In summary, the evidence shows that Romas and Irish Travellers have significantly worse mental health outcomes than the general population; this is a theme that was common to all countries studied. This trend is particularly marked in women, but more unclear in adolescents and children. There is a link between Romas’ physical health and health-related quality of life, which are also both worse than the general population, and their mental health. Romas and Travellers attempt suicide more often. Romas are likelier to attempt suicide multiple times, but evidence varies between studies on whether they are more or less likely to die by suicide. Research conducted more recently in the UK has shown that Romas have a higher suicide rate than the general population. Romas are also found to be likelier to impulsively attempt rather than deliberately planning an attempt. Mental health is shown to be affected for both communities by socioeconomic factors as well as discrimination and prejudice from the general population. Before interpreting these findings, it is important to note that the quality of evidence is limited, with most studies being cross-sectional or prevalence studies and with very few cohort studies. This dearth of high quality evidence may reflect the specific challenges in conducting research on these groups as well as lack of available funding.

A major factor associated with mental health in many of the studies was housing. The physical environment and housing situation of Roma and Traveller communities makes up a large part of their connectedness with their culture. Therefore, housing situations that are seen as unideal can have a large impact. It has been acknowledged by the UK government that there is a shortage of sites where Roma/Traveller communities can stop with their mobile residences. The 1994 Criminal Justice and Public Order Act took away the consequences that local authorities would be subject to if they did not provide public sector sites for Roma/Traveller populations. As a result, these authorities have not been meeting the need for caravan pitches where Roma/Traveller populations can legally and safely stop [65]. As of 2021, there were only 59 permanent pitches and 42 temporary pitches available in all of England, with 1696 families on the waitlist for somewhere to live [66].

As a result of this situation, Roma/Traveller families in the UK are increasingly being forced to stop their caravans on unauthorised land [8]. Local authorities often evict these unauthorised roadside camps within days, forcing them to move on in search of somewhere else, where there is risk of the same incidents occurring again [67]. Similar incidents occur across Europe. In May 2024, the government of Italy was found to have violated the European Social Charter in its discriminatory housing policies towards Roma communities [68]. In the Czech Republic, a half of Romas have reported feeling threatened by evictions. Even during the COVID-19 pandemic, where moratoria against evictions were in effect, evictions of Romas continued [69]. Nomadic Romas are made to move between various unstable locations, unable to spend any prolonged period in one spot. These forced displacements are unsustainable and can cause a deep sense of vulnerability. The inability to live life according to the cultural ideals that have been a formative part of one’s identity can be very damaging to one’s mental health [70]. Spurred by the feeling that cultural change is being forced on them, and that there is a deliberate, powerful attempt to destroy their way of life, Romas/Travellers in the UK and Ireland are becoming increasingly anxious and depressed [53, 67].

On the other hand, the legislative and systemic difficulties associated with maintaining their traditional lifestyle makes many Romas/Travellers feel forced to give up travelling altogether. They are pressured into attempting to assimilate into settled society, which also leads to worse health outcomes. Parry et al. found that living in a house or council site was associated with higher prevalence of long-term illness and higher severity of anxiety. Furthermore, Romas/Travellers who rarely travelled were found to have the worst health status and health-related quality of life [27]. In Ireland, policy changes over the last few decades are seen to have contributed to a growing feeling that the nomadic way of life is becoming criminalised, and this is eroding Travellers’ sense of self-worth [58].

Another issue altogether is the quality of the housing that Romas do receive, both those that are on the move and those who attempt to settle. Encampments are often located in areas with poor sanitation and little access to drinkable water [8]. In the European Union, local authorities have been known to use forced evictions and house demolitions as tools to rid municipalities of their Roma inhabitants [69]. What results is the ghettoization and isolation (both physical and social) of Roma communities. Restricted to the outskirts of their municipalities, they form segregated settlements in areas with substandard conditions and a lack of basic essential infrastructure [69]. In Ireland, there are similar phenomena; Travellers believe issues with housing, including forced settling and unsuitable conditions, are a key contributing factor towards developing poor mental health [53, 58].

Being able to choose where to stay, and when to leave, gives people a sense of control over their own lives. Forced to constantly move or to settle, Romas feel this sense of control is collapsing; this is especially true when attempts to assimilate are met with more hostility [67]. It erodes their ontological security, or the aspect of their wellbeing stemming from a sense of stability in, and control over, one’s own life and environment [71]. This fundamental lack of security and peace in their physical environment may be a large driving factor behind the poor mental health outcomes that this community faces. This idea is supported by findings from Olah et al., where ethnicity was not found to have any effect on mental health once socioeconomic factors were accounted for. The single largest factor that was correlated with a poor mental health was living in a segregated settlement [64]. Vazsonyi et al. also showed that concerns about neighbourhood safety is associated with anxiety [48].

Discrimination is not just limited to housing policies; Romas and Travellers are regularly targeted by hate crimes, including hate speech and racist attacks [18, 53]. Travellers and Romas report being excluded from services, both essential and recreational, because of their ethnicity. There are widespread reports of Romas/Travellers feeling that they must hide their ethnicity to participate in society, keep employment, and avoid discriminatory attacks [53, 58, 72]. Discrimination was seen as the strongest predictive factor of poor mental health in Traveller populations [73], This is widely acknowledged by Travellers themselves, who believe the regular prejudice and hate they face has had a negative impact on their mental health [53]. Additionally, Quirke et al. found that a large portion of Travellers feel they and the general population had equal access to mental healthcare. However, those who did not feel this way were significantly likelier to have experienced discrimination from the general population [42]. This shows that not only does discrimination directly impact mental health, but it can also create a lack of trust in the healthcare options that settled society has in place for Travellers to get help. To add to the issue, the segregated settlements that they are forced to live in provide them with virtually no opportunity to integrate into mainstream society, reinforcing their status as outsiders and worsening the discrimination [69].

This segregation from settled infrastructure also creates a cycle of poverty, subjecting entire communities to lives of little to no education and low income. In the UK, Roma and Traveller pupils have the lowest educational attainment of all ethnicities, and are the least likely to stay in school after GCSEs [14]. The 2016 Irish Census shows a similar trend for Travellers in Ireland; 28% of Travellers over the age of 25 had left school before the age of 13, compared to just 1% of the general population [74]. This translates into a lack of employment. A European survey in 2021 found that 57% of Roma are unemployed, compared to the EU average of 28% [15]. Their economic status reflects the same; the survey also showed that 80% of Roma are at risk of poverty compared to the EU average of 17% [15]. Lower socioeconomic position is associated with negative mental health effects, and persistent low income is strongly related to higher rates of mental health problems [75]. In qualitative interviews with Travellers, a common theme that emerged which provides more evidence for this point. Lack of education, unemployment, and the resulting financial instability significantly contributes to the mental distress that Travellers experience, especially men [53, 58]. A lack of education, employment, and income also allows negative stereotypes about Roma to be reinforced.

Roma communities’ housing difficulties, lower sociodemographic position, and experiences of discrimination all exacerbate each other, creating a campaign of social exclusion. These socioeconomic factors alienate an already vulnerable community, and this has negative effects on mental health. Social exclusion and alienation can be associated with higher severity and frequency of depressive and anxious symptoms [76]. Interventions in this domain are very difficult to implement successfully. As evidenced by current trends, large-scale policy change accompanied by compliance and willingness from local authorities is needed to improve housing conditions and tackle discrimination. Programmes and policies to address the discrimination that these communities face exist in most countries, but a report from 2015 found that their implementation was widely ineffective [77]. It found that marginalisation during policy formulation, lack of funding, and poverty all work to limit Roma representation in government [77]. Properly implementing these policies and removing barriers to Roma representation in policy-making, may prove to be very effective at combatting stereotypes and reducing discrimination. Increasing access to education and reducing unemployment should be priorities, as these will allow for vertical mobility of Romas within the respective societies that they reside in. In qualitative interviews, participants stated that employing more Travellers in health services targeted toward Travellers would help increase trust in these services. They mentioned this could also include more Travellers in non-clinical roles, such as receptionists [59]. The knowledge that their own people are working as representatives of a service would help them feel more at ease in engaging with it. This may work on a multifactorial level to not only increase engagement with settled services, but also decrease unemployment and help lift these communities from poverty.

Another consequence of the poor socioeconomic conditions discussed in the previous section is their impact on healthcare. Romas have significantly worse physical and mental health outcomes [17]. This disparity was clearly elucidated by Watkinson et al. and Hayanga et al. [20, 33]. Romas report higher levels of several chronic health conditions, including cardiovascular disease, arthritis, and diabetes, and they are the likeliest to have multiple long-term conditions [20, 22, 23, 27]. Chronic illnesses are associated with higher rates of mental health problems, largely due to the psychological impact of having a chronic condition [78]. In some cases (such as arthritis) common pathophysiological processes also increase the risk of mental health disorders such as depression [79]. This can make the condition harder to treat, creating a loop where mental and physical health worsen each other [80]. Furthermore, in Zelko et al., physical symptoms that Romas faced were associated with higher levels of mental health diagnoses, including mobility issues, chronic pain, and inability to partake in everyday activities [50]. What results is a bidirectional link between physical illness and mental health concerns; both exacerbate each other and lead to a greater and more severe burden on the patient [79]. Therefore, poor physical health status of Romas not only negatively affects their mental health status, but it also creates a vicious cycle by which physical and mental symptoms both get worse.

Romas in both the EU and the UK have lower access to and utilisation of healthcare services than the general population [28, 81]. Roma and Traveller culture tends to be fatalist and stoic in relation to its perspective on health; it is widely believed that ill health is a normal part of life, and nothing can be done about it [82]. As mentioned before, there is also a sense of alienation from “settled” institutions; studies have shown that Romas fear hostility and prejudice from healthcare providers, making them less likely to turn to them [17]. Romas have faced discrimination within healthcare; for example, forced sterilisation of Romas was widespread in Europe until the early 1990s [81]. In Roma culture, a great deal of importance is put on the “collective”, or the immediate Roma community that one resides within. A Swedish study found that Roma women almost always presented to primary care as a small group of patients all experiencing the same symptoms and wanting the same treatment [83]. They found comfort in this group setting, as it gave the women the support of a community whose approval is needed to seek the help they need [83]. Stigma surrounding mental health is even more pervasive in Roma and Traveller communities, with mental health very rarely being discussed openly [84]. This stigma makes it very hard for Roma and Traveller individuals to access care for mental ill health, with men facing additional barriers due to gender norms [84]. Most Travellers who were offered group psychotherapy at one community mental health team in Ireland declined this treatment option [46]. The examples in this paragraph show that the collective’s opinion, whether that of validation or stigma, has an impact on health and help-seeking behaviours [83].

The example regarding group psychotherapy also shows that members of these communities are likelier to forego utilising healthcare services at all if these services force them to face a group of other Travellers in a vulnerable, “ill” state [46]. However, it is interesting to note that in Ireland, studies show Travellers utilise healthcare services more than the general population, fitting with their poorer health status [82]. Rather than a difference between Irish Travellers and GRTs in the UK, this seems to be due to a difference in the Irish and UK healthcare systems. This is evidenced by the fact that Travellers in the Republic of Ireland utilise healthcare services significantly more than those in the UK province of Northern Ireland, which falls has the same healthcare system as the rest of the UK [82]. This may be due to the success Ireland has had in implementing its “medical card” programme within the Traveller community. This programme allows low-income individuals to access healthcare services free of charge, and also allows them to do so anywhere in the country—suiting those maintaining a nomadic lifestyle [85]. 92.6% of Travellers had a medical card, which reduces financial barriers, as well as other barriers to healthcare by providing them with a physical symbol of entitlement to access healthcare services like any other Irish citizen [19]. Additionally, there are “Primary Health Care for Traveller Projects” across Ireland, which are partnerships between the Irish government’s healthcare service and Traveller organisations [7]. They work to train Travellers to become community health peer workers, essentially resulting in culturally competent health support [7]. Although similar programmes exist in the UK, they are not standardised throughout the country [86, 87]. They also have no evidence of working in partnership with Roma/Traveller organisations to inform their care, which is perceived to be crucial by Travellers [59].

The disparity highlighted above between Travellers in Ireland and Romas/Travellers in the UK show that despite the power of stigma, improving access to healthcare services may improve their utilisation rates as well. General practices often require a permanent address for registration, which many Romas/Travellers do not have. In the UK, where there is no “medical card” system and very fragmented programmes targeted at Roma/Traveller communities, this makes it near impossible to access primary care [87]. This is especially true considering these communities are caught in a cycle of unauthorised camping and forced evictions. There is a heavy reliance on walk-in centres and hospital emergency departments, which have no continuity of care or follow-up capabilities; this can lead to interruptions in treatment and leads to worse health outcomes [17]. Romas/Travellers in the UK use hospital emergency departments significantly more often than the general population, but are far less likely to be registered with a GP [88]. This is in sharp contrast with Ireland, where Travellers still access hospital services more than the general population, but have equal rates of access to primary care [73]. Across Europe, 26% of Romas are not covered by health insurance [89]. There is also a dearth of medical facilities and professionals who work in the remote areas and segregated Roma settlements [81]. These factors make it much more challenging for Romas who need mental healthcare to access it. Issues that can be treated are thereby allowed to remain unresolved and worsen, further compounding the negative mental health status of this community. Rees et al. found that those Romas and Travellers in Wales who were registered with a GP utilised mental healthcare resource at a higher rate than non-Romas [43]. This suggests that Romas/Travellers who are given access to mental healthcare do utilise it and improving this access would result in more Romas and Travellers getting the care they need [43].

However, the same study found that although attendance rates at first psychiatric appointments were the same between Romas/Travellers and the general population, follow-up attendance was significantly lower in the Roma/Traveller population [43]. Based on this, more needs to be done to emphasise the importance of continuity of care in this community, so that mental health professionals can maximise the impact of their care. Other interventions in this area should focus on improving education on mental health issues to destigmatise this topic. Roma health mediators could have a huge impact in this area. These are Roma individuals trained to act as liaisons between the Roma community and the healthcare system. In countries that have Roma health mediator programmes, there has been increased education about health and vaccination rates in the Roma community, among many other benefits [90]. Using these programmes to target mental health could be a targeted, effective way to improve outcomes. The Irish Primary Health Care for Traveller programmes are an example of an intervention that trains Travellers to become ambassadors of healthcare within their communities [7]. Traveller Mental Health Liaison Nurses have also been used in Ireland and have been received extremely well by the community [56]. Attributes that raised trust in these services included privacy, cultural competence, emphasis on holistic methods of maintaining well-being, and the ability to signpost to mainstream social/healthcare services [56]. It is crucial that these interventions are standardised across countries and work equally alongside organisations that represent these communities to inform their activities. Lopez et al. used a church organisation to promote a safe space where issues surrounding substance abuse and mental health could be explored and solutions discussed [54]. Using respected community institutions where individuals spend a significant amount of socialising time may help to reduce the shame and guilt associated with issues such as mental health [54]. Additionally, improving access to primary care is essential, as this would improve continuity of care and reduce reliance on hospital emergency department and walk-in centres. Primary care physicians should be given information on how to register and care for nomadic people. A programme similar to the Irish medical card programme, but specifically tailored to allow people with no fixed address to access GP appointments, m