Received: 9 March 2021 | Revised: 11 August 2021 | Accepted: 16 August 2021

DOI: 10.1111/nin.12457

ORIGINAL ARTICLE

Ethnic minority patients in healthcare from a Scandinavian

welfare perspective: The case of Denmark

Nina Halberg1,2 | Trine S. Larsen1,2,3 | Mari Holen1

1
Department of People and Technology,
Roskilde University, Roskilde, Denmark
2
The Research Unit of Orthopaedic Nursing,
Copenhagen University Hospital, Hvidovre,
Denmark
3
Department of Clinical Research,
Copenhagen University Hospital, Hvidovre,
Denmark
Correspondence
Nina Halberg, Department of People and
Technology, Roskilde University,
Universitetsvej 1, 4000 Roskilde, Denmark.
Email: ninah@ruc.dk
Abstract
The Scandinavian welfare states are known for their universal access to healthcare;
however, health inequalities affecting ethnic minority patients are prevalent. Ethnic
minority patients' encounters with healthcare systems are often portrayed as part of
a system that represents objectivity and neutrality. However, the Danish healthcare
sector is a political apparatus that is affected by policies and conceptualisations.
Health policies towards ethnic minorities are analysed using Bacchi's policy analysis,
to show how implicit problem representations are translated from political and so-
cietal discourses into the Danish healthcare system. Our analysis shows that health
policies are based on different ideas of who ethnic minority patients are and what
kinds of challenges they entail. Two main issues are raised: First, ethnic minorities
are positioned as bearers of ‘culture’ and ‘ethnicity’. These concepts of ‘othering’
become both explanations for and the cause of inappropriate healthcare behaviour.
Second, the Scandinavian welfare states are known for their solidarity, collectivism,
equality and tolerance, also grounded in a postracial, colour‐blind and noncolonial
past ideology that forms the societal self‐image. Combined with the ethical and legal
responsibility of healthcare professionals to treat all patients equally, our findings
indicate little leeway for addressing the discrimination experienced by ethnic
minority patients.

KEYWORDS
culture, ethnic minority patients, ethnicity, inequality in health, nursing, othering,
policy analysis, Scandinavian welfare states

1 | INTRODUCTION
During the coronavirus disease 2019 (COVID‐19) pandemic,
Denmark as a nation has emphasised and advocated a common
responsibility to minimise the spread of the virus. This appeal is
based on solidarity in the sense of keeping everyone safe and
protecting people particularly vulnerable to infection. Nonetheless,
specific societal groups have shown a higher prevalence of COVID‐
19. This has been explained and conveyed through different nar-
ratives. For example, elderly people and other vulnerable groups
have been described through a caring narrative, in which it is the
responsibility of the nation to care for them and protect them from
the virus (Pabst, 2020). Conversely, ethnic minority groups have
been described through a narrative of inadequacy. Certain popu-
lation groups, especially Pakistani and Somali communities, have
been singled out as unable to adhere to COVID‐19 guidelines
and have therefore had a high prevalence of positive cases. On
15 August 2020, the Danish Prime Minister, Mette Frederiksen,
stated in a press conference that too many people with a
non‐Western background were becoming infected with COVID‐19.
She further questioned whether socioeconomic factors really were
the full explanation (Vestergård, 2020). During this press con-
ference, she singled out ‘non‐Western’ citizens and questioned
their health behaviour. She argued both for and against social and

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economic inequalities as the cause of the higher prevalence. This is
an example of political and societal discourses being transferred
into healthcare.
By adopting a policy analysis as proposed by Bacchi (2009), this
paper takes the case of Denmark and analyses how different
policies rely on specific implicit problem representations of ethnic
minorities in relation to healthcare. As healthcare systems are a
cornerstone of the Scandinavian welfare states, we will examine
how implicit representations of ethnic minorities as ‘problematic’
in political and societal policies are translated into healthcare
and affect ethnic minority patients' encounter with the Danish
healthcare system.
2 | BACKGROUND
2.1 | The concept of ethnic minority patients
Ethnic minority groups are not a homogeneous group. On the
contrary, they include people with a wide range of nationalities
and educational, linguistic, cultural and occupational back-
grounds. Definitions most often assume a social group that
either differentiates itself or is differentiated by others from the
majority population (Jeppesen et al., 2019; Singla, 2012).
However, ethnicity is a contested concept. There is no set defi-
nition of ethnicity and within nursing, it has been criticised for its
essentialist, homogeneous and fixed cultural characteristics
(Culley, 2006). Furthermore, it is a concept coined by a Western
discourse of actively defining and delimiting a nonhegemonic
group of people (Hervik, 2019). Taking the case of Denmark, this
group is variously described as, for example, ‘non‐Western’, ‘im-
migrants’, ‘descendants (of immigrants)’, ‘different ethnic back-
ground to Danish’ or just simply ‘ethnic’ (Hervik, 2019;
Yilmaz, 1999). Within the Danish healthcare system, the most
common terminology is ‘patients with a different ethnic back-
ground/origin to Danish’. In this article, we use the term ‘ethnic
minorities’ to describe our focus on a particular group of people.
We acknowledge the complexity relating to the concept of ‘ethnic
minorities’ as a homogeneous group but still retain the concept in
this article, as our focus is this group of patients, defined by
certain concepts. Furthermore, ‘ethnic minorities’ is also under-
stood as an analytical concept in which the emphasis is on
structural discourses producing health inequalities related to
ethnicity (Fylkesnes et al., 2018).
2.2 | The Scandinavian welfare states and ethnic
minorities
Historically, the Scandinavian countries of Denmark, Sweden and
Norway are known and acknowledged for their social welfare
states. The Scandinavian welfare states differ from other states
by having a unique equalising effect founded on social politics
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ET AL.
(Esping‐Andersen, 2015). This is based on the main purpose of
equalising differences between citizens by guaranteeing minimum
wages, free access to healthcare and schools as well as providing
care for elderly people and poverty relief (Dahlborg et al., 2020). A
keystone of the welfare state is the healthcare model adopted in the
1930s. In Denmark, universal access to healthcare is ensured by the
Danish Health Act (Vrangbæk, 2020). Equity is a key value and is
supported by the primary aim of ensuring equal and easy access to
healthcare (Dahlborg et al., 2020; Vrangbæk, 2020). Despite a
primary goal of equity and statutory universal access to healthcare,
Scandinavia faces similar health inequalities concerning ethnic
minority patients as described internationally (Nielsen et al., 2019).
Politically, Denmark has been at the forefront of the rise of right‐
wing parties in Europe since the 1990s. As a result, Denmark has one
of the most restrictive integration policies in Europe today
(Hervik, 2019) and the public debate on ethnic minorities is quite
confrontational. In addition, and in comparison to the other Scandi-
navian countries, Denmark has moved strongly towards a progressive
neoliberal agenda (Vallgårda, 2011). As seen in the Danish Health
Act from 2007, this agenda has a strong bearing on the welfare
state and at the same time involves an asymmetrical power
relationship of holding patients solely responsible for their health
(Dahlborg et al., 2020). This discrepancy between ‘equity’ and ‘re-
sponsibility’ in combination with the rhetoric that follows a restrictive
foreign policy makes Denmark an interesting example to explore how
political and societal discourses relating to ethnic minority patients
are translated into the Danish healthcare system.
2.3 | Aim
The aims are (1) to analyse how political and societal discourses
relating to ethnic minorities are translated into the Danish
healthcare system and (2) to discuss how these discourses affect
ethnic minority patients' encounters with the Danish healthcare
system.
3 | METHODOL OGIC AL APPROACH
To explore political and societal discourses in relation to healthcare
for ethnic minority patients, we use Bacchi's (2009) methodological
framework and policy analysis.
3.1 | Policy documents
According to Bacchi (2009), policies are understood in a broad
sense and include texts from governments, institutions and the
media. Selecting policies is an interpretive process in itself
(Bacchi, 2009). We have taken politicians' statements on the
COVID‐19 pandemic in the mainstream media in Denmark to
analyse how ethnic minorities and healthcare are represented in

HALBERG ET AL.
the public (Christensen, 2021). Furthermore, we have searched for
institutional guidelines concerning ethnic minorities in healthcare.
Very few official and national policies exist, but to illustrate
representations of ethnic minority patients in healthcare policies,
we include a regional guideline concerning ‘The use and ordering of
interpreters’ (Region Hovedstaden, 2021). This policy is aimed at
healthcare professionals and the focus is on non‐Danish speaking
groups, which often indirectly involve ethnic minorities. Finally, we
have included a policy from the Danish Society of Public Health
called ‘Paths to Ethnic Equality in Health’ (Hempler et al., 2020).
This guideline is aimed at healthcare professionals, decision‐
makers, administrators and researchers (Hempler et al., 2020).
All three policies are contemporary and help us to understand the
way ethnic minority patients are represented as a category in
Denmark (Bacchi, 2009).
3.2 | Problem representation
According to Bacchi (2009), policies are proposals for change and
the question to ask is ‘What's the problem represented to be?’
(WPR). This approach challenges the view of government policies
being the best effort to deal with fixed and identifiable ‘pro-
blems’. When analysing policies relating to ethnic minorities and
healthcare, we examine what lies beyond the aim of the policy.
This means including the government as an active part in shaping
specific understandings of ‘problems’, and their creative or pro-
ductive role is under investigation in the policy analysis
(Bacchi, 2009). Bacchi offers six interrelated questions to direct a
WPR approach to the policy analysis. These aim at identifying
how the problem is represented (1), investigating assumptions
underlying the problem representation (2) and the origin of the
problem representation (3), looking for unproblematic elements
(4), describing the effects of the representation (5) and finally,
discussing how the representation could be questioned, disrupted
and replaced (6) (Bacchi, 2009).
From the perspective of Bacchi (2009), policy analysis is about
analysing how meaning is created. Problem representations are
connected to specific governmental discourses, and we analyse the
problem representations in the included policies in the first two
sections of the analysis. In the first section, we discuss how dis-
courses shape a societal self‐image of social egalitarianism and in the
second section, we discuss how neoliberal practices affect the con-
ceptualisation of health and healthcare in relation to ethnic minority
patients. This step of the analysis includes identifying the problem
representation and its origin, after which we turn to identifying un-
derlying assumptions and unproblematic elements (Questions 1–4).
The third section of the analysis demonstrates the effects of the
problem representation, through the discourse of ‘othering’ (Ques-
tion 5). In the fourth section, we will discuss and challenge the
dominant problem representations found in the analysis by elabor-
ating on how these are translated into healthcare practices (Question
6) (Bacchi, 2009).
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4 | ANA LYSIS
4.1 | Social egalitarianism
According to Hervik (2019), the media are inseparable from politics
and play an important role in co‐constructing racialization. To in-
vestigate the translation of ‘ethnic minorities’ into healthcare, we
include another COVID‐19 related example from a recent news story
in March 2021 on the Danish national news channel TV2. A political
discussion emerged about possible compulsory testing among re-
sidents living in an area called ‘Vollsmose’. To contextualise Volls-
mose, it is one of 15 residential areas on the ‘ghetto list’ in Denmark,
where the majority of residents belong to ethnic minorities. The term
‘ghetto list’ was adopted in 2011 by the then Prime Minister Lars
Løkke Rasmussen and the purpose was to ‘bring back the ghetto
to society’ as the areas did not have primary ‘Danish values’
(Simonsen, 2016). Vollsmose has therefore been negatively re-
presented over the last decade and, as the word ghetto implies,
has negative connotations opposed to Danish nationalism
(Simonsen, 2016)1. Due to a higher incidence of COVID‐19 cases in
Vollsmose, the current Danish Prime Minister Mette Frederiksen
made an urgent proposal in parliament suggesting compulsory tests
in Vollsmose. She did not win a majority of the votes but continued to
emphasise that the area was a problem due to the residents:
The responsibility of keeping transmission down lies upon
the individual, not the authorities… Today there are so
many options to get tested, I quite frankly find it con-
frontational when some people say we have to bring the
tests to them… As Mr. Matthias Tesfaye [the Danish
Minister of Integration] has previously expressed, he is
the Minister of Integration, not a nanny. (Frederiksen as
cited in Christensen, 24 March 2021.
Politician Pia Kjærsgaard from the right‐wing party Dansk Folk-
eparti (The Danish People's Party) commented on the statements: ‘It
is of no use that you do not dare to state the obvious fact, this is a
cultural problem’ (Kjærsgaard as cited in Christensen, 24 March 2021).
As noted in the introduction, specific groups of people are singled out
based on a notion of ‘different cultures’ and in this case, it crosses
over into legislation. The expression ‘nanny’ both demeans ethnic
minorities and positions them as acting childishly for choosing not to
follow recommendations. Ethnic minorities are then left powerless
and portrayed as unequipped to take care of their own health and
thereby endangering the ‘Danish people’. This emphasises the neu-
tralised hostile rhetoric in the mainstream media and among leading
politicians in Denmark. Furthermore, the problem representation
shows how ethnic minorities are associated with inappropriate health
1
Further elaboration on the complexity related to the concept of ‘ghetto list’ and its im-
plications for ethnic minorities is beyond the scope of this article. For more detail, see
Simonsen (2016). Ghetto‐Society‐Problem: A Discourse Analysis of Nationalist Othering.
Studies in Ethnicity and Nationalism, 16(1), 83–99. https://doi.org/10.1111/sena.12173.

4 of 9 | HALBERG
behaviour and ‘non‐Danishness’, and reveals a discourse in which it is
legitimate to suggest legislation for compulsory testing among a
specific group of people with a ‘problematic culture’. In a well‐known
democracy, it can be perceived as surprising that this kind of pro-
position even reaches the national parliament. Nonetheless, Hamed
et al. (2020) discuss how the increasing nationalist and anti‐
immigration discourse of European exceptionalism influences the
ethnic minority populations, by perceiving them as less deserving of
healthcare services.
The handling of the COVID‐19 pandemic with an emphasis on
people's common responsibility is in line with the Scandinavian wel-
fare states as these are based on notions of solidarity and collectivism
(Dahlborg et al., 2020; Palmberg, 2009). This has given the Scandi-
navian countries a positive and even idealistic image. We define this
as the origin of the problem representation (Bacchi, 2009). Equality
has been a core value in the self‐image of the Scandinavian countries
since the welfare states were developed (Palmberg, 2009). This is
argued to be based on a Lutheran‐Evangelical tradition and draws on
values grounded in the Enlightenment (Hervik, 2019; Mulinari
et al., 2009; Palmberg, 2009). The Scandinavian countries are per-
ceived to be more humane than the rest of the West, being wel-
coming not exploiting, representing the good helper in a humanitarian
perspective as well as maintaining an image of having no colonial
legacy (Bradby et al., 2019; Mulinari et al., 2009; Palmberg, 2009).
Although it is unfamiliar to many Danes, Palmberg (2009) thoroughly
examines Denmark's involvement in the slave trade, colonial en-
terprising and missionizing Western/Christian superiority. Blaagaard
(2009) demonstrates this as an international image by analysing an
article in The New York Times on the Danish sperm bank Cryos In-
ternational. She finds Scandinavian people to be constructed as a
pure and desirable identity worth reproducing (Blaagaard, 2009).
However, this is an image based on ‘equality as sameness’ (Gullestad
(2006) as cited in Hervik, 2019). The Scandinavian identity is con-
structed through a homogeneous and habitual whiteness
(Blaagaard, 2009; Hervik, 2019).
Since the 60s and 70s, there has been a considerable increase in
immigration to Scandinavian countries. Data show the population
born abroad, and descendants of people born abroad, compared to
the total populations. In 2017, the percentage in Sweden was 22%, in
Denmark 13% and in Norway 17% (Bjerre et al., 2019). Denmark
divides the percentages between Western and non‐Western im-
migrants,2 whereas both Norway and Sweden currently only divide
by continent. An estimated half to two‐thirds of immigrants have a
non‐Western origin (Mock‐Muñoz de Luna et al., 2019). Over the last
15–20 years, populist, neo‐nationalist and anti‐immigration parties
have gained votes and popularity in Denmark. Intolerance towards
ethnic minorities has also grown over the last 20 years (Hervik, 2019)
and ethnic minorities are often depicted as a threat to national
2
Western/non‐Western countries defined: Western countries: All 28 EU countries as well as
Andorra, Iceland, Liechtenstein, Monaco, Norway, San Marino, Switzerland, The Vatican,
Canada, USA, Australia, and New Zealand. Non‐Western countries: All other countries
(Jeppesen et al., 2019).
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ET AL.
identity and values. These political and societal discourses affect the
public perceptions of ethnic minorities. Historically in Denmark, the
Somali community has been problematized as difficult to integrate
due to their ‘cultural’ and ‘racialized’ differences. Furthermore,
‘Muslim culture’ has also been negatively represented (Hervik, 2019).
Nevertheless, this is often dismissed and an important part of the
neutralisation of the rhetoric lies within a postracial, colour‐blind and
noncolonial past ideology (Hervik, 2019). The Danish self‐image of
social egalitarians inhibits the recognition of discriminatory beha-
viour. When potential discrimination is addressed, it is explained as
‘one bad apple’ and as not having structural connections (Rødje and
Thorsen (2019) as cited in Hervik, 2019). This means that possible
discrimination in the public sphere is rarely discussed in Denmark
(Hervik, 2019), as it opposes an image of social egalitarianism per-
meating the Scandinavian welfare states. In healthcare, this is further
complicated by the entry of what we call ‘neoliberal practices’. We
will now discuss these implications.
4.2 | Neoliberal practices
Since the 1980s, a global neoliberal agenda has influenced the
Scandinavian model (Mulinari et al., 2009). Neoliberalism implies a
free market and is tied to both political and individual freedom
(Ahlberg et al., 2019). This has resulted in a conflict between com-
petitive market strategies and social democratic politics (Mulinari
et al., 2009). In healthcare, the governance system of new public
management has increasingly taken over and concepts such as pro-
ductivity and efficiency have become central (Dahlborg et al., 2020).
This ideological change has shifted the Scandinavian welfare states
further away from the original social democratic values towards an
economy‐driven healthcare system, similar to that of other high‐
income countries (Dahlborg et al., 2020). However, Dahlborg et al.
(2020) found that the new public management discourses are often
legitimised and integrated into a welfare state discourse. This means
that neoliberalist reforms are jeopardising democratic welfare values
(Ahlberg et al., 2019). In practice, this reduces the government's
ability to regulate inequalities and leads to blaming it on individual
responsibility (Ahlberg et al., 2019). As the Danish Prime Minister
underlined, the responsibility is upon the individual. This is also ac-
centuated by the Scandinavian welfare states implicitly attempting to
make the population behave in a certain way (Dahlborg et al., 2020).
Neoliberalist ideals of cost‐efficiency, productivity and individual
responsibility also permeate the healthcare sector. This is illustrated
in the regional guideline which describes the use of interpreters
during a hospital stay. Here it is stated:
‘It is up to the health professional in charge of the
treatment to assess whether there is a need for assis-
tance from an interpreter’… ‘Patients who have resided in
Denmark for over three years will be charged a fee’… ‘The
patient cannot refuse an interpreter for financial rea-
sons’… ‘The healthcare professionals can inform patients

HALBERG ET AL.
about charging a fee for interpreting’. (Region
Hovedstaden, 2021)
This regional guideline is based on several implicit problem re-
presentations. Charging patients a fee for healthcare runs contrary to
the idea of equal access to healthcare. Additionally, it largely affects
citizens from ethnic minorities and therefore adheres to the current
political anti‐immigration and discriminatory climate. Correspond-
ingly, it holds the patients responsible for not mastering Danish
adequately and takes away their right to refuse. It also leaves the
assessment entirely to the healthcare professional and leaves
the patient powerless. Thus, the healthcare professionals become the
objective evaluators of the patients' needs. Ultimately, the institu-
tional authority has defined a set timeline of 3 years, deemed ap-
propriate to determine when it is acceptable or unacceptable to need
an interpreter. This guideline creates unequal access to healthcare
and transfers current political discourses into direct encounters
between healthcare professionals and ethnic minority patients.
These neoliberal practices of ‘efficient and productive’ treatment
alongside a focus on ‘individualised responsibility' have specific
consequences in relation to ethnic minority patients. Ahlberg et al.
(2019) argue that neoliberal ideals are combined with colour blind-
ness, which leads to a risk of generating a focus on cultural or ethnic
backgrounds as reasons for social inequality. In practice, this means
that when ethnic minority patients do not live up to their responsi-
bility, their cultural or ethnic background is described as the reason.
We will now elaborate on this perspective in what we term a dis-
course of ‘othering’.
4.3 | Othering
The effects of the implicit problem representations of ethnic minority
patients, as illustrated in the previous sections, can be understood as
a process of ‘othering’. Othering as a concept originates within
postcolonial theory (Jensen, 2011). Spivak (1985) was the first to
systematically use ‘othering’ as a concept. Based on the British co-
lonial power in India, she sees othering as the offered and relegated
subject position of others in discourse (Jensen, 2011). According to
Jensen (2011), ‘othering’ is a discursive practice in which powerful
groups define subordinate groups based on ascribed problematized
inferior characteristics. Within nursing, ‘othering’ processes are based
on a dominant social standard in which difference is created with a
subordinate. These further reinforce exclusion and marginalisation,
and patients are generally ‘problematized’ or ‘non‐conforming’ based
on gender, ethnicity and/or race. These processes negatively affect
patient care (Roberts & Schiavenato, 2017).
In society and politics, despite a self‐image as social egalitarians,
a Danish whiteness discourse constructs a national identity based on
belonging through ‘race’ or ethnicity that contains a division between
‘the nation’ and ‘the immigrants’ (Mulinari et al., 2009). Mulinari et al.
(2009) describe how citizenship in the Scandinavian welfare states
goes ‘hand in hand with ethnic discrimination in all parts of social and
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political life’. The cultural discourse constructs ‘immigrants’ as an
undifferentiated group with inherent cultures that separate the
‘West’ from the ‘rest’ (Mulinari et al., 2009).
Even though the concept of racism was discredited after the
Second World War, Palmberg (2009) asks whether it has taken on a
new form through the concept of ‘culture’. Likewise, ‘ethnicity’ is
used to describe ‘the others’ (Mulinari et al., 2009). Culture and
ethnicity are then perceived to be politically neutral (Hilario
et al., 2018) and are used as legitimate ways of describing ‘others’.
In the Danish welfare system, this is also implied through the
introduced phrase ‘a different ethnic background/origin to Danish’. This
is a common and perceived neutral way of describing ‘non‐Western’
immigrants, both in society and in healthcare. However, this also
raises the question ‘Can you have a different ethnic background and
be Danish?’ It excludes people from having a sought‐after back-
ground as Western or Danish. As with the term ‘non‐Western’, it is a
language of exclusion and describes the incompatibility of being both
ethnically ‘different’ and Danish. It also leads back to a Scandinavian
whiteness discourse in which the inhabited culture and ethnicity of
the Scandinavian majority is neutral, invincible and the starting point.
In a policy guideline called ‘Paths to Ethnic Equality in Health’
(Hempler et al., 2020), the conclusion consists of eight re-
commendations for creating ethnic equality in health. Some of these
recommendations target local communities, interdisciplinary colla-
boration across sectors as well as the need for interpreters (numbers
2, 3, 4 and 7). The recommendations directly related to the encounter
between ethnic minorities and the Danish healthcare system include:
1. Increased focus on challenges and special needs, e.g.
health literacy, linguistic, cultural and social differences
among ethnic minorities in policies and strategies (…) The
National Board of Health could revitalize their focus on
ethnic minorities. (Hempler et al., 2020)
This recommendation has an implicit problem representation of
‘othering’ ethnic minorities into having ‘special needs’ based on lit-
eracy, language, culture and social differences. Furthermore, they
support our notion of a lack of public policies relating to ethnic
minorities which we encountered during our initial search for policies.
This omission follows the explicit and implicit notions of social ega-
litarianism but can also be questioned due to the wide problematizing
of ‘ethnic minorities’ in healthcare. Recommendation 5 includes:
Strengthening the competencies of the professionals (…)
It is of great importance that the professional reflects
upon his or her own cultural position and prejudices as
well as the human tendency of categorizing. The beha-
viour of the professional can become a restricted frame
for understanding citizens with a different cultural
background from the professionals themselves (…) Edu-
cation and continued education in cultural competency
for professionals within pedagogy, education, social and
health sciences. (Hempler et al., 2020)

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Furthermore, Recommendation 6 focuses on the health compe-
tencies of ethnic minorities:
Health competencies are a combination of the personal
competencies and the surrounding resources deciding
people's possibility of finding, understanding, assessing
and using information concerning health. (Hempler
et al., 2020)
Implicit problem representations appear. First, the guideline
specifically addresses the consequences of a lack of reflection on
professionals' personal positions. Secondly, health competencies are
defined and normatively placed upon ethnic minorities with a specific
understanding of what ‘good health behaviour’ (Hempler et al., 2020)
is and entails. Third, they recommend education in cultural compe-
tency. We will return to this concept of ‘cultural competency’ in the
fourth section of the analysis. First, we will elaborate on the per-
spectives of healthcare professionals' positioning and ‘good’ health
behaviour.
In Western biomedicine, the body is seen as universal and ob-
jective and amenable to interventions using standard approaches
(Lock & Nguyen, 2018). This means treatment is implemented as ‘one
size fits all’ and is ‘colour‐blind’ (Singla, 2012). It also means when
patients do not adapt properly to a predesigned treatment, their
agency is undermined as they are constructed as passive recipients in
Scandinavia (Dahlborg et al., 2020). Health interventions then aim to
change the behaviour of the patients (Choby & Clark, 2014) and
patients are expected to take an active role in their care. The failure
to do so becomes the responsibility of the patients (Mannion &
Exworthy, 2017). In nursing, this means that conceptual models and
theories primarily focus on patients through their individual beha-
viour (Hilario et al., 2018). However, many individualised interven-
tions have had limited success, which could be due to a lack of
patient agency as well as the incorporation of reciprocal structural
relations of society, its institutions and power relations (Choby &
Clark, 2014).
A further factor involved is healthcare professionals being posi-
tioned as scientifically rational (Hamed et al., 2020). As Bell (2021b)
discusses, tenets of equal treatment and colour blindness are present
in Western nursing education. Nursing is portrayed as monolithic and
apolitical in which differences are erased and historical influences are
denied (Bell, 2021a). This leads to nursing professionalism and
identity being constructed as universally desirable and eventually
neutralised. If these constructions are not intentionally interrupted,
they are reproduced (Bell, 2021b).
In summary, the tendencies of healthcare professionals to be
socialised into high levels of autonomy, as well as their strong pro-
fessional identities based on scientific rationality and core ethical
principles, could also complicate discussions of discrimination
(Hamed et al., 2020). Marginalised identities risk becoming further
marginalised (Bell, 2021a) by becoming problematized ‘othered’ pa-
tients (Hilario et al., 2018). Consequently, the risk of discrimination,
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ET AL.
based on socially constructed differences, could contribute to health
inequalities (Bell, 2021a).
4.4 | Problem representations of ethnic minority
patients translated into Danish healthcare
We will now discuss the ways in which the problem representations
of ethnic minority patients are translated into the Danish healthcare
system and form contemporary practice. We will examine the con-
cept of ‘cultural competency’ as it is promoted in the guideline
(Hempler et al., 2020). Furthermore, to illustrate current care prac-
tices in the Danish context, we also include an empirical example
from a special issue of the Journal of the Danish Nurses' Organization
‘Sygeplejersken’ (The Nurse) on the topic of ‘culture gap’
(Witthøft, 2016). In this section, the focus is on discussing and
challenging the problem representations we found (Bacchi, 2009).
With regard to encounters between healthcare professionals and
ethnic minority patients, the literature describes a range of barriers
that complicate care and treatment, including ‘cultural differences’,
prejudices, different understandings of illness, language and com-
munication barriers, limited time and so forth (Joo & Lui, 2020;
Nielsen et al., 2019). In Western healthcare systems, these barriers
are explored through the concept of ‘culturally competent care'.
Culturally competent care is provided on the basis of cultural com-
petency. Cultural competency is acquired through different models,
training programmes and frameworks, and is evaluated through dif-
ferent measurement tools (Gustafson, 2005; Joo & Lui, 2020).
However, the effectiveness of such interventions lacks evidence
(Alizadeh & Chavan, 2016; Drevdahl, 2018; Joo & Lui, 2020). One of
the pioneers of culturally competent care is the American nurse and
anthropologist Madeleine Leininger. She introduced the theory of
transcultural nursing in the 1950s, and her first book on the subject,
‘Transcultural Nursing: Concepts, Theories, Research and Practice’, was
published in 1978 (Leininger, 2002). The aim was to promote cultu-
rally competent care for patients from different cultures
(Gustafson, 2005; Nielsen et al., 2019). Hempler et al. (2020) also
promote cultural competency. Internationally, the concept of cultural
competence still prevails (see for e.g., Alizadeh & Chavan, 2016; Joo
& Liu, 2020; Sharifi et al., 2019), despite growing criticism of the
concept. Some of these critiques include the essentialist use of the
concepts of ‘ethnicity’ and ‘culture’ in which the concepts are un-
derstood as fixed entities belonging to ‘the other’. This leads to a
Western stereotyping of ‘others’ and uses notions of ‘ethnicity’ as
another variable in a standardised approach (Lock & Nguyen, 2018).
At the same time, influences of individualised, depoliticised and lib-
eral discourses fail to acknowledge societal and political discourses
(Drevdahl, 2018). By contrast, it is in the individual interaction that
the healthcare professional (representing the system) encounters the
culturally diverse patient with an open approach to their ‘different
dimensions of culture, including values, health beliefs, religion and phi-
losophy’ (Sharifi et al., 2019).

HALBERG ET AL.
In the articles in the special issue on the topic of ‘culture gap’, the
failure to care sufficiently for patients with ‘a different ethnic back-
ground to Danish’ is debated (Witthøft, 2016). One nurse explains
her dilemma: ‘These are patients who have the right to receive the same
treatment as other patients. We are required to deliver equal treatment
to all people, and it is really frustrating when you cannot do that’
(Witthøft, 2016). She further elaborates on the ‘culture gap’:
A family like that [ethnic minority] takes up the whole
ward when they moan and pray throughout the ward, it
is a very powerful sensation. I find it a very cultural ex-
perience, the way they react. The mother is pulling her
hair and hitting her chest. And I am very unsure about
what I am allowed to do. If it will offend her if I put my
arm around her. (Witthøft, 2016)
In this quotation, culture is seen as a neutralised and causal de-
scription of behaving ‘inappropriately’. In the special issue, barriers of
language and culture are the main causes of the failure to treat
equally, as well as patients' lack of knowledge of the healthcare
system. The nurse is aware of this and wants to adhere to her legal
and ethical responsibility, but the problem representation is de-
scribed through the patients' culture and ethnicity. The perspectives
of the patients are not considered, and the nurse does not reflect
upon her own position, ethnicity or culture. The representation is
discussed through the perspective of the nurse's description of
characteristics of the ethnic minority patients that differ from the
majority and norm. Correspondingly, Jæger (2013) analyses the dis-
course of culture within ethnic minority health, based on articles in
‘Sygeplejersken’. She concludes that culture is presented by the
majority as ‘a set of beliefs and practices originating “elsewhere” and
somewhat incongruent with Danish life’ (Jæger, 2013). She also finds
that recommendations are based on the individual, responsible sub-
ject (Jæger, 2013).
Here we see parallels to the way Danish politicians describe
‘culture’ as belonging to problematized ethnic minorities, as well as a
lack of acknowledgement of their own position. However, when
political and societal discourses of ethnic minorities are translated
into healthcare, ‘culture’ takes on a different form, as healthcare
professionals want to adhere to professional, legal and ethical
guidelines. The ‘challenges’ are described in a more subtle manner
and concepts of ethnicity and culture are neutralised to objectively
describe the encounter with ethnic minority patients.
This directly relates to the concept of cultural competency.
Hempler et al. (2020) use the definition of Seeleman et al. (2009),
which focuses on gaining knowledge of the needs and barriers among
ethnic minorities, being aware of one's own position as well as con-
veying information in a way that all citizens are able to follow
(Hempler et al., 2020). Nevertheless, a lack of inclusion of how
structural discourses affect healthcare might be one of the factors
behind the lack of evidence relating to interventions focused
on ethnic minority patients (Culley, 2006; Drevdahl, 2018;
Gustafson, 2005; Lock & Nguyen, 2018). Yet there are many cultural
14401800, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nin.12457 by Vanderbilt University, Wiley Online Library on [06/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 7 of 9
competence models (see Drevdahl (2018) for a detailed review).
Despite newer theories of cultural humility and cultural safety em-
ploying a more critical lens (Bell, 2021b), the concept of culture itself
can be debated. The concept was originally coined in anthropology,
but since the 1970s it has been heavily debated, as it was used to
define ‘foreign’ and ‘non‐Western’ populations as fixed entities.
Around the same time, the concept of cultural competency was de-
veloped. One of the problems with the concept is the lack of a
common definition (Sharifi et al., 2019). Nevertheless, ‘culture’ within
cultural competency is still understood as having fixed qualities
(Culley, 2006; Grillo, 2003). The concept of culture has in many ways
lost its anthropological analytical significance and is both used and
abused in political discourses (Rytter, 2019; Wright, 1998). Based on
the (mis)use of the concept of ‘culture’ in politics, society and
healthcare, we question the usefulness of the concept when theo-
rising and discussing ethnic minority patients, as it seems to inevitably
lead to constrictive, alienating and one‐way thinking.
5 | D IS CU SS IO N
By using a policy analysis as proposed by Bacchi (2009), we have
found implicit problem representations within policies addressing
ethnic minority patients and healthcare. Within the self‐image of
‘social egalitarianism’, the Scandinavian welfare states are known for
their solidarity, collectivism, equality and tolerance, which are also
grounded in a postracial, colour‐blind and noncolonial past ideology.
This leads to ethnic minorities being positioned as bearers of ‘cul-
ture’ and ‘ethnicity’ but also to experiences of discrimination based
on these ‘othering’ concepts. Instead, these concepts become ex-
planations of inappropriate healthcare behaviour and in combina-
tion with ‘neoliberal practices’ they hold ethnic minority patients
exclusively accountable for notions of ‘inappropriate healthcare
behaviour’. When translated into healthcare, clinicians' legal and
ethical responsibility to treat all patients equally could increase the
difficulty of acknowledging possible discrimination. The healthcare
system is founded on providing free and equal treatment to all
patients, and if discrimination takes place, it must be found in the
individual encounter. However, the healthcare system is a political
apparatus, and we have shown how political and societal discourses
influence ethnic minority patients' encounter with healthcare in
Denmark.
Health inequalities pertain to systematic variations in health
(Drevdahl, 2018). In healthcare, this can be seen in terms of ethnic
minority groups' experiences of prolonged social disadvantages and
even discrimination. Health equity is the elimination of health in-
equalities based on disadvantages or discrimination (Braveman (2014)
as cited in Drevdahl, 2018).
Health equity has been accentuated since the WHO Commission
on Social Determinants of Health was established in 2008 (World
Health Organization, 2008). Despite an increased focus and a long‐
standing ethical code of conduct emphasising antidiscrimination and
equality in nursing (Stievano & Tschudin, 2019), health inequities

8 of 9 | HALBERG
concerning ethnic minority patients remain an international issue
(Chauhan et al., 2020).
The global COVID‐19 pandemic has accentuated pre‐existing
health inequities among ethnic minority groups worldwide. As our
analysis shows, in addition to increased numbers of COVID‐19 cases
in these groups, this pandemic has also led to blaming particular so-
cial, ethnic, religious, cultural, or racial groups, also known as ‘the
other’, simply based on membership of that particular group
(Thorne, 2020). When exploring social and health inequities, Hilario
et al. (2018) emphasise how nursing knowledge and inquiry cannot be
abstracted from social, political and historical discourses. Taking the
case of Denmark, we have shown how societal and political dis-
courses are influenced by ‘social egalitarianism’ and ‘neoliberal
practices’ and when translated into healthcare, lead to forms of
‘othering’. This undermines ethnic minority patients' possibilities of
addressing experienced discrimination within the Danish healthcare
system, and ultimately risks increasing health inequities.
6 | C ONC LUS I ON
The Scandinavian welfare states' image of social egalitarianism entails
explicit notions of equality, solidarity and tolerance, which are fol-
lowed by implicit notions of a postracial, colour‐blind and noncolonial
past. In healthcare, an ethical and legal responsibility to treat all pa-
tients equally combined with neoliberal practices of placing respon-
sibility solely on patients creates a difficult setting for discussing
experienced discrimination of ethnic minority patients in the Danish
healthcare system. However, the healthcare system is a political
apparatus and a cornerstone of the Scandinavian welfare states. We
have shown how discourses in politics and society translate into
healthcare and lead to conceptions of inappropriate health behaviour
as well as cultural and ethnic ‘othering’. Ultimately, the Danish
healthcare system represents a Scandinavian discourse in which the
native culture and ethnicity of the Danish majority is neutral, in-
vincible and the basic premise of any discussion.
D A TA A V A I L A B I L I T Y S T A T E M E N T
Data sharing not applicable to this article as no datasets were gen-
erated or analysed during the current study.
ORCID
Nina Halberg http://orcid.org/0000-0002-9056-3530
Trine S. Larsen https://orcid.org/0000-0001-5410-7987
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How to cite this article: Halberg, N., Larsen, T. S., & Holen, M.
(2022). Ethnic minority patients in healthcare from a
Scandinavian welfare perspective: The case of Denmark.
Nursing Inquiry, 29, e12457.
https://doi.org/10.1111/nin.12457