The health visitor, the ecological approach and the assessment of health need with a focus on the gypsy and traveller community.

07 February 2020

Jacqueline Cattenach explores the links between child development and health and cultural factors in this most marginalised of groups.


Contact Jacqueline Cattanach, MSc PG Dip PG Cert RGN BN at [email protected]

Research summary

  • This paper asserts the importance of health visitors understanding the impact of wider health determinants, including social and cultural factors, on health behaviours, in order to improve community engagement, reduce health inequalities and develop practice.
  • It can provide a basis for the unique contribution they can make, as a profession, to the lives of children and families, including marginalised, minority groups where reports of reduced cultural awareness can act as a barrier to improved child health outcomes.
  • Literature pertaining to key features of a child’s development, including physiological, psychological and emotional factors, is critically analysed.
  • Bronfenbrenner’s social-ecological model (Bronfenbrenner, 1977) is used as a framework to explore the link between health behaviours and factors at both person, family and community level.
  • The impact of these wider contextual factors on child health is further emphasised with a particular focus on gypsy/traveller families – amongst the most socially excluded and disadvantaged groups in society, which consistently report higher rates of infant mortality, still-birth and lower immunisation rates, together with increased levels of hate crime and racial discrimination.


The ecological systems model (Bronfenbrenner, 1992) assumes a positivist approach to child development and forms part of the learning required for health visiting core skills together with the saultogenic or health creating approach (Cowley et al, 2015; Antonovsky, 1987). Moreover, an awareness of this approach is a prerequisite to avoiding victim blaming and an over emphasis on individual factors (Chambers and Ryder, 2018). This is particularly relevant at a time where student health visitors are recruited from midwifery, mental health, learning disability and general nursing backgrounds (Gopee, 2010) with variable knowledge, skills and qualifications.

One such group that have experienced increased levels of discrimination and inequality and who could arguably benefit the most from this approach are gypsy travellers (House of Commons Women and Equalities Committee, 2019; Equality and Human Rights Commission, 2018). In fact, research asserts gypsy travellers are amongst the most socially excluded and disadvantaged groups in society (Hyde, 2007, cited in Themelis, 2009; Clark, 2006; Commission for Racial Equality, 2005) with a denial of rights (only recognised as an ethical and legal group in Scotland in 2008) and media coverage that continues to misleads public opinion and strengthen negative stereotypes (Shubin and Swanson, 2010). Moreover, annual statistics consistently report higher rates of infant mortality, still-birth and lower immunisation rates (Cromarty, 2019; 2017; Clark and Greenfields, 2006), together with increased levels of hate crime and racial discrimination (Cromarty, 2019), providing one explanation for higher rates of self-reported of social isolation and low confidence accessing services and health care. 

It is in this context that this paper will assert the importance of the health visitor in understanding the impact of wider health determinants including social and cultural factors on health behaviours to improve community engagement, reduce health inequalities and to help understand and develop practice. Furthermore, it can provide a basis for the unique contribution they can make, as a profession, to the lives of children and families (Malone et al, 2016) including marginalised, minority groups where reports of reduced cultural awareness can act as a barrier to improved child health outcomes.


Community-based nurses and particularly health visitors have been the recent focus of Government policy and investment (Public Health England, 2017; Scottish Government, 2015; NHS England, 2014; DH, 2013; DH, 2011), with population based health promotion strategies highlighted as a means to promote early intervention and prevention (Cowley et al, 2015; Scottish Government, 2015). This has led to a debate on the level of expertise, skill and knowledge required by the health visitor (Kemp et al, 2017; Barlow et al, 2010) with education based on NMC standards (Nursing and Midwifery Council, 2018) and policy guidance (DH, 2011). However, many assert that the most crucial factor is the approach taken by the health visitor which must focus on health creation whilst recognising the importance of the person in situation or context (Malone et al, 2016; Byrne et al, 2010; McIntosh and Shute, 2007). 

Literature supporting the need to consider individual child factors within the wider context of familial, environmental and social factors continues to grow (Barlow, 2019; Runyan and Runyan, 2019; Bryans et al, 2009; Scottish Executive, 2005). This includes the work of Cowley et al (2015) who assert the importance of social, economic and emotional health determinants on health behaviours and the importance of building families and linking with community resources. Indeed, the need for affectionate relationships and to feel a sense of belonging are well recognised in terms of a child’s health and development (Volling, 2019; Cabrera et al, 2018; Bretherton, 2010)  and feature in high position on Maslow’s hierarchy after safety and physiological need (Maslow, 1989). Bryans and colleagues (2009) support this method emphasising the need for health visitors to work with individuals whilst being sensitive to the social context, supporting and enabling parents to access community resources which will benefit both the parent and the child (White et al, 2017; Aveling, and Jovchelovitch, 2014).

This paper will discuss and critically analyse literature pertaining to key features of a child’s development, including physiological, psychological and emotional factors. Bronfenbrenner’s social-ecological model (Bronfenbrenner, 1977) will be used as a framework to explore the link between health behaviours and factors at both person, family and community level (Appleton and Cowley, 2008). 

In addition, the impact of wider contextual factors on child health will be further emphasised with a particular focus on gypsy traveller families. Unfortunately, there remains a lack of consensus on how the term gypsies and travellers is defined, reflected in the inclusion of numerous groups within this term. Moreover, families from various backgrounds, cultures and beliefs are grouped together, from Romany Gypsies to Scottish, Welsh, English and Irish travellers (Cromarty, 2019). However, what we do know is that gypsy travellers are a highly heterogeneous group of people whom share some common characteristics including cultural values, close extended family networks, independence, travel and occupational flexibility (Clark and Greenfields, 2006). 

The ecological approach will now be explored as a structure to guide the assessment of health needs and risk factors. 

The ecological approach

The social ecology concept or whole community approach identifies connections between the psychological and physical aspects of health alongside the degree to which these support or prohibit individual choice and social inclusion. It does this by recognising and considering the wider social, cultural and environmental influences of health, many of which may be external to the individual and out of their direct control (Lucero et al, 2018). It also helps to move away from overly simplified, traditional models of health promotion, including models of empowerment and self-responsibility which focused heavily on individual risk factors and behaviours (Springer and Evans, 2016; Stott et al, 1994).

Researchers, including Wold and Mittlemark (2018) together with Green (2018) and Sallis et al (2003), assert that although the basic principles of individual participation and context found within the social-ecological model or systems model of health promotion are not new concepts, there has been an increased recognition of and focus on the wider social and structural factors that can influence health. Furthermore, there is now an awareness of the ethical implications (Medvedyuk et al, 2018) and negative health outcomes associated with offering lifestyle advice alone without any thought for the context (Lupton, 2013).

One such model, which is particularly helpful at understanding the “person in context”, is Bronfenbrenner’s ecological model (Bronfenbrenner, 1979, cited in Tudge et al, 2016). This model, not only considers health in a social context, but identifies the relationships between the contextual layers or systems, which many previous models have failed to do (Bambra et al, 2010). For example, the interaction between the child, his family and community environment, and the wider social landscape are depicted by layers or systems where specific problems are considered alongside wider environmental and cultural influences (Kelly and Symonds, 2017). Thus, moving away from the traditional view that child development is only about the child and their immediate environment. 

The ecological systems theory can be used to support the understanding of child development by linking the inherent qualities of the child, or personality features with the influence of multiple environments, also known as ecosystems (Darling, 2015). Moreover, Bronfenbrenner and Ceci (1994) assert that due to the connectivity of factors it is not enough to consider the individual genetics of a child without identifying the social context and nurturing environment available. 

This view is supported by researchers looking at resilience, child development and wellbeing under stress who support the notion that every child is vulnerable to the social-ecological features that they experience, and no child is immune (Ungar, 2011; Lester, Masten and McEwen, 2006). This is particularly pertinent for gypsies and travellers where strong nomadic traditions and strong family attachments act as protective factors for children (Powell, 2016) against the environmental and social stressors caused by prejudice, persecution and insecure, unsafe living environments (Cemlyn and Action, 2014). Although, Stokes (2009) points out that gypsy, traveller cultural traditions can also be a source of risk, including the belief that children are too young to understand grief and the inclusion of children in death rituals, which reduces opportunities for resilience and negatively impacts on emotional wellbeing.

There are four distinct layers known as the microsystem, mesosystem, exosystem and macrosystem (Bronfenbrenner, 1992) (See: Appendix, 1). Each system is influenced by each other, from the intimate home environment (microsystem), including relationships with others (mesosystem), to the school environment (exosystem) and the impact of wider social and cultural influences (macrosystem). What is important, particularly in terms of the health needs assessment, is that the child remains at the centre and viewed in relation to the specific internal and external factors identified within each system (Bronfenbrenner and Morris, 2006). Thus, supporting a more integrative approach to child health and developmental practice and the view that children are nested in families in communities which are part of the larger socio-cultural environment (Coulton et al, 2007).

The developing child

Using the ecological model this paper will now consider each of the systems in relation to child development, with a particular focus on the gypsy and traveller child and their families. This will not only provide a general insight into adversities, but will stand to inform and support how crucially important the external socio-cultural environment is to health and development of children and why some are more susceptible to external stressors than others. 


The microsystem considers the immediate environment together with activities and relationships as experienced by the child and includes the direct impact of the parent-child relationship. Moreover, the child, who is dependent on the individual caregivers to have their basic care needs met, is the central focus.

At birth the baby has many billions of neurons which connect or synapse together over the first three years of the child’s life (Balbernie, 2011). Common to all is the pruning of neurons or synapses to improve brain efficiency. However, as demonstrated with animal research, social stimulation increases the connections or synapses per neuron, resulting in improvements in performance and cognitive skills (Rao et al, 2010). Twardosz and Lutzker (2010) label the importance of this informal and formal stimulation in brain architecture as experience-dependant plasticity. Moreover, they are supported by research identifying the impact that a positive, nurturing environment can have on levels of resilience (Haddadi and Besharat, 2010) identifying areas of the brain particularly sensitive to social contact and stimulation at different times (Kentner et al, 2019; Gapp et al, 2016; Vivinetto et al, 2013). Lou et al (2018) support this view whilst describing resilience as multi-dimensional construct where specific internal factors found within the child including personality, genetics and temperament help explain those with heightened resilience despite exposure to difficulties. 

Gypsy and traveller children are highly valued and likely to have all their physical care needs met (Stokes, 2009). Moreover, nuclear family structures together with wider extended family, kinship and community support strong attachments support resilience (Sellars, 2014). However, Cromarty (2019) asserts that new mothers from the gypsy travelling community have an increased risk of maternal low mood and heightened anxiety (Cromarty, 2019), known to impact directly on the mother-baby bond and attachment (Henderson et al, 2018). Roderigo et al, (2019) support this view identifying structural alterations to the frontal lobe of babies’ brain associated with emotion and empathy when social contact is reduced. However, the role of paternal anxiety and depression is increasingly explored with emerging data identifying a link between a father’s low mood and high anxiety with poorer outcomes in children (Sweeny and MacBeth, 2016), particularly relevant for this minority group where gypsy and traveller men self-reported more than double the level of anxiety and stress than the UK average (Mental Health Foundation, 2016), and have a prevalence rate of depression at 25.9% compared to 9.4% in the GP population (Van Cleemput, 2018). 

When considering the development of children theory, it is essential to consider the influence of the parents and parenting (Bowlby, 1989). Moreover, this must include the cultural context to understand the individual child rearing goals and objectives of populations (Zarnegar, 2015). In terms of the travelling community, research tells us that these women rarely work or live outside the family unit, have reduced material resources and have few social contacts, if any, outside the extended family circle (Casey, 2014). Social isolation, together with the stereo-typical gender roles, inter family structures and privacy, increases the risk of domestic abuse (Alhabib, Nur and Jones, 2010) which has significant consequences for the emotional and psychological and emotional development of the child (Jackson, Kiernan and McLanahan, 2012). However, we cannot assume that this is the case. In fact, Allen (2011), using a mixed methods design, concluded that though a significant number of travelling women experienced domestic violence, figures were no higher than the general population. Although Femi-Ajao et al, (2018) question the reliability of research data which looks at domestic violence within ethnic minority groups, but which does not account for culturally mediated factors including gender roles and inter family structures which can influence disclosure. 

Adverse childhood experiences

From the original foundational research by Felitti et al, 1998, there is a growing body of knowledge supporting the impact that adverse experiences in childhood and adolescence (ACEs) can have on physical and mental health into adulthood (Madigan et al, 2017; McKelvey et al, 2016; Edwards, 2006), including research linking ACEs with a heightened risk of cancer (Holman et al, 2016), chronic pain (Nelson et al, 2018) and diabetes (Huang et al, 2015) in adulthood. Exposure to poor maternal mental health, domestic violence and all form of childhood abuse, together with the broader concepts of neglect and poverty (Holman et al, 2016) are typically referred to as ACEs within the research. However, there remains a lack of clarity into the definition of an ACE; how they should be measured and how they are differentiated from normal stressors (McLauhghlin, 2016). 

Continuing this debate, Soaves et al (2016) argue that socioeconomic status should be independently considered as a powerful predictor of poor mental health in adulthood as opposed to an ACE, whilst, Sapienza and Masten (2011) assert the need to consider the impact that culture has on the adversity and levels of child resilience. Particularly pertinent for children from gypsy, travelling communities who are more likely to live in lower income families, and experience social exclusion and prejudice as a result of their particular cultural traditions (Van Cleemput, 2018). 

What we do know is that multiple risk factors matter, with cumulative effects of multiple ACEs highly predictive of negative child outcomes (Cicchetti and Toth, 2005). Some authors suggest this can be as little as two (Sabates and Dex, 2012), three (Fergusson et al, 2003) or four (Bellis et al, 2013), particularly if the ACEs are of a chronic nature (Danese and McEwan, 2012). In agreement, Tan (2014) asserts the need to intervene early when a child is exposed to adversity, as increased rates of successful recovery are positively correlated to the length of exposure (Finkelhor et al, 2015; Brotman et al, 2012). Unfortunately, there is a dearth of research into the health needs of gypsy and traveller children. However, existing research, including the largest epidemiological study (Van Cleemput et al, 2007) would suggest a higher rate of poverty, adult illness, pain, disability, depression and anxiety (Parry et al, 2007), all chronic in nature.

There is no consideration for the different combination of ACEs with much of the research focused on the number of risk factors only. In addition, the context of the exposure in terms of the age of the child, the resources available or the processes by which the child is exposed are frequently omitted, key features required when assessing child development (Bronfenbrenner, 1986). This is also a lack of ACEs research which considers ethnicity and culture, other than as a risk factor (Felitti et al, 2019), with great variation reported in terms of the impact of ACEs on specific ethnic minority groups (Sabates and Dex, 2012). However, this is not surprising giving the differences that exist in relation to social, environmental and financial factors within minority groups (Millan and Smith, 2019).  


Not every child who experiences toxic stress will have poorer health and development outcomes (Traub and Boynton-Jarrett, 2017). Indeed, Pizzolongo and Hunter (2011) are among a growing number of researchers who have evidenced positive adaption of children despite adversity, otherwise known as resilience. There is no agreement on the definition of resilience, however, some descriptions identify resilience as an outcome and the capacity of the individual to overcome adversity (Traub and Bonyton-Jarrett, 2017) whilst others describe it as the process of normal development despite difficult circumstances (Collishaw et al, 2007). Antonovsky (1987) defines resilience as the ability to manage and feel in control, resulting in an improved feeling of security and positive achievement. A view supported by Newman (2004) who identifies key characteristics and personal qualities associated with resilience which include self-efficacy and self-esteem, together with a secure base. However, for minority groups, including the gypsy and traveller community, a deficit model of health (Collins, 2000) where cultural practices have been considered the cause of poorer health, not only accounts for social mechanisms of blame, prejudice and discrimination (Wemyss et al, 2015) but leads to reduced individual self-efficacy, isolation and self-esteem (Smith and Newton, 2017), arguably reducing resilience at both an individual and community scale.


Parent-child interactions

Health is not merely the absence of disease but a feeling of wellbeing and the ability to successful engage with their surroundings (Marmot et al, 2010). Responsive relationships are essential for biological development, especially during the early years (Rilling and Young, 2014), supporting young children to learn to cope and manage their emotions through experiences and expression (Forry et al, 2013) into adolescence and adulthood (Feldman, 2015). However, cultural beliefs including the view that children are too young to understand, deny gypsy and traveller children the opportunity to discuss emotions and loss (Stokes, 2009), particularly relevant in the context of increased mortality rates and insecure living accommodation, where families are increasingly broken up (Cemlyn and Clark, 2005).

Numerous studies report on the dysfunctional relationship between the parent and infant which leads to a neglectful environment offering no protection or support for continued cognitive, physical, social or emotional development (Glaser, 2011; Rees, 2008; Repetti et al, 2002; Rees, 2008). It is suggested that with the absence of a secure attachment to a main caregiver, mental health conditions and physical problems later in life have been recorded, including gross motor, fine motor and cognitive problems, reduced self-esteem, anger and control problems. (Miller and Kinsbourne, 2012). It is recorded that developmental issues recorded in childhood are especially noticeable when parental mental health problems impact on the wellbeing and bond with the infant during the third trimester in pregnancy until the age of two years (Waters et al, 2000). These include speech delay at 12 months (Sylveste and Merette, 2010), cognitive delay (Brandon et al, 2014; Naughton et al, 2013) and behavioural problems and aggression in children at the age of 4 years (Kotch et al, 2008). 

Featherstone and Gupta (2018) assert that children are social actors that require healthy social ties. A view supported by Pierson (2016) who describes the weak social ties and clear disadvantage that traveller children face due to family position, within a social context. However, there are others who believe that an absence of close friendships, reduced ability to socialise with peers and build effective social networks are consequences of the nomadic lifestyle (Myers et al, 2010). Continuing this theme, Frehill and Dunsmuir (2015) found that traveller children have a higher absence rate from school and are among the lowest achieving pupils. However, Foster and Norton, (2012) believe that absence is directly related to sense of school community and not ethnic background. Unfortunately, both sets of data are the result of small-scale surveys which lack rigour or the ability to generalise. In fact, Parameshwaran and Engzell (2015) concur that it is the ability of children to adapt to a new environment which can have serious implications for wellbeing, and which must be supported by improved social attitudes including those of teachers and health care professionals (Bhopal, 2011a).

Family context

The position for children in society has radically changed with a legal duty to consider what the children are saying (Jose et al, 2012; Scottish Government, 2014; UN General Assembly, 1989). This has resulted in a widening gap between adults and childhood (Stokes, 2009). Gypsy/travelling families experience much less separation between adults and children with extensive intergenerational mixing from birth. This is supported by distinct cultural beliefs and lifestyle choices (Bhopal, 2011b), where children are treated with a stoic approach and their emotional capacity is misunderstood (Stokes, 2009). The misconception that children are too young to understand, could lead to children overhearing adult conversations and arguments, which can have a negative impact on their emotional and psychological wellbeing (Richardson and Ryder, 2012). 

The Working together to Safeguard Children Report (Department of Education, 2015) listed numerous harmful parent and child interactions causing isolation and humiliation. However, a focus on parental actions is only one way to consider the problem. Instead, Glaser (2002) developed a framework which assists practitioners to manage and recognise forms of abuse. He prioritised the psychosocial needs of the child and identified the importance of context in which care giving is provided, including parental risk factors, family and environmental issues. Moreover, he designed a tiered system that recognises the impact of wider contextual issues, including the failure of a parent to recognise how their behaviour impacts directly on the child, the influencing interactions with peers, and the experience of education. An issue which could be applied to the gypsy and traveller child whose parents prioritise the meeting of cultural norms over social contact with peers and a school education.

There is an importance placed on the gypsy and traveller child to continue the intergenerational process and uphold family traditions (McCaffery, 2014). Family based learning is prioritised with socialisation restricted to extended family members (Casey, 2014). Hamilton (2016) and Derrington (2007) argue that this is causing cultural dissonance for children who attempt to operate within a dual cultural framework, leading to challenges with self-identity as defined by gypsy, traveller cultural beliefs and social belonging (Ní Laoire, 2011). Cromarty (2019) supports this view, asserting that psychological and social difficulties reported by gypsy, traveller children lead to increased levels of school exclusions, racial abuse, bullying and significantly reduced levels of educational attainment. 

Maternal mental health

Mental health problems elevate the stress experienced by a mother leading to some women feeling overwhelmed (Karam et al, 2016). This has the potential to lead to a negative relationship between mother and baby where there is reduced sensitivity and positive interactions (Ainsworth et al, 2015). This lack of face to face play for young babies can have a significant impact on development (Giusti et al, 2018; Bedford et al, 2017; Jackson et al, 2012; Scottish Government, 2012 ; Bowlby et al, 1989 ) and is predictive of a child’s cognitive ability at the age of two ( Feldman et al, 1997). However, Scroufe et al (2010) assert that the lack of responsive, emotional care does not just affect cognitive development, but impairs function and development in all areas. Moreover, the developing brain relies on information from the environment to which it is particularly sensitive, and without is the cause of dysfunctional attachment (Koehn and Kerns, 2018; Rose et al, 2018). 

Several studies have attempted to measure rates of maternal mental health within the gypsy travelling community reporting increased levels of anxiety and stress linked to social and economic factors (Goward et al, 2006). McFadden, et al (2018) believes this is a result of marginalisation and exclusion of minority groups from social, economic and political systems. Moreover, recommendations include the need for culturally sensitive services and the inclusion of gypsy travellers in mainstream data collection. Van Cleemput et al (2007) add to this debate by asserting lower expectations and normalisation of poor health within this distinct community and reduced access to health services (Smith and Newton, 2017). 

There is difficulty in accessing sample groups, and relying on research data from small sample numbers may impact on the reliance and validity. For example, gypsies and travellers with greater economic resources are more likely to live in conventional housing with data more likely to be drawn from more visible members living by the road side and in sites. Thus, cultural deprivation explanations could be further reinforcing inequalities and power relations when causal factors are more likely to be similar to other poor and marginalised groups exposed to poverty, poor accommodation and poor lifestyle choices (Robinson and Reeve, 2006). 

Exposure to domestic abuse

Exposure to domestic violence or trauma during childhood leads to disorganised attachment relationships (Sousa et al, 2011). This is caused by the threat of feeling out of control, leading to an emotional response which severely inhibits the emotional response towards the infant (Farmer and Lutman, 2014). Moreover, this then reduces the opportunity for social learning and exploration and ability of the child to cope with future stressors (Banducci et al, 2014). 

Ahmad and colleagues (2004) question the reliability of research data which looks at domestic abuse within ethnic minority groups but which do not account for culturally mediated factors including gender roles and inter family structures which can influence disclosure. More recently, Allen (2011), using a mixed methods design concluded that a significant number of gypsy/traveller women experienced domestic violence, although figures were no higher than the general population. However, due to the fact that there is no routine monitoring of this minority group and barriers to accessing support are increasingly likely, it is difficult to draw any significant conclusions. 


Structural factors are important and can have a direct impact on cognitive and behaviour development of the child (Greenfields and Brindley, 2016). Living in an environment which is overcrowded, frequently hostile and where safety is at risk from pylons, pollution and traffic can have a profound impact on the physical and psychological health and development of the child (Greenfields and Smith, 2010). Clark et al (2018), assert that gypsies and travellers experience extremely high levels of hostility and racism on a daily basis. Moreover, a lack of authorised sites leaves many parking illegally in dangerous, polluted ground with a lack of basic amenities and safe places to play (Powell, 2016).

School environment

Feinstein et al (2006) assert that children are social actors that require healthy social ties. Predictable routines and activities which stimulate learning are important together with the need for a secure relationship with the teacher (Sciaraffa et al, 2017). Moreover, unpredictable, chaotic routines, poor engagement with education and truancy are associated with negative cognitive development outcomes from infancy through to adolescence, including poorer language development (Cook et al, 2017), lower IQs and education attainment (Nikulina et al, 2011).

Reports from the Office of National Statistics (2014) together with numerous researchers, (Derrington, 2016, cited in Richards and Armstrong, 2016; Frehill and Dunsmuir, 2015; Bhopal, 2011b) have reported that gypsy/traveller children have a higher absence rates and are among the lowest achieving pupils. Foster and Norton (2012), believe it is caused by a reduced sense of school community and not ethnic background. Moreover, Smith (2010) concurs that it is the ability of children to adapt to a new environment which can have serious implications for wellbeing and which must be supported by improved social attitudes including those of teachers and health care professionals (Law and Swann, 2013). However, despite high levels of peer bullying and discrimination (Waulters et al, 2017), Hamilton (2016) asserts that education goes against cultural norms creating bullying from within the community, which can be equally damaging to a child’s social and cognitive development. 

Ethnic minority status: Gypsy/traveller communities

Gypsies and travellers became recognised as a unique ethnic group by British law in 2000. However, it wasn’t until 2011 that they became included in census monitoring (Cromarty, 2017). This could explain the lack of statistical information available on child health and development within this community or could just reflect the inability of a postal survey to capture data from mobile populations. On the other hand, it could be that the long history of exclusion, oppression and marginalisation, together with the unique culture of this tight knit community, has led travellers to avoid inclusion and thrive on exclusion (Jackson et al, 2012). Whatever the reason, there remains a distinct lack of data available regarding the health and development of children born into this minority group, frequently perceived as an antagonist group whose very existence threatens the values of civilised society (Cihan Koca-Helvaci, 2016). 


Culture is not consistently considered in child maltreatment research, with populations commonly lumped together in terms of geographical area or census categories (Fontes, 2005). As a result, little is known about the impact of culture on maltreatment, with researchers focused more on identifying which cultures have a higher prevalence as opposed to explaining why culture has this effect (Warner et al, 2012). Dubanoski and Synder’s pioneering work linked specific cultural practices and beliefs to child maltreatment. In this case the particular cultural value of physical aggression and punishment was significantly linked to heightened numbers of child maltreatment. 

Culture in child protection and welfare work is not optional but a necessity. There is a disproportionate number of ethnic minority children and families in the child protection system (Drake et al, 2009). A lack of understanding of cultural practices of minority populations has the potential to maintain power relationships (Smith and Ruston, 2013) with systems formed by powerful groups and social structures causing privilege and suppression - an important aspect of the client/worker relationship.

Professional ideology

The barriers faced by travellers in terms of health services was the focus of a recent review of the literature by McFadden et al (2018). Ninety-nine studies from 35 countries published during the year 2000-2015 were rigorously analysed and synthesised. A main finding highlighted was the need for improved cultural awareness of health professionals and the importance of tackling language barriers and low literacy skills to increase access to this marginalised group. Strategies to improve engagement with this hard to reach population include a mobile health unit as described by Alunni (2015), who used an ethnographic design to identify improved rates of health service uptake. However, this approach could also be viewed as widening equalities by discouraging travellers to access mainstream services, whilst increasing stigma and discrimination (Williams and Jackson, 2005). 

In summary...

This review has further explored an ecological approach to assess the health and development of the child including the impact of wider social, environmental and cultural factors. 

It has been identified that child individual factors are important but must be considered as part of a wider assessment, including the need to identify culture as both a risk and a protective factor, depending on the environmental context. 

Professionals must be aware and avoid presumptions made on specific needs, beliefs and behaviours belonging to a neighbourhood area, specific community or minority group. For example, although high poverty rates in an area is associated with higher rates of child maltreatment, robust and strong social connections can act to buffer this, particularly true of specific cultures, including gypsy travellers. 

Appendix 1:

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