LAST AMENDED Asylum Seekers and Primary Care in Malta

Asylum Seekers and Primary Care in Malta: A Critical Exploration of Healthcare Encounters Submitted in partial fulfilment for the award of Doctor of Philosophy Joanna Depares De Montfort University December 2016 Abstract 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 i 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. ii Acknowledgements There are numerous people whom I wish to thank for making this thesis possible. Firstly I would like to thank all the participants who accepted to be a part of this study and who shared their experiences with me so very generously. This gratitude is also extended to staff members of the respective non-governmental organisations and governmental entities, who were so willing to share their wealth of knowledge with me, as well as provide practical support. I would like to thank Prof. Lorraine Culley and Dr Nichola Hudson, my two supervisors, for their invaluable guidance throughout the process and for their patience and encouragement in those instances that I felt I was floundering. I would like to thank my family, close colleagues and friends who have supported me through these last six years. These include Maria and Mike who selflessly lent me their beautiful apartment in Gozo for months on end when I needed a quiet space; those close colleagues who helped broaden my vision through their discerning insight; other dear friends who let me know that I was not forgotten by contacting me on a regular basis with words of encouragement; and Emma, Lucia and Mia for brightening my days. I would like to thank my colleagues in the Nursing Department for providing me with the time I needed despite an increase in their own workload and finally, the University of Malta for providing the funding. iii Table of Contents Chapter One: Introduction Introduction 1 Personal Interest in Topic 1 Asylum Seeker Migration to Malta since 2002 2 Politico-Legal Considerations 3 Detention 6 Open Centres 7 Integration 9 Xenophobia and Racism 11 International Responses 13 Forced Migration, Health and Primary Healthcare 15 Primary Healthcare in Malta 16 Justification for Study 18 Terminology 20 Structure of the Thesis 20 Chapter Two: Asylum Seekers, Health and Healthcare – A Conceptual and Empirical Review Introduction 22 Race, Racialisation, Racism and Health 25 Ethnicity, Ethnocentricity and Health 27 Culture, Culturalisation and Health 30 Cultures of Care 33 Culturally Competent Care 34 Cultural Safety 35 Primary Healthcare Delivery Systems: Biomedical and social models of care 37 Cross-Cultural Healthcare Encounters: Migrants in the Primary Healthcare Setting 40 Goal 1: Developing Therapeutic Relationships 41 Goal 2: Gathering Information and Assessment of Needs 46 Goal 3: Addressing the Patient’s Problems and Needs Effectively 49 Conclusion 51 Chapter Three: Methodology and Method Introduction 54 Methodology 54 Critical Ethnography 55 Postcolonial Theory 57 Researcher Positionality 60 Method 62 Data Collection Methods 63 Data Collection: Participant Observation 63 Research Sites 64 Physical Setting 64 Entry to the Field 66 Sites and Periods of Observation 68 Observing Encounters 69 iv Data Collection: Semi-structured Indepth Interviews 71 Recruiting Asylum Seekers 72 Recruiting Cultural Mediators 77 Recruiting Healthcare Professionals 78 The Interviews 79 Interviewing: Insider/Outsider Positions 80 Interviewing: Power and Power Relationships 81 Interviewing: The Interpreted Interviews 83 Processing the Data 86 Transcription 86 Data Analysis 87 Phase 1: Familiarisation 88 Phase 2: Generating Initial Codes 88 Phase 3,4 & 5: Searching for, reviewing, defining and naming themes 89 Ethical Considerations 89 Ethical Approval 90 Measures to Ensure Confidentiality 90 Informed consent 90 Participant Risk 93 Critical ethnography, Postcolonial Research and Ethics 94 Establishing Credibility 95 Truth Value 95 Consistency 96 Neutrality 96 Applicability 96 Limitations 97 Conclusion 98 Chapter Four: Seeking Refuge and Beyond – The Migratory Process Introduction 99 The Long and Perilous Journey 100 Life on Hold 103 Life on the Edge 106 Physical and Psychological Scarring 113 Through the Eyes of the Healthcare Professionals 116 Summary 120 Chapter Five: Seeking Mutual Understanding –Communicating Within the Healthcare Encounter Introduction 122 Linguistic Discordance 123 “It’s not just the Language” 132 Mistrust and Misunderstanding 147 Power Differentials and Control 160 Summary 164 Chapter Six: Seeking Resolution Introduction 166 v Finding the Way 166 Providing Care 177 Needing Support 184 Summary 188 Chapter Seven: Healthcare Encounters – A Chaotic Bricolage Introduction 189 The Candidacy Framework 190 Intersectionality 193 Identification of Candidacy 194 The Supremacy of ‘Western’ Knowledge 195 Shame, Stigmatisation and Identity 197 A Biomedical Approach to Care and Transnational Conversations 200 Identification of Candidacy: A Conceptual Overview 203 Navigation and Permeability of Services 204 Navigational Assistance and Social Capital 205 Mobilisation of Resources 207 Discriminatory Services and Practices 210 Permeability and Racism 214 Navigation and Permeability of Services: A Conceptual Overview 216 Appearances at Health Services 217 Linguistic Discordance 218 Linguistic Discordance: Trust and Distrust 223 Cultural Discordance 228 Cultural Discordance: Hierarchical Ranking 229 Cultural Discordance: Uncertainty and Discomfort 231 Appearances at Health Services: A Conceptual Overview 232 Adjudications, Offers and Resistance 232 Deservingness 233 Expectations and Compliance 236 Continuity of Care 238 Adjudications, Offers and Resistance: A Conceptual Overview 240 Operating Conditions and Local Production of Candidacy 241 Operating Conditions and

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