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The Letter and Spirit of the Law: Barriers to Healthcare Access for Asylum Seekers in France

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This article focuses on the barriers to healthcare access experienced by asylum seekers in France. Based on data from a qualitative analysis involving 52 semi-structured interviews with asylum seekers, it uses critical race theory (CRT) to understand informal obstacles to healthcare access that are not identifiable in the study of national legislation. Our findings are twofold. First, institutional barriers result from the mismatches between administrative procedures to ensure healthcare access and the real-world concrete difficulties that asylum seekers have to face because of their ethnic and national backgrounds. Second, psychological barriers that hinder refugee from requesting and obtaining proper healthcare (mistrust of public authorities, feeling of discrimination) can be more fully explained by considering the experiences of trauma, insecurity, and marginalization that asylum seekers are forced to endure once they depart from their country of origin. From an academic point of view, this study highlights the importance of including subaltern people in considering the migratory phenomenon, in order to uncover the less visible aspects of discriminatory process. From a political point of view, this study calls for the modification of certain aspects of the asylum procedure which are not suited to the concrete situation of asylum seekers.

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  1. Here, we do not refer to consultation with doctors to obtain evidence of their trauma, in order to include this in their application file as refugees. Rather, we are referring to access to healthcare during the waiting period following the filing of the application.

  2. Here we use the term “psychological barriers” because it is a convenient way to describe a mindset or a false belief, preventing someone from doing something that is in his/her power. This does not mean that we reduce the problem of barriers to care to individual attitudes that hold participants individually responsible for their lack of access to healthcare. On the contrary, we will see that these mental barriers are the result of a set of structural constraints that affect the way in which the participants in our study perceive the world, and that their avoidance strategies may even be the result of a logical and coherent reasoning process.


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We ensured that all participants gave formal informed consent, using an information sheet (in English and French) that explained the purpose of our research, and how the data would be used. When the person did not speak either language, we asked the translator to explain the contents of these documents. Participants agreed to give their age and the name of their disease, when they were sick. We do not disclose the family names of the participants, however, a few participants wanted to remain anonymous, so we gave them fictitious names (* in Table 1).

Table 1 List of interviews

Contact with interviewees

We used a “snowball sampling” technique to compose the sample, since this method is particularly recommended for investigating hard-to-reach populations (Schepers et al., 2017). The methodology for collection and analysis was inspired by Glaser and Strauss (Glaser & Strauss, 1968; Small & Gott, 2012). Contact with refused asylum seekers was established through the NGOs and unions.

However, snowball sampling is not considered to be representative of a larger population. Consequently, in order to limit potential biases, we used two tools: linear snowball sampling (subjects give several contact references, but only one new subject is recruited from among them) and the use of key informants (experts who know the target population and provide access to a diverse sample in terms of gender, national origin, and age) (Salganik, 2006). Starting from there, we followed a two-step procedure.

In the first step, we identified organizations that could provide initial access to people who fit the characteristics of the study: people who had applied for political asylum in the Paris region and who were still waiting for an answer at the time of the interview. We contacted NGOs that focus on the protection of asylum seekers and refugees (Center Primo Levi, France Terre d’Asile). Two employees of these associations gave us access to the field and the respondents. Information was provided about the project to potential respondents and interviews were set up with volunteers. Through our contact with the associations, we put together a diverse group of participants in terms of national origin, age, and gender.

In the second step, the interviewees were invited to circulate the information to other people they know and for whom this project could be relevant. Here we used linear sampling: each individual participant recommended exactly one other participant. The reason is that people tend to designate people they know, friends, close acquaintances, and people of similar national descent. We wanted to increase the diversity of respondents’ origins in terms of gender and national origin. We did not want a given nationality to be overrepresented. After expanding the sampling to other rejected refugee groups, the data became richer and the differences between respondents’ origin became more varied.

Interviews were divided into two parts. The first part gave participants an opportunity to freely explain their migration journey, without interruption and without constraint. The goal was to be immersed in the context in which they live and to identify the general structural constraints they had to face. The second part of the interview consisted of more targeted questions about their access to healthcare institutions and the strategies they use to overcome obstacles to care.

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May, P. The Letter and Spirit of the Law: Barriers to Healthcare Access for Asylum Seekers in France. Int. Migration & Integration 22, 1383–1401 (2021).

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