Apologies have been received from the Cathaoirleach, Deputy George Lawlor.

The witnesses are all very welcome. I remind all those in attendance to ensure that their mobile phones are on silent mode or switched off. As we are within the precincts of Leinster House, witnesses are protected by absolute privilege in respect of the presentations they make to the committee. This means they have an absolute defence against any defamation action for anything said at the meeting. However, they are expected not to abuse this privilege and it is my duty as Chair to ensure it is not abused. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are also reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against any person or entity outside of the Houses, or an official of the Houses, either by name or in such a way that makes him or her identifiable.

On the agenda for today's meeting of the committee is an engagement with our witnesses to discuss Traveller health. The witnesses are Dr. Patricia Fox and Dr. Kate Frazer of the School of Nursing, Midwifery and Health Systems at UCD, and Dr. Julie Broderick of the UCD School of Public Health, Physiotherapy and Sports Science.

I invite Dr. Fox to make the opening statement and we will then proceed to a question and answer session.

I thank the committee members for the invitation to discuss the research evidence and related matters regarding Traveller health. I am an assistant professor at the UCD School of Nursing, Midwifery and Health Systems. I am accompanied by my colleague, Dr. Kate Frazer, who is an associate professor in the same school, and Dr. Julie Broderick, who is an associate professor in the UCD School of Public Health, Physiotherapy and Sports Science. By way of background, we have led on or participated in various research studies related to Traveller health. Dr. Frazer was a researcher on the All-Ireland Traveller Health Study 2010, which was led by UCD Professor Cecily Kelleher. Dr. Broderick was a lead researcher on "Scoping review on Physical Health Conditions in Irish Travellers", which was published in 2023. I recently led a study, "Cancer Awareness and Attitudes among the Traveller Community in Ireland", which was commissioned and funded by the HSE national cancer control programme, NCCP. This was a co-designed study led by UCD in collaboration with Pavee Point Traveller and Roma Centre, the NCCP and the HSE national social inclusion office. It was published last Thursday, 4 December 2025. Dr. Frazer was a researcher on this team. Our backgrounds are in nursing and physiotherapy and collectively, our academic and research expertise includes cancer, public health, epidemiology, social inclusion and health equity.

The committee members will be aware that the 2010 All-Ireland Traveller Health Study, AITHS, was a comprehensive, commissioned a study of Traveller health status and health needs which included all Travellers living on the island of Ireland, North and South. This comprised a census of an estimated 40,000 Travellers on the island of Ireland and a number of sub-studies. From that study, from the most recent census in the Republic of Ireland and from a 2023 scoping review by Dr. Broderick, we know that Travellers experience poorer health outcomes when compared to the general population and have poorer life expectancy and health expectancy.

Several related peer-reviewed papers have subsequently been published, including a paper by Quirke et al. in 2022, "The Experience of Discrimination and Engagement with Mental Health and other Services by Travellers in Ireland", which concludes that culturally competent services need to be developed because Travellers experience high levels of discrimination which negatively affect their engagement with health services. According to the AITHS, over 40% of Travellers experienced barriers when accessing health services, including discrimination. Only 41% of Travellers expressed complete trust in healthcare professionals versus 82% in the general population, and just over 50% of Travellers reported concerns about the quality of care they received within health services.

The aims of a more recent study, "Cancer awareness and attitudes among the Traveller Community in Ireland", were to understand Travellers’ awareness of cancer risk factors and signs and symptoms; to identify barriers and enablers to cancer risk reduction and early diagnosis of cancer, including access to health services and engagement with cancer prevention and risk-reducing behaviours; and to assess the impact of the social determinants of health on health-related behaviours. The study methods included a survey of 483 Travellers, which was conducted by Traveller community health workers, interviews with 22 Travellers and interviews with 15 primary care healthcare professionals. From this research, we learned that racism and discrimination are root causes of the difficulties Travellers experience in adopting risk-reducing lifestyle behaviours, participating in screening and accessing healthcare. The social determinants of health, such as overcrowded or poor living conditions, poverty, unemployment, limited education and limited transport access, further restrict engagement with healthcare and have a significant impact on health outcomes.

Travellers face specific barriers to accessing healthcare. These challenges include a lack of cultural appropriateness, difficulties attending appointments due to not receiving post or being unable to read letters received, and the provision of jargon-heavy written materials that may be inaccessible to those with limited literacy. Travellers also face individual barriers to engaging with healthcare. Concerns about privacy and confidentiality can delay help-seeking, while fear and fatalism about cancer are prevalent. Embarrassment or shame when discussing certain body parts or symptoms can further delay symptom recognition and help-seeking. Travellers are not a homogeneous population, and individual skills, knowledge, cancer awareness and attitudes vary. For example, in the survey, those aged 65 and older tended to hold the most negative views of cancer and were less likely to agree that cancer can often be cured.

The primary healthcare Traveller projects were seen as transformative. Traveller community health workers play a critical role in educating Travellers about cancer prevention, screening and early detection as they are trusted members of the community who form a vital bridge between the community and health services. For example, one key enabler of screening participation was speaking with the local Traveller community health worker.

Modifiable risk factors for cancer persist. For example, 36% of Travellers smoke compared to 21% of the general population. Smoking prevalence was higher among men, at 44%, than women, at 32%. Weekly alcohol consumption was 22% versus 44% in the general population. Sun protection behaviour among adults is moderate, with the use of sunscreen at 63%, but only 2% reported taking no sun protection measures for their children. Fewer Travellers consumed the recommended five or more portions of fruit and vegetables daily than in the general population, 11% versus 44%. Similarly, low numbers of Travellers were aware of dietary components as a risk factor for cancer. For example, just 20% noted the lack of whole-grain consumption as a risk factor. Participation in screening at least once was high for breast and cervical screening among those who received an invitation. The relevant percentages were 84% for breast screening and 88% for cervical screening. Uptake for bowel screening was lower, at 60%, as is the case for non-Travellers, although the numbers were small so it is difficult to have certainty here. The requirement for an ethnic identifier was also underlined so that Travellers can be identifiable within research to determine health outcomes and equity.

Based on this study and the earlier all-Ireland Traveller health study, we recommend that Ireland’s national Traveller health action plan and the national action plan against racism are fully implemented with a particular focus on national Traveller health action plan goals 1 to 4, inclusive. Goal 1 is to strengthen the governance, monitoring and structures to support the implementation of the national Traveller health action plan and within that, to ensure an ethnic identifier is urgently implemented to accurately identify Traveller-specific health needs, monitor access to services and measure the impact of targeted initiatives. Goal 2 is to improve Travellers' equality of access, participation and outcomes in mainstream health services through a human rights-based approach. Goal 3 is to address the social determinants of health through targeted and mainstreaming measures through cross-departmental and cross-agency collaboration. Goal 4 is to enhance Travellers’ access to culturally appropriate primary healthcare through investment in Traveller health units and primary healthcare for Travellers' projects. That is very important. Implementation of these recommendations will lower cancer incidence, mortality and morbidity in Travellers and in doing so, will decrease the economic burden of cancer care in Ireland. We will be happy to elaborate on some of the more in-depth details of this research for the committee today. I thank the members for listening.

I thank Dr. Fox for her presentation and opening statement, which I read before we came in. I have some comments and one or two questions. Dr. Fox included some statistics. I have been a member of the Traveller committee for a number of months and every time somebody comes before the committee, their statements are shocking. Dr. Fox said that 41% of Travellers express complete trust in healthcare professionals, which is exactly half the figure in the general population. Half of Travellers reported concerns around the quality of care they receive from health services, which is very disappointing. Dr. Fox also talked about specific barriers. I would like to know what we can do about them. She mentioned that Travellers miss appointments because they do not get the post or do not have the literacy to read appointment letters. I have seen that in my constituency office. Travellers come in with letters notifying an appointment for the previous week. They are sometimes jargon-heavy letters, which are problematic if Travellers have limited literacy. They sometimes struggle to read what is there.

In Limerick, some good work has been done and I commend the Mayor of Limerick and the regional executive officer of the HSE. They set up a cross-agency team to deal with health equality in the Limerick region. We in Limerick have more issues than other areas. My basic question is this: what will be done to advertise more broadly how we address the issue of missed appointments? Can the language in appointment letters be changed? Can we ask for that to be done? Can we make sure there is follow-up to a letter? Perhaps there could also be a phone call to follow up a letter or something like that. By and large, nobody who gets a hospital appointment will not go. People wait for appointments for a long time. If they miss the appointment, it will be recorded as their fault in the records even if they did not understand what they were doing. What can we do to make that easier?

I was both surprised and not surprised to hear that Travellers do not eat the proper amounts of fruit and vegetables. What specifically can we do about that?

On the postal issue, one of the things that came out of our research and our interviews with public health nurses is that they have a very important role in liaising with the Traveller community health workers and supporting Travellers directly. The public health nurses would talk about helping Travellers to understand what was meant in the letters. As we said, they have great difficulty in understanding some of the terminology, for example, what is meant by an endoscopy, so the role of the designated public health nurses working in the Traveller community is very important.

Also very important are the Traveller community health workers, particularly as they have that trust within their own community. We think continued investment in the primary healthcare for Traveller projects is really critically important.

Without breaking data protection, that is, with the person's consent, would there be any issue with the letter going to nurse and the person?

Apparently that happens. That is what the public health nurses mentioned to us. They remind people about appointments and all of those types of things. There seem to be some very good systems working there. The post is a major issue, unfortunately, particularly with the bowel screening programme. We could argue that appointment details could be sent via text message, but bowel screening kits need to be sent by post, so that is a major problem. It was reflected in the fact that some people did not receive notification about bowel screening.

Dr. Fox is saying it would just go in the post. It would not go by post and text.

BowelScreen needs to send kits in the post.

Sorry. What about the fruit and vegetables aspect?

That, again, is where we think the role of the Traveller community health workers comes in because they can educate people about the importance of healthy eating. We had a lovely little booklet from the national cancer control programme that has the images on it in relation to what is important in terms of the risk factors for cancer. Through the research they were distributed to households. Again, however, to have it coming from and through the Traveller community health workers is important.

The other issue relates to cultural sensitivity within the health system. That is critically important. We are trying to do that. My colleague Dr. Frazer is doing it through by means of public health teaching. We need to look at that in relation to our third level programmes. It certainly came up as an issue.

The results from the cancer awareness study reinforce what we already knew 15 years previously with the all-Ireland Traveller health study. For me, it was a case of sitting back and thinking about what happened. We want to give every child the best start in life. In the context of looking back over the 15 years, I think "What happened for the Traveller community?" The Deputy asked about how we notify people of appointments. If we can put in systems that can support people, then that is what we need to look at doing. That came out in the all-Ireland Traveller health study, as did information on the rates of discrimination. In recent days, there was a report on TV about maternity services which indicated that one in five people accessing such services is unhappy with their experience. However, we look at the staggering percentages here that we have known about for 15 years. For me, it is the idea of public health nurses and other colleagues getting somebody else's appointment. Is that othering, however? Is that really the solution? Is it part of the solution? Are there other ways to look at this in a systematic way and ask what we need to do to make a difference? That is really reflecting on the whole of society. That is healthcare professionals, but this study shows that it is where people interact on so many different levels and the various systems that were put in place. I have a lot of thoughts about that as well. We were talking about fruit and vegetables and what is available in people's areas. In schools, we have food dudes and everything else, but what does that look like if your experience in schools is very different? From Hannagh McGinley's report last year about what school looks like and the challenges involved, we know that. We have all the evidence.

Since Dr. Frazer referred to schools, I want to mention Moyross school. What it does is fantastic. The provision of food is supported by the community centre. Up to 1,000 children are fed in different schools across the north side of Limerick. They are healthy foods and the kids are rushing into school, which you do not normally see.

It is across the life course, so it is that space of how we bring it close to people and embed it. We need to learn from good practice and from where it is working according to Travellers, Traveller organisations and, as Dr. Fox said, from the Traveller health projects.

In the context of the all-Ireland Traveller health study, we used to have about 44 or 47 Traveller health projects. There are fewer of those now. Why is that? Why did it happen?

Absolutely. Deputy Connolly is next.

I thank the witnesses for their evidence. One of the conclusions of the paper by Quirke et al. is that "Culturally competent services need to be developed". Is that the same as culturally specific, because Exchange House Ireland, with which the committee discussed this matter previously, is certainly of the view that there needs to be a mental health service for the Traveller community. Is that the same as what is outlined in the paper by Quirk et al.?

The main thing coming through our interviews was that there needed to be greater flexibility. I do not think anybody was suggesting that there was going to be something completely different; they were suggesting that there should be greater flexibility, that people should think outside the box about making appointments available at times that may be more suitable or that we should go out into the community more with mobile units. It should not be a rigid nine-to-five system because that might not be suitable for all people. Those were the main points in that regard.

Does the Quirke paper from 2022 outline what a culturally competent health service would look like?

I think it does. Brigid Quirke's work is embedded in the all-Ireland Traveller health study data. There is also the paper I wrote with Catherine McGorrian. We looked at the extent to which people are accessing health services. What we are finding is consistency in evidence coming through this report, and it is consistently indicating that things are not good. What the Deputy is saying is right about what needs to happen. My perspective is very much rooted in evidence and in what I have read. It would be very much about asking how can we work more with the Traveller community and Traveller organisations in order that they can tell us the examples of where it has worked well and where the systems have worked well. Part of that, which very much came out in Dr. Fox's study, is the projects. However, Travellers always seem to be the community that has to provide more evidence, if the Deputy knows what I mean. People say we need more data, but we need an ethnic identifier. Then it is in the system and we can do something about it.

On the lack of trust compared with the general population, is that because of discrimination and mistreatment? Dr. Fox's study indicates that there was a degree of fear and fatalism about the health outcomes. What is the basis for the lack of trust?

The lack of trust is historical. That is certainly one of the points that came up. It is not just within the health system; it is elsewhere as well. They talked about employment. There might be more young Travellers finishing school but what the Travellers said is that was fine but they are still not being employed. That was what we heard. People were having to cover up their identity in order to get employment. That relates back to the issue of cancer. Some of the health professionals talked about how when they were in their workplace they might meet somebody at the water cooler and talk about whether we have gone for breast or cervical screening. If you are not in employment you are not going to have that positive influence, so it all relates back to the social determinants of health like poverty and not being able to afford a taxi to get to an appointment when you are too sick to go on the bus.

I am just concerned about that lack of trust. That is probably causing members of the Travelling community to stay at home when they should be going to get adequate treatment and a diagnosis. I think the medical profession is professional in its treatment of people. That is obviously a general statement. My own experience is that they are professional and use proper terminology. Is the Travelling community not sensing that?

In this study, when people were asked if they had a symptom who they would discuss it with first, most of them said they would discuss it with a GP. Hopefully, that shows that things are changing. Some of that may be coming from the All-Ireland Traveller Health Study. The GPs we spoke with talked of the importance of having a good relationship and ensuring they are clear and careful that they are not discriminating.

I turn to the difference in those who are happy to go to CervicalCheck or BreastCheck compared with BowelScreen. Is there a gender issue and a greater reluctance among men in the Travelling community?

Yes.

What is the basis for that? Is it reflected in general society or the general population?

One thing is that more Traveller community health workers are female. They are more educated and understand the impacts of not attending for screening. It came through in our interviews with health professionals who for the most part talked about how, when it came to health, it would be females attending with males in the family. There tended to be a concern about fatalism. I go back to that point about fatalism. It was considered to be a rational enough consideration given that there is such a difference between the life expectancy among Travellers versus the general population. One doctor made the point that a Traveller could argue why they are being told about something that may kill them in 20 years when they are not going to have the same life expectancy as the doctor.

Dr. Fox made the interesting point that if a member of the family has to visit the GP, it might the mother who would go with them. Is that a cultural thing as well? Across general society we have probably seen changes in that regard, thankfully, during recent decades.

That seems to be very much what came through. It was primarily the mothers who were attending. It is more traditional.

Okay. That would replicate in other roles within the family as well. The traditional roles are probably still culturally more prevalent in the Traveller community than the general population.

We think so, based on this.

Okay.

I thank the witnesses for attending and for their research and work in this area. It is important and is great to see. I am concerned to hear again about the barriers facing Travellers in accessing healthcare. Social determinants of health like overcrowding, unemployment and lack of education continue to present a recurring theme in this committee and all of our hearings. The State fails time and again to properly address these issues. We have repeatedly seen how the State has not treated issues like systematic discrimination and racism with the seriousness and urgency they deserve. Today we are hearing about the direct impact of this on Travellers' experiences in adopting risk-reducing lifestyle behaviours and attending healthcare screenings. It is concerning. The State's failure to address these issues is having serious harm on people's life outcomes and the health of Travellers. It is something that needs to be addressed. It would be good to hear from the HSE, the Department of Health and the Minister about the implementation of the national Traveller action plan and how we can ensure the State does the policy it has agreed to do. There is a role for us as a committee to hold those State bodies to account regarding the commitments they have made to the Traveller community and to deliver on those. I would be interested in pursuing that further.

I have a number of questions. If I understand correctly, the All-Ireland Traveller Health Study 2010 is probably a landmark and large piece of research. Is it now dated? Is there a need for another version of that? I know the identifier was mentioned as addressing some of the gaps in the research. Do we need to do a large piece of research again and if so, what is required for that? I would also like to hear a bit more about developing culturally competent services. What are the key components of that and what would be required? What needs to be teased out? It was also mentioned that the primary healthcare for Traveller project has been transformative. It is great to hear. How do we ensure those projects continue to be resourced, to be expanded and to have that impact for the community? It is great when you hear that things are really working and having an impact. It would be good for us to understand how that can sustained and continued, particularly if it is working well from the witnesses' perspective. They also spoke about the National Traveller Health Action Plan, and goals 1 to 4 in particular. What are the challenges in implementing those? What can be done by the Department and the HSE with regard to the implementation? It is concerning to hear the comments about fewer Traveller health projects. How do we reverse that trend as well? I again thank the witnesses for their work and their time today. We appreciate it.

A new all-Ireland Traveller health study is an interesting thought. The previous one was done in 1987 by Professor Joe Barry, but it did not include and was not done with Travellers. The 2010 one was undertaken with, for and by Travellers. The training and support of 400 peer researchers was fantastic, but what have we done with that evidence? There is a sense of retraumatising people. Does the Deputy understand? We keep going out and asking people to be peer researchers and collect more data that tells us they are discriminated against, they live in poverty and they have absolutely dreadful circumstances. How many times do they need to come back, because how many times would I have to say that?

What the current study has shown is that Travellers are engaging in screening services, which we did not know before. We know there is higher literacy than there was during the AITHS. The AITHS showed us that 20% of Traveller mortality was the result of cancer. It also showed us that male Travellers have a life expectancy of 15 years less and women have a life expectancy of 11 and a half years less. Suicide rates are six times higher and infant mortality is three and a half times higher. We can keep producing studies that might show it is a little better, but is that where the money needs to go? If there were more than 40 Traveller healthcare projects when this study was done and now there are fewer, why is that, when the evidence exists? That is one thing I would say. The Traveller health projects are about a targeted approach. The Traveller health strategy has looked at targeting services. However, how are we then looking to mainstream services? The Deputy spoke about the thinking around cultural competency. The Traveller projects and organisations are very good at organising the anti-racism training that we had to go through. How many people undertake anti-racism training? The people that the Travellers are engaging with, who have such a detrimental impact on their lives, are more than health professionals. For me, that is it. I do not know if I have answered the question.

Will the Deputy repeat the other part of his question?

I was thinking about the sustaining of primary healthcare for Travellers projects. They can be transformative. How do we ensure they get sustained and continue to do that work? Will Dr. Fox talk a little more about the impact they have had and what she has seen?

We know from our discussions with Travellers, as Dr. Frazer has mentioned, there were unfortunately many more to begin with and they are now fewer. The fact that they are there and are able to bring a lot of the information to the community means we are back to the issue of trust. These health messages would not otherwise be conveyed. We would definitely like to see more investment in them.

Some of the healthcare professionals mentioned to us their limited work time and said they would need to have longer but there are issues in relation to the payment structure. There is definitely a need for them. Judging from some of the limited awareness around some of the risk factors around cancer, we can see there are still great deficits in terms of the understanding of what those factors are. We are only looking at cancer, so things like alcohol, being overweight and obesity or lack of physical activity would come into play. Quite a high proportion of people do not understand that those are risk factors. It is the same with HPV. An investment at that level would be very important in relation to people being more aware of those risk factors and therefore taking the necessary measures to, hopefully, prevent the development of cancer, given the impact on individuals, their families, communities and, of course, the State because the treatment required once cancer develops is incredibly expensive.

I thank Dr. Fox.

I thank Dr. Fox. I call Senator Rabbitte.

The research produced has a number of elements. I am very struck by the fact that we keep asking the same questions and still keep getting the same answers. It is really about embedding the ethnicity indicator. I was just trying to do my little biteen of research. It is done in schools, and seemingly schools, as part of the enrolment and everything, are quite good at it. Is there a reason we do not do it in health or that it is not there? I am just trying to understand why we would leave it out. Why is it not embedded? Where is the roadblock? We include it in the census.

Yes, correct.

I am just trying to understand where the barrier is. Dr. Frazer might know and it would be helpful - or she might have an opinion, which I would appreciate hearing - why we do not have this across the system.

I can offer an opinion.

Yes, please do. An opinion would be helpful. I am not asking for the research.

It will be based on fact, in fairness.

Absolutely, yes.

I will give my own opinion around this. The AITHS came out in 2010 and that called for an ethnic identifier. Multiple reports were produced and contained so much about all the information and the harrowing lives, and also the strengths. I suppose this is one thing I want to point out. I am always so much in awe of people who show up to services and engage in research based on what I read. It still took seven years after that study was produced for Travellers to get minority ethnic status in Ireland. What was the delay there? I do not know. Again, if we think about why the ethnic identifier was not provided for in tandem with that, I do not know. It is in this space: why is there always a piecemeal approach when things come? It is really important for others, including the Minister for Health, the HSE and other Departments, to ask why they do not want that. Is it perhaps because Travellers do not want it because of stigma and a fear of identification? Is this part of the issue as well?

Does it bring more rights? Is there a fear among policymakers?

Once people know something, they have to do something about it. If it is there and embedded, and if more data is being produced annually of what is happening as people are running reports, then people have to do something with the information. If an effort is going to be made, we have to make a difference here. Sometimes, I do hear an argument made. Again, I do not want to speak for Travellers, but I want to-----

No, of course.

I hear that there could be a fear of stigma and identification, as many Travellers would say, because of the experiences they have. However, this brings me back to the point that we need to build trust. If we are going to put in a system, we have to work with the communities to say why we are doing it. We have to explain it is important to identify in this way because outcomes can be better for individuals and the community at large. Among Travellers, 5% of people are over the age of 65. In the general population, it is around 13% to 16%. We have a long way to go to say what needs to happen. I think that a lot of the evidence is already there.

Absolutely. I suppose, for the last ten months we have sat as a committee, repeated statistics keep coming back to us. There are the numbers on the over-representation in prisons, and the extremes of everything all the time. This is why I find it amazing we do not have that tracker for the simple reason that the statistics keep coming into the room here to tell us about the situation when it comes to mental health, over-representation in the justice system, etc. At the same time, we are doing it in education.

Turning to earlier intervention and the need to do a systematic change earlier, while we acknowledge and applaud the work going on currently, it is a sad statistic that literacy and numeracy is still a problem in 2025. I find it disturbing at this stage that basic literacy and numeracy, including text messages and other things, at this are at this level. I can understand people might not understand a word in a message, but "appointment" is the important piece within it. People feel they have to share the information with a third party in order to get their health checks done. In 2025, that is a primitive situation to have people in. At the same time, the women are doing a great job and minding the kids, but who is minding the men of the house? Is there a reluctance there? Why do they not trust or engage with their GP services? That is possibly one of the reasons we have a higher rate of suicide within the Traveller community. Nobody is minding the men. I absolutely do not mean in any way to say their wives are not minding them. There is not a trust, though, or an understanding as to why it is important. I will go back to my questions. What do the witnesses think we need to do from building the change with the younger generation with engagement? The witnesses have done phenomenal work, but we cannot just keep doing research in this area. It is implementation that is required.

I think one of the most important things is around employment.

Right.

Unfortunately, a high proportion are still unemployed. There is the fact that even though, as we were told, some are getting the educational qualifications, they are still not being called for interviews because of their names.

Or their addresses.

We can go back to that for some many different things and in relation to it. People are understandably not going to have the same level of trust in the system if they are not being employed and not able to get housing, again because they cannot afford it. We can go back to the issue of healthy eating; this is because they cannot afford the more expensive healthier food. A lot of this situation goes back to employment. For younger people in the Traveller community, it would be really great to see that there would be some system, some supports or something changed in relation to them being able to have a brighter future in terms of employment, because so much comes back to this aspect.

Can I have one last minute?

Yes. I think Dr. Frazer might want to come in on this question as well.

Yes, go on, Dr. Frazer.

I was just thinking about this point. To build on what Dr. Fox said, I also think that within the Traveller community it is about role-modelling. Who do Travellers see as Travellers in the health services and in government? Who can Traveller younger people see in those kinds of role-modelling situations around them? Another one would be Traveller health workers. They are a lynchpin. It may not be here in these statistics, but again how much data do we need to say that?

What does that workforce look like? We call them Traveller health workers, but they are actually workforce. When we look at workforce planning, what does planning around that look like? Where is the trajectory of where you can go next? Sometimes within mental health services - I see it in homeless services as well, including in other countries - we talk about peer navigators through the health systems. I have seen that in the US. We have peer navigators. They are called Traveller health workers. What you call someone depends on whether you value the role. What is the education and training around that and can people see where they could go with that if they start here? If people have difficulties at school or leave school early, how do we support that within the system to allow people at any time to be supported at whatever point they feel safe and secure to jump back into that network? It is about supporting that.

I just want to speak about rolling out interventions that can work. This was a very small-scale exercise programme. We had members of the Traveller community. We organised transport and we were very flexible about the time. It was no problem if they turned up late. It was trauma-informed, low threshold, there were minimal barriers to entry and we were building up trust. The group engaged really well with this health behaviour exercise targeting frailty. These things can work and interventions can work if they are designed in the right way.

Was that gender specific?

It was mostly women from the Traveller community. They engaged extremely well with the programme. It was Traveller-specific to start with and then they integrated into the wider group and worked extremely well. Sometimes it is about starting small interventions and seeing if they work and then replicating them if they do work well.

That is the question – replicating them if they do well or mirroring it in another cohort. We all have the statistics on male suicide. Is there a way of replicating it and flipping what was done to the men?

Absolutely. It is just a case of having some funding to try it and see if it works. It could certainly be done from a research perspective and then we could roll it out on a bigger scale.

Who funds the research? I am sorry for going beyond my time but it is an important train that we are on. To keep it health-focused, who funded the last piece of research Dr. Fox did?

It was the national cancer control programme, the NCCP, for the cancer awareness study. The research Dr. Broderick was talking about was separate.

The Health Research Board. It is important for us to get our main entities orientated to this type of research.

That is so interesting.

Sometimes we get money for research but then it is a once-off and we want it to continue. Do members understand that? The idea is that we want to try something else. That is where I am at. Sometimes I get sad because I want to do something but the question is who we go to for money because it is just not there. Then a new project comes along. There is always something else. I hear what Senator Rabbitte is saying. I think she is right. It is that space where, if we know something works, how we get the secondary funding. If it is built in, then it could be accessed to be able to try it in another area in other ways.

I thank the witnesses very much. We have had a lot of people before the committee and there is a lot of research and delving into problems. In the case of the witnesses, we are talking about cancer awareness and attitudes. We talked about the study in 2010. We have gathered so much information but from what I see on the ground the actions are very limited. Did we get any sort of an indicator on whether cancer has increased between 2010 and the recent study in 2023 on cancer awareness and attitudes? That was not the aim of the study but is there evidence of any description to say that we can see that cancer has increased, decreased or otherwise in the Traveller community?

Do we see a similar effect in the mental health services between 2010 and 2023? Even through Covid huge numbers of people were presenting with mental health problems. I am curious about that.

The outreach of public health nurses is extremely important, in particular on Traveller sites, and where people are not in ordinary housing, as we call it. Do we do enough outreach? It is quite difficult to get someone to go to a satellite clinic, a health centre or otherwise. People have fears about that. They do not like being out of their community.

The other issue that is not mentioned in this study relates to drugs and alcohol. We do not get a picture about it. We are talking about awareness and attitudes but there is also a big problem with drugs and alcohol. The drugs situation is probably worse in the Traveller community. I am not sure whether the witnesses agree with that but it appears to me that is the case.

I wish to focus on the dealings the witnesses have had with local authorities. I have had loads of cases where people on Traveller sites needed ramps or other things. Some of the caravans, for instance, on the sites are not suitable. They have high steps, which do not suit a person with a disability. The needs are not catered for. I do not know whether the witnesses have experienced that, but I have. I have tried to get local authorities to deal with it but it does not come easy. In many cases, Traveller families are very personal. They want to be seen in their own place. They want people to come out and visit them and take on board their concerns on health or otherwise. That is what I find.

Travellers can feel very isolated. The witnesses mentioned that. They have issues such as poverty and unemployment. Deputy Quinlivan mentioned the post not being delivered. We have that every so often. They do not even get the letters sent to them by the public nurse or otherwise. That is a big problem in a number of areas. My big concern is that even with all the research and the actions that are being put in place that we have heard about from the people who have come before the committee, there is not enough action being taken on the ground. That is my observation.

There are a lot of points and questions there. The witnesses can feel free to respond as they wish.

On the first point about whether cancer is on the increase, we do not know because a study has not been done since and we do not have the ethnic identifier. We were in Pavee Point for the launch of the report last Thursday and I spoke to some of the Traveller community health workers there. They were talking about so many more people they knew who had developed cancer. Anecdotally, they feel that it has increased. It accounts for 20% of the deaths among the Traveller community. It is actually 30% or a little over in the general population. We feel the difference there is probably because, as Dr. Frazer mentioned, there are so many fewer older people in the Traveller community over the age of 65.

We know cancer is much more common as we get older. That is probably why it is a little lower.

On living conditions on the sites, the public health nurses talk to us about issues like those the Deputy mentioned. Going back to cancer risk factors and the importance of exercise, they would talk about some of the sites being of such poor condition that it was impossible to safely walk on them because of the rubble and debris on the sites. That is a major issue. Even on early detection of signs and symptoms of cancer, there is the fact there may be overcrowding, so someone might not be able to be breast aware, or if they are using toilet facilities, because they have to go out to a Portaloo, they may not be aware if they are passing blood. Again, it all comes back to those poor living conditions.

We did not look at the drugs and alcohol aspect. This was mainly focused on cancer. However, some of our interviewees among the primary healthcare professionals talked about the fact that drugs were an increasing problem. We know Pavee Point is doing some excellent work. Mayo Traveller health workers are leading some of those projects around drugs and alcohol. I was speaking to one of them last week. It is something they are very much focused on.

The public health nurse would probably report back on some of this but the sanitary conditions are very bad in many places.

Absolutely.

Some are outdoors, which is not conducive to good health.

Being able to collect a specimen for a bowel check is very difficult in those situations.

On people’s homes, we know 80% of Travellers live in houses. The minority who live on sites have very poor conditions but the homes people live in can often have very poor conditions as well. It is about acknowledging that too.

On public health nurses, when I was in UCD many moons ago and teaching a public health nursing course, I used to invite in public health nurses who were Traveller-specific. They were Traveller support public health nurses who came out of the Traveller strategy around 2005. Most of those people have not been replaced due to cutbacks in the health services. It seemed to be an additional piece to their job as opposed to a dedicated one. When I looked at the trust of public health nurses in the all-Ireland Traveller health study it was very high. When it looked at primary care workers, public health nurses came out very high. It is a question of where the investment goes. As the Deputy articulated, public health nurses are mandated to go into people’s homes. They see the conditions and they are there to see how they can make it better. It is across a life course for the person they are visiting and the wider family as well. We need to acknowledge where the investment is going. Do we have enough public health nurses? I would say "No". Do we need strategically appointed public nurses or look to see where they are targeted? Yes. Again, it should not be in competition with the Traveller primary care workers but in addition. All these things are in addition to what currently exists. That is my opinion.

Do the public health nurses engage with the local authority to tell it what they have experienced or seen in terms of the conditions or otherwise? Is there a mechanism there?

Yes. They write letters and they report it to their assistant directors when they go back. There is an assistant director in north Dublin, Jackie Austin, whom I work a lot with. So much time is taken up with trying to get someone on the phone or follow up. Even the power of the public health nurse is not seen enough, as the Deputy is pointing out. The position someone has should be truly acknowledged in the wider system. It is about making sure that when they point out about steps, no heating or whatever is going on for people it flags up a reaction and not just a noting. Sometimes I wonder where the information goes. Does it just get added to a list or does it prompt something to happen?

I thank the witnesses. I apologise for being late. As I explain every week, I have another committee and it clashes with this so I am late. Apologies I missed the debate and I am not sure what was discussed.

The first thing that strikes me is the question of life expectancy. I presume the meeting has touched on that earlier in terms of what is the average life expectancy of both male and female members of the Travelling community.

For Traveller men it is 15 years less, and for women, the all-Ireland Traveller health study found it is 11.5. Joe Barry’s original study from 1987 used to refer to 12 to 14 years, whereas in 2010 it was found men’s life expectancy had reduced, so over time things had not progressed.

I note the witnesses' statement referred to higher incidence of cancer and so on. There are also lifestyle issues – a higher smoking rate, addiction issues and so on. What would the witnesses point the finger at in terms of that life expectancy? I presume it is a mix of issues including quality of accommodation, sanitary facilities, as Deputy Ellis said, and so on. There is no one factor to highlight but a mix of contributing factors, I suppose.

Our final report discussed the social determinants of health. Discrimination is definitely at the centre of all of that, as we talked about in relation to unemployment. People might be even afraid to sign up to go to a gym or go on a walking course or exercise classes. Travellers have to think about that and may not go because of the fear of discrimination. It goes back to that.

It is a combination, a myriad of issues. From our point of view, many of us would attend a GP regularly and so on. I suspect that is an issue as well and that many members of the Traveller would not attend GPs on a regular basis. Would that be a fair comment?

From our research it was clear the women are definitely very good and certainly excellent about bringing their children but that is less so of the men.

That is also the case in the general population. Is it a bigger issue in this community in terms of non-attendance for male individuals?

Yes, with GPs in particular.

Mental health is obviously a huge issue. Again, I apologise if this was debated earlier. It is a far bigger issue in the Traveller community than the general population community. Is that the witnesses’ experience?

Certainly that was coming through. We did not focus on it in the survey. However, in our interviews with the health professionals, that did come through. A lot of times a lot of psychosocial issues were coming up which, again, came back to discrimination, for instance, a child being bullied at school, needing to get support in relation to housing or a letter for the local authority or whatever. They talked about the fact that a person who had a cough which was ongoing for a few weeks or months all gets lost in the system because there are so many of these other issues which take over.

Would there generally be information around access to medical cards and so on? Would the witnesses have found that was not an issue in terms of those who qualified for medical cards, that they had them?

For the most part, yes, although there were some difficulties around the loss of a medical card at 16 years. That was something that came up and required further initiative. That is going back to literacy, which could be where someone is not literate, or it could be around digital literacy, so those issues would become problematic.

You could have somebody with acute mental health problems, as was mentioned in one of the interviews, spending all time trying to sort out access because of not having a medical card.

Even with a medical card, there are certain charges and costs. I imagine that is an impediment to access to healthcare.

Absolutely. Public health nurses mentioned a patient who had advanced cancer and who was too sick to go on the bus, who did not have a car because they could not afford it and who could not afford a taxi. Going back to the lack of understanding and recognition of underlying issues, in the hospital it was a case that they did not show up for the appointment. There was no attempt to understand why that was the case.

There is also the time away from family, activities, work and so on for those getting health treatment. I presume that is a big issue. People are not in a position to take time out or would find it difficult to do so. I will leave it at that. I thank the witnesses.

I have a few questions. If members want to come back in for a second round, they are welcome to do so. The first is on breastfeeding. Have the witnesses conducted research into the levels of breastfeeding among Traveller women and on supports for Traveller women to keep up breastfeeding? It is low in the general population anyway, but it is probably even lower in the Traveller community. Maybe it is higher, I am not sure. Are there lactation nurses, La Leche League supports or other supports for Traveller women to start breastfeeding and keep it up?

The cancer study did not look at that specifically. When the all-Ireland Traveller health study was published, the rate of breastfeeding was 2%. It is currently around 15%. Pavee Point and the projects have engaged to look at that. For me, that is not surprising because there is the risk of the inherited disorder galactosemia. There has to be a blood test when the baby is born. To the best of my knowledge and if I am not held to account on this, the lab testing is Monday to Friday, nine to five. If you have a baby at 5.15 p.m. on Friday, the blood test cannot be sent until the following Monday morning. You cannot breastfeed until you have the result of the test.

The structural and systemic barriers in place are part of the conversation around supporting Travellers and looking at that. I cannot answer that, but my colleagues and I are doing research on breastfeeding. We did studies in north County Dublin as well. We work with Pavee Point. It is leading on that. What is being done in one Traveller organisation should be replicated. It is not reinventing wheels. Maybe somebody could explain it to me. I go into public health nursing students and talk about this. I tell them I do not have the answer for it. Maybe there is a good answer. Maybe it is the specific testing of that, but it has never changed.

I am not sure that is something we could discuss further or have addressed, but it is hugely important. Have the witnesses looked at the importance of children's play and parents' and siblings interaction with children, particularly those of preschool age, in terms of bonding? Is the research looking at that or has it given consideration to it?

That is not part of my research. I could not really comment on that.

I have never read anything about that. The right to play is embedded in the UN Convention on the Rights of the Child. It is a really good question. For all I have read, it has never come up. We think about what people's play areas could look like. A lot of the research I do is on families experiencing homelessness and the impact of the lack of space on physical activity, which is then identified by schoolteachers. Children could not roll, for example, because they were in hotels. I have not read about that from a Traveller perspective.

It is extremely important from a developmental perspective, for family bonding and for the interaction of parents with their children. When you are further hampered by atrocious living conditions, it is low on the priority list. We had discussions here on attendance at preschools. There are some Traveller-specific preschools, including one I am familiar with in Kilkenny. Those formative months are critical to a child's development. It is an interesting area that could do with further research.

Maybe there is good work going on in preschools and projects which we are unfamiliar with. There is not the funding going in there. I agree with the Cathaoirleach that it is about what we prioritise. It is giving everyone the best start in life, which involves all those elements. For Travellers, however, we are looking at other things and saying this is what is important, rather than saying that everything is important.

Absolutely. It is all-important. Dr. Fox said there is a significant fall-off in the number of primary healthcare projects around the country. Do the projects meet regularly to share experiences and best practice? Do the witnesses have figures for the number of projects currently up and running versus the number when the projects started to be rolled out?

I was asking about that. I was looking at the all-Ireland Traveller health study. I think it is either 44 or 47 in that report. When we started, it was 27. There is a discrepancy. Sometimes the HSE might say there are 30 projects. Regardless of whether it is 27 or 30, it is not in the 40s. Based on the all-Ireland Traveller health study, which looked at over 40 projects, the assumption was there would be more of them by this point, rather than fewer. As part of the study Dr. Fox led on, we were meeting in Pavee Point. Part of the recruitment, similar to what we did in the all-Ireland Traveller health study, was to have all the projects come together to share what is going on and see what is happening. I cannot speak for them but it must be a bit demoralising to see fewer projects 15 years on from something everybody showed up to.

I think you are right. We are looking at our work programme for 2026 and we might bring some of those projects in. It might be useful to have a deeper conversation with them. I agree with the word "transformative". That is exactly what they have been. They are phenomenal projects but we should have many more of them.

The point that has consistently struck me in the past few months during our deliberations is the lack of consistency in application and approach. Many good projects get up and running in small pockets around the country, run for a year or two and are defunded or not continued. It is hard to even carry out longitudinal research when projects are not maintained. There has been good and important work done on nutrition, women's health, men's health and Traveller horse projects, all of which are interrelated and relate to the general well-being of the Traveller community. The lack of consistency is frustrating from our perspective.

Absolutely. Again, on the study, it would have been impossible without the Traveller community health workers. We would not have been able to do that survey because, understandably, going back to the trust issue again, people would not have that same trust in us as they do with the Traveller community health workers, who are members of their own community. Both from the research point of view and in terms of the education and getting the health messages across, that is so important.

The only thing I would add is to ask why the funding is so limited and why it is stand-alone. Why is it not repeated and embedded within the system? Why are the Traveller organisations not trusted with the money to be able to continue on the service they provide? Why must Traveller organisations apply and get funding of, say, €10,000 or €20,000 and then when the funding stops, they must apply again? In fact, it is the Traveller organisations and the projects that keep supporting all our research and we keep asking how we can build trust. Part of that is engaging with the Traveller organisations and hearing what needs to happen. It is a case of asking how they can make it happen and what they need and giving the money to them. What is the fear about where the money will go? Do members know what I mean?

I agree. I have a final question. It is rare to meet a member of the Traveller community who is over 70 or 75 years of age, typically. We know that there are issues around life expectancy. Has research been conducted with older members of the Traveller community on their health and well-being, their housing needs and the health issues that affect them in older age?

I can only speak for myself when I say that I have had these conversations with Traveller organisations when looking at future research on mid-life and older age. We have talked about what that looks like. Mid-life for the Traveller community looks very different from that for the settled community. That is something, but currently, there is not research that I know of.

There is a big research gap around that and how people age, what happens in terms of mobility and frailty, how they manage with limited access to housing and how adaptations can be made when they need it, etc. There is a big gap in our knowledge about this.

Do any members wish to comment?

I have just one observation after the group's very valuable contribution. If you do not have the policy, the money cannot follow.

Correct.

If we do not have the indicator in health, the money cannot follow. We have it in the prison services because that is how we must have all the statistics. We have it in education and we have it in the census.

Local authorities too.

Yes, we have it in the local authorities. To me, the gap is within health, be it primary care, mental health - we have not even gone into disabilities or children who await an assessment of need.

Yes, or maternity.

I can only imagine, coming from a former ministerial role, but we do not have the indicator. It is incumbent on us to find out from the Department of Health why we do not have the identifier because we have it in other Departments. The Department of Health is the outlier. Money cannot follow the policy because really we are not funding it.

Correct.

I think the Senator has made a proposal that we write to the Department on this matter.

I would say we should bring in the Department officials. Right up to the Secretary General, I would like to have an answer.

Okay. I wish to express huge thanks to Kate, Patricia and Julie for their compelling evidence, which is really valuable to our work. We will stay in touch, which will be really important as we continue our work. This committee really wants to make an impact. Again, I thank them for all of their work. It is hugely valued. Happy Christmas.

Thank you very much.

I thank the committee for the opportunity.

Thank you for the opportunity.

The committee is adjourned until its next meeting in private session on 18 December.