Sodemann, Morten

University of Southern Denmark Research Output

Structural violence and simplified paternalistic ideas of patient empowerment 
decreases health care access, quality & outcome for ethnic minority patients 
 
Increasing complexity of health care organization, rapid hyperspecialization of medical care, lack of ’patient literacy’ and pressure 
on patients to take over responsibility, challenges political dreams of equal access to patient centered high quality secure care.  
 
Morten Sodemann, Dorthe Nielsen, Dlama Rasmussen, Charlotte Sølver Rehling 
The Migrant Health Clinic, Odense University Hospital, Department of Infectious Diseases, Penthouse, 2nd Floor, Sdr. Boulevard 29, DK-5000, Odense C., www.ouh.dk/indvandrerklinik 
Contact person: Morten Sodemann, Professor,  Tlf. +45 60111923, e-mail: msodemann@health.sdu.dk. 
Lessons learnt 
 Hyperspecialized hospital care and time constraints shifts responsibility for coher-
ent patient care to patients and their relatives which introduces a selective hid-
den inequity for ethnic minority patients  
 Low patient literacy among health professionals leads to hidden inequities in in-
formation, follow-up and possibility for patient empowerment 
 Hyperspecialization of hospital care, mechanistic ideas of patient centered care &   
faint ideas of patient literacy threaten to increase inequity in access and outcome 
for ethnic minority patients 
 Individuals belonging to ethnic minorities become less literate, lose language 
skills and quickly develop decision fatigue in case of illness while their networks 
become less usefull, challenging modern principles for patient centered care 
 Imperfect models of patient empowerment, incapacitation and intrinsic structur-
al violence in health care threaten equity in health and patient safety 
 Models of individualized doctor-patient clinical co-production, methods fordeci-
sion support should be developed 
 Health professionals should improve their patient literacy (patient knowledge) 
Issue 
P 
atient centered care, health literacy asses-
sments and patient empowerment are interlin-
ked and have gained political momentum in 
attempts to increase patient satisfaction and quality of 
care. Clinical experience from The hospital-based Mi-
grant Health Clinic at Odense University Hospital  has 
previously demonstrated how failures in clinical asses-
sment and communication with ethnic minority pati-
ents have long term consequences. Inequity in hospital 
care to ethnic minorities continues to be a challenge 
with many hidden barriers. 
Description of the problem 
 
I 
n a continuous effort to identify in-hospital 
barriers to equal care we conducted qualita-
tive analysis of selected patients with com-
plex somatic conditions investigated in multiple 
hospital departments. The patient cases analysis 
was conducted in real-time and indicates synergi-
stic barriers to equity in hospital care for ethnic 
minority patients  
Results/changes 
A 
ssumptions behind patient centered care turn out to be insufficient with regard to individual patient 
needs. Contrary to the intention patient centered care increases patient vulnerability and generates hid-
den inequalities. Health care systems exercise concealed structural violence in attempts to protect simple 
routines, limit system challenges, simplify administration and to avoid development of specialized clinical care ad-
justed for patient subgroups with special needs.  
Stressed patients struggle to be granted time for questions, expression of anxiety and to express ambiguities but in-
stead they are met with new information and home tasks.  With increasing information load and pressure to take 
responsibility for decisions regarding treatment patients react with a decision fatigue that frustrates health workers. 
Low ‘patient literacy’ of doctors together with a generally low ambiguity tolerance among doctors, jeopardizes com-
munication, confuses patients and lead to misinterpretation of health information - hence patient questions are re-
garded as irrelevant and discarded as “cultural misperceptions”.  
Normally patients’ relatives are regarded as necessary partners of patient care but for ethnic minority patients rela-
tives are regarded as irrelevant ‘interpreters’ and hence discarded. Patients often lack a functional social network of 
relatives willing and able to assist.  
Hyperspecialization, strict adherence to referral criteria and protection of department  routines exclude ethnic mi-
nority patients with multiple diagnoses, unexplained symptoms and a weak social network from normal quality spe-
cialized care. Time constraints shifts responsibility for coherent patient care to patients and their relatives which in-
troduces a selective hidden inequity for ethnic minority patients.  
Varying organization, speed and expectations of patient involvement between departments confuses ethnic minori-
ty patients  leading to their incapacitation, medical errors and no-shows. Medical errors and patient errors are re-
garded as “expectable” and “unpreventable” by health workers because of unchangeable language and cultural bar-
riers, hence not reported.  Likewise, lack of interpreter use is not regarded as an error as it is seen as a patient prob-
lem not a hospital problem. 
Invitations to patient engagement in decisions can be anxiety provoking but are also regarded as “No-no” options, 
hence patients feel deceived into already selected choices and consequences that are too complex and overwhelm-
ing. 
Ethnic minority patients are excluded from patient user satisfaction surveys because they are un-able to read or re-
fuse to participate because of fear of retaliation from social services or withdrawal of residence permits. 


Structural violence and simplified paternalistic ideas of patient empowerment decreases health care access, quality &amp; outcome for ethnic minority patients

Structural violence and simplified paternalistic ideas of patient empowerment decreases health care access, quality & outcome for ethnic minority patients

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University of Southern Denmark Research Output

Structural violence and simplified paternalistic ideas of patient empowerment decreases health care access, quality &amp; outcome for ethnic minority patients

Abstract

Similar works

Full text

Available Versions

University of Southern Denmark Research Output

Structural violence and simplified paternalistic ideas of patient empowerment decreases health care access, quality & outcome for ethnic minority patients