Introduction
Members of Gypsy, Roma and Traveller communities (hereafter referred to as GRT) form a group mainly present in Europe and share the following characteristics: they self-identify as ethnically, culturally or socially belonging to a group considered under the GRT umbrella, traditionally have a culture of nomadism and commonly face social stigma and discrimination.1 Communities under the GRT umbrella represent a population with diverse backgrounds, ethnicities, cultures and lifestyles but this grouping is consistent with healthcare policy, other research and also by the communities themselves.2–4 In the UK, Gypsies, Irish Travellers and Roma are recognised ethnic minority groups5 protected under the UK Equalities Act 2010.6
Difficulty in defining the population is reflected by wide ranges in the estimates of population size.7 8 Historical and continued discrimination towards GRT is likely to contribute to estimates of population size being significantly lower than the true number of GRT.9 Population estimates by the European Union Agency for Fundamental Rights (FRA) state that the European Union population exceeds 8 million.8
This review focused on research in Organisation for Economic Co-operation and Development (OECD) member countries as these closely match the global distribution of GRT and have comparable levels of healthcare coverage10 and literacy rates.11 Given their relative similarity in socioeconomic and cultural conditions, it seems likely that GRT would face similar healthcare challenges in these countries.
According to a 2020 report by the FRA, which surveyed 4659 Roma and Travellers in six European countries, the life expectancy of Roma and Travellers at birth is between 9.8 and 10.2 years less than in those in the general population.8 These health inequities are present in multiple countries and GRT groups. In Ireland, Standardised Mortality Ratios for Irish Travellers are 3.5 times that of the general population.12 A systematic review of perinatal health outcomes in 13 European countries found that GRT infants had higher rates of preterm birth, growth restriction and mortality and linked poor GRT maternal outcomes with social determinants of health such as smoking, deprivation and poor nutrition.13 In England, GRT are significantly more likely to have a long-term illness or disability which limits daily activities or work and report a higher prevalence of chest pain, respiratory problems and arthritis.14 GRT have lower rates of immunisation uptake15 (with associated higher rates of vaccine-preventable diseases16) and increased rates of suicide.17 The UK government has recognised that GRT are ‘among the most disadvantaged people in the country and have poor outcomes in key areas such as health and education.18
The FRA report also found that approximately one-quarter of GRT children live in a household characterised by severe material deprivation, approximately half of GRT adults had experienced some form of hate-motivated harassment in the past 12 months and between 50% and 85% of adults were not in employment.8
Average illiteracy rates among GRT groups may be as low as one-third,8 with a similar proportion never having been enrolled in formal education in some countries (eg, UK).8 Friends, Families and Travellers, a UK-based GRT charity, has reported that 40% of their beneficiaries report low or no literacy.19
In the general population in OECD countries, individuals with low literacy are 1.5—4 times as likely to experience a given poor health outcome.20 21 They are likely to feel embarrassment over their low literacy,22 are more likely to misunderstand drug warning labels23 and experience worse physical and mental health.24 The latest data on literacy rates among 25–64 years old ranges from 96.23% to 99.8% in OECD countries.11
There are no published reviews exploring the effects of low functional literacy on health in GRT communities. This systematic review explores the relationship between low literacy and physical and mental health outcomes in GRT individuals. In this way, it considers literacy as a significant social determinant of health.