Asylum Seekers and Primary Care in Malta: A Critical Exploration of Healthcare Encounters

There is a substantial body of literature that highlights disparities in asylum seeker health and healthcare access and the difficulties that healthcare professionals face when providing care to asylum seekers and refugee populations. Few studies, however, have explored these processes within the context of Maltese society. This study aimed to gain an insight into cross-cultural healthcare practices through an exploration of clinical encounters between asylum seekers and healthcare professionals in the primary health care setting in Malta. The research design was guided by an ethnographic approach, with data collated through observation and in-depth interviews. The observational period consisted of one hundred and thirty hours spent mainly in a government Health Centre, with a focus on healthcare encounters between asylum seekers and healthcare professionals and included a series of informal conversations. Formal, semi-structured one-to-one interviews were carried out with 11 asylum seekers, two cultural mediators and seven healthcare professionals. Data were analysed inductively using thematic analysis informed by postcolonial and intersectionality theories within a candidacy framework. The analysis produced three main themes, namely: “Seeking Refuge and Beyond – The Migratory Process”; “Seeking Mutual Understanding – Communicating within the Healthcare Encounter” and “Seeking Resolution”. The first theme provides the asylum seekers’ poignant testimonials of their pre and post migratory experiences, including both the perceived impact of these on their physical and psychological health and the healthcare professionals’ perspectives of the asylum seekers’ migratory journey. The second and third themes represent both asylum seekers’ and healthcare professionals’ experiences of, and practices within healthcare encounters, with narratives that show how both these groups have the common aim of achieving a satisfactory resolution to the presenting problem. Notwithstanding this, the three themes show the extent to which cross-cultural healthcare encounters fail to achieve this common aim because of a range of factors that impact on service provision and ultimately, on individual healthcare interactions. These findings have guided the creation of a multilevel framework that illustrates the impact of various discourses and structures on the formation of an assortment of elements, which intertwine in a chaotic bricolage that ultimately shapes cross-cultural healthcare encounters. These elements include linguistic and cultural discordances, power asymmetries, trust/mistrust issues, incongruent expectations and issues of asylum seeker deservedness, being played out in an unsupporting environment. The utilisation of a critical constructivist position that negates essentialist generalisations has enabled a multi-layered analysis that presents a counter balance to common culturalist explanations of healthcare encounters. Postcolonial theory has revealed how healthcare encounters are influenced by the colonialist creation of categories of ‘Us’ and ‘Other’ and an uncritical belief in the supremacy of ‘Western’ knowledge. Recommendations are made for healthcare research, education, practice and policies. One of the recommendations is for the identification and implementation of an effective information system, which collects the necessary data to enable the development of services and practices that effectively address asylum seekers’ primary healthcare needs. Other recommendations include the establishment of a working group with a remit to review existent structural systems and policies for their potential to produce inequitable and discriminatory healthcare practice within the primary setting, as well as identifying and implementing educational strategies that would produce reflexive healthcare professionals able to discern previously unquestioned inequities to challenge an unjust status quo.