UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): a qualitative interview study

Background: Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services, including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations. Aims: (1) Investigate the barriers to and facilitators of acceptability and uptake of immunisations among six Traveller communities across four UK cities; and (2) identify possible interventions to increase uptake of immunisations in these Traveller communities that could be tested in a subsequent feasibility study. Methods: Three-phase qualitative study underpinned by the social ecological model. Phase 1: interviews with 174 Travellers from six communities: Romanian Roma (Bristol); English Gypsy/Irish Traveller (Bristol); English Gypsy (York); Romanian/Slovakian Roma (Glasgow); Scottish Showpeople (Glasgow); and Irish Traveller (London). Focus on childhood and adult vaccines. Phase 2: interviews with 39 service providers. Data were analysed using the framework approach. Interventions were identified using a modified intervention mapping approach. Phase 3: 51 Travellers and 25 service providers attended workshops and produced a prioritised list of potentially acceptable and feasible interventions. Results: There were many common accounts of barriers and facilitators across communities, particularly across the English-speaking communities. Scottish Showpeople were the most similar to the general population. Roma communities experienced additional barriers of language and being in a new country. Men, women and service providers described similar barriers and facilitators. There was widespread acceptance of childhood and adult immunisation, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough. Cultural concerns about vaccines offered during pregnancy and about human papillomavirus were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified by Travellers and service providers as barriers for some. Trustful relationships with health professionals were important and continuity of care was valued. A few English-speaking Travellers described problems of booking and attending for immunisation. Service providers tailored their approach to Travellers, particularly the Roma. Funding cuts, NHS reforms and poor monitoring challenged their work. Five ‘top-priority’ interventions were agreed across communities and service providers to improve the immunisation among Travellers who are housed or settled on an authorised site: (1) cultural competence training for health professionals and frontline staff; (2) identification of Travellers in health records to tailor support and monitor uptake; (3) provision of a named frontline person in general practitioner practices to provide respectful and supportive service; (4) flexible and diverse systems for booking appointments, recall and reminders; and (5) protected funding for health visitors specialising in Traveller health, including immunisation. Limitations: No Travellers living on the roadside or on unofficial encampments were interviewed. We should exert caution in generalising to these groups. Future work: To include development, implementation and evaluation of a national policy plan (and practice guidance plan) to promote the uptake of immunisation among Traveller communities

Social Inclusion and the `Get Heard' Process Implications for the Horizontal and Vertical Integration of Governance and Policy in the UK

Since 1997, there has arguably been a 'rediscovery' of those most at risk of poverty and social exclusion by New Labour. Within this context, it is important to consider the European, national and sub-national policy frameworks within which interventions are being developed. The European Union's 'Open Method of Co-ordination' is of relevance given its emphasis on making a decisive impact on poverty and social exclusion by 2010 through stimulating domestic policy processes in the form of National Action Plans on Inclusion (NAPSI). It also attempts to provide a coordinating framework for member states to exchange policy ideas and practices. As part of the development of the 2006-8 UK NAPSI, a Social Policy Task Force worked jointly with the Department of Work and Pensions to take forward the 'Get Heard' process — a mechanism to ensure that the views of those at the 'grassroots' could be fed into the process of developing the plan. This article presents key findings from one case study area (Merseyside). There is a subsequent consideration of the degree to which either informal or more formalized arrangements are conducive to securing enhanced horizontal and vertical integration in governance frameworks, policy making and service delivery for those most marginalized

The dilemma for staff in 'playing a game' with a person with profound intellectual disabilities: empowerment, inclusion and competence in interactional practice.

Games between staff and people with intellectual disabilities serve to promote social engagement and inclusion. However, when the person has limited and idiosyncratic communicative abilities, it may be hard to gauge what his/her own view of the matter is. We examine video-taped records of two episodes in which a staff member of a group home prompted a resident with profound intellectual disabilities to play a verbal and a non-verbal 'game'. We examine how the staff member in these two cases designs her actions to solve the dilemma she faces between, on the one hand, abandoning an activity when the resident does not provide clear indications that she/he wants to continue or, on the other hand, persisting with it until the resident begins to enjoy it or, at least, participate more fully. The solution lies in a pervasive institutional practice: treat resistance or ambiguity as temporary reluctance. We discuss these interactions as examples of how principles of empowerment, inclusion and independence play out in the details of everyday interaction

Saying no to the staff: an analysis of refusals in a care home for people with severe communication difficulties.

People with severe communication difficulties may attempt to exercise control over their lives by verbally or non-verbally refusing an activity proposed by supporters. We detail examples in which such refusals are treated by care home staff as a temporary reluctance, warranting further attempts to persuade the individual to co-operate. We identify the following conversational (and bodily) practices by which staff achieve their institutional ends: appreciating a resident's behaviour as something other than refusal; formulating the invitation again in a no-blame format; minimising the task required; escalating the invitation to a request and an order; moving the person bodily; and positively glossing the proceedings. Dealing with refusals illustrates the dilemma faced by institutional personnel in health and care settings in accepting choices which might disrupt the efficient management of the service

Promoting choice and control in residential services for people with learning disabilities.

This paper discusses the gap between policy goals and practice in residential services for people with learning disabilities. Drawing on a nine month ethnographic study of three residential services, it outlines a range of obstacles to the promotion of choice and control that were routinely observed in the culture and working practices of the services. Issues discussed include conflicting service values and agendas, inspection regimes, an attention to the bigger decisions in a person's life when empowerment could more quickly and effectively be promoted at the level of everyday practice, problems of communication and interpretation and the pervasiveness of teaching. We offer a range of suggestions as to how these obstacles might be tackled

Young, gifted, and caring: a project narrative of young carers, their mental health, and getting them involved in education, research and practice

Young carers are a global phenomenon. The UK estimates it has in excess of 175 000 young carers, the onset of their caring role often occurring between 8 and 10 years of age. Of these, 17 000 are caring for a parent who has severe mental illness, a significant factor for children entering the health and social care system, as up to 60% experience mental health difficulties themselves. This paper reports on the outcome of a participatory project aimed at better understanding the needs of young people. A World Café event was hosted, bringing together those involved in promoting the mental health of young people in a partnership consortium. The event was led by young service users and carers. Important issues raised by the young carers were being excluded from being included; stuck in the here and now, ignoring the future; a hole in the net; and ensuring the hidden is on the agenda. The World Café gave the university the privilege of insight into what local young carers need to improve their mental health, and more importantly, how we can utilize our skills to help them achieve their goals