from AITHS (2010) and data on the general population from the Survey of Lifestyle, Attitudes and Nutrition (SLÁN, 2007) to examine how the daily activities from Travellers and non-Travellers are limited by illness, health problems or disability. As can be seen in Figure 2, taking into account the ‘sample sizes and allowing for design effects, the differences between Travellers and the general population are statistically significant in all age groups’ (Watson et al., 2017: 60).

Figure 2:Daily activities limited by illness, health problems or disability.

Original source: Watson et al. (2017: 60).

The South East Traveller Health Units SE THU Strategic Plan 2015-2020 was developed with broad representation from Travellers, Traveller Community Health Workers, Traveller Mens Health Workers and Traveller Health Project Coordinators and other stakeholders identified two main barriers to health care for Travellers:

1. Stigma: this prevents Travellers discussing, and addressing issues within their own communities. Fear of services and a lack of trust in a service’s ability to understand Travellers was an issue that was frequently raised.

2. Institutional racism: a lack of understanding of Traveller culture in health services prevents Travellers from accessing health care (HSE, 2015).

13

2.7 HSE strategy and initiatives for Traveller healthThe HSE have a number of ongoing initiatives in relation to Traveller health. Such initiatives began in 1992 when a group of Traveller women who were involved in a personal development course at Pavee Point identified the improvement of health status for people within their community as a primary goal which led to the piloting of Primary Health Care workers with the aim to facilitate Traveller participation in health. Following this, the first Primary Health Care for Travellers’ Project [PHCTP] was established as a joint partnership initiative with the East Health Board and Pavee Point. The pilot began in October 1994 in the Finglas/ Dunsink areas and had the following objectives:

• Establish a model of Traveller participation in the promotion of health • Develop the skills of Traveller women in providing community based health services • Liaise and assist in creating dialogue between Travellers and health service providers • Highlight gaps in health service delivery to Travellers and work towards reducing inequalities that exists

in established services (Pavee Point, 2005).

In 1995 the Taskforce of Traveller Community set in motion the establishment of the Traveller Health Advisory Committee [THAC] and the Traveller Health Units [THU] in 1998. The THAC was representative of the DoHC, HSE and National Traveller organisations such as Pavee Point, Irish Travellers Movement and the Travellers Women Forum and produced Traveller Health – A National Strategy 2002-2005 (DoHC, 2002) that put the health status of Travellers higher on the political agenda (Kelleher er al., 2003).

A proposed action of the 2002 Strategy was the need for Traveller Cultural Awareness Training for Health Service staff. The onus was placed on the THU’s to ensure that appropriate training for health service providers was offered with regard to their understanding of and relationship with Travellers:“The creation and maintenance of a positive awareness among all those involved in the health services of the cultural traditions and distinct identity of the Traveller community will be necessary in order to ensure respect for that identity and those traditions. This will involve the provision of appropriate in-service training, in consultation with representative Traveller organisations, on matters concerning Traveller culture and societal attitudes relating thereto” (DoHC, 2002: 9)

According to Kelleher et al. (2003: 2) the National Health Strategy: Quality and Fairness – A Health System for You’ (DoH, 2001) represented ‘a marked departure from previous national policy’ as it promoted a ‘new vision for Traveller health services’. Kelleher et al., suggested that the new Traveller health strategy provided an approach to dealing with Traveller health, based on the ethos of community development and aimed to empower Travellers to look after their health. The strategy was allocated €8.3 million for the implementation of the 122 proposed actions. The main principles of the Travellers Health Strategy included:

• Establishment of active partnerships between Travellers, their representative organisations and health service personnel in the provision of health services

• Provision of awareness training for health personnel in relation to Traveller culture, including Traveller perspectives on health and illness

• Strengthening of Traveller health units comprising health board staff and Traveller representatives, with responsibility for planning and implementing the Strategy in each health board

• Development of initiatives to increase Travellers’ awareness of general medical services and to make services more accessible, having regard to the Traveller communities

• Provision of designated public health nurses in each health board to work specifically with Traveller communities

• Replication of the successful ‘Primary Health Care for Travellers Project, which established a model for Traveller participation in the development of health services

• Promotion of various ‘peer-led’ initiatives to strengthen the links between Travellers and various health services • Establishment of a permanent liaison mechanism between the Department of Health and Children and

the Department of the Environment and Local Government, to collaborate in efforts to improve Travellers’ living conditions on halting sites (DoH, 2001: 68).

The 2002 Strategy also called for an updated Traveller Health Study. The AITHS was launched in 2007. This was the first Traveller health status and health needs study that involved all Travellers living on the island of Ireland. It aimed to develop and extend the data collected in the previous survey of Travellers’ Health Status conducted in 1986. Through consultation with the Traveller community, it intended to inform appropriate actions in the area of Travellers’ Health (AITHS, 2010: 5). Some of the Traveller Community Health Workers participated as peer researchers in the AITHS and their involvement was considered key to the success of the study.

14

In light of the continuing challenges for Travellers in relation to life issues including health, in 2015, the South East Traveller Health Unit published a new Strategic Plan for Traveller Health in the South East Community Health Organisation Area. The plan was developed by Travellers for Travellers. The plan builds on the work that the South East Traveller Health Unit and focuse on enhancing access for Travellers to health services and improving the overall health status of Travellers within the region.

The TCAT programme is delivered by Traveller Community Health Workers workers, mostly women. Their role also incorporates a range of skills and responsibilities within their communities undertaking:

• Health education and promotion, administrative work, informing policy development, providing training, research, identifying new services and creating Traveller access to existing services, making presentations, networking, writing reports, media work, lobbying and representing Traveller health interests (McCabe and Keyes, 2005: 4).

The Traveller Culture Awareness Training programme is part of the strategic plan with the objective to bring about more informed health service responses as a result of enhanced understanding of Traveller culture and Traveller specific challenges. Between 2015 and 2020 the THU aims to deliver Traveller health and cultural competency training to priority health services personnel and to other agencies that can influence the social determinants of health. The results of the training can then be evaluated by Travellers in respect of influence on service delivery.

2.8 Cultural awareness and competence training Cultural competence is broadly defined as the ability of care providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients (Betancourt et al., 2002). Individual values, beliefs, and behaviours about health and well-being are shaped by various factors such as race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation and occupation. As was seen in section 2.4, Travellers as a distinct ethnic group in Ireland experience severe health disparities. Such disparity is also seen in other countries in relation to ethnic minority groups. In Europe, the ‘Migrant-friendly hospitals’ [MFH] project identified that the health status of ethnic minority populations is “often worse than that of the average population” (Schulze, 2003; Ingleby, 2012). There is a clear link between culture and patient safety outcomes (Johnstone and Kanitsaki, 2006), and health disparities and lower quality care are exacerbated when healthcare professionals fail to address ethnicity, culture and language in the provision of health services (Wilson-Stronks, 2008). Cultural competence has therefore gained attention as a strategy to improve quality and outcomes in health care (Betancourt and Green, 2010). A culturally competent health care system can help improve health outcomes and quality of care, and can contribute to the elimination of such ethnic health disparities.

Current initiatives to address health disparities in Europe include the development of Equity Standards to address disparities in health care (Task Force on MFCCH, 2017). The goal of a culturally competent health care services should be to provide the highest quality of care to every patient, regardless of race, ethnicity or cultural background. Important to note, however, is that cultural competence is a process rather than an ultimate goal, and is often developed in stages by building upon previous knowledge and experience.

The components of cultural competence education for health professionals generally include cultural awareness, cultural knowledge and cultural skills (Sue, 2009). Increasing knowledge about cultures, typically through a list of common health beliefs, behaviours, and key “dos” and “don’ts,” provides a starting point for health professionals to learn more about the health practices of a particular group. The conceptual framework identified by Horvat et al (2014 ) identifies four key domains that describe core ingredients of successful cultural competence education interventions: Educational content (knowledge, assessment and application), pedagogical approach (teaching and learning methods), structure of the intervention (including delivery and format, frequency and timing) and participant characteristics (teacher/ facilitator and target audience).

Professional development, education or training aimed at improving the cultural competence of health professionals or in healthcare organisations is predicated on the assumption that certain skills and understanding will enable health professionals to become more responsive to the healthcare needs of diverse population groups, and thus improve health outcomes (Betancourt et al., 2003). A systematic review of interventions designed to improve cultural competency, concluded that “the evidence base is relatively weak, and there continues to be uncertainty in the field” (Truong, 2014).

However, a non-Cochrane review concluded that there is good evidence that cultural competence training improves staff knowledge, attitudes and skill, and that the provision of training to staff improves patient satisfaction (Beach et al., 2005). Horvat et al. (2014) in their Cochrane Review identified five studies assessing the effects of

15

cultural competence education for health professionals on patient-related outcomes. There was positive, albeit low quality evidence, showing improvements in the involvement of culturally and linguistically diverse patients in their care. The reported findings either showed support for the educational interventions or no evidence of effect. No studies assessed adverse outcomes. The quality of evidence however, was insufficient to draw generalizable conclusions. Horvat et al. (2014) also recommended, following their review that cultural competence education programmes need to be better specified and described including their conceptual rationale, actual content, delivery, organisational support and approach to evaluation.

2.9 Other Culture Awareness Training InitiativesThe research team sought to identify previous studies in the area of Traveller Culture Awareness training programmes. One such study related to Traveller Culture Awareness Training was undertaken in the South East of Ireland in 2011, wherein a Train the Trainer programme was undertaken in a collaboration with Institute of Technology Carlow [ITC] and Waterford Institute of Technology [WIT]. Three adult Travellers (two females and one male) successfully completed the FETAC level 6 Train the Trainer programme (original number was 6 participants) with a view to delivering Traveller cultural awareness workshops within educational and state agency settings. The programme ran from October 2010 – March 2011 and involved a dedicated tutor and a co-facilitator/mentor with classes being delivered on Saturday mornings. Workshops were subsequently delivered within two Third level educational settings (WIT and ITC), Waterford Area Partnership Ltd, Waterford City Council (Traveller Inter-Agency Group) and in a Secondary School Waterford.

The Train the Trainer Initiative was evaluated by Community Consultants. Their report highlighted the need for Trainer preparation, conducting a Training Needs Analysis taking cognisance of literacy levels and learning styles. The use of practical training methodologies and the full involvement of the participants in the design of the workshops was identified as crucial in the success of this programme. It was noted that the participants had a high level of literacy and experience of educational settings – subsequent programmes may require a level of pre-development support work prior to participation at this level of training. The relevance of the programme in terms of working towards a practical objective (i.e. the delivery of cultural awareness workshops) also played a part in reinforcing commitment and attendance, as did the sense of equality amongst tutors and students – each party had learning and knowledge to share. It seemed in this initiative that there was a real sense of Traveller culture being valued and an opportunity to celebrate this culture and work towards removing stigma and enhancing increased understanding between the Traveller and settled communities. The learning gained and sense of achievement amongst the students was huge – “we got the qualification and we could actually do the work”; this link between learning and putting it into practice was seen as pivotal to not only heightening confidence and self-esteem amongst students but also acted as a blue print for education and training opportunities for adult Travellers. No evaluation was detailed however of the workshops that were delivered by the trainers.

It seems that Traveller Culture Awareness Training as recommended in the 2002 Strategy document (DoHC 2002) is being delivered in various formats around Ireland. One such example is that TCAT programme in Cork which has been in operation since 2012. Prior to that time, Travellers involved in community development and the THC workers delivered ‘Traveller Talks’ to local service providers. The training at that time was not formally structured and as such was open to ‘different messages’ being delivered about Traveller Culture to the service providers. The TCAT programme being delivered currently has a dedicated TCAT Coordinator who supports the facilitators in the delivery of the programme. There are 8 active Traveller facilitators who have undertaken a specific TCAT train the trainer course that included core elements including social analysis of Traveller specific issues in education and health as well as facilitation skills to provide continuity and consistency of delivery.

The programme has been delivered to a wide range of service users. Similar to the TCAT programme that is being delivered in the SECH area the content is bespoke to the client groups needs and there is a degree of flexibility in the time taken to deliver the programme, however the average length is 2 hours. Differences between the SECH programme and Cork programme include that the service providers are charged for the training which helps to finance the TCAT programme. The facilitators are mostly THC workers but TCAT is in addition to the workers part-time hours. Cork TCAT also employs Travellers who are not THC workers to deliver the programme. The TCAT Coordinator is employed on a part time basis and is responsible for marketing the programme, providing additional training for the facilitators, for example in IT and presentation skills. The Coordinator also prepares programme materials, provides de-briefing support for the facilitators after the programme has been delivered and markets the TCAT programme. Approximately 2,700 service providers have participated in Cork TCAT. Since October 2012 they have delivered 180 programmes with an average of 15 participants (their preferred number) per programme.

16

2.10 Traveller Culture Awareness Training SECHThe Clonmel Traveller Community Health Project, employing three Traveller Community Health Workers and a Coordinator, commenced work in February 2005. The idea for a Traveller Culture Training Pack was first identified as needed by the South East Traveller Health Unit and was developed by the Clonmel Traveller Community Health Project for the region. The Traveller Community Health Workers supported by their Coordinator facilitated their first Traveller Culture Workshop in October 2005.

The main sources of material for the training pack were taken from the ‘Traveller Friendly Services Programme: An Intercultural Training Programme’ which was developed by the Health Promotion Service and the Traveller Health Unit in the Western Health Board. The Clonmel Project was granted permission at the time to use the material in that pack. The National Consultative Committee on Racism and Inter-culturalism Training Pack was also a source of material for the Clonmel Pack.

The Clonmel Traveller Community Health Workers completed a 6 months in-house training in all aspects of Traveller Culture, Discrimination, Racism and Inter-culturalism before delivering workshops. They delivered 5 workshops in 2005, mostly to local community groups to hone their skills before bringing the training to a wider audience of HSE staff and staff from other agencies who have a responsibility regarding the social determinants of health. The programme up to 2012 was delivered by the Clonmel Traveller Community Health Workers for the entire region. By 2012 there were other Traveller Community Health Projects/ Traveller Community Health Workers in the South East Region who could also deliver this training. The Regional Traveller Health Network, led by the Clonmel Traveller Health Project and the Health Promotion Officer also a representative on the South East THU revised and updated the Training pack to include the results of the All Ireland Traveller Health Study 2010. Facilitation training was provided by HSE Health Promotion staff in the South East resulting in Traveller Community Health workers in each county delivering their own training, using the revised course and workshop materials. Coordinators in each of the projects followed on with ongoing facilitation support for Traveller Community Health Workers.

The programme began in Waterford from 2008 and likewise has not been offered since 2015. Kilkenny, Carlow and Wexford TCAT programmes commenced in 2013 and are currently ongoing. TCAT programmes are generally delivered within the workplaces of the services/sectors receiving the training, i.e. hospitals, schools, universities, community development centres, county council offices and also within the THCP centres.

There were variations in relation to the number of TCAT programmes that were delivered since programme commencement, for example, Clonmel Traveller Community Health Workers delivered approximately 40 programmes; Carlow have delivered approximately 2-3 programmes per year since 2013; Kilkenny have delivered an average of only 3-4 programmes in total since 2013 and Wexford Traveller Community Health Workers have delivered approximately 10 programmes also since 2013. In Waterford only three programmes were delivered. It seems there is uncertainty in relation to the total number of TCAT programmes delivered. The number of service providers participating in the TCAT programmes varied significantly across the regions, however it seemed that on average 20 participants attended each TCAT programme. Using that estimation would suggest a total of 1,200 service providers have participated in TCAT in the region since 2007.

Training duration varied amongst all services. Generally the TCAT programme required one half day or an average of 2.5- 4 hours to complete depending on programme delivered, but could take a full day. On average there were three facilitators delivering each TCAT programme; this includes two Traveller health workers and one Coordinator. The role of Coordinator is to set out and plan training including resources etc., while the Traveller Community Health Workers deliver the actual training, including answering questions, only calling on the Coordinator who remains present if there is an issue that they cannot or do not want to deal with.

The TCAT programme content is a tailored package and generally the focus is based on and delivered in consideration of different modules such as ‘What is culture?’ and ‘What is ethnicity?’ The programme layout generally encompasses: introductions; group exercises; discussions; questions and answers. The mode of TCAT delivery is through general discussion, power points, over-head projectors and via interactive training material and resources. The use of visual aids is incorporated into the training package and these include both videos and DVDs. Content for the visual aids is derived generally from previous works conducted by Wexford Local Development. It was reported that such interactive materials clearly outlined the importance of ethnic status to Travellers and was deemed significant by facilitators, not only as a training resource, but also in terms of highlighting Travellers as a distinct ethnic grouping in Ireland.

17

Programme content is adapted to particular groups, for example, mental health services and schools. For example the inclusion of bereavement within the Travelling culture or when working with a particularly challenging or difficult group:

In general, TCAT is largely a targeted programme initially aimed at front line health care professionals; however, demand for the training filtered to other sectors. Since programme commencement in 2007, TCAT has been delivered to a range of sectors preliminary within the public health sector. Examples of some of the services throughout the SECH region that have previously received the training include; HSE staff- community mental health nurses, nurses, midwives, doctors, social workers; guards; County Council - Local Traveller Accommodation Consultative Committee; fire service; Education Sector- teachers, lecturers, students, special needs assistants; Community Development Organisations including National Learning Centres and childcare settings. In terms of promotion, some Traveller Community Health Workers have used promotional leaflets (see appendix 13).

2.11 Rationale for the StudyOne of the recommendations of the Traveller Health – A National Strategy 2002-2005 was the need for Traveller cultural awareness training for health service staff. The TCAT programme was first piloted in the HSE SECH region in 2005 and was reviewed and officially launched in 2013. The overall programme to date has not been evaluated. A key goal of the recently published SETHU SE THU Strategic Plan 2015-2020 is to prioritise Traveller health and cultural competency training for front line health service providers. Thus this evaluation is timely for the HSE SECH.

18

Chapter 3. Study Methodology and Methods3.1 Introduction This chapter sets out the methodologies and methods utilised for this research. First the aims and objectives of the research are identified (section 3.2). The study design is then discussed and the stages of the mixed methods study illustrated (section 3.3). The data collection tools are detailed in section 3.4. The study participants (section 3.5), data analysis methods (section 3.6) and ethical considerations (section 3.7) are then detailed. 3.2 Study aim and objectives The aim of this study was to evaluate and analyse the Traveller Cultural Awareness Training Programme and its impact in line with Community Development principles.

The study objectives were to:

• Describe and analyse the organisational structure of the programme as this relates to the varied geographical implementation of the programme;

• Analyse the degree of common understanding and shared beliefs of key stakeholders as this relates to the aims and objectives of the programme;

• Examine and analyse the adaptations that have been made to the originally designed programme;• Assess programme compliance with expected standards as these relate to principles of good practice in

relation to cultural competency and education; • Examine how the Traveller Cultural Awareness Training can inform the development of a Traveller Cultural

Competence Pack.

3.3 Study designThe study design uses an explanatory sequential mixed methods design (Creswell and Plano-Clark, 2011) which is in keeping with the aim and objectives of the study. Explanatory sequential mixed method study designs involve multiple stages of data collection where the stages may run sequentially and concurrently (Creswell and Plano-Clark, 2011; Andrew and Halcomb 2009). Creswell and Plano-Clark suggest that an explanatory sequential design ‘occurs in two distinct interactive phases’, as used in the current study, the researcher collects and analyses the quantitative data, then collects and analyses the qualitative data and finally merges the finding to produce an overall interpretation.

Figure 3: Sequential mixed methods design

The explanatory sequential design chosen as the research design for this study consisted of three key stages.

• Stage 1: an examination of completed programme evaluation forms. • Stage 2: survey questionnaires for the Traveller Health Project Coordinators, the Health Promotion

Officers and the TCAT programme attendees were designed using open ended questions.• Stage 3: focus groups with Traveller Community Health Workers Programme Facilitators and Traveller

Health Project Coordinators, Travellers and interdisciplinary teams.

3.4 Data collection toolsThere were four separate surveys utilised in the evaluation of the TCAT programme. The first was designed by the programme organisers and collected the views of people who had completed the TCAT programme evaluation tool (see Appendix 1). The second was designed by the research team and explored the views of the Health Promotion Officers who were involved with the initial training of the Traveller Community Health Workers to facilitate the TCAT programmes. The third was designed by the research team to elicit the views of the Coordinators of the ongoing delivery of the workshops and the fourth was designed as follow-up for people who had previously taken part in a TCAT workshops and explored the impact of the programme on the participants.

Quantitative Strand:Collect analyse and interpret quantitative results

Qualitative Strand:Collect analyse and interpret qualitative results

Merge:Overall interpretation

19

Surveys provide an effective way to collect data (Patten 2016). Survey research can be convenient and an inexpensive way to accumulate large amounts of data in a short amount of time. An extensive geographical area can be covered, they offer greater assurance of anonymity and results can be processed quickly.

Focus groups were held with TCAT Programme Facilitators, Travellers and Interdisciplinary Workers. The focus group approach is defined as ‘group discussions organised to explore a specific set of issues’ (Kitzinger 1994: 103). The focus group approach is a way of collecting qualitative data by joining a group of people in an informal group discussion focused around a particular subject or set of issues. Ideally the focus group should be held in a social setting and moderated by a group leader ‘so as to generate descriptive and explanatory information’ (Lane et al 2001:46).

3.4.1 Health Promotion Officers Questionnaire

A questionnaire was sent to the HSE Health Promotion Officers (see appendix 2) who were involved in the development and initial roll out of TCAT programme and training of Traveller Community Health Workers as programme facilitators. The survey was distributed through Survey Monkey© and designed to explore their views on the programme, operationalisation of the programme delivery and facilitator training needs using open ended questions. Thematic analysis was applied to identify patterns and themes.

3.4.2 THP Coordinators Questionnaire

A questionnaire was also used to elicit the views of the TCAT programme from the THP Coordinators (see Appendix 3) who were involved in the delivery and co-facilitation of the TCAT workshops in the region. The survey consisted of open ended questions that explored their views: on the programme, the usefulness of the programme, suggestions for improvement, training the Traveller Community Health Workers and supports that may be required. The data was collected using SurveyMonkey© and thematic analysis was applied to identify patterns and themes.

3.4.3 TCAT Past Participants Questionnaire To find how the TCAT programme had impacted on the participants who had attended the training a questionnaire was distributed to service providers who had previously completed the training. The THP Coordinators acted as gatekeepers to the TCAT past participants and, with line management approval, distributed the survey through a link provided to SurveyMonkey© and using contact details supplied by the THP Coordinators.

3.4.4 TCAT Workshop Evaluations

The TCAT programme started in the region in 2007 and approximately 1,200 people from a wide range of services have attended the programme. At the end of each TCAT workshop the facilitators asked the participants to complete an evaluation form. The completed forms were collected and stored by the Traveller Health Projects Coordinators. The research team requested copies of the completed evaluations for analysis. In all 580 evaluations were received from Carlow, Tipperary, Waterford and Wexford. The evaluations dated from 2007 – 2017. Participants who completed these evaluations consisted of HSE frontline staff including: general medical practitioners, community nurses, mental health professionals, speech therapists and social workers. The Traveller Community Health teams also delivered the workshop to the wider community and the participants who completed these evaluations included: Garda, community and rural development workers, council employees, early childhood workers, housing workers, Vocational Education Committee (now Education and Training Board) tutors, transition year student and other interested groups. All the evaluations have been given an identifying code. The code includes letters to identify where the evaluation originated for example C = Carlow, T = Tipperary, WD = Waterford and WX = Wexford and they are numbered.

The analysis of the evaluations is based on the seven questions asked in the evaluation survey:

1. Overall how would you rate the workshop?2. How would you rate the pace of the workshop?3. What was gained?4. What was most helpful?5. What was least helpful?6. How would you rate the facilitator’s style?7. Any further comments?

There was a slight difference in the layout of the forms so it was decided to combine – ‘is there any aspect of the workshop you would change’ with ‘what was least helpful’. Three questions (1, 2, and 6) were closed questions

20

and formatted as Likert with multiple choice answers. The other four questions (3, 4, 5, and 7) were open ended questions. Using open ended questions allowed the respondents to express themselves in their own words which can lead to collection of data that is richer and more complex than that collected through closed questions. After manually coding the open ended questions a codebook (see Appendix 5) was designed to provide numeric variables for the sets of answers given and then entered into a SPSS data matrix. Some answers were grouped because they overlapped or had similar replies. After the data entry was complete, the data was cleaned and screened to detect anomalies and outliers. Finally, descriptive statistics were performed on the seven questions to provide an overall view of the evaluations.

3.4.5 TCAT Facilitators Focus Groups

In all five focus groups were held with the Traveller Community Health Workers workers and THP Coordinators to discuss their view of the Traveller Cultural Awareness Training. Tipperary, Wexford and Waterford each have two THP Coordinators so they decided to meet with the research team together. The Kilkenny and Carlow focus groups consisted of the individual workers from those projects. The Coordinators arranged the venue, the time and provided the Traveller Community Health Workers with the information sheets. The discussion was recorded with the consent of all present. The recordings were then analysed using qualitative methods and recurring themes identified.

3.4.6 Travellers Focus Groups

Focus groups were also held to discuss Travellers views of the Traveller Cultural Awareness Training Programme. Once again the research team relied on THP Coordinators to arrange the venue date and time for these discussions to take place. One discussion took place during an interdisciplinary Traveller Forum Annual General meeting. Another discussion was held with the men’s group at the Tipperary Rural Travellers Project and the third was with the women’s group from the Carlow Community Health Project. The discussions were recorded and analysed as in section 3.6.

3.5 Population and sampleThe population for the study came from the HSE (Health Promotion Officers), Traveller Community Health Project Staff (Coordinators and Traveller Community Health Workers) and Travellers. To address the research questions purposeful sampling was used as key stakeholders were identified by the Research Steering Committee who had experience relating to the TCAT programme and therefore could offer a perspective on the central concepts explored in this study.

Table 1: Stakeholders Data Collection tools

Stakeholders Data Collection Tool

TCAT Evaluations Questionnaire

Past Participants of TCAT Questionnaire

Health Promotion Officers Questionnaire

Traveller Health Project Coordinators Questionnaire

TCAT Facilitators Focus Groups

Traveller and interdisciplinary groups Focus Groups

3.6 Data analysis methodsThe data for this mixed methods study consisted of qualitative data from the focus groups and the open ended questions and quantitative data from the programme evaluation forms.

3.6.1 Quantitative data

Data was analysed using the statistical analysis programme IBM-SPSS 24. For analysis of the completed evaluations a codebook was designed and a data file created using 15% of the completed surveys. The data from the surveys (n=580) was manually coded and inputted to the SPSS software. The data was screened and cleaned to check for errors. Analysis was conducted using descriptive statistics.

21

3.6.2 Qualitative data

For the purpose of this study thematic analysis was used for analysis of the qualitative data collected during the focus groups. Thematic analysis is a method for finding, analysing and reporting patterns. It involves searching the data set to find repeated patterns of meaning. Thematic analysis requires immersion in the data by repeated reading and re-reading (Braun and Clarke, 2006). Data was analysed through consideration of the principles of Richie and Spencer (1994). Each transcript was coded, with the codes being further developed into categories and themes. To enhance the rigor of the analysis, data was analysed by two researchers and findings compared.

3.7 Ethical approvalEthical approval for the study was obtained from the Regional Ethics Committee HSE South East and the Research Ethics Committee Waterford Institute of Technology. All procedural ethics were addressed. A member of the Travelling Community (Margaret Casey- Coordinator of Tipperary Rural Traveller Project and a member of Traveller Health Unit ) sat on the WIT Ethics Review Panel for this project.

The research team involved with the study were bound by national and international Codes of Good Practice in Research, and by professional standards within their disciplines. The rights and dignity of participants were respected throughout by adherence to models of good practice related to recruitment, voluntary inclusion, informed consent, privacy, confidentiality and withdrawal without prejudice. Information sheets and consent forms developed for use in the project were reviewed by the steering committee prior to their use. Information sheets outlining the aims and objectives of the study and consent forms (see Appendices 6 - 11) were prepared for all those participating in all stages of the research. Contact details of the researchers were provided so that any additional queries could be addressed and consent could be withdrawn. Both written and verbal consent were obtained before the focus group interviews. The voluntary nature of participation was emphasised throughout the data collection process and participants were free to withdraw from the study at any time without fear of penalty. Similarly, all identifying information was removed from the data and participants were assigned code numbers.

Due consideration was given to the literacy levels of the participants and all information was provided in plain English. Individuals with literacy challenges were offered the opportunity of a read aloud of the information sheets and consent form.

Focus groups can provide a challenge to the maintenance of privacy and confidentiality. Participants were asked to keep the information from the focus group confidential - this request was included on the information sheet and consent form and participants were reminded of this at the beginning of the focus group. Participant anonymity was protected in all the data by coding and the recordings of focus groups erased once all data was transcribed.

22

Chapter 4. Study Results

The results presented include details of the sample (section 4.1). The questionnaire data is presented including the completed programme evaluation forms (section 4.2), Health Promotion Officers questionnaire (section 4.3) and the THP Coordinators questionnaire survey (section 4.4). The results of the focus groups are detailed including the Traveller Community Health Workers facilitators focus groups (section 4.5) and the Travellers focus groups (section 4.6). The results of the TCAT programme past participant questionnaire are then provided (section 4.7). Finally a summary of the results is outlined (section 4.8).

4.1 Sample accrualAs can be seen in Table 2 below the number of evaluation forms analysed was significant and represents approximately 48% of all the participants who completed the TCA training in the HSE SECH area. The Coordinators (n=8) represent 100% of the THP Coordinators currently employed in this area. All Health Promotion Officers (n=3) were included as they were involved in the original TCAT programme. The facilitator’s focus groups consisted of the majority of Traveller Community Health Workers (75%) and all the THP Coordinators involved in the TCAT programme. The Travellers focus groups were made up of Travellers (n=27) who were willing to discuss their views on Traveller Cultural Awareness and a range of professionals (n=11) involved in Traveller projects and services.

Table 2: Sample Details

Stage Population Number

Programme Evaluations 1,200 580

THP Coordinators survey 8 8

Health Promotion Officers survey 3 3

Past participants survey 1,200 32

TCAT facilitators focus groups 36 26

Travellers focus groups N/A 38

4.2 TCAT Programme evaluation questionnaireAll completed received programme evaluation questionnaires were analysed (n= 580). Respondents were asked how they rated the workshop. The answers were coded from 1 = poor to 5 = excellent. Of the evaluations analysed (n=580) no one selected poor and only 1% selected fair. As Figure 4 shows the majority of respondents (n=486) thought the workshops were either very good or excellent.

Figure 4:Overall workshop rating

23

Regarding the pace of the workshop, as the can be seen in Figure 5 the majority (81.5%) thought that the pace of delivery was just right.

Figure 5:Pace of the workshop

It seemed participants felt that they had gained from the workshop. Answers were grouped into the categories shown in Table 3 below. A small number (n =17, 3%) did not answer the question.

Table 3: Gains from the Workshop

n %

Knowledge of Traveller Culture 169 29

Awareness of barriers and discrimination/ challenged preconceptions 94 16

Current Travellers culture and projects 18 3

Understanding Traveller Culture 113 19.5

Getting to hear others views 32 5.5

Insight into cultural issues 121 21

Confidence in working with/making connections with Travellers 16 3

No answer 17 3

Total 580 100.0

It could be argued that knowledge and understanding Traveller culture are one in the same. However when considering the responses recorded the answers are different. Here knowledge of Traveller culture includes the responses (n=169) that said ‘knowledge of Traveller culture’ as well as those using one word answers for example ‘knowledge’ or ‘information’. Understanding of Traveller culture includes answers (n=113) that refer to having gained a better, clearer or deeper understanding for example “a deeper understanding of the culture” (R23) or “a better understanding of issues facing Travellers in relation to accessing education and employment” (R50). The responses grouped under insight into Traveller issues (n=121) include those that said they had gained greater insight into Traveller issues as well those that identified a particular issue such as: “better insight into the behaviour of families and friends of an ill person in hospital” (R209). Those three categories represent 69.5% of responses suggesting that the workshops are meeting one of the objectives of the TCAT programme; that is to provide information on Traveller culture and how this impacts on the use of services.

24

Another objective of the programme was to identify the main barriers experienced by Travellers in accessing services. Raising awareness of barriers and discrimination for Travellers as well as challenging the respondents’ own preconceptions of Travellers was the fourth largest category of responses at 16%. For example: “I have been made more aware of the barriers Travellers have to face daily” (R33) and “knowledge of Travellers culture and beliefs that will assist us in delivering a mental health service to Traveller groups” (R540).

Participants were asked what they found most helpful in the workshop. The most frequent answer was that Travellers were present. Collectively the participants (58%, n=335) recorded that they benefited from hearing first-hand experiences from the Traveller Community Health Workers points of view during the Q+A sessions and the discussions.

Figure 6:What I found most helpful

A further 5.9% (n=34) appreciated the honesty, openness and frankness of the of Traveller Community Health Workers. The other responses included gaining knowledge about Traveller projects (6%, n=35) and realising that the Traveller Community Health Workers were a valuable resource when working with Travellers. Another group (n=24) thought that learning about levels of discrimination was most helpful, whilst other respondents (n =88) thought that the workshop material and contents such as the DVD, the PowerPoint or the information pack were of the most benefit. The responses suggest that the majority of people who attended the workshops found that learning about Traveller culture from the Travellers facilitators present was very effective.

Participants were asked what was least helpful about the workshop. Due to the differing formats of the evaluations sheets it was decided to combine that question with ‘what would you change about the workshop’. The responses were very similar and more often than not as can be seen in Figure 7 neither of the questions were answered. The respondents that did answer (n=173) said that they found it all helpful or would not change anything. A further 11% (n=64) thought the workshop should be longer and that more time should be spent talking and listening to the Traveller Community Health Workers.

Figure 7:Least helpful aspects of workshop

25

Some respondents referred to practical problems on the day such as the poor quality of sound on the DVD or the venue being too small for the amount of people present (n = 21). While some respondents (n=41) mentioned particular exercises that they did not think were useful but did not elaborate. Others respondents (n=19) referred to people interrupting during the workshop and having to listen to some peoples negative attitudes as being unhelpful. For example “interruptions from the floor when facilitators were attempting to respond” (R134) and “some people in the group had negative attitudes, I don’t think this changed” (R305).

Respondents were asked to rate the facilitators style with a closed question five point multiple choice answer ranging from poor to excellent. As Figure 9 shows poor was not selected by any of the respondents(n=580) and 83% thought the facilitators were either very good or excellent.

Figure 8:Rating the Facilitator’s style of delivery

The final question of the TCAT workshop evaluation asked for any more comments. Again 45% n=177) did not add a further comment. For those that did comment the majority (55%, n=221) were in praise of the workshop and the facilitators. Other comments (n=46) included that it “could be longer” (R242) and “a longer day, more focused discussions with Travellers” (R515).

Table 4: Other comments regarding workshops

n %

Could be longer/more time to learn about Traveller culture 46 8

Great/Excellent/Enjoyable Workshop/Presentation/Presenters 221 38

Training should be refreshed/spread further/updated 41 7

Need for change/still some way to go 22 4

Opportunity for honest talk in safe environment with Travellers 35 6

Opportunity to establish links/improve confidence when working with Travellers 9 1.5

No answer 177 30.5

More Traveller input including men and young people 29 5

Total 580 100

4.3 HealthPromotionOfficersQuestionnaireA questionnaire (see appendix 2) was distributed to the three Health Promotion Officers who were involved in the initial development of the programme and training the Traveller Community Health Workers to facilitate the workshops. The survey was designed with eight open ended questions to explore their views on the TCAT programme and the training needs of facilitators.

26

4.3.1 Views of the TCAT Programme

The Health Promotion Officers were first asked about their views of the TCAT programme and were in agreement that the appropriate length was a full day, that the content was suitable for purpose and that ‘delivery by members of the Travelling community is vital’ (HPO 3). They also referred to the experiential aspects of the workshops especially through the group work and interactive exercises that are of benefit to the facilitators and participants.

4.3.2 Usefulness / benefits of the TCAT Programme

They were asked what they thought where the useful benefits of the programme and they identified the benefit of increased understanding of Traveller culture and their specific needs for service providers: “Really useful for frontline staff in particular, many of whom may not have even spoken to a Traveller outside of work interactions, helps to break down barriers on both side, to put faces to names in the services and promote the work of the Traveller Community Health Workers, can result in a shift in attitude towards one another which can be very beneficial”.

They also referred to the personal benefits for Traveller Community Health Workers who can develop transferable skills through the facilitation training as well as developing personal skills in communication which in turn leads to raised self-confidence.

4.3.3 Changes made to the TCAT Programme

Two of the Health Promotion Officers were not aware of any changes that had been made to the programme, the other discussed how the programme can be tailored by the individual TCAT teams to suit specific audiences. The example given was concentrating on legal issues when working with an audience made up of mainly Gardaí. This respondent thought that tailoring the content to suit specific groups is beneficial as it resulted in a workshop that would be focused to the service provider and therefore relevant to that service. However, it should be noted the TCAT teams provide training for mixed groups so the training cannot always be user specific and as such the Traveller Community Health Workers have to be prepared to answer questions on a wide variety of topics during mixed group training.

4.3.4 Key training needs of TCAT facilitators

All the Health Promotion Officers agreed that facilitation skills are essential key training needs for the Traveller Community Health Workers to deliver the TCAT programme. Confidence building and personal development training where also needed. The workers, according to one response, need the ability to deal with resistance and learn how to respond to challenging questions or opinions from the participants objectively. The Traveller Community Health Workers also need a good degree of literacy and the confidence to discuss statistical information.

4.3.5 Training needs of new TCAT facilitators

Health Promotion Officers were also asked if a new Traveller Community Health Worker was to be trained as a TCAT programme facilitators what training would be recommended. Responses indicated that a new worker would need facilitation and presentation skills as well as personal development and confidence building. As a prerequisite the Traveller Community Health Worker would need to have a high degree of maturity as well as good literacy and communication skills.

Their opinions on the amount of time that would be needed to train a Traveller Community Health Worker to facilitate on the TCAT programme ranged from 6 to 10 sessions of group work facilitation skills over a number of weeks or months. One Health Promotion officer stressed that the training needs to take place over time rather than being grouped into continuous days. When asked for further clarification on this view she said that self-awareness and personal development are core competences for any facilitator training and that potential facilitators need time to strengthen these aspects of themselves. Facilitator training is better done over time as this allows the potential facilitator time to reflect on their learning and develop confidence, competence and self-awareness. She also mentioned that

“TCAT could be quite a challenging course [for the Traveller Community Health Workers]. We want participants to be open and honest and to examine their attitudes. It takes a lot as a facilitator to ‘hold’ this in the group and use these attitudes as learning”.

4.3.6 Support needs of new TCAT facilitators

The final question asked about the level of support that would be needed for Traveller Community Health Workers facilitators that were new to delivering the programme. The Health Promotion Officers thought that ongoing

27

support would be needed from the programme Coordinators. Suggestions included additional training, peer learning from experienced Traveller Community Health Workers, supervision /de-briefing after each workshop to review how it went as well as reflecting on their personal delivery. The new workers would also require support from the TCAT Coordinators before and after each session and they should only be co-delivering the programme with more experienced TCAT facilitators.

4.4 THPCoordinatorsQuestionnaireA questionnaire (see appendix 3) was distributed to the THP Coordinators (n=8) who were involved in the delivery of the TCAT workshops in the HSE SECH region. It was designed to elicit the views of the TCAT programme. The Coordinators support the Traveller Community Health Workers in the delivery of the workshops. The survey consisted of eight open ended questions that explored their views on the programme as well as the training needs of the Traveller Community Health Workers and supports that are required to deliver TCAT programme.

4.4.1 Views on the programme

The responses showed that the Coordinators view the content of the programme to be comprehensive, allowing for a degree of flexibility for the facilitators to target particular audiences, for example participant groups from education or health services. One thought that there needed to be more attention paid to Traveller culture and the training was an opportunity to inform people of the positive aspects of Traveller culture. The Coordinators were in agreement that the model of delivery for the programme was good and the Traveller Community Health Workers were an essential part of that. The Coordinators also agreed that the Traveller Community Health Workers were effective.

The Coordinators were not in agreement on the ideal length of delivery of the TCAT programme. The answers ranged from one and a half hours to a full day. Two Coordinator thought a full day was best, one suggested that a full day was needed to cover all the information. On the other hand another thought that a full day was “too short to result in changing attitudes”. Others thought that the shorter workshops were sufficient and that evening or half day sessions were more popular with the participant groups.

4.4.2 Usefulness / benefits of the programme

The Coordinators answers indicated that they perceived that Traveller Community Health Workers benefit from delivering the programme: “It allows the facilitators from the Travelling community to take ownership of their culture and explain it themselves”.

Another benefit was that the training allowed people from settled community to gain a better understanding of the Traveller community and see a positive side of Travellers. The Coordinators pointed to benefits of service providers getting the opportunity to meet and talk Travellers face to face. For some service providers this can be the first time they have had that opportunity. Another benefit is that the training provides an opportunity for service providers to raise, and for Travellers to hear, their concerns about the access and participation in services provided.

4.4.3 Training required for Travellers’ facilitating the programme

There was broad agreement that facilitation skills were required to deliver the programme. The Coordinators mostly agreed (n=5) that the Traveller Community Health Workers needed a specific skill base to undertake the training and have not just the ability but the desire to deliver the programme. One Coordinator thought that the training the workers had received was well delivered and the Traveller Community Health Workers involved in the facilitation of the programme had developed a good level of confidence.

4.4.4 Supports provided for the programme

The Coordinators were clear in their role that they are there to support the Traveller Community Health Workers delivery of the programme. However, their role in the programme delivery is substantial. According to one Coordinator they take the bookings, adapt and update the programme for each group, organise the equipment, resources and venue, deliver refresher courses for facilitators before each training programme, delegate roles and responsibility of facilitators, coordinate the paperwork for each training programme i.e. attendance sheets, evaluation forms and trainer packs, as well as conduct a debrief with the facilitation team after the workshop. The Coordinators take a back seat during the workshops and stress that they are there to support the Traveller Community Health Workers in their role as facilitators of the training.

28

4.4.5 Other supports that might be required for Traveller facilitators

There was general consensus that the Traveller Community Health Workers would benefit from further training so that they could facilitate the workshops with greater confidence and skill. There was reference to particular skills such as ICT and PowerPoint. Additional resources in terms of both time and equipment being made available so that the Traveller Community Health Workers could have time to practice and update their skills. There was a suggestion to link with other Traveller Community Health Workers who facilitate the TCAT training regionally which would be useful. Ongoing support was also seen as being needed for facilitators to stay up to date and able to address issues such as Traveller Ethnicity Recognition.

4.4.6 Suggestions for improvements to the programme

Suggestions included the allocation of hours to deliver the training as this interferes and puts extra demands on the Traveller Community Health Workers hours. The Traveller Community Health Workers at present are allocated, depending on the project, between 5 and 12 hours per week. One training session can take, again dependent on not just the project but the time available to the service provider, between 2 and 6 hours. This does not include preparation and supervision after that can easily double the training time and can be more than the Traveller Community Health Workers allotted weekly working hours.

Another suggestion was that the training should be mandatory for all public service workers. The training being made mandatory would change how the programme is rolled out at present where the onus is on service providers to request TCAT which suggests that the people who have taken the training to date have done so by choice. Again, the Coordinators, stressed the need for updated information and training for the facilitators.

4.4.7 Changes made to the programme over time

The Coordinators were in agreement that while there had not been any official modifications made to the original programme it had been adapted to suit differing attendees. The programme was originally designed as a full day workshop but some groups deliver a condensed version to suit the participant’s timeframes. In addition some exercises have been updated by the individual groups such as using different photographs in the stereotype photograph activity or using You Tube clips instead of the original film. Some of the exercises are not used and some groups do not use the presentation. This suggests that there has been considerable modification to the training that was first developed in 2006. The Coordinators recognise that there needs to be a degree of fluidity built into the training that can be delivered to a wide range of service providers that may require different timeframes. There is also the need for a programme that is generic that can be delivered to mixed groups of services providers.

4.4.8 Impact of the Changes

Not all the Coordinators had an opinion on the impact of the changes but those who commented agreed that changes to the training were essential to keep the information up to date.

“It is more than ten years since the original programme was designed and it needs to be refreshed”.

The programme was originally designed for health service workers but the programme today is being delivered to a wide range of services providers. The Coordinators are aware that this has impacted on the modification of the training that must allow for the differing audiences.

“Keeping the material fresh makes it more interesting, appealing and valuable to the audience”.

4.4.9 Suggestions for the future roll out of the programme

All eight Coordinators had ideas on the future roll out of the programme. These opinions ranged from the need to increase awareness within the general population, that the training be more widely available, having two to three dedicated Traveller Community Health Workers teams in each CHO area and a Coordinator to oversee the training in each area. They also stressed that the content needs to be regularly updated and resources should be made available for equipment so that the delivery of the training is consistent and professional.

4.5 TCAT Facilitators Focus Group4.5.1 Introduction

In total four facilitators’ focus group interviews were conducted and took place across four different regions within the SECH region, namely Waterford, Wexford, Carlow and Kilkenny. These focus group discussions included a number of participants (n=26) - both THP Coordinators and the Traveller Community Health Workers who facilitate the TCAT programmes. Focus group discussions were conducted in the TCHP offices. Three main themes emerged

29

from the focus group discussions; (i) advantages of TCAT programmes; (ii) problems encountered in delivering TCAT programmes including negative and discriminating views participants have of Travellers and (iii) the impact on TCAT delivery. These themes incorporated a number of sub themes and these are broken down and presented in the following sections 4.4.2-9. Initially, all focus group participants were asked the question regarding their experience of having delivered the TCAT programme. This opened up a general discussion on programme delivery and these findings supported section 2.10.

4.5.2 TCAT operational delivery As described earlier in section 2.10 the TCAT programme has been delivered across a broad range of sectors and services. It was delivered in Clonmel from 2007-2015 and in Waterford from 2008-2015. It commenced in Kilkenny, Carlow and Wexford in 2013 and is currently ongoing. Participants acknowledged their uncertainty in relation to the total number of TCAT programmes delivered. The number of service providers participating in the TCAT programmes varied significantly across the region and approximately 1,200 service providers are estimated to have participated in TCAT in the region since 2007.

Training duration varied amongst all services. Generally the TCAT programme required one half day or an average of 2.5- 4 hours to complete depending on programme delivered. There were generally three facilitators delivering each TCAT programme including two Traveller Community Health Workers and one Coordinator. The role of the Coordinator is to set out and plan training including resources. The Traveller Community Health Workers deliver the actual training, including answering questions. 4.5.3 Programme content As described in section 2.10 the TCAT programme content is a multimodal package including general discussion, power points, over-head projectors and interactive training material and resources.

Programme content is adapted to particular groups, ifor example the inclusion of bereavement within the Travelling culture or when working with a particularly challenging or difficult group: “we will do more on equality as we feel that they may not be very good on that particular area”.

4.5.4 Targeted training programme In general, TCAT is largely a targeted programme initially aimed at front line health care professionals; however, demand for the training filtered to other sectors as detailed in section 2.10. In terms of promotion, facilitators noted that some Traveller Community Health Workers have used promotional leaflets (see appendix 13) and one service called for a ‘standard’ promotional leaflet to be developed.

Increasing the scope of the programme to target both the public and private sector was highlighted and an interesting discussion arose. Although the majority of all focus group participants agreed that there is a need to increase the scope and breadth of the current programme to reach more front line health staff and public sector employees in general, focus group participants highlighted the need to go beyond this sector to target the private sector, in particular shop keepers and public houses. However, facilitators from one of the services in the South-East spoke of their own experience having previously worked in this area. Although acknowledging their previous efforts were more in line with advocacy measures, facilitators warranted caution in targeting the private sector: “I don’t think a private business would be motivated to take part [agreement] I think its public service that we need to look at but I don’t think anyone in the private sector would be interested [in TCAT] unless they were very enlightened or progressive”.

4.5.5 Training and characteristics required to facilitate TCAT It was reported that formal training for TCAT facilitators to deliver the cultural awareness programme was not consistent. Some facilitators had extensive training delivered by the Health Promotion Department as part of the original Traveller Community Health Workers training whereas those coming to the role later had received in-house training. Therefore training to become a TCAT facilitator was based on experiential learning, co-ordinated in house training coupled with facilitation group skills delivered by HSE. It appears that the training was focused on equipping the facilitators with necessary facilitation skills to build confidence in speaking to groups. The facilitators themselves draw on their own life experiences. Characteristics required to deliver training were reported and these include; excellent understanding of Traveller culture/ norms; motivation to deliver programme; confidence (confidence working with large groups and confidence to work with new people); good awareness/ knowledge of the local area; good facilitation skills; good leadership and management skills and; the ability to communicate and work with professionals. The importance

30

of inexperienced group facilitators working with Traveller Community Health Workers who had facilitation experience was highlighted as a prerequisite to effective TCAT delivery.

Another issue raised in relation to this point was that of gender imbalance within the Traveller Community Health Workers projects, most facilitators working with the Traveller Health Units were women. Programme facilitators acknowledged this was due to the historical nature of the Traveller health programmes targeted at women. However, it was noted that the issue of gender imbalance has been acknowledged by the Traveller Community Health Workers projects and they are actively working on getting more men involved. One area reported that they have employed a male Traveller health outreach worker. They noted that for their service their employees undergo a part time 3 year training course [within the academic year], and thus this would be required for the ‘new male Traveller health worker’ to acquire the same level of training as their female equivalent:

“a big undertaking but it may be well worth it”.

4.5.6 Mandatory TCAT training for front line staff

Finally, in relation to TCAT programme delivery the topic of mandatory TCAT for all front line public service staff ensued. Discussion arose and the majority of focus group participants agreed and welcomed the idea of mandatory TCAT for all public service employees and called for attention to be drawn to this area in further developing current TCAT programmes.

4.5.7 Perceived advantages of TCAT The overall consensus amongst the facilitators’ was that they were satisfied with the TCAT programme. The facilitators outlined a number of advantages to delivering the programme and these included; increasing awareness of Travellers throughout the South East; increased confidence amongst the Traveller Community Health Workers; building relationships with service providers; improved health and wellbeing and; increased employment opportunities. These advantages are outlined in more detail in the sub-themes below. It is noteworthy that in some examples provided, particularly in relation to improved health and well-being that the participants drew on retrospective and anecdotal data.

a) Increasing awareness of Communities TCAT was credited for increasing awareness amongst participants attending the training programmes of Traveller communities throughout the South-East of Ireland. Facilitators spoke of the importance of delivery the programme and the reason they initially got involved as Traveller Community Health Workers being to raise the profile of Travellers and to help break down barriers and associated discrimination. Facilitators noted that participants of the TCAT responded well to their ‘openness’, ‘honesty’ and ‘willingness to answer very personal and often insulting questions’. This in turn was reported to have broken down barriers and encouraged a sense of ‘acceptance’ amongst participants as for many participants of the TCAT it was their first time ever meeting a Traveller:

“… you can see the change in them when they are going out…you can see that you are changing the views on Travellers”

Facilitators were probed and asked about their views on how TCAT could be improved within their regions. From here, facilitators noted that the introduction of a specific module on Nomadic communities on a national and international scale would further raise the profile of Travelling communities in Ireland. Facilitators from one region in the South-East who previously included this topic reported an overwhelmingly positive response from participants:

“when you talk about nomadism worldwide you bring in the concept that there are structural issues there that create disadvantage that is visible… it’s the disadvantage that offends people and we have found that very useful”

Further discussion in relation to the importance of incorporating such a module into TCAT divulged that an understanding of Nomadic way of life increases the peoples overall understanding of Travelling communities:

“This helps to answer peoples questions as to why Travellers are different to the general society because that is still a running question for people when they don’t understand [Travellers]”.

31

Also, the importance of outlining the presence of Travelling families within particular regions was also noted to assist participants understanding of Travelling communities. Attention was drawn to the fact that often there is a ‘hushed fear’ amongst people in relation to Travellers. However, TCAT assisted in increasing people’s awareness. Ultimately, these were noted as important elements of the TCAT programmes in terms of raising peoples understanding of Travelling communities. Note: it was unclear from the other groups whether a specific module on Nomadism is included in their delivery.

b) Increased confidence, communication skills and working with professionals: Confidence was mentioned repeatedly as a core characteristic required by facilitator’s in order to effectively deliver the TCAT. Prior to facilitating the delivery of the TCAT programme, facilitation skills training have generally been completed by the facilitators. It was very clear from the focus group transcripts that this training instilled confidence amongst the facilitators which in turn enabled them to become more proficient in their delivery of TCAT:

“…back before we did the course we would have been nervous…we have more confidence in ourselves now because of the training…if came to me a few year ago [before completing training] I know myself I wouldn’t have talked to you”

This increased confidence amongst the facilitators was reported to have aided their communication skills, in particular, with people they didn’t know and also with professionals:

“I think that the people delivering the programme that if they are not well prepared, then it can do more harm than good [agreement] because they can meet hostility out there and if they are not ready for that if they are not prepared and if they do not know how to deal with it they can get rattled when they are there and they can react in a way that mightn’t be the best way”.

Confidence, communication skills and ability to work with professionals were highlighted as key characteristics required by the facilitators to effectively deliver the TCAT. The facilitation skills training equipped the facilitators with the necessary skills; however, these skills were further developed through delivering the TCAT programme. Thus, this programme harnessed a number of key skills and attributes amongst facilitators.

c) Building relationships with local service providers; Participants acknowledged that local service providers were often unaware of the existence of the Traveller Community Health Workers within their communities. The TCAT was advantageous in raising the profile of the services of the Traveller Community Health Workers and the THU. In turn, this increased awareness whereby in a number of cases service providers followed up in relation to specific cases and in general increased awareness amongst service providers of Traveller health services situated within their community.

“… It’s almost like a referral service in a way… it’s not just a one off training session, it’s a form of building relationships with the service providers”

As a result, facilitators reported that participation in the TCAT programme empowered both service providers and the Traveller Community Health Workers; enhancing and developing future interactions. Thus, TCAT may have assisted in breaking down barriers that may have previously been embedded within local communities throughout the South-East.

4.5.8 Challenges and opportunities encountered in delivering TCAT

Further to the advantages of TCAT as described in section 4.4.7, a number of challenges and opportunities were described. A number of sub themes emerged and these included; time - in particular the availability of Traveller Community Health Workers; key performance indicators [KPIs]; lack of consistency in TCAT delivery mode; lack of resources; lack of skills required to effectively deliver TCAT. Organisational and personal barriers were described as hindering effective delivery of TCAT programmes while inclusion of this training within a national KPI and the flexibility in programme delivery was both a challenge and opportunity. The subthemes are described in more detail below.

32

a) Time and the availability of the Traveller health workers The time and availability of the Traveller Community Health Workers were highlighted as major causes of concern across all areas of the South-East, particularly in relation to the time required to adequately prepare and deliver impactful TCAT programmes. The delivery of TCAT within the part-time working hours of the Traveller Community Health Workers were deemed inadequate and overall far too time consuming to deliver within their remit which in some cases led to ‘burn out’ amongst facilitators:

“I find it very difficult to keep it [TCAT] moving on because the days are gone with your part time hours and that’s when people get burnt out”

In addition, facilitators noted that the demands of their role within their working hours hindered opportunities to recruit new services/professionals to avail of their training and/or in helping to raise awareness/promote their services:

“We don’t have the time to go out around [area] to see if new people wanted to do the training”.

In relation to the time consuming nature involved in the preparation of and delivery of TCAT; facilitators were probed and asked what could be done to assist existing TCAT programmes in terms of their delivery. To this facilitators responded that additional groups could be developed within the local regions of the South-East [SECH] but outside of the current Traveller health project teams as current programmes are running to capacity which evidently had a knock on effect in delivering TCAT programmes:

“What I can see working is have a team outside of the health projects but maybe linked in that are trained up [to deliver TCAT] and that is their function”

Thus, going forward in relation to developing TCAT, separate entities or specialised units linked to the local health Traveller projects within the SECH region could be developed to progress the programme, particularly in terms of reach within communities. Mention was made to an existing specialised units currently in place in Cork for delivery of training.

b) Key Performance Indicators [KPIs]Nationally the TCAT programme is not recognised under the HSEs KPIs despite being a key principle of the 2002 Traveller Health Strategy to provide awareness training for health personnel in relation to Traveller culture. This was reported to have impacted on the delivery and the time awarded to the provision of TCAT, in one particular region. Furthermore, it was suggested that TCAT is not prioritised within these services and this was attributed to be directly related to their work not being recognised under their KPIs:

“we are not motivated to do the TCAT because there is so much effort involved and it’s all coming out of our own time and we don’t even get to put it down as our KPIs”

Although beyond the scope of the current evaluation, this finding calls for a national review of KPIs and further research will be required in this area.

c) Flexibility of Delivery Across all regions there appeared to be variations in the delivery of the programme and it was clear that each region developed their own training package and style, thus there is no standalone training TCAT package. This could suggest a lack of consistency in TCAT delivery. This was reported to be due to a number of reasons, including the group of participants and training setting:

“We find that we cannot deliver just the one training to all groups”.

This highlights the advantages to fluidity and mirrors findings mentioned previously in Section 4.4.3 Programme Content.

d) Resources; Facilitators reported a lack of resources within services to effectively deliver interactive training, i.e. Wi-Fi, laptops, extension cables. This was highlighted as impeding the delivery of programmes:

“I would say, with the [limited] resources we have now we could deliver the training at most once a month and that’s pushing it”

33

Facilitators called for an increase in resources to assist in their delivery of TCAT. They discussed the difficulties of trying to borrow necessary equipment, relying on older poorly functioning equipment.

e) Lack of skills to effectively deliver TCAT It was reported that in some areas, Traveller Community Health Workers, albeit working part time hours, are possibly available to deliver TCAT programmes, however; their skill set to manage and deliver group based programmes are deemed inadequate by programme Coordinators:

“…skill levels of our current employees are ‘not compatible’ to facilitate group programmes [like the TCAT]”.

From this, the facilitators were probed in this area and asked why they felt their current employees were not deemed ‘compatible’ to deliver TCAT? To this, the facilitators replied that their current employees were not able to deal well with the negative questions and did not have the confidence to communicate directly with a group of professionals and/or have the drive to deliver the programme. Consequently, in this particular area of the South-East, the reduction in the numbers of skilled Traveller Community Health Workers resulted in their TCAT programme ceasing delivery.

A number of conclusions can be drawn from this, the first is that these reports suggest that the decline in the number of programmes delivered throughout the South-East in recent years, may, in part, be due to the part time employment Traveller Community Health Workers. In addition, a lack of time to plan, prepare, deliver and recruit participants for the TCAT programmes strongly points to the need to re-orient current services to facilitate TCAT. On the other hand, it also highlights the need to enhance the training and skills of current workers so that they can effectively deliver the programme.

4.5.9 Discrimination against Travellers and the impact on TCAT delivery

The third theme to emerge was that of the view and perception of the Travelling community in general within our society. Discriminating views towards Travellers were acknowledged throughout the transcripts, and there was an overall acceptance that the efforts and work delivered through TCAT will never reach out to everyone:

“…if people are born and bred prejudice, 4 hours of training is not going to change them…but all you can do is your best”

In these focus groups it was reported that for the purpose of TCAT the Traveller Community Health Workers having experienced discrimination and negativity can viewed in a positive light. This is because, being a Traveller: ‘you learn to live with and deal with such remarks’. For example, facilitators reflected on previous negative remarks, insults and difficult questions experienced in their delivery of TCAT and regarded such remarks to be ‘part and parcel’ of their work: “They can hit you with very difficult questions”. Even though the facilitators encountered significant negative comments and insults, throughout the majority of the programmes they delivered, it was reported that the advantages of delivering the programme outweighed the negatives: “we will get on with the insults” if it means positively raising the profile of the Travelling community.

When focus group participants were asked did they ever receive any training in the area of dealing with negative comments and insults, the facilitators replied, they had not. The majority of facilitators reported they did not feel such training was necessary, however, when asked about improving the programme in terms of attracting new Traveller Community Health Workers, some participants called for increased training in the area of dealing with difficult people:

“… You could be going into groups who have a certain mind-set about the Travelling community… so I think there should be some sort of training on how to deal with anyone that throws you a smart comment or difficult question”.

This finding mirrors the need for experienced group facilitators and the characteristics required to deliver training (as highlighted in section 4.4.8). However, the introduction of training to deal with difficult people should be considered in the development of existing training programmes for group facilitators.

34

4.6 Travellers Focus Groups

4.6.1 Introduction

A total of three Traveller focus group discussions were conducted and took place across three different regions within the SECH region, namely Kilkenny, Tipperary and Carlow and took place within the offices of the PHCTP. Thirty-eight Travellers and members of interdisciplinary teams participated in these focus groups.

The Traveller focus group discussions differed to the facilitator’s focus groups (as documented in Section 4.5 above) in that, the Travellers participating in these focus groups had limited or no previous knowledge of the TCAT programme. Rather, the aim of these focus groups was to gain an understanding, from the perspective of Travellers, of the benefits (if any) associated with such cultural awareness training programmes within their respective communities. Four main themes emerged from the Traveller focus group interviews and these included; (i) views on cultural awareness training programmes; (ii) lack of awareness of Traveller culture, norms and beliefs; (iii) benefits of cultural awareness training and; (iv) the need for a more targeted approach to cultural awareness training delivery.

4.6.2 Views on cultural awareness training programmes Initially, participants involved in the Traveller focus group discussions were asked about their ‘views were in relation to cultural awareness programmes’. Travellers unanimously agreed that cultural awareness training programmes serve as an integral component to raising awareness of Traveller culture and called for an increase in such programmes:

“I’d say if you asked a 1,000 Travellers they would all agree that is a very good programme…it should be done in every county and in every town”.

Programme Content In terms of programme content, Travellers highlighted the need for up-to-date and current information to be included in cultural awareness training programmes. According to the Travellers the general population have an outdated view of Travellers. These views have been heightened through dated stereotypes that are presented by the media and programmes such as ‘My Big Fat Gypsy Wedding’. Further, in terms of content, Travellers reported that cultural awareness programmes should include information on ‘ethnicity’ and ‘what that means for Travellers today and for Travellers in the community’, whilst still acknowledging important historical Travelling culture:

“…upskill and develop our [current] generation and preserve what we need to preserve”.

Thus, future cultural awareness training programmes should be mindful of content and update resources or modules as necessary in consideration of best available research in addition to traditional cultural beliefs. 4.6.3 Lack of awareness of Traveller culture, norms and beliefs

Travellers participating in these focus groups reported a lack of awareness of traveller culture, norms and beliefs amongst those living within their respective communities. This was particularly evident within the health sector as it was noted that front line health care staff often showed a lack of empathy towards Travellers in respect for their sick/deceased i.e. in terms of the numbers of Travellers that will visit the hospital in large numbers:

“they [health sector employees] all need to understand that we come from ‘packs’ in our communities”.

Further to this, Travellers time management skills was highlighted as an area causing ambiguity amongst health care workers, i.e. in terms of keeping to appointments. Finally, there was a clear sense of uncertainty amongst health workers [secretaries] in relation to Travellers literacy skills:

“you are told to go away over there and fill out that form… but most Travellers don’t know how to read and write”.

These findings point to ‘gaps’ in current knowledge and understanding of Travelling culture, norms and beliefs and areas that should be addressed when developing future TCAT programmes.

Discrimination against Travellers and the impactFurther to this, discrimination against Travellers and the impact of discrimination was attributed to a lack of understanding in relation to Traveller culture, norms and beliefs. Travellers participating in these focus groups

35

spoke of the impact of discrimination and prejudice against the Travelling people. The impact of discrimination against Travellers was reported in some cases to have significantly impeded Travellers advancement in terms of education and employment opportunities:

“Sure what’s the point…once they know you are a Traveller they will never give you a job after anyway…”

Travellers reported that a lack of awareness surrounding Traveller culture, norms and beliefs heightened such discrimination/ prejudice within their communities and called to strengthen and further develop cultural awareness training programmes like TCAT.

4.6.4 Benefits of cultural awareness training programmes

A number of benefits of cultural awareness training programmes emerged. Travellers participating in these focus group discussions attributed the benefits they had seen within their communities to the TCAT programme. Attention was drawn to a case example. One Traveller spoke of their experience where they believed that cultural awareness training programmes had positively influenced and changed the views of front line health care staff. In this example, the Traveller reported a case where a member of her immediate family was sick in hospital. All members [approx. 15-20 Travellers] that had come to show their respects were greeted and shown into a separate waiting room within the main hospital campus. From here a policy was put in place- ‘3 in and 3 out’ at any given time. In other words, only three Travellers were allowed to visit the family member at any one time. When the agreed time was up the three members vacated the room and a further three members were allowed in to visit and this continued until all members got their chance:

“for me what I found that if you give them [front line health staff] the respect they will respect you back”

Further to this, some participants of the Traveller focus groups acknowledged an increased understanding of Traveller culture in addition to increased confidence amongst heath care staff [nurses] and these were attributed to having previously participated in cultural awareness programmes.

4.6.5 The need for a targeted approach to TCAT delivery

The general consensus across all Traveller focus groups discussions was the need for a more targeted approach to TCAT delivery, with a particular emphasis on targeting more public sector employees. Within the public sector, a number of key target areas were highlighted and these included; education sector- in particular primary schools; health sector; county councils. Further to this the private sector and the Travelling community were highlighted as areas warranting future training. Furthermore, mandatory cultural awareness training was highlighted and welcomed amongst participants of the Traveller focus group discussions.

Public Sector Employees; Education SectorTargeting TCAT at primary school level was deemed important by the majority of Travellers participating in the focus groups. Travellers felt that targeting both teachers and pupils at primary level would greatly benefit their communities in terms of increasing knowledge and awareness in relation to Travelling culture, norms and beliefs. When probed as to why specifically target primary schools as opposed to secondary/ third level, Travellers reported that although targeting all groups was overall very important, primary schools gave rise to an age group which were deemed more likely to respond positively to education and awareness raising and ‘accept’ Travellers as members of their community:

“…it needs to be encouraged and rolled out through the schools through the places where the [younger Traveller generations] are going to learn… places where they can adapt to their background to preserve it”.

Public Sector Employees; Health Sector The need to target more public sector employees and front line health care staff in general was reported. In particular the need to target ‘graduates’ or those ‘still in training’ were deemed important to target because: “if you can educate them [through TCAT] while they are still learning they will know more about us [Travellers] when they start their jobs”. Nurses, midwifes, public health nurses and doctors as well as porters, secretaries and security guards were all reported to be the key members of the health care sector to target in future programmes.

Private sector Further to this the need to target the private sector was highlighted and an area warranting attention and in particular, the need for TCAT programmes to be targeted at shop keepers and public houses. Travellers spoke of the public discrimination they receive and called for TCAT to target these areas.

36

Travelling communities Some Travellers participating in the focus groups highlighted the need to target training at the Traveller community. These Travellers reported that within the Travelling community a ‘generation gap’ is emerging and in some case Travellers are not ‘identifying’ themselves as a distinct cultural group. Attention was drawn to ‘younger generations’ and increases in ‘emigration’, ‘suicide’ levels, and emerging groups of Travellers who no longer identify as such that can cause fractions within the Travelling communities. Calls to educate Travellers on current Traveller patterns within society were highlighted. These areas although beyond the scope of the current study should be considered for inclusion in future programmes.

Overall calls for increasing targeted programmes were regarded favourably by Travellers in terms of raising awareness of Traveller culture, norms and beliefs. It is noteworthy that Travellers highlighted the need to target the housing authority (county councils).

4.7 PastParticipantsQuestionnairePast participants of the programme (2013-2017) were invited to complete a questionnaire (see Appendix 4). In all, 58 direct email invitations to complete the questionnaire were sent out and 11 were returned within the timeframe of the project. As this was a very small percentage of the estimated 1,200 past participants an additional email with a link to the survey was sent directly by the THP Coordinators that resulted in a further 20 completed questionnaires and a final sample of (n=32) 2.66% of the total number who had attended the training.

The questionnaire was designed to explore if the training had an effect on the participant’s behaviour when working with Travellers on a professional basis and collected their views of the benefits of the programme. It also sought to ascertain the impact or change, if any, in their interactions with Travellers since undertaking the programme.

4.7.1 Length of time since programme completion It had originally hoped to get responses from people who had completed the training between 6 and 24 months previously but the time since the participants had undergone the training and completing the survey ranged from 54 to 6 months. The average was calculated at 18 months.

4.7.2 Area of work

The training has been delivered to a wide range of service providers and Figure 12 shows the range of professional backgrounds of the people who have completed the training. The professions specified included: local authority, education, social protection, health administration and community/rural development.

Figure 9:Professional background of past participants

4.7.3 Views of the TCAT programme

In terms of length of delivery the majority of the past participants thought it was just the right length. The past participants thought that the content of the programme was fit for purpose with interesting and relevant information that raised their awareness of Traveller culture. The respondents also thought that the model of delivery was very good. Just six respondents added further comments such as:

“It should be rolled out to all front line public service staff and schools”and

“Very helpful to meet the Traveller workers”

37

4.7.4 Usefulness or benefits of the TCAT programme

The responses to this question were positive and reflected on the content as being useful for breaking down barriers and in one respondent opinion it was “beneficial to my work practice”. When the responses from this survey were compared with the workshop evaluations that were completed on the day of the training it would suggest that the past participants opinion of the knowledge they had gained from the training had not diminished over the passage of time.

4.7.5 Impact has the programme on interactions with Travellers

The majority of the past participants (n=25) were of the opinion that the training had impacted on their interactions with Travellers. They referred to having more understanding and empathy as well as being less likely to pass judgement on the Travellers that they had interactions with. For example:

“I would say I am more confident working with them”and

“It’s made me more tolerant and given me a better understanding”.

The remaining respondents (n=6) said that the training had little or no impact on their interactions either because they had no contact with Travellers (n=2) or that their cultural awareness of Travellers was already raised (n=1).

4.7.6 Work style / behaviour changed since undertaking the programme

Again the responses to this question where mostly positive with just six saying that their work style or behaviour had not changed since undertaking the training. For the people who remarked that there was a marked change said that they had developed more confidence, patience and tolerance when working with Travellers:

“I know more about Travellers, I am more confident working with Travellersas I now know that they want to interact with us”

and“maybe more patience to trust (this is vital)”

and“Yes I have more understanding [able] to shape my service delivery”.

4.7.7 Other content that should have been included in the programme

The majority of the past participants (n=18) did not think that any other content should be included in the training. Once again the comments of the remainder (n=13) corresponded with additional comments from the evaluations. They thought that there should be more up to date background information on Traveller culture and specifically Nomadism (n=2). The lack of a male point of view/ involvement in the training was also referred to as well as barriers to education coming from within the Traveller Community and the barriers for Travellers accessing training and employment.

4.8 Summary of ResultsOverall the results from all 6 data collection tools used in this mixed methods evaluation show that there are similarities emerging throughout the findings. Table 5 below illustrates themes shared in the study findings.

4.8.1 Evaluation questionnaire summary

The evaluation questionnaires analysed (n= 580, 48% of total) identify how the TCAT programme raised awareness of Traveller culture and issues for Travellers accessing services for those who attended the training. They show that the participants were provided with information on Traveller culture and how culture can affect the use of services and the main barriers experienced by Travellers in accessing services. The evaluation surveys show that one of the TCAT programmes greatest strengths are the Traveller Community Health Workers who deliver the training.

The evaluation survey did not ask for ways of moving forward to improve access and uptake of services for Travellers but some of the participants did comment on the need for change of attitudes and their own attitudes changing because of the training. The evaluation surveys were completed at the end of the workshops and therefore could not determine if the training was effective in the longer term.

The evaluation surveys collected data based on the first two levels of the Four Levels of Evaluation (Kirkpatrick 1994) and showed participant’s reaction to and satisfaction with the training and the learning they had obtained.

38

4.8.2 Health Promotion Officer questionnaire summary

The Health Promotion Officers were in agreement that a full day training was appropriate for the TCAT programme, that the content was fit for purpose and that the programme being delivered by members of the Travelling community was vital. They also referred to the personal benefits for the Traveller Community Health Workers who facilitate the programme in terms of developing transferable skills in facilitation, communication and increased self-confidence.

The Health Promotion Officers were not involved in the ongoing delivery of the programme and therefore not involved in the modifications made by the individual groups. The HPO who was aware of changes thought that tailoring the content to suit specific groups would be beneficial and more relevant to the particular service. As far as the training needs required for Traveller Community Health Workers to deliver the programme they suggest as a prerequisite the Traveller Community Health Workers would need to have a high degree of maturity as well as good literacy. They identified the essential key training needs as being: facilitation skills, confidence building, personal development training as well as training in the ability to deal with resistance and learn how to respond objectively to challenging questions or opinions during the workshops.

Their opinions on the amount of time required to train Traveller Community Health Workers to facilitate on the TCAT programme ranged from 6 to 10 sessions as facilitator training is better done over time as it allows for reflection on learning and time to develop confidence, competence and self-awareness. The level of support needed for new and experienced Traveller Community Health facilitators is high as the TCAT programme is challenging for the facilitators and the participants.

4.8.3 Coordinators questionnaire summary

The Coordinators were in agreement that a degree of fluidity needs to inbuilt into the TCAT programme that is dependent on the wide range of service providers attending and their available timeframes. There was consensus that the content of the programme was effective in raising awareness of Traveller culture but the content needed to updated and refreshed for example with regard to Traveller ethnic minority status.

There was agreement that the Traveller Community Health Workers need a specific skill set to deliver the programme that consists not only the ability to develop facilitation skills but also the desire and confidence to deliver the programme. The Coordinators were explicit that their role is to support the delivery of the TCAT programme. They are responsible for the coordination and administration of the programme and are there in a supporting role on the day. It is the Traveller Community Health Workers who facilitate the training and in agreement with the findings from the evaluations they point to benefits of service providers getting the opportunity to meet with and talk to Travellers, to raise concerns and build links.

Suggestions for improvement to the TCAT programme included addressing the allocation of hours to deliver the training as this interferes and puts extra demands on the Traveller Community Health Workers’ hours. It was also suggested to expand the potential audience by introducing mandatory TCAT for all public service workers. Again, the Coordinators stressed the need for updated information, additional resources and training for the facilitators.

4.8.4 Facilitators Focus Groups

The facilitator focus group interviews conducted during this evaluation gave rise to interesting findings. Firstly, it is noteworthy that since 2007, an estimated number of 1,200 service providers across the SECH regions have participated in the TCAT programme. In relation to the TCAT operational delivery (Section 4.4.2), it was evident that the facilitators were satisfied with the programme, in particular, the tailored TCAT package and the advantages to the fluidity of TCAT delivery were deemed significant. Confident, experienced group facilitators were reported to be amongst the key characteristics required to deliver training and finally facilitators called for and welcomed mandatory TCAT training for all front line staff.

Despite the fact that the facilitators reported that the advantages of TCAT outweighed any disadvantages associated in delivering the programme; it was very clear that a lack of time, TCAT not being recognised as a KPI, lack of skills and resources hindered facilitator’s delivery of TCAT and calls were made to strengthen the scope and breadth of the programme. 4.8.5 Travellers Focus Groups summary

It was clear from the Traveller focus groups that the current TCAT programme needs to be targeted more broadly at service providers. The need to encompass the education sector and in particular the need to target primary schools was highlighted as an area warranting further attention. However, in general all sectors were reported

39

to potentially benefit from increased TCAT delivery, including Travellers themselves. Further to this, it is evident that discrimination and prejudice is still a very real problem facing the Travelling community today and more work needs to be attributed to this area when developing future TCAT training packages. 4.8.6 Past Participants Questionnaire summary

The findings from the questionnaire of past participants suggest that for the respondents who found the TCAT training a positive experience on the day their opinion had not altered over the passage of time. The majority of respondents felt that the training had impacted on their interactions with Travellers and that their work style / behaviour had changed to some degree since undertaking the TCAT programme. Unfortunately the sample was too small to be representative and further research needs to done in this area but the findings indicate that an inbuilt follow-up survey of past participants could be beneficial to the future roll out of the TCAT programme.

Table 5: Overall Summary of Findings

STAGE 1 QUAN.*

STAGE 2 QUAN.

STAGE 3 QUAN.

STAGE 4 QUAL.**

STAGE 5 QUAL.

STAGE 6 QUAN.

TCAT PROGRAMME OVERVIEW: PROGRAMME OVERVIEW:

TCAT Evaluation Forms

THP Coordinators

Health Promotion Officers

TCAT FacilitatorsFocus Groups

Traveller Views Focus groups

Past Participants of TCAT

(1.) CONTENT Very Good Overall good/ further training

Overall good/ further training

Overall good/ further training

N/A Mostly Good

(2.) TIME Just right 2hrs - Full day Full day 2hrs - Full day N/A N/A

(3.) DELIVERY Very good /excellent

THC workers essential to delivery

Delivery by Traveller Facilitators vital

Needs to be delivered by experienced trained Traveller facilitators

Delivered by Travellers

Good/ very good

BENEFITS OF THE PROGRAMME

Travellers as facilitators

Travellers as facilitators

Travellers as facilitators

Travellers as facilitators

Travellers need to be involved.

Travellers as facilitators

ADDITIONAL THOUGHTS /FUTURE ROLL OUT

Up to date information on Traveller Culture

Training needs be more widely available, having two to three dedicated teams in each area and a Coordinator to oversee the training in each area.

Facilitators need support as the TCAT programme is challenging for the facilitators and the participants.

Training needs to be more widely available, and should be delivered to all service providers who work with Travellers

Training needs to be more widely available, and should be delivered to all service providers who work with Travellers

Up to date information on Traveller Culture

40

Chapter 5. Discussion and Recommendations

This study sought to evaluate the Traveller Culture Awareness Training Programme as delivered by the Traveller Health Unit SECH. The aim of the TCATP was to contribute to improving the health status of Travellers by improving their uptake of health services and other public services that influence health outcomes. The objectives of the programme were to:

• To raise awareness of Traveller health issues • To provide information on Traveller culture and how this impacts on use of services• To identify the main barriers experienced by Travellers in accessing services • To identify ways of moving forward to improve access and uptake of services

The study used a mixed methods approach to data collection to obtain the views of key stakeholders regarding the TCAT programme and how it was achieving the above aims and objectives. The key stakeholders were the Programme Facilitators, Coordinators, the Health Promotion Officers, Travellers and Programme participants. The overall sample accrual for the study was good with, the views of all the Health Promotion Officers and Coordinators obtained using questionnaires and 75% of the Traveller Community Health Workers Facilitators participated in focus groups. Travellers were invited to participate in focus groups and thirty-eight took part. Programme participant evaluation forms, completed immediately after the programme, were analysed with the Research team accessing 48% of the programme evaluation forms. Past programme participants were also invited to take part so as to examine the longer term impact of the programme but only 32 responses were received from past programme participants. Study objectives will now be discussed in relation to the study findings .

5.1 The organisational structure of the programme The organisational structure of the programme as this relates to the varied geographical implementation of the programme was considered by the research team. The study remit as originally planned with the Steering Group was to examine the delivery of TCAT within SECH, focusing particularly on the previous two years of programme delivery. However, limiting to the previous two years proved problematic. Evaluation forms as received by the Research Team were not time framed and hence it was difficult to focus on previous two years only. However, following a discussion with the Steering Committee it was agreed that as the programme had been rolling out in its’ present format since 2007 the inclusion of older data would not affect the study findings.

It was seen that the number of programmes delivered varied widely across the geographical spread of SECH as detailed in section 2.8. No training had been undertaken in the last two years in one region due to a lack of trained suitable facilitators. In another region, it was reported that the programme delivery had tapered off in recent years due to job time pressures.

Where the training had been delivered, the organisational structure in place was very similar. The programme administration was undertaken by the Coordinators. They plan dates, organise venues, including organising necessary equipment and paperwork, invite participants and send reminders. Coordinators also hold a pre -programme session with the Traveller Facilitators to prepare for the group attending. The programme is then delivered using a team approach, with two/ three Traveller Healthcare Workers depending on number of participants expected, within minimal input from the attending Coordinator, who only steps in if asked to address an item by the Facilitators. Finally, the programme is evaluated by the delivery team post-delivery, utilising the participant evaluation forms and a delivery team evaluation of the programme. The issue as to whether the Coordinators should continue the full administration and organisation of the programme was raised, with a view expressed that the programme should be fully Traveller led. If this were to be the case. it was identified that further training and support would have to be organised for Travellers to take on this role.

It was identified that there were wide variations in programme delivery. This wasn’t just between geographical areas but also varied considerably depending on the planned programme participants. For example, the programme could take a mental health focus, for example bereavement, where the attendees were from mental health services. Programme delivery could also vary depending on the interest and participation of the attendees on any given day, where changes could be made mid-programme if interest was waning as the programme progressed or where the attendees were requesting more information on specific areas/ topics.

41

5.2 Common understanding and shared beliefs of key stakeholders The degree of common understanding and shared beliefs of key stakeholders as this relates to the aims and objectives of the Traveller Culture Awareness programme was reviewed by the research team as arising from the study findings.

Across the range of stakeholders it seemed there was agreement that the aim of the programme was appropriate and the programme as delivered achieved the objectives: raising awareness, providing information, discussing barriers and means of improving access to services.

It was noteworthy that while the programme was devised to be delivered to health care professions, it has in fact been delivered far more widely to a diverse range of disciplines and inter-professional agents. This would seem to be appropriate when one considers the broader determinants of health, that Travellers will interact with a broad range of professionals and that these professionals and inter agency groups need to have an awareness of Traveller culture. However, it was then difficult to ascertain exactly how many health care professionals took part in the training and what impact the training might have on Travellers accessing health services.

5.3 The adaptations made to the originally designed programme;The research team examined the adaptations that were made to the originally designed programmes. An outline of the programme being delivered was provided to the Research team (see Appendix 12) and the research team were offered the opportunity to attend the training.

It seems that the programme is delivered differently and adapted frequently as outlined by the Facilitators focus groups and Coordinators questionnaires. Even when the programme was developed, it was acknowledged that such adaptations could be made, that a shorter version of the programme could be delivered and the programme could be tailored to the needs of the group attending. It seemed there was agreement that such adaptations are made based on knowledge of participants who will be attending and also that during a training programme changes are made depending on how the training is progressing. Whether a set programme could always be delivered seems therefore unlikely. Specific adaptations that have been made included videos have been updated by some programme delivery teams but these resources have not been used across the region.

5.4 Assess programme compliance with expected standards as these relate principles of good practice in relation to cultural competency and education based principles of design; As identified by Horvat et al., (2014) educational programmes that seek to enhance cultural competency should address key elements: educational content (knowledge, assessment and application); pedagogical approach (teaching and learning methods); structure of the intervention (including delivery and format, frequency and timing); and participant characteristics (teacher / facilitator and target audience).

Looking at each of these elements as identified by the evaluation study, it can be seen that the educational content included is structured as modules that can be delivered depending on the participants. There is no assessment built into the programme. However this would seem appropriate as the programme is not formalised and is of a short duration. The content application would seem to be good, it draws on empirical studies to inform the participants of the key issues that Travellers face and very importantly is delivered by ‘experts’, who are members of the Travelling community themselves.

The pedagogical approach for the originally designed programme appeared not to be articulated, however looking at the Facilitators Manual (see Appendix 12), it can be seen that there a variety of teaching strategies used, for example PowerPoint lecture format, discussions, group and individual activities. The layout of the sessions was also quite structured, however could be easily broken up into modules for separate delivery. The evaluation team did not receive exact details of the training received by Facilitators but this included communication, facilitation and presentation skills training, all of which would be required for programme delivery.

Regarding the structure of the programme, as outlined in section 5.1, there was variation in terms of programme delivery, format, frequency and timing. Delivery was always undertaken by Traveller Facilitators supported by Coordinators. The format varied from 1.5 hour sessions for full day programmes. The frequency of programme delivery also varied, depending on the region and influenced by factors including availability of Coordinators and trained facilitators.

The participant characteristics varied considerably depending on the target group attending. The Facilitators were always Traveller Community Health Workers supported by Coordinators of Traveller Community Community

42

Health Projects, all of whom are employed by Organisations funded through HSE Section 39 Funding. The role of the Coordinator would seem to be important in terms of organisation and support of the Facilitators and would need to be continued. It was suggested that perhaps a Traveller could take on this role , but it was also acknowledged that for a Traveller to take on this organisational role additional training and on-going support would be required. That the programme would continue to be delivered by Travellers is extremely important and of value inherent within the programme.

5.5 Informing the development of a Traveller Cultural Competence PackAs identified in section 2.8, cultural awareness training is an element within cultural competence development, along with knowledge and skills development (Sue et al., 2009). The programme as delivered includes both awareness raising and develops the participants’ knowledge on Traveller culture. The element of cultural competence which therefore has not been addressed is skills. The programme as currently delivered would need to be substantially changed if skills development were to be included. To develop cultural competence skills would require teaching and learning strategies such as exposure, demonstration, practice and reflection. The value of such culture skills development is obviously important and could have a strong impact on Traveller- professional interaction, but would need substantial consideration in terms of programme development and resourcing. Getting health professionals to engage with the programme so as to raise awareness and level of knowledge would seem to have been a challenge, for example with a problem of staff release. Where further release may be required for additional skills development so as to move toward cultural competence attainment could prove problematic.

5.6 Study Limitations As with all research studies, there are limitations to the study that affect the generalisability of the study results and may impact on the study validity. The study was limited to SECH and while there is culture awareness training available nationwide, this evaluation is not addressing these programmes. The evaluation forms were spread over a wide time frame and it was not possible to fully link the evaluation to a specific programme delivered, so hence the evaluations may have referred to programme of differing lengths and focus. The research team were provided with only 48% of the completed evaluation forms and only a very small number (32 participants) responded to the questionnaire which was looking at the views post programme and possible impacts on work life and Traveller interactions. The research team worked with the Steering Group which had Traveller stakeholders. The research team would have liked to have included Travellers more in the study roll out, data collection and analyses and while this offer was made, it was not taken up by any Traveller. 5.7 Conclusions and Recommendations The findings from all stages of this evaluation clearly identify that the participants in the study recognised the value of the TCAT programme and the need to continue to offer training in this area. This is in line with best practice and this programme is important and included in the South East Traveller Health Unit SE THU Strategic Plan 2015-2020. It is included that ‘Priority health services receive Traveller health and cultural competency training’. It was however also evident that there is a need to address the future rollout of the programme and how it can best be organised, resourced and delivered.

R1. The HSE should continue to offer Traveller Culture Awareness Training

In relation to programme content, this evaluation recommends TCAT continue to be delivered utilising a ‘module by module’ format. Specific short training modules should be developed on topics relevant to specific key target groups. The current ‘TCAT Training Manual’ (see Appendix 12)- guides programme content in terms of delivery and includes the following sections; Prejudices and Influences; Traveller Health Statistics; Traveller Culture and History DVD + Overhead; Definitions; Myths and Beliefs; Service Providers - Experience of working with Travellers; Barriers to Accessing Services “Travellers Experience”; Role of Community Health Workers; Strategies for Change. In reference to module development, this evaluation recommends to build on this guide and include up to date statistical information, social analysis, ethnic identifiers, nomadism and include more interactive materials.

R2. Continue to use the modular approach to delivery of the awareness training and build on these modules

The evaluation findings identify the need to develop the scope of the current programme and in particular the

43

need to target more front line health care staff and public health sector employees. This evaluation estimated that approximately 1,200 service providers across the HSE SECH region had previously participated in TCAT (since programme commencement in 2007) but no data was available to the evaluation team to determine the breakdown in the numbers of previous participants of TCAT per sector.

Therefore, it could be the situation that key front line healthcare professionals may not in fact be receiving this important training. This evaluation therefore recommends offering this training to more front line staff, those that have regular contact with Travellers. Health professionals identified for such training from the focus groups included: maternity services, paediatric services, primary care and public health services and all those working directly with Travellers. Priority groups identified in the SE THU Strategic Plan 2015-2020 were health services/ social work services, local authority/public representative, schools and training institutes/ media/ business/ Chamber of Commerce/ Gardaí, social services. In terms of offering, consideration also needs to be taken of the need to ‘market’ the programme, making it more visible to staff who may interested in undertaking the programme, perhaps creating a webpage and distributing flyers on the programme to key settings

R3. HSE should identify the priority staff who require this training and target these for programme delivery

The evaluation team are aware that it can be a challenge to get staff to engage with this training. Consideration needs to be taken therefore as to how best to get this engagement. An issue which could be causing reluctance to attend could be the difficulty with release. The THU need to consider how best to deal with this challenge. It has been identified in the findings that the programme is delivered in a modular format wherein programme elements are included or omitted. To address the difficulty with staff release, preparation of key modules which could be delivered in on-line mode could provide greater coverage to a wider range of participants and address key elements of Traveller culture awareness. It should be stressed however that the success of the programme to date has been in the Traveller interactions with the programme participants and the question and answer sessions. Undertaking an on-line programme could be used as a preparation for a face to face delivered programme, shortening the duration that would be required for delivery but retain the very valuable element of Traveller- participant interaction.

The on-line programme would need to be developed in a full and genuine collaboration with Travellers to ensure that their voice is heard in this programme development. The modules which could be delivered in an online modality would need to be identified and then expertise in the preparation of online programmes would need to be resourced. The format could include videos, voice overs, online exercises and mini quizzes built in to encourage engagement and enhance learning of the participants. A certificate of completion could then be printed out by the participant and displayed in the workplace. A focus group item raised was to include cultural awareness training as part of the training for new health and social care professionals and the Gardaí. An online programme would enable the easier inclusion of such content in other educational programmes.

R4. Consider development of an online programme on Traveller Culture and Issues to support the current programme delivery model

R5. Allow for a completion certificate from the online programme as for the current programme

R6. Ensure full Traveller involvement in the development of this programme

R7. Promote the inclusion of the online programme in educational programmes for health and social care professionals and the Gardaí

The SE THU Strategic Plan 2015-2020 outlines a proposal for the development of Cultural Competency Training for Service Champions. As this has not yet commenced in the region, the evaluation team did not specifically

44

address this. The proposal for service champions and the roll they would play within services to promote Traveller Culture awareness is undoubtable important but would seem to be not yet operational. A pilot of such a champion programme would seem warranted to test the feasibility and operational issues that may arise.

R8. Pilot the Service Champion Model within a service and evaluate

The ideal would be to build up a critical mass within prioritised services of those with Traveller culture awareness undertaken. However it would seem in order to attain a cohort of trained personnel, value must be placed by services and staff on receiving this training. Inclusion of culture awareness training as a requirement for staff in prioritised services and putting in place a KPI on the number of staff trained and monitoring of this indicator would be means of developing this critical mass. Development of service champions could then also be put as a KPI for services but perhaps this is a later stage development.

R9. HSE need to include Traveller Culture Awareness Training as a KPI for target groups

Another strategy which could be considered to encourage the engagement of key priority staff in this training could be development of the programme so as to obtain Continuing education units (CEUs) for health and social care professionals. The various registration boards either have such continuous professional development requirements currently or are moving towards such a requirement. These registration boards have mechanisms in place where training programme can be awarded CEUs. The THU may consider obtaining such accreditation for the training as a means of incentivising health and social care staff to participate in the programme.

R10. Consider obtaining CEU points for the Traveller Culture Awareness Training Programme

With the new Ethnicity recognition and as new data on Traveller health issues becomes available, there may be a requirement for follow up training. However, until a substantial cohort of front line staff have received training, consideration of – upskilling/ re-training is a more long term issue. The SE THU Strategic Plan 2015-2020 identified the possibly of sharing of programmes/ resources, that is those which have been trialled and found to be successful. Certainly the TACTP has been shown in this evaluation to be successful in raising awareness of those attending. There is substantial expertise available now within the THU in terms of trained and experienced programme facilitators. The evaluation team are of the view that this cohort can be used to develop and support more programme facilitators. If the programme is to reach its full target audience, there will be more programme facilitators required. Currently only Traveller Community Health Workers act as facilitators, the evaluation team suggest that other Travellers could also become involved in delivery of the programme, with of course the proviso of requiring full training and ongoing support.

It seems that there is only one male Traveller Community Health Workers at present in SECH, but he is not a programme facilitator/ It is important therefor to consider involving more Traveller men as programme facilitators.

R11. Train more Travellers, either Traveller Community Health Workers or non-Traveller Community Health Workers to be programme facilitators

Facilitators participating in this evaluation were credited for their confidence, communication, motivation to deliver programme, facilitation, leadership and management skills and these were largely attributed to having previously participated in facilitation skills training. This evaluation highlights the need to build on current training (facilitation skills training) and recommends that all facilitators’ delivering TCAT receive validated and certified training. The evaluation previously conducted on training for delivery of Traveller culture awareness identified that having a validated programme was valued by the Travellers who received the award. This training should be considered mandatory for any new Facilitators. It was felt by the current facilitators that further training was needed on dealing objectively with challenging and difficult questions/ people.

45

R12. Consider providing a NQF validated programme to new and existing trainers

Resources to support the programme were also raised in the evaluation. These resource issues include equipment, administration and delivery requirements.

A barrier linked to programme delivery was the lack of equipment resources to effectively deliver TCAT programmes, for example over-head projectors and videos were still used by some facilitators delivery these programmes. The need for increased resources, i.e. laptops and equipment required to assist with more interactive training delivery modes are required to present a professional programme. Common sharing of training resources should be encouraged and required materials provided to all programmes across SECH regions. Additionally, facilitators will need to be trained to confidently deliver interactive training materials, ICT and PowerPoint presentations.

R13. Ensure that there is suitable ICT and other equipment to enable effective programme delivery, perhaps sharing this from a central location

Programme delivery could perhaps be co-ordinated from a central unit. This could assist in part to reduce resource demands. A central administrator / Coordinator could promote/ market the programme, organise delivery teams, book venues, maintain a database and ongoing evaluation of the programme. If the programme is to be delivered more widely, the need for such administrative/ organisation support will become more of a demand. The maintenance of a central database is an important point, it would allow for monitoring of programme delivery, informing the achievement or not of KPIs should they be introduced and enable follow up of programme participants, perhaps in terms of upskilling.

R 14. Create a centralised administration/ co-ordination system for organising the delivery of the training

One of the key barriers to programme delivery highlighted amongst all groups participating in this evaluation was in relation to the time required to prepare, refresh and deliver TCAT programmes. Part time working hours of facilitators in addition to current projects running to capacity were all linked to the decline in the number of TCAT programmes delivered across all HSE CHO 5 region in recent times.

It seemed therefore that there is a lack of trained facilitators available to deliver the programme. Creation of a bank of trained facilitators (both THU and non THU Travellers) who could work across the region could in part help in ensure that the programme is delivered across the region and can continue to be delivered into the future.

R15. Create a bank of facilitators who can deliver the programme across the region

Another key resource issue is that facilitators only work part time hours. While it is acknowledged that there are a number of reasons for this, it reduces the facilitators availability for their regular work for that week and also reduces the number of programmes that can be run. Indeed, lack of facilitator time was a reason given in one region for the non-running of the programme for a number of years. If the programme is to be more frequently and widely delivered, the issue of resourcing of facilitators must be addressed, and should include the time for programme preparation, delivery and team evaluation post programme.

R16. Consider how the facilitators can be resourced to allow for more programme deliveries

46

It was evident from both the evaluation forms and the past participant forms received that the programme is effective in terms of raising awareness and developing knowledge among the participants of Traveller culture and the issues they face for those who attend the training. The Traveller focus group findings identified however that substantial lack of knowledge on Traveller culture still exists. It was not possible to ascertain the actual impact of the training conducted to date. One Traveller in the focus group reported seeing a benefit from the training when dealing with hospital staff. Should a critical mass of staff receive the training, it is likely that there would be more positive benefits for Travellers receiving such services. However, without such a base of trained staff, it was not possible for the evaluation team to examine the effectiveness and impact of the training to date. The creation and maintenance of a database of past programme participants would allow for ease of follow up for future evaluations and examination of programme impacts.

R17. Maintain a central database of training provided

In order to address the recommendations above, there will be cost implications. It is beyond the scope of this evaluation to address these costs. However possible costs identified include programme delivery equipment costs, centralised co-ordination, additional Facilitators training and work hours, additional work hours for current Traveller Community Health Workers and costs associated with the development of an online modules(s) from the training programme.

47

References

All Ireland Traveller Health Study: Our Geels, AITHS (2010) ‘Summary of Findings’.Available: http://www.paveepoint.ie/wp-content/uploads/2013/10/AITHS-Summary-of-Findings.pdf

Andrew, S. and Halcomb, E., (2009), Mixed Methods research for Nursing and Health Sciences, Sussex: Wiley-Blackwell.

Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, Palacio A, et al. 2005 ‘Cultural competence: a systematic review of healthcare provider education interventions.’ Medical Care, 43(4): 356-73.

Betancourt JR, Green AR, Carillo JE, Ananeh-Firempong O.(2003). ‘Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care’. Public Health Reports,118 (4): 293-302.

Betancourt JR, Green AR. (2010). ‘Linking cultural competence training to improved health outcomes: perspectives from the field’. Academic Medicine, 85(4): 583-5.

Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund.

Braun, V. and Clarke, V. (2006) ‘Using Thematic Analysis in Psychology’, Qualitative Research in Psychology, 3(2), 77-101.

Cavaliero, T., (2016) Irish Traveller women negotiating home and school environments: identity, space and embodiment. Ph. D., Sligo: Institute of Technology, Sligo.

Collins, M. (2015) ‘Community Organisations Engaging with the Positive Duty ‘, in Public Sector Duty: A positive duty in mainstreaming equality and human rights on a statutory basis in Ireland, Dublin, Pavee Point Traveller and Roma Centre.

Commission on Itinerancy. (1963) Report of the Commission on Itinerancy. Dublin: The Stationery Office.

Committee on the Elimination of Racial Discrimination (2017) http://www.justice.ie/en/JELR/UNCERDIRL5_6_7PR_DRAFT_for_CONSULTATION_(003).pdf/Files/UNCERDIRL5_6_7PR_DRAFT_for_CONSULTATION_(003).pdf. Accessed 11th December 2017

Central Statistics Office, CSO (2016), ‘Irish Traveller per 1000 of Total Population by Province, County or City, Census Year and Statistic’. Available: http://www.cso.ie/px/pxeirestat/Statire/SelectVarVal/Define.asp?Maintable=CD716&Planguage=0

Creswell, J. and Plano Clark, V. (2011) Designing and Conducting Mixed Methods Research, 2nd ed., London: Sage.

Crowley, N. (2015) ‘Seeking Action on the Duty ‘, in Public Sector Duty: A positive duty in mainstreaming equality and human rights on a statutory basis in Ireland, Dublin, Pavee Point Traveller and Roma Centre.

Department of Health and Children. (2001) Quality and Fairness: A Health System for You Health Strategy. Dublin: The Stationery Office

Department of Health and Children. (2002) Traveller Health a National Strategy 2002-2005. Dublin: The Stationery Office.

Gerrish, K. and Lathlean, J., (2015), The Research Process in Nursing, 7th Edition, Sussex: Wiley Blackwell.

Government of Ireland, (2000-2015) Equal Status Acts 2000-2015, Dublin: The Stationery Office

Government of Ireland, (2003) European Convention on Human Rights Act 2003 Number 20 of 2003, Dublin: The Stationery Office

48

Government of Ireland, (2014) Irish Human Rights and Equality Commission Act 2014 Number 25 of 2014, Dublin: The Stationery Office

Health Service Executive, HSE., (2008), National Intercultural Health Strategy 2007-2012, Dublin: Health Service Executive.

Health Service Executive, HSE., (2015), South East Traveller Health Unit: SE THU Strategic Plan 2015-2020, Dublin: Health Service Executive.

Horvat L, Horey D, Romios P, Kis-Rigo J. (2014). ‘Cultural competence education for health professionals’. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD009405. DOI: 10.1002/14651858.CD009405.pub2

Housing (Miscellaneous Provisions) Act, (2002), Dublin: Irish Statute Book.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009405.pub2/full Important Cochrane review 2014

Ingleby D, Chiarenza A, Devillé W, Kotsioni I (2012). Inequalities in Health Care for Migrants and Ethnic Minorities. Vol. 2, Antwerp: Garant Uitgevers.

Irish Human Rights and Equality Commission (2017) Public Sector Equality and Human Rights Duty [online], available: https://www.ihrec.ie/app/uploads/2016/09/Public-Sector-Equality-and-Human-Rights-Duty-Leaflet.pdf [accessed 31 May 2018].

Irish Travellers Movement, (2017), Irish Travellers Movement / Strategic Priorities / Accommodation. http://itmtrav.ie/strategic-priorities/accommodation/

Johnstone MJ, Kanitsaki O. (2006). ‘Culture, language, and patient safety: making the link’. International Journal for Quality in Health Care, 18(5): 383-8.

Kelleher K, McGinley A and Healy C. (2003) Traveller Health: A Research Project to Develop an Action Plan for the Mid- Western Health Board. Limerick Department of Public Health

Kirkpatrick, D., (1994), Evaluating training programs: the four levels, San Francisco: Berrett-Koehler.

Kitzinger, J., (1994), The Methodology of Focus Groups: the importance of interaction between research participants, Journal of Sociology of Health and Illness, Vol. 16, No. 1, pp. 103-121.

Lane, P., McKenna, H., Ryan, A.A. & Fleming, P. (2001). Focus group methodology. Nurse Researcher, 8, (3), 45-52.

MacGréil, M. (2011) Pluralism and Diversity in Ireland, Dublin: Columba Press.

Mahmoud, E., and Molloy, O., (2016), Heatmap. Available: www.researchgate.net/profile/Mahmoud_Elbattah2/publication/305563701/figure/fig6/AS:412810124251136@1475433011025/Figure-14-Heatmap-Overall-predicted-cost-within-every-CHO-The-predicted-cost-with.png

McCabe C and Keyes F. (2005) A Review of Travellers’ Health using Primary Care as a Model of Good Practice: Pavee Point Primary Health Care for Travellers’ Project. Dublin: Pavee Point Travellers’s Centre

McGinnity, F., Grotti, R., Kenny, O. and Russell, H., (2017), Who Experiences Discrimination in Ireland, Dublin: Irish Rights and Equality Commission and Economic and Social Research Institute.

Nolan, B., and Maitre, B., (2008). A social portrait of communities in Ireland. Dublin: The Office for Social Inclusion.

O’Mahony, J., (2017), Traveller Community National Survey, Dublin: The National Traveller Data Steering Group and The Community Foundation of Ireland.

Patten, M., (2016), Questionnaire Research: A Practical Guide, London: Routledge.

Pavee Point, (2011), Evidence of discrimination and its impact on Travellers and Roma. Available http://www.paveepoint.ie/wp-content/uploads/2014/06/Discrimination-Impacts.pdf

49

Pavee Point Traveller and Roma Centre, (2015) ‘Public Sector Duty: A positive duty in mainstreaming equality and human rights on a statutory basis in Ireland’, in Dublin, Pavee Point Traveller and Roma Centre.

Pavee Point Traveller and Roma Centre, (2017) PAVEE POINT Strategic Plan 2017-2021, Dublin: Pavee Point Traveller and Roma Centre.Pawson, R. and Tilley, N., (1997) Realist Evaluation, London: Sage.

Ritchie, J. & Spencer, L. (1994). Qualitative data analysis for applied policy research by Jane RiTraveller Community Healthie and Liz Spencer in A. Bryman and R. G. Burgess [eds.] ‘Analysing qualitative data’, (pp.173-194). London: Routledge.

Schulze B, Krajic K, Trummer U, Pelikan JM. (2003). Responding to cultural diversity in hospitals: the European project. ‘Migrant-friendly hospitals’ Vienna HPH Newsletter, 23/03. 2003

SLAN (2007), Morgan, K., McGee, H., Watson, D., Perry, I., Barry, M., Shelley, E., Harrington, J., Molcho, M., Layte, R., Tully, N., van Lente, E., Ward, M., Lutomski, J., Conroy, R. and Brugha, R., SLAN 2007: Survey of Lifestyle, Attitudes & Nutrition in Ireland: Main Report. Dublin: Department of Health and Children; 2008.

Sue S, Zane N, Gordon C, Nagayama Hall GC, Berger LK.(2009). ‘The case for cultural competency in psychotherapeutic interventions’. The Annual Review of Psychology, 60: 525-48

Truong M, Paradies Y, Priest N. (2014). ‘Interventions to improve cultural competency in healthcare: a systematic review of reviews’. BMC Health Services Research;14(1):99.

Walsh, J. (2015) ‘A legal perspective on the public sector duty’, in Public Sector Duty: A positive duty in mainstreaming equality and human rights on a statutory basis in Ireland, Dublin Pavee Point Traveller and Roma Centre.

Watson, D., Kenny, O. and McGinnity, F., (2017), A Social Portrait of Travellers in Ireland, Dublin: Economic and Social Research Institute.

Watson, D., Lunn, P., Quinn, E. and Russell, H., (2011), Multiple Disadvantage in Ireland: An Analysis of Census 2006, Dublin: Equality Authority and Economic and Social Research Institute.

WHO-HPH Task Force on MFCCH (2017). WHO-HPH Task Force on Migrant Friendly and Culturally Competent Health Care. 2017. (Available at: http://www.hphnet.org/index.php?option=com_content&view=article&id=291:task-force-om-migrant-friendly-a-culturally-competent-health-care&catid=20. Accessed 8th December 2017.

Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. (2008) One Size Does Not Fit All: Meeting The Health Care Needs of Diverse Populations. Oakbrook Terrace, IL: The Joint Commission, 2008.

50

Appendices

Appendix 1 Evaluation QuestionnaireTraveller Culture Training - One Day workshop

EVALUATION SHEET

Location Date

Facilitators

Q1 - Overall how would you rate the workshop?

1. Poor 2. Fair 3. Good 4. Very Good 5. Excellent

Q2 - Was the pace of the programme?

1. Too slow 2. A bit slow 3. Just right 4. A bit fast 5. Too fast

Q3 - What I gained from the workshop...

Q4 - What I found most helpful...

Q5 - What I found least helpful...

How would you rate the facilitator’s style?

1. Poor 2. Fair 3. Good 4. Very Good 5. Excellent

Q6 - Any Other Comments:

Thank you

51

Appendix 2 Health Promotion Officers QuestionnaireWe are interested in your views on the Traveller Culture Awareness Training Programmes.

1. What are your views on the programme? For example in terms of length of delivery, content, model of delivery and any other items.

1.1 Length of delivery

1.2 Content

1.3 Model of delivery

1.4 Any other

2. What do you see as the usefulness or benefits of the programme?

3. Are you aware of changes which have been made to the programme? Please select the appropriate answer

Yes No

4. If yes, what changes are you aware of?

5. What are your views on the impact of these changes?

6. What do you think are the key training needs of programme facilitators

7. If New Staff are brought on board as Traveller Facilitators what level of training do you think they

8. In your opinion how much time is needed to train a Traveller Facilitator?

9. If New Staff are brought on board as Traveller Facilitators what level of support do you think they will need to have?

10. Would you be willing to link with the research team further, either through a face to face or telephone interview. If interested please leave your email address and our research assistant Deirdre Byrne will be in touch to arrange the details.

52

Appendix 3 THP QuestionnaireWe are interested in your views on the Traveller Culture Awareness Training Programmes.

1. What are your views on the programme? For example in terms of length of delivery, content, model of delivery and any other items.

1.1 Length of delivery

1.2 Content

1.3 Model of delivery

1.4 Any other items

2. What do you see as the usefulness or benefits of the programme?

3. What are your views on the training required for the Traveller Facilitators Programme?

4. As a Coordinator what supports do you provide for this programme?

5. What other supports might be required for Traveller Facilitators?

6. What would be your suggestions for improvements to the programme?

7. What changes are you aware of that have been made to the programme since its initial development?

8. What do you think has been the impact of these changes?

9. What would be your suggestions for the future roll out of the programme?

10. Would you be willing to link with the research team further, either through a face to face or telephone interview. If interested please leave your email address and our research assistant Deirdre Byrne will be in touch to arrange the details.

53

Appendix 4 TCAT Past Participants QuestionnaireTraveller Cultural Awareness Training Evaluation Questionnaire

You are being asked to complete this questionnaire as you previously undertook the Traveller Culture Awareness Training Programme. This programme is currently being evaluated by a research team from Waterford Institute of Technology (WIT) and your views will help improve the future roll out of this programme.Any information gathered from the questionnaire will be treated in the strictest confidence.Please answer all questions.

1. How many months is it since you undertook this training?

2. In what area do you work?

Health Professional Social Worker Garda Social Care Worker Other (please specify)

3. What are your views on the programme? For example in terms of: Length of delivery

Content

Model of delivery

Any other items

4. What do you see as the usefulness or benefits of the programme?

5. What impact has this programme had on your interactions with Travellers? Please illustrate with examples where possible.

6. Has your work style / behaviour changed in any way since undertaking the programme?

7. Is there other content that you think should have been included in the programme?

8. Would you be willing to link with the research team further, either through a face to face or telephone interview. If interested please provide your email/telephone number and our research assistant Deirdre will be in touch

54

Appendix 5 Evaluation Questionnaire Code bookCode Book for Workshop Evaluations

The evaluation consists of 7 questionThree questions 1, 2, and 6 are formatted as Likert with multiple choice answers and the other four questions 3, 4, 5, and 7 are open ended questions. I have devised a code book for these questions. There were a wide range of answers but there are quite a lot of overlapping or similar replies. I have condensed the answers to less than 8 per question.

Q 3 What I have gained from the workshop 1. Knowledge of Traveller culture 2. Awareness of barriers/discrimination 3. Current Traveller culture 4. Understanding of Traveller culture 5. Hear others views 6. Insight into cultural issues 7. Appreciation of Traveller culture 8. Confidence in working with Travellers/making connection 9. No answer

Q 4 What I found most helpful 1. Question and answer section 2. Discussions with the Traveller Community Health workers 3. Hearing Travellers POV 4. Learning about levels of discrimination 5. Increased understanding 6. Honesty/frankness of Traveller Community Health workers 7. Hearing about/making links to Traveller projects and THC workers 8. All helpful 9. No answer

Q 5 What you found least helpful 1. Nothing/all helpful 2. Less time spent on introduction 3. Sound on the video/DVD 4. Too short 5. Some of the exercises 6. More up-to-date information/future plans 7. No answer 8. Interruptions

Q 7 Any other comments 1. Could be longer 2. Great/excellent/enjoyable workshop and presenters 3. Training should be expanded to wider audience and refreshed 4. Need for change 5. Opportunity for honest talk in a safe environment 6. Mostly hear negative stories 7. No answer 8. Traveller men/young people included

55

Appendix 6 TCAT Focus Group Consent Form

An evaluation of the Traveller Cultural Awareness Training

CONSENT FORM:

Please insert your initials in the box opposite each statement:

I have read the information form and understand fully the purpose of this study, and what my participation will involve.

I am satisfied that any queries, which I had, were answered satisfactorily.

I am participating in this study of my own free will.

I am aware that I can withdraw from the study at any time.

I am aware that all information I give will be in confidence and that my name will never be used with this information.

I am aware the interview will be audiotaped.

I am aware that I can request a copy of the interview transcription within one month of its’ recording.

Participants Signature Date Researchers Signature Date

Name in Block Capitals Name in Block Capitals

56

Appendix 7 Travellers Focus Group Consent Form

An evaluation of the Traveller Cultural Awareness Training

CONSENT FORM:

Please insert your initials in the box opposite each statement:

I have read the information form and understand fully the purpose of this study, and what my participation will involve.

I am satisfied that any queries, which I had, were answered satisfactorily.

I am participating in this study of my own free will.

I am aware that I can withdraw from the study at any time.

I am aware that all information I give will be in confidence and that my name will never be used with this information and that information from the focus group will be kept confidential I am aware the interview will be audiotaped

I am aware that I can request a copy of the interview transcription within a month of its’ recording

Participants Signature Date Researchers Signature Date

Name in Block Capitals Name in Block Capitals

57

Appendix 8 Information Health Promotion Officers

Department of Nursing and Health CareWaterford Institute of Technology

Date

Dear Sir/ Madam

The Department of Nursing and Health Care at Waterford Institute of Technology were recently successful in securing the role of evaluating the Traveller Culture Awareness Training programme with the research being undertaken in a collaboration with the Social Inclusion Department.

As part of this evaluation, the research team hope to get the views of key stakeholders regarding this pro-gramme. The Traveller Health Unit are sending this on to you on behalf of the research team.

The Research Team are hoping that as you were involved in the initial development and training of programme facilitators that you would complete the attached questionnaire or complete the questionnaire online via this link.. . The questionnaire includes your views on the programme, the usefulness of the programme, meeting the training needs of facilitators and suggestions for improvement of the programme.

The answers you provide will give valuable information on the programme and will inform its future development. Returning of the completed questionnaire or completing online signifies consent.

We would be very grateful if you could facilitate us in this request.

The research team will ensure that no one will be identifiable from the questionnaires when the data is collated and we will also ensure the safe storage, return/ destruction of the questionnaires on project completion.

Yours sincerely

Deirdre Byrne

Research Assistant for the TCATP EvaluationOn behalf of the WIT Research Team

58

Appendix 9 Information Traveller Health Project Coordinators

Department of Nursing and Health Care Waterford Institute of Technology

Date

Address to Sender

Dear Coordinator

Re: An evaluation of the Traveller Cultural Awareness Training

The Department of Nursing and Health Care at Waterford Institute of Technology were recently successful in securing the contract to evaluate the Traveller Culture Awareness Training programme with the research study being undertaken in collaboration with the Social Inclusion Department with ethical approval for the study ob-tained from the Research Ethics Committees, HSE, South East and Waterford Institute of Technology.

A key part of this evaluation will be getting the views of the Traveller Culture Awareness Trainers who facilitate the Traveller Culture Awareness Training.

The research team hope that your team would consider taking part in a group conversation on the programme, the content, delivery and your suggestions for the future delivery of this training. If your team is happy to take part, the research team would like to meet with The Traveller Culture Awareness Trainers on your team you work with in delivering the programme for a conversation about the programme. This will take approximately one hour. We may then bring all of the TCA Trainers from the region together for another conversation, again lasting about an hour. Might take more than an hour?

The research team will make sure that what is said at these conversations are used only for the report (and is therefore confidential) and when the evaluation report is being written up, we will make sure that no one can be identified as everyone being interviewed will be given a number code and only this code will be used in the report ( and is therefore anonymous). We really hope that your team will consider takingpart and if you are interested, please contact Deirdre Byrne, Research Assistant yourself or your Coordinator who will let us know you are interested in taking part. We will then be in touch with you to discuss this further as to where and when the conversations will be held and to get your agreement to take part in the study.

Yours sincerely

SD or RA

On behalf of the WIT Research Team

59

Appendix 10 Information TCAT Focus Groups

An evaluation of the Traveller Cultural Awareness Training

INFORMATION SHEET

What we are trying to do?

The Traveller Culture Awareness Training has been delivered over the last few years and the HSE now want the programme reviewed. The Department of Nursing and Health Care at Waterford Institute of Technology are working with the HSE to carry out this evaluation. We would like to speak with you in relation to your views as you have been delivering the programme. Your views and suggestions will inform the roll out of the programme in the future.

What does it involve?

We will ask you to take part in a conversation with our research team which includes Travellers. This discussion will be held with the other facilitators you have worked with a later conversation to which all programme facil-itators are invited. The conversation will be audiotaped. You will have the opportunity to request a copy of the transcribed conversation. The conversation will explore your experiences of delivering the programme, the training you received and think is necessary, your views on the content included in the programme, the usefulness of this culture awareness training for those attending the programme, out-comes that you have seen from the programme and suggestions for improvements.

Consenting to participate?

It is entirely up to you whether you take part and to what extent. You can change your mind at any time without giving any reason.

Confidentiality

All information is kept strictly confidential and your name will never be used with this information.

Any questions? If you have any questions at any time, please feel free to contact us:

Deirdre Byrne Dept. of Nursing & Health CareWaterford Institute of Technology Cork Rd. WaterfordEmail: dbyrne@wit.ieTel: 051 845548

Dr. Suzanne DenieffeDept. of Nursing & Health Care Waterford Institute of Technology Cork Rd. WaterfordEmail: sdenieffe@wit.ie Tel: 051 30247

60

Appendix 11 Information Travellers Focus Group

Traveller Culture Awareness Training Evaluation

INFORMATION SHEET

What we are trying to do?

The Traveller Culture Awareness Training has been delivered over the last few years and the HSE now want the programme reviewed. The Department of Nursing and Health Care at Waterford Institute of Technology are working with the HSE to carry out this evaluation with ethical approval for the study obtained from the Research Ethics Committees, HSE, South East and Waterford Institute of Technology.

We would like to speak with you in relation to your views as a Traveller. Your views and suggestions will inform the roll out of the programme in the future.

What does it involve?

We will ask you to take part in a conversation with our research team. This conversation will be held on your own if you wish or in a group with other Travellers. The conversation will be taped. You can ask for a recording of your interview. The conversation will explore your views on the need for Traveller culture awareness training programmes, what content should be included, what you see as the benefits of such programmes, whether you have examples of benefits arising from the programmes that had been delivered and what groups you think require this training

Consenting to participate?

It is entirely up to you whether you take part. You can change your mind at any time without giving any reason.

Confidentiality

All information you give during the conversation is kept strictly confidential and your name will never be used with this information.

Any questions? If you have any questions at any time, please feel free to contact us:

Deirdre Byrne Dept. of Nursing & Health CareWaterford Institute of Technology Cork Rd. WaterfordEmail: dbyrne@wit.ieTel: 051 845548

Dr. Suzanne DenieffeDept. of Nursing & Health Care Waterford Institute of Technology Cork Rd. WaterfordEmail: sdenieffe@wit.ie Tel: 051 30247

61

Appendix 12 TCAT Programme Facilitators Manual

Traveller CultureAwareness TrainingFacilitators manual

62

Acknowledgements

This pack was compiled by the 8 regions of the Regional Traveller Health Network 1. Waterford Traveller Community Health Project

Dungarvan Traveller Community Health Project

2. North Wexford Traveller Community Health Programme, Wexford Local Development Company Limited.

Kilkenny Traveller Community Health Project

3. South Wexford Traveller Community Health Project. Wexford Local Development

Carlow Community Traveller Health Project

St Catherine’s Community Services Centre

Clonmel Traveller Community Health Project

Tipperary Rural Travellers Primary Healthcare Project

Funded by HSE South East Traveller Health Unit.

63

Traveller Culture Awareness TrainingProgramme for One Day Workshop

10am - 4pm

10.00am Introduction to Workshop • Aims and Objectives • Ground Rules

10.30am Group Introductions

10.50am Concerns and Expectations

11.15am BREAK

11.30am Prejudices and Influences

11.45am Traveller Health Statistics Traveller Culture and History DVD + Overhead

12.15pm Definitions Myths and Beliefs

1.00 - 2.00pm LUNCH

2.00pm Service Providers - Experience of working with Travellers

2.30pm Barriers to Accessing Services “Travellers Experience”

3.00pm Review

3.15pm Where do we go from here? Role of Community Health Workers Strategies for change

3.45pm Evaluation

64

IntroductionsTraveller Facilitators Introductions

1. Introduce themselves to group –

Who we are

Where do we come from (background, training, job, etc.)

What we hope is to create an environment that the group would feel comfortable to ask what ever questions you like today.

Group Introductions

2. Group to work in twos

Each person to tell partner something about themselves

Each partner feeds back to large group

Exercise No. 1optional (depending on time / group)

Hopes and Expectations

Break up into groups of 4

Each group to make 2 lists:

What you hope to get from workshop Any fears or concerns about workshop

One person from each group to feed back

Facilitator to write up feedback on the flipchart

This sheet to be revisited at the end of the training

65

HANDOUT 1Health Service Use by Travellers (All Ireland Traveller Health Study)

1. Access to health services is good, with Travellers stating that their access is at least as good as that of the rest of the population.

2. Over 94% of Travellers in Rep. of Ireland have a Medical Card with this figure rising to 99% in the older age group.

3. Nearly 97% of all Travellers in Rep. of Ireland are registered with a GP.

4. However, the research reports that the healthcare experience is not as good as the general population, with communication cited as a major issue by both Travellers and service providers.

5. Barriers identified were waiting list (62.7%), embarrassment (47.8%) and lack of information (37.3%)

6. Complete trust in health professional (41.0%) was lower than general population (82.7% all and 81.8% GMS cardholders)

7. 82.7% of Travellers interviewed said they got their health information/advice from Traveller Community Health workers and the Traveller organisations.

8. 25% of Traveller women compared to 13% of general population had a breast screening.

9. 23% of the Travellers had Smear test compared to 12% of general population.

Key Findings of All IrelandTraveller Health Study (2009/2010)

(THESE ARE POWERPOINTS 1 – 5)

• Life expectancy for Traveller men is 15 years lower than for settled men It has decreased by 5 years since the last survey in 1987

• Suicide rates are nearly 7 times higher for Traveller men than settled men

• Life expectancy for Traveller women has increased to 70 This is still 11.5 years lower than settled women

• Main causes of death in Traveller community are heart Disease, cancer and lung disease

• Factors such as accommodation, education, employment, Poverty, discrimination and access to and use of services are also factors

• The population profile of the Traveller community is similar to developing countries, with a high birth rate, two thirds of the population under 25 but with fewer older people

• Just under half of all Travellers reported experiencing discrimination

• Only half of Traveller adults had completed primary school

66

ACCOMMODATIONPOWERPOINT 6

Table 1 Number of Traveller Families – November 2010

Number of families in 2010 No. of families %

(a) Local Authority Standard Houses (incl. Voluntary Housing) 3,453 36.46

(b) Private Rented Accommodation 2,380 25.13

(c) Group Housing 709 7.49

(d) Permanent Halting Site Bays 619 6.54

(e) Unauthorised Sites 444 4.69

(f) Own Resources 561 5.92

(g) Private Houses assisted by Local Authorities 481 5.08

(h) Sharing Housing 451 4.76

(i) Basic Service Bays / Transient Halting Site Bays 207 2.19

(j) Sharing Permanent Halting Site Bays 136 1.44

(k) Sharing Basic Service Bays / Transient Halting Site Bays 29 0.31

Totals 9,470 100 %

Source : Dept. of Environment, Community & Local Govt. Annual Count of Travellers Report 2011

Attitudes to Travellers• 73% of people surveyed agreed that Travellers should be facilitated to live their way of life decently • 79.4% would be reluctant to buy a house next door to a Traveller • 59.1% agreed “I would be willing to employ a Traveller”• 73.2% agreed they would consider a Traveller competent to serve on a jury

This is from “Emancipation of the Travelling People”, Fr. Michael Mac Greil, S.J. (stats from 2007/2008 National survey) published July 2010

National Survey on Health of Traveller Women• 71% women experienced verbal abuse because they were Travellers• 25% of those who suffered verbal abuse also subjected to physical violence• 34% of Traveller women suffered from long term depression (approx. 9% among settled women)

Pavee Point National Survey on Health of Traveller women 2007

67

HANDOUT 2Travellers (Pavee Point)

Travellers are a minority ethnic group, documented as being part of Irish society for centuries. Travellers have a long shared history and value system, their own language, customs and traditions. The distinctive Traveller lifestyle and culture, based on a nomadic tradition, sets Travellers apart from the sedentary population or ‘settled people’.

While Irish Travellers are native to Ireland, they have much in common with European Travellers and Gypsies. For example – a nomadic tradition, living in extended families and European gypsies also have to resist attempts to absorb them into the settled population, in order to retain their identity.

Cultural Practices

• Nomadic – from occasional to regular journeys – often described as a state of mind• May consider occupation of houses as essentially temporary in nature• Traveller women have primary roles as home-makers in their own communities• Music and storytelling used as bearers of culture• Language – Cant important part of Traveller heritage – also specific use of English language.• Extended family structures – live and travel in large groups• Travellers predominantly marry within their own community, marriage of close relatives is common• Space for work, home and children is not segregated.• Traditionally Traveller children have been fully part of adult society, speaking freely and frankly within

adult company• From the earliest age, children are integrated into the family work unit, learning skills by apprenticeship.

The acquisition of these essential skills supports the positive identity of the child. Unfortunately, these skills are not always appreciated when the Traveller child enters mainstream provision. This can have a negative effect and damage the self worth of the Traveller child.

“There is a special minority within each minority culture – children. In the dominant society the children of a minority must endure along with their parents the problems of social and cultural discrimination, and they are even more exposed to the risk of cultural dissolution, “

- Children of Minorities, UNICEF 1993

HANDOUT 3Origins of the Travelling People

Who are the Travellers?

There are many theories about the origins of the Travelling people, such as:• They are descended from Irish people who lost their land at the time of the Famine (This would mean that they

were one time settled people)• That Travellers existed in Ireland well before the Famine• This is supported by the fact that there are more than 10,000 Irish Travellers in the U.S. These people left Ireland

in the mid-19th C, bringing with them all the customs, lifestyle and marriage patterns of the Travelling people• Travellers existed in Ireland and Britain in 1562. There is a theory that these people came from where was

known as “Little Egypt”, they became known as Egyptians and this was shortened to “Gypsies”. It is thought that some of these gypsies may have intermarried with Irish Travellers.

• From the 12th Century the word “tinker” (Tin Ceard = Tin Craft) appeared many times in written documents. These were a group of Travelling crafts people who played an important role in Irish society and in the Irish economy.

• Traveller tradition is a very oral one so not much has been written about Travellers. There is some evidence to show that Travellers did not just come about in the last couple of centuries. There are lots of stories in Irish mythology that mentions people who had a different identity and culture from the rest of Irish society.

Barriers experienced by Travellers in accessing servicesFlipchart this – what do the group think the barriers might be?

Write down what they say and then show POWERPOINT 7 vFacilitators notes

68

Traveller Culture DVD This DVD (‘Our Ways, Our Culture’) will cover traveller culture and history such as

family relationships, nomadism, language etc.

Discussion following DVD – Facilitators will have a Q & A session with group

What did you think of the DVD?

Any questions on any part of it?

What is Traveller Culture - Ethnic Identity

Culture not static, it is alive, adapting and changing all the time Some aspects include:

• Marriage patterns • Way of rearing children • Nomadism • Family based self-employment (as opposed to wage labour) • Importance of family and extended family • Religious beliefs • Language

Culture is everything – how we act, how we make decisions, and everything else that is important

69

POWERPOINTS 7, 8 & 9Types of Discrimination

How do Travellers experience racism and discrimination?

Ask this question and then give examples – POWERPOINT 12 & 13

70

HANDOUT 4Discrimination

The Employment Equality Act, 1998 outlaws discrimination in employment across nine specific grounds. Discrimination will have occurred when a person is treated less favourably than another is, has been or would be on the basis of any of the mentioned grounds.

The nine grounds covered are:

• Gender• Marital status• Family status• Age• Disability• Race• Sexual Orientation• Religious belief• Membership of the Traveller Community

The Equal Status Act, 2000, extends the remit of the Employment Equality Act, 1998, to include outlawing discrimination on the nine grounds in the provision of goods or services, the procurement of accommodation and access to education.

Defining Discrimination

Discrimination may be defined as the differential treatment of individuals, or groups based on specific grounds.

HANDOUT 5There are three different types of discrimination:

Direct Discrimination

When a person is treated less favourably than another and is on any of the nine grounds. For example if a person was denied promotion because of lack of qualifications or if a woman was asked about childcare responsibilities during an interview.

Indirect Discrimination

This is discrimination by impact or effect. Indirect discrimination is subtle and occurs when there are practices that outwardly seem reasonable and appear to apply to everyone but operate to the disadvantage of a particular individual or group. An employer cannot establish a non-essential barrier to a job. Demanding an artificially high standard of written or spoken English, not essential to carry out a job, for example, could be discrimination on basis of race.

Discrimination by Association

This occurs when a person is treated less favourably because of association with another belonging to a specified group. For example, if a person is denied a place on a training course or denied access to accommodation because of an association with a person of different race or different religious belief.

71

DISCRIMINATION (N.C.C.R.I. Pack)Explanatory notes for trainers

• In this exercise we will try to emotionally and intellectually understand the effect of discrimination and its justifications. Here it is important to get the participants to reflect on past experience of discrimination, be it as victims or perpetrators.

• Where the participants have been discriminated against, you do not need to know exactly what happened in the particular cases as some experiences may be too personal to divulge, but rather try to get them to recognise the feelings, the grounds, the power and their responses in those instances of discrimination

• Where the participant is the discriminator, again there is no need to get all the details of the discrimination, but rather get the discriminators to identify their feelings, their justifications and their power.

• Anybody can be discriminated against and everybody has the potential to discriminate whether intentionally or unintentionally.

• We have established what prejudice is and we have explored the notion of power, it is now easier for us to explain and understand how discrimination can happen.

OPTION: DISCRIMINATION (NCCRI Pack)Objectives

• To define and understand discrimination• To examine the different levels of discrimination• To reflect on past experience of discrimination, be it as victims or perpetrators.

Materials

• Flip Chart• Sheets of paper and pens• HANDOUT: DISCRIMINATION & HANDOUT DISCRIMINATOR

Time

• 30 minutes

Instructions

• Distribute HANDOUT; DISCRIMINATION individually to participants• Take the feedback and write the results on the flipchart• Distribute HANDOUT; DISCRIMINATOR individually to participants• Take the feedback and write the results on the flipchart.

OPTION: Group Worksheet - DISCRIMINATIONAsk the group to recall an occasion when you were at the receiving end of Discrimination

(Through action or inaction)

Feelings What happened What did you do? Who had the power?

1.

2.

3.

4.

PREJUDICE + POWER = DISCRIMINATION

72

OPTION: DISCRIMINATION - WorksheetGroup Exercise

Ask the group to recall a situation when you were the discriminator?

Feelings What happened? Who had the power?

73

HANDOUT 6Discrimination - Fact Sheet

• Travellers are widely acknowledged as one of the most marginalized and disadvantaged groups in Irish society

• Travellers fare poorly on every indicator used to measure disadvantage; unemployment, poverty, social exclusion, health status, infant mortality, life expectancy, illiteracy, education and training levels, access to decision making, gender equality, access to credit, accommodation and living conditions. (ESRI, July 1986, paper no. 131)

GROUP EXERCISEUNDERSTANDING PREJUDICE

Objectives

• To explore our prejudices, stereotypes and assumptions• To understand that we all live with images

Materials

• Handout: NCCRI photographs portraying people of different origins living in Ireland• Sheets of paper and pens• Imagination

Time - 30 mins

Instructions Part 1

• Distribute the photographs, one per person or one per group according to number of Participants

For each picture, ask participants to Imagine:1. Name2. Nationality3. Profession

• Invite them to present the picture to the rest of the group• Ask participants the reasons why they chose one particular name or nationality for the person in the

photograph• Make a list of the reasons on the flipchart

74

UNDERSTANDING PREJUDICE (NCCRI)

• Reveal the real names, nationalities and professions of the individuals on the photographs• Discuss the origins of the different perceptions• Discuss how we incorporate these stereotypes• Ask participants to say if the exercise was difficult /easy and why• What did they learn?

Explanatory notes for trainers

• This exercise should be done at the beginning of a session, before introducing the definition of discrimination or racism

• The idea is to establish that we all carry images or prejudices. The key word in this exercise is PREJUDICE. It simply means to ‘pre-judge’ before hearing or seeing the evidence, hold an opinion or bias which is not based on facts, reason or first-hand knowledge. We all make assumptions.

• The challenge is to be aware of our prejudices and stereotypes because they are just images and assumptions, which sometimes have little to do with reality. Therefore we should not rely on them to make assessments as they can lead to discrimination.

• It is very important that the group reflect on the danger of stereotyping and think about the origins of our images. Because we all carry prejudices and stereotypes, we all have the potential to discriminate; therefore, the facilitator should not judge a participant for their choice or comment.

Instead of simply informing the participants that we all live with images and that we all make assumptions this exercise allows us to demonstrate the fact by exploring our own prejudices and stereotypes about other individuals or groups of people. Once this is clear to everyone, then we can explore the definitions of key terms. Needless to say that images and prejudices are major components of the definition of discrimination

Part 3 UNDERSTANDING PREJUDICE Photos (N.C.C.R.I.)

1. Sophie Kiang 6. J.J Rolle

Geneticist Actor / Singer / Songwriter British (in Ireland since age 5) African American Origins: Swiss/Chinese

2. Jude Hughes 7. Shashi Paschal Rami

Tailor Actor Irish Irish Origins: Irish/Caribbean Origins: Irish / Indian

3. Oliver Hughes 8. Patricia Tambwe Bora

Son of Jude IT Worker Irish Origins: Congolese / Burundi

4. Ian Brennan 9. Kay Ellis

Garda Signmaker Irish British Origins: Indian/Irish Origins: England / Ireland

5. Thomas McCann 10. Phil Mullan

Community Development Worker Information Officer Irish Irish Traveller Irish - Nigerian

75

POWERPOINT 14DefinitionofPrejudice

WHY ADDRESS RACISM? (NCCRI Pack)Tutors notes

Objectives

• To initiate a discussion about the reasons for combating racism• To explore the different motivations behind anti-racism work

Materials

• Flip chart , Pens and paper , HANDOUT - WHY ADDRESS RACISM?

Instructions

• Divide participants into small groups• Ask them to reflect on the following question:

Why address racism?

• Write the feedback on the flipchart• Distribute HANDOUT ‘WHY ADDRESS RACISM?’

Explanatory note for trainers

The important point here is to see that there are various reasons why racism should be addressed, such as:• Morality• Legislation• Changing demographics• Economic motives• Policy developments• Improvement of quality of life for all

76

HANDOUT 7WHY ADDRESS RACISM?

Morality

• Religious beliefs• Values

Legislation

1. National levelEquality legislation outlaws discrimination on a range of nine grounds, including, race (colour, nationality, ethnic or national origins): gender; marital status; sexual orientation; religious belief; age; disability and membership of the Traveller community.

• Prohibition of Incitement to Hatred Act (1989)• Employment Equality Act (1998)• Equal Status Act (2000)

This legislation is accompanied by an Equality Infrastructure to oversee and implement the Equality legislation: a) the Equality Authority and b) the Office of the Director of the Equality Investigations – The Equality Tribunal.

2. European levelCouncil directive 2000/43/EC of 29 June 2000 implementing the principle of equal treatment between persons irrespective of racial or ethnic origin. Also known as the Race Directive International level - Examples include: • The Universal Declaration of Human Rights (1948) • The International Covenant on Civil and Political Rights (1966)• The International Convention on the Elimination of all forms of Racial Discrimination (1989)

WHY ADDRESS RACISM?CHANGING DEMOGRAPHICS

• There is no such thing as a mono-cultural society• Immigration• Concern that the workforce should reflect the population profile• Travellers or other ethnic minorities• Foreign workers recruited abroad, such as the Pilipino nurses, the Indian IT specialists, etc.

ECONOMIC MOTIVES

• It’s good for business in general• The business approach focuses on compliance with the law to prevent costly court cases and bad publicity

or other problems such as high turnover among members of ethnic groups• Risk of wasting or underrating people’s contributions and potential• Some comparisons need a strategy to be able to reach certain markets• Service delivery is strengthened and made easier when the diversity of the community is reflected in the

workforce and it is weakened when customers’ needs are not met in a sensitive way• Good for reputation and credibility• Appropriate professional practice concern about public image. It is important to be seen as doing the

right thing• More access to new skills, technologies and knowledge.

77

POWERPOINT 15DefinitionofRacism

MYTHS AND BELIEFS ABOUT TRAVELLERS – Optional Tutors notes

Introduction

The purpose of this session is to help participants to look at their beliefs about Travellers.

Objectives

Participants will be able to:• Identify commonly held beliefs about Travellers• Explore the source of those beliefs• Explore the ways in which these beliefs affect the provision of services to Travellers

MATERIALS

Flip chart, Markers, Hand-outs,

ACTIVITIES

1. Handout 8 – individual work 2. Small group discuss each statement 3. Large group discuss WORKSHEET

DESCRIPTION OF ACTIVITIES

Handout When giving out Handout , ask each participant to write down three or four things they have heard about Travellers, emphasising that they do not have to be true. One Community Traveller Health Worker to sit in with each small group to discuss.

Small group discussion

Give out HANDOUT 8. Ask each small group to discuss each statement and to put them into the appropriate section of the worksheet

Large group discussion

When all the statements have been written on Handout 8 – in large group ask each small group reporter to read out their statements while the tutor writes them (in shorthand) on the flipchart, under the appropriate headings: “agree they are true”; “agree they are false” or “disagree or are unsure”. When they are all transferred to the flipchart discuss some of them in large group.

Note: Instead of using Handout 8 you can write questions on flipchart.

EVALUATION

The tutor will know from feedback etc. if objectives were met.

POINTS OF INTEREST (Myths and Beliefs)

• Focus on where people heard their information e.g. “Where did you hear that”?• Focus on why people agree or disagree with the statements• Focus on general statements e.g. “are you saying – all Travellers, most Travellers, some Travellers or

majority of Travellers”?• Draw out generalisations• Draw out common stereotypes• Where do we get most of our information from?

78

HANDOUT 8Write down three or four things you have heard, read or seen about Travellers. (They don’t have to be true). Tick in the appropriate box whether you believe they are true, false or you are not sure. One example is done for you.

Statement True False Unsure

Travellers live 5 years on average less than the general population

79

WorksheetIn your small group discuss all the statements on Handout 8.Decide whether you agree that the statements are true, agree that they are false or disagree as a group.

1. We agree that the following statements are true

2. We agree that the following statements are false

3. We disagree or are uncertain about the following statements

80

POWERPOINT 16Service Providers experience of working with Travellers?

Questions for groups

• As Service Providers what is our experience of working with Travellers?• What issues have arisen in this work?• Which of these issues are ours and which are the Travellers?

81

HANDOUT 9Barriers to access- the Traveller experience

• Literacy / numeracy /ability to read a clock• Language• Fear• Low self esteem• Lack of confidence• Prejudice• Discrimination• Lack of respect for the Traveller way of life and culture• Poor postal delivery• Poor living conditions• Poverty and its implications• Lack of education• Lack of sensitivity and privacy• Lack of crèche facilities• Travellers’ lack of trust in the service• Lack of a friendly helpful attitude from service providers• Racism• Lack of information and unclear communication• Lack of transport• Lack of helpful consultation with Traveller community

82

WorksheetBringing about Change

Some suggestions from service providers of how Travellers can contribute to change:

83

POWERPOINT 17Some suggestions of how Traveller Community Health Workers can contribute to change

POWERPOINT 18Where do we go from here?

Final round – One thing our area / Dept can do to contribute to change is….

Additional pieces of resource supplied in each Cultural Awareness Training Pack

• HANDOUTS 1 – 9 (Master copy supplied)• Understanding Prejudice (Laminated Photographs supplied)• Traveller Culture DVD (‘Our Ways, Our Culture’)• AITHS and other information slides – acetates and powerpoint on email • Evaluation sheet for participants

84

Traveller Culture Training One Day workshop

EVALUATION SHEET

Location Date Facilitators

Q1 - Overall how would you rate the workshop?

1. Poor 2. Fair 3. Good 4. Very Good 5. Excellent

Q2 - Was the pace of the programme?

1. Too slow 2. A bit slow 3. Just right 4. A bit fast 5. Too fast

Any comments?

Q3 - What I gained from the workshop...

Q4 - What I found most helpful...

Q5 - What I found least helpful...

Q6 - Any Other Comments:

How would you rate the facilitator’s style?

1. Poor 2. Fair 3. Good 4. Very Good 5. Excellent

Any comments?

Thank you

85

Appendix 13 TCAT Marketing Leaflet

Appendix 14 TCAT Completion Certificate

86

The Wheel of CultureTraveller Culture

The Teapot

For centuries the kitchen table has been the gathering space where stories have been told and where comfort and support has been offered over a mug of tea. A space for conversation, sharing, a shoulder to cry on and a hand of support, all with the healing mug of tea. Our Teapot is a strong, powerful worn metal teapot that has been witness to many gatherings around the table. Here we have exposed the inner spirit of the teapot and covered the exterior with jewels, making it the jewel of the table. A cup of tea starts the conversation. We welcome our family, friends and visitors with a cup of tea. ‘ The Door is always open’.

Family

Our Children always come first. Family is everything to us. We have large extended families and we like to keep in close contact with each other. ‘Family Gatherings’ are very important to us. The Children are represented on our table cloth by the decorated lollypop sticks.

Religion

We have very strong religious beliefs. Mass on Sunday is a ‘Family Gathering’ for us. We have a tradition of going to see priests and nuns to ask for advice and to ask them to pray for our families. We always have Holy Water in our homes and in our cars. ‘Holy Water keeps evil away night or day’.

Travelling on the Road

Traditionally we travelled around Ireland in caravans and we lived as ‘Free Spirits’. We miss the old times, even though they were the hard times. The men would go off during the day and women would all cook, clean, wash clothes, look after the children, together, we shared everything. We really looked out for each other. Settling down into houses has taken away some of this sharing and caring.

Patrons / Graveyards

We call the ‘Blessing of the Graves’, the Patron. We go to at least five different ‘Patrons’ each year because of our extended families. In Wexford alone, we go to the Patrons in New Ross, Wexford Town, Gorey, Enniscorthy and Bunclody.

Love of Music

As family gatherings we sing and tell our stories through song, we express our feelings through song. Traditionally and still today some Travellers play the accordion or the mouth organ. The younger generation love music too, but nowadays it is CDs and stereos.

Weddings Weddings are another time when families get together. The sacrament of marriage is very important to us. ‘Going to a wedding is the making of another’.

Rosary Beads

We always keep rosary beads in our homes. When anyone is sick or in trouble we say the rosary together.

The Gammon

The Gammon is our language and we use this language to communicate with each other. The Gammon has been used for centuries.

Horses

Horses are a Travelling man’s pride. Horses have been passed down from generation to generation. Horse Fairs are a big get together for Traveller men. Traveller men come from all over to swap and deal their horses and the horse fairs.

Creativity

Travellers love to design and create decorative pieces using their hands. For years, Travellers did not know how to read and write and this was how they expressed themselves.

The Wheel of Culture was created by the Wexford Traveller Community Health Programmes in April 2012

87