Ethnic disparities and (non)adherence in standardized treatment: implications through an equity lens

Abstract

Background

In order to achieve optimal outcomes for patients, standardized treatment has gained traction in recent years. By unifying care based on the best available evidence, standardized treatment has been described as a means to mitigate health disparities. Despite this aim, ethnic and racial disparities are well-described. Standardized treatment depends on adherence from patients. However, how staff position patients’ health behavior and assess, adapt, and intervene to improve adherence is underexplored. In this article, we aim to investigate how ethnically minoritized patients’ health behavior is positioned under a gaze of (non)adherence.

Methods

This is an ethnographic study based on nine months of fieldwork in two orthopedic departments in Denmark. The work of both departments is based on the standardized concept of Enhanced Recovery After Surgery (ERAS). The participants include patients (n = 13), relatives (n = 6), and hospital staff (n = 79). The data were analyzed using abductive analysis.

Results

The analysis shows that when ethnically minoritized patients were positioned as nonadherent, the staff drew on essentialist and stereotypical problematizations of ethnicity to accommodate perceived differences. In this manner, ethnicity was connected to ideas of cultural food habits, collectivist family structures and un-stoic and exaggerated pain behavior.

Conclusions

This paper advances knowledge on how inequitable care and treatment manifests in clinical practice, illustrating how dominant understandings and conceptualizations at the intersections of health, ethnicity, and (non)adherence produce marginalization in standardized pathways. Ultimately, perceived non-adherence has important consequences for minoritized patients, as we find that it causes potential inaccessibility to standardized pathways due to ideas of ineligibility, undertreatment of pain, as well as underrepresentation of minorities in patient seminars and even same-day surgeries.

Background

Promoting and advancing equity in healthcare is an international imperative [1, 2]. Socially disadvantaged and marginalized groups report receiving inadequate healthcare, including inequitable treatment caused by discrimination and stigma [3]. Research shows that ‘race’ and ethnicity are paramount to health inequities; this is connected to racism, xenophobia, and discrimination [4]. Ethnic and racial minority groups are defined differently between countries and consist of diverse groups globally. The term minoritized refers to the process of groups in society and healthcare becoming minoritized due to perceived ethnic or racial markers of, e.g., language, appearance, skin color, religion, and names. This is linked to processes of marginalization and othering [5, 6]. ‘Race’ and ethnicity are thus social categorizations and do not exist as fixed biological, genetic or generic categories [7].

Studies from North America, Australasia (Australia and New Zealand), and Europe show adverse health outcomes for ethnically and racially minoritized patients. These include a higher risk of birth complications and stillbirth, increased mortality, as well as poor treatment and undertreatment [2, 4, 8– 11]. These adverse health outcomes remain even if various variables are controlled for, e.g., socio-economic status and education [8, 9, 12]. Conversely, health equity may be achieved by eliminating disadvantages and discrimination [13].

The terms health inequity, inequality and disparity are often used interchangeably in health research; however, they differ in definition [14]. While health inequalities and disparities refer to the systematic differences in health between different groups, health inequity refers to inequalities or disparities based on uneven, unjust or disadvantaged systemic and structural conditions [13, 15]. These different definitions require different problematizations, understandings and solutions.

In this study, we engage with inequitable healthcare. Despite the vast amount of research descriptively (re)documenting the existence of inequities, less research engages with how inequitable care and treatment are manifested in clinical practice [1, 6, 8, 16, 17]. To promote change to reduce disparities in clinical practice, it is necessary to include structural conditions that affect care and treatment. Therefore, our equity focus implies that we do not view encounters between patients and hospital staff as isolated but as shaped by the structures that surround these encounters. This means that we explore how health (in)equities are (re)produced in clinical practice in the intersections between ethnicity, disparities, and standardized healthcare.

As a means to mitigate health disparities, standardized treatment has gained traction as a pathway to ensure optimal outcomes as well as safety and quality for patients by unifying treatment based on the best available evidence [18–22]. Standardized treatment is therefore perceived as a neutral (objective and evidence-based) form of intervention. This approach is based on a ‘one-size-fits-all’ rationale, drawing on a biomedical understanding of the body as universal, which implies that all patients are inherently equally receptive to standardized approaches. With this understanding, standardized treatment is implemented to ensure equality through consistent and high-quality access to care for all [23, 24]. In this study, we focus on Enhanced Recovery After Surgery (ERAS). ERAS is a patient-centered, evidence-based, multidisciplinary approach to surgical care designed to optimize a patient’s recovery and reduce hospital stays. ERAS is based on the idea of creating equal access to care and its use has been increasing as a means to eliminate disparities and achieve equitable treatment by delivering best-evidence surgical care [21, 22]. ERAS pathways implicitly rely on adherence (or compliance) by patients, but also by staff [19, 21, 25]. Yet, while research shows lower ERAS protocol adherence among minoritized populations, the mechanisms involved remain largely underexplored [21]. Orthopedic surgery is highly standardized, and procedures often follow ERAS protocols [26]. In orthopedic research, ethnic and racial disparities are well-described and recent studies show adverse health outcomes including underutilization of surgery, PROM (patient-reported outcome measures) scores, length of stay and postoperative outcomes [27–30]. As disparities are connected to lower protocol adherence, the solution to mitigate disparities is to increase adherence [19, 25]. Adherence can be defined as the proactive behavior of actively choosing to follow predefined guidelines [31]. Adherence is described as a more affirmative concept than compliance, but they both relate to patients following guidelines [31].

There are five key elements of an ERAS pathway, namely preoperative information, surgical stress, pain management, (early) mobilization and oral nutrition [36]. Except for surgical stress, the other four elements require what Thorne et al. (2016) explain as the active compliance of patients, in contrast to elements that they describe as passive compliance, such as sedation.

In clinical practice, healthcare staff assess and intervene as a means to support what is portrayed as adherent health behavior for patients in order to ensure the best possible outcomes. Research shows how the definition of, and focus on, adherence creates dilemmas for staff as they seek to provide standardized care while simultaneously supporting adherence by incorporating patients’ individual needs and preferences in order to mitigate any disparities [32, 33]. Since the solution to mitigate ethnic disparities is to increase adherence [19, 25], it is relevant to explore how connections between adherence and ethnicity affect treatment and care. With this article we aim to investigate how ethnically minoritized patients’ health behavior is positioned under a gaze of (non)adherence.

Methods

Data collection

Design and participants

An ethnographic design guided the study [34]. The data were collected from May 2021 to January 2022. Initially, two informal brainstorming meetings were conducted with nurses (n = 4) to openly explore orthopedic treatment and care for ethnically minoritized patients. These were recorded and transcribed verbatim using Word365 and Transcribe. Fieldwork was conducted in two orthopedic departments in two hospitals and consisted of participant observations, conversations, and interactions with patients (n = 13) and their relatives (n = 6), as well as with the hospital staff, including nurses, doctors, physiotherapists, occupational therapists, and radiographers (n = 79). Patients were approached when they arrived at the hospital and asked if they wanted to participate in the study. Inclusion criteria were being 18 + years of age and accepting the aim of the study. The staff included were those involved in the treatment and care of the patients. The ethnographer (NH) followed patients’ pathways through inpatient wards, the X-ray department, surgical procedures, to recovery and in the hallways in between. During fieldwork, notes were jotted down and later elaborated into thick descriptions [35]. Ultimately, the empirical data consisted of over 160 pages of tightly written field notes and transcripts from the brainstorming meetings. In this article, we focus on the hospital staff and how they positioned ethnically minoritized patients during standardized treatment. All names are pseudonyms.

Study setting

The study setting is two orthopedic departments in the Capital Region of Denmark. Denmark provides universal healthcare which means that all citizens with a Danish social security number have access to free and equal healthcare. Both departments work according to the concept of ERAS and patient pathways are standardized in pre-surgery, peri-operative and post-surgery [22].

Data analysis

Abductive analysis

This study draws on abductive analysis, in which the data and unexpected findings are connected to an existing theoretical framework [36]. By using abductive analysis, we aim to answer the research question of how ethnically minoritized patients’ health behavior is positioned under a gaze of (non)adherence. Based on the four active elements of ERAS pathways that require patient adherence, we analyze doings and sayings in the clinical practice, including specific situations from the fieldwork with staff and patients (doings) as well as descriptions from the meetings and conversations with hospital staff (sayings). These are seen as inherently connected to broader structures of the organization [37]. The analysis is structured according to the four proactive elements of preoperative information, nutritional guidelines, early mobilization, and pain management.

Rigor

Trustworthiness was achieved through different strategies. During initial meetings between the authors, different ideas, conceptualizations, and critical reflections were documented and discussed. The first author (NH) initiated the idea of the analysis and compiled the field notes, which were then read by all researchers and discussed in the group and on whiteboards. This process informed the triangulation and credibility of this study. Furthermore, documentation of the collected data through fieldnotes and transcripts, as well as the analysis strategy, ensured dependability. By providing thick descriptions of fieldnotes as described by Emerson et al. (2011), we confirmed transferability. The initial findings were discussed with clinical practitioners, which ensures confirmability. Adopting strategies of triangulation, credibility, dependability, transferability, and confirmability ensured trustworthiness in this study [38].

Ethical considerations

The patients all received written and oral study information. The information pamphlets were translated into eight languages by a professional translation bureau and then checked by people who are bilingual in Danish and in one of the other eight languages. This led to corrections by the translation bureau. In this way, the written information was provided in the language preferred by the patients. A consent form was signed, and a copy handed out to each patient with the pamphlet. The staff were verbally informed and continuously reminded of the ongoing study. Following informal conversations, the staff were asked if the conversations could be used as part of the data. The continuous right to withdraw consent was emphasized to patients, relatives, and staff. Posters containing information about the study and contact details were placed in all included wards in hallways and offices.

The study was approved by the Danish Data Protection Authority (P-2020‐1068) and registered by the Regional Committee on Health Research Ethics (H-20072465).

Results

The data revealed that the staff positioned ideas of adherent patient behavior as a central aspect of achieving (or failing to achieve) standardized care and treatment in clinical practice. This was present in general but as we explored the staff’s ideas of adherence in specific situations or general statements on ethnically minoritized patients, we found these to be connected to ideas of ethnicity and culture. Through the four active elements of ERAS, we illustrate how these connections both actively and covertly impacted the care of ethnically minoritized patients.

Preoperative information and the connection to ethnicity

Preoperative information is described as a fundamental element of ERAS, which includes a variety of processes to ensure appropriate expectations in patients and their families. This is achieved by providing psychological support and suitably adapted information to make patients fully aware of the recovery goals and encourage them to take an active part in their recovery [39].

For patients in elective settings, the initial activity is to attend a patient seminar. During a conversation, the nurses Hanne and Laura reflect on the realization that ethnically minoritized patients might have reduced participation:

Hanne: I’m also thinking about the patient seminar. They [minoritized patients] did not participate nor did the relatives come [suspended at the time due to COVID-19]. I’m not sure if they know exactly what they’re going into… pain management and… But I haven’t had any feedback about whether they felt prepared. I think it’s a mental journey for many of them. Laura continuous: I’m also thinking about same-day surgeries… most would be ethnic Danes… because it does require that you get and understanding the information faster and that you participate and accept the terms from the start.

Laura mentions ‘ethnic Danes’, which is a euphemism for white Danes, but as racial markers are highly discouraged in the Danish context, ethnic Danes is often used. Ethnic Danes are presented as the majoritized who understands the information, while ethnically minoritized patients become placed as ‘the others’ who do not automatically understand or get the information. Ultimately, Laura and Hanne both reflect upon whether ethnically minoritized patients are underrepresented during patient seminars and even in same-day surgeries. This would create health disparities based on ethnic status. Understanding preoperative information and guidelines (which also requires Danish reading skills) is seen as key to enter and become eligible for ERAS pathways. In their explanations of underrepresentation, they connect an ethnically minoritized position to not necessarily understanding the information fast enough or accepting the terms of ERAS in the right way. This was further connected to low compliance:

(…) Not taking care of your diabetes either, but low compliance can be many things… it can be based on language, not going to school for many years, which all lead to not understanding the guidelines.

In this instance, the idea of what low compliance entails regarding ethnically minoritized patients is elaborated. Rather than a social categorization, ethnicity is connected to a specific set of generalized attributes of e.g., language, education, knowledge, understanding, and mentality, that interfere with adherence during standardized treatment. In a situation of attempting to understand low compliance, the explanations are based on stereotyping and homogenizing a very diverse patient group. This affects how ethnically minoritized patients are viewed and accommodated but ultimately also risks affecting how eligible they are perceived to be to enter ERAS pathways.

Nutritional guidelines and the connection to culture

A second element of ERAS pathways is food intake. Normal oral food intake is explained as a daily intake of approximately 1000 kcal and 80 g of protein, which encompasses nutritional therapy [40].

To fulfill the nutritional requirements, the staff must record the food intake of patients. This was explained as difficult due to different food habits:

They [minoritized patients] often bring their own food. It kind of clashes with our aim to record their diet but as long as they eat, I think that’s more important than recording the food.

Recording oral food intake requires that patients eat the prepared and pre-calculated food provided by the hospital. However, the patients stated that the food provided by the hospital was quite different from their normal diet. As the nurse in the quote states, the assessment of oral intake follows this recording, but she also acknowledges the importance of food intake as part of the treatment. According to the requirements of the nutritional guidelines, bringing one’s own food interferes with the protocols and thus becomes nonadherent behavior. The patient’s proactive behavior of eating other food regardless of what the food consists of is thus positioned as incompatible with the requirements of ERAS pathways.

Furthermore, nutritional guidelines were also based on the ability to read Danish:

She [nursing student] asks if Baran wants to see the [food] menu and hands it to him. I [NH] know that Baran does not read Danish, but he doesn’t say anything. After a while, she asks if he wants to keep the menu and Baran answers that he does not.

In this instance, the possibility that Baran was unable to read Danish was not considered and Baran did not disclose this. Following nutritional guidelines then requires Danish reading skills in the same way as the written preoperative information.

To explain different food habits, a nurse connected food to ideas of culture:

I also feel… and this might be a prejudice but that ethnic minorities often have a higher degree of… diabetes, obesity, and high blood pressure. And they miss out on all the prevention we have here in the Danish welfare state. Also, because they have a different culture (…) where they can eat anything they want (…) it just goes against… their new knee or hip, if you get what I’m saying.

Here, ethnicity and the right nutritional (health) behavior becomes entangled with knowledge but is also related to culture. In such situations, ethnically minoritized patients’ proactive behaviors regarding food intake become positioned as culturally, linguistically, and dietarily divergent from the norm. The first nurse adapted the care to the patients by circumventing the nutritional guidelines, thus adapting standardized care to individual patients. This created conflicting demands as the staff felt obligated to follow prescribed guidelines, but promoting the consumption of food from home required bending the rules. While the diet of the hospital food was largely unquestioned, the explanation of what created health behavior outside the standard (or norm) focused on culture. When staff aimed to individualize care, they simultaneously related the differences to culture. Culture is thus portrayed as something ‘they have’ that is both differentiated from ‘the Danish welfare state’ and explained in paternalistic terms of ‘being able to eat anything they want’. It reveals an essentialist understanding, where culture represents a set of fixed attributes that is insufficient to meet the requirements of ERAS pathways.

Early mobilization and the connection to collectivism

Early mobilization is a central element of ERAS pathways, and the goal is to achieve meaningful mobilization as soon as possible after surgery. There is no clear definition of the term, but some activities included are sitting upright, transferring from bed to chair, getting up from a chair, exercises in or out of bed and walking in the room or hallway. Targets often include the total amount of time that patients spend out of bed as well as the frequency and distance of their walking [41].

Patients cannot be discharged before they fulfill pre-defined requirements of early mobilization, and it is therefore important for hospital staff to support and document the completion of early mobilization. However, the staff described how they found it challenging to support some patients’ willingness to engage with early mobilization. When describing ethnically minoritized patients, they related the lack of early mobilization to general family-oriented structures:

There is also the aspect of being a good daughter which means taking care of your mother… it’s good that they take care of their parents, but it can also be a challenge for early mobilization. We tell them that it is also exercise when your dad moves his own legs, and they often say: ‘Yes we know but…’ and then they move his legs for him.

As with the example of food, this nurse had a positive outlook of relatives taking care of patients. However, due to the pre-defined requirements of early mobilization, family structures are seen as a constraint of mobilization rather than as a positive aspect of caregiving.

Family structures of collectivism were inherently connected to ethnically minoritized patients and placed in opposition to a more individualized Westernized family structure. One nurse explained this with reference to a before-and-after COVID-19 period:

Before, there were many relatives [with minoritized patients], and the patients spent a lot of their energy on having them around. So, we found that they didn’t have the energy to exercise because they [patients] felt tired and exhausted.

In the quote, this nurse explains that during COVID-19 and the restrictions that followed, relatives were not allowed in the hospital. Many of the staff found the family-oriented structures potentially problematic, as they involved many relatives visiting. This was expressed by another nurse:

I think… We don’t experience it as much these days because of COVID-19 but often they [minoritized patients] bring a lot of relatives and they take up space… They both take up space physically, but they also want information a lot which… sometimes it becomes a clash of cultures and the mutual expectations… Things don’t always correspond.

Because of the COVID-19 restrictions, there were fewer visitors, and the staff found that patients exerted less energy interacting with relatives and that this energy could instead be used for e.g., postoperative mobilization.

Within the understandings of early mobilization, relatives became positioned as an interference with the standard that requires adherent (proactive) behavior from patients, while they were portrayed as an asset in relation to qualitative aspects such as caregiving. Ultimately, this duality of either positioning relatives as aiding or inhibiting (the right) proactive health behavior was based on essentialized understandings of collectivism that were inherently connected to an ethnically minoritized position.

Postoperative pain management and the connection to stoicism

The fourth active element of ERAS pathways is dynamic postoperative pain management, as this enables early postoperative ambulation and rehabilitation. Higher postoperative pain scores are related to complications and inadequate postoperative pain management may have long-term consequences. Research assessing implementation shows poor compliance with ERAS protocols in aspects such as pain management [42].

Pain management is often measured by objective pain assessment tools. In the Danish context, the Numeric Rating Scale (NRS-11) is often used to assess patients’ pain. However, in this study, pain management was not always a neutral and objective measurement in clinical practice. This became apparent during an observation where Jamil was assessed by the anesthesiologist as one who could ‘take the pain’:

The anesthesiologist comes in. He says that Jamil does not need any sedatives as he looks like someone who ‘can take it’ (…) He asks if Jamil has any questions and Jamil answers, ‘You know what you’re doing’. When the doctor puts the needle in, Jamil’s face tightens but he does not say anything. Afterwards the doctor says, ‘That went well’ to which Jamil replies, ‘Yes’

In this episode, the anesthesiologist assessed Jamil by his appearance and positioned him as a patient who could tolerate pain. Proactive behavior of pain management was then linked to being able to take pain. On the other hand, Jamil showed pain by his facial expression, but this was not included in the assessment. For Jamil to be positioned as the adherent patient, he therefore needed to minimize the expression of pain. How Jamil’s position as an ethnically minoritized patient became entangled with pain is expressed in the following quote:

Mathilda: We believe they’re in pain. But they do exaggerate….

Sara: Especially the young men.

Mathilda: I do think the whole ‘ethnic pain’ exists. It’s very psychological.

Sara: It’s also the way it hurts… when they point to a 7 [Numeric Rating Scale (NRS-11)], then ‘you yell’.

Mathilda: So, it’s very important to tell them: ‘I’m helping you with the pain’.

Pain management is explained for ethnically minoritized patients through notions of ‘ethnic pain’. This entails stereotyping patients based on notions of exaggeration, which leads to de-legitimizing pain behavior. It is a discriminatory concept that has no validity as all humans are ethnic. Yet it is not perceived to include all patients, and, in this manner, ethnicity becomes connected to a minoritized position and understood as an attribute that some people have, and others do not have. Ultimately, it undermines the pain of minoritized patients. On the other hand, the adherent behavior of pain management can be tied to notions of displaying stoic behavior. As Jamil was commended for not expressing (too much) pain, it might imply that people ‘like him’ tend to express pain, as the next example shows:

Rehan recounts an episode from the night before. A nurse had come in at night and Rehan had asked for pain killers as he told the nurse how much pain he was in. He was crying. The nurse had just responded ‘fantastic’ and did not give him any more medication. Rehan tells me he does not understand why anyone would say such a thing.

In this last example, adherence to pain management takes on a different form from the first example, as Rehan is positioned as not being able to take it (and maybe exaggerating). The guidelines require management of pain but, in this situation, Rehan is refused adequate pain relief. Regardless of the intention of the staff, the response shows a serious lack of adequate care. In the clinical practice of ERAS pathways, the proactive behavior of pain management is complex, as pain is connected to exhibiting appropriate pain behavior. In the pursuit of commending Jamil, a norm of holding back pain appears. For ethnically minoritized patients, inappropriate pain behavior was portrayed through essentialist explanations of what could be understood as un-stoic behavior [43]. Ultimately, expressive pain behavior interfered with the requirements of adequate pain management during standardized treatment which in clinical practice was based on essentialized understandings of ethnicity.

Discussion

By analyzing the four proactive elements of the ERAS protocol, we have explored how ethnically minoritized patients are positioned during standardized treatment through the gaze of (non)adherence. We find that healthcare staff experience conflicting demands as they seek to provide standardized treatment while simultaneously integrating groups of patients whose behavior is perceived to fall outside the requirements of the standard. We find that nonadherent behavior become entangled with essentialized and stereotypical understandings of ethnicity that were understood, explained, and connected to cultural food habits, collectivist family structures and un-stoic and exaggerated pain behavior. This practice risks leading to the undertreatment of pain, in addition to the underrepresentation of ethnically minoritized patients in seminars and same-day surgeries, thus creating adverse ethnic disparities.

However, the doings and sayings of healthcare staff cannot be understood without including the context. As described in the introduction, the definitions of health disparity, inequality and equity rely on different problematizations, understandings, and solutions. It is not just a question of individual prejudice or stereotyping, but staff also use the language that is available. For example, in health literature, the focus on improving care for ‘ethnic minorities’ is often connected to ‘cultural competencies’, ‘cultural safety’ or ‘cultural humility’, which intrinsically interweaves ethnicity and culture [44]. Furthermore, nonadherent behavior is often connected to ethnically and racially minoritized groups, which links ethnicity and race to nonadherence [21]. Yet when connections between ethnic disparities and nonadherence are found but not explored further in the literature [21], it affects how ethnically minoritized patients are perceived and encountered in clinical practice. In this manner, the available language is transferred from literature into clinical practice but in unforeseen ways, as we find that essentialist ideas of culture and ethnicity come to explain nonadherent behavior. To further explore these connections, we will first discuss the theoretical links between ethnic disparities and adherence. Following this, we will discuss our findings by showing the connections and implications of the ways in which concepts in literature are translated into clinical practice in standardized treatment. Finally, we expand the conversation and discuss implications of disparities versus inequities as a theoretical lens that ultimately affects clinical practice for staff, relatives, and patients.

Linking ethnic disparities to nonadherence

As adherence is frequently positioned as a key strategy to mitigate ethnic and racial disparities [19, 45], it becomes relevant to explore the construction, understanding and use of adherence. As a concept, adherence involves an inherent understanding that the provision of information will naturally increase adherence. In this understanding, information is connected to a linear causality where the rationale is that patients who know (and are correctly informed) can choose to act according to the design and intention of standardized treatment. Action then becomes a matter of choice and will. However, this understanding is based on a liberal point of view based on the notion that all people have the same prerequisites to act, which simultaneously undermines sociopolitical structures and people’s embeddedness within social positionings of, e.g., gender, race and ethnicity [46, 47]. (Non)adherence does not address the (in)equity embedded in the provision and reception of healthcare, including the complexities of power, negotiations, understandings and unequal positionings [48]. Attributing disparities in adherence to minoritized groups, without accounting for structural disadvantages or intersecting positionings, risks reinforcing health inequities by framing nonadherence as a function of ethnicity or race.

Today, there is generally increased awareness of the possible pitfalls of reporting ethnicity and race without considering other social factors that risk falsely attributing findings to ethnicity [28, 49, 50]. The strong focus on behavior relies on dominant health discourses of self-responsibility and individualism [51, 52]. We found that, as behavior was linked to a homogenized and essentialized understanding of the patients’ ethnicity and culture, it not only explained nonadherent behavior but also maintained a perception of the majoritized as not behaving ethnic or cultural. Likewise, research finds that concepts of ‘culture’ and ‘ethnicity’ stick to ethnically minoritized patients. This positions specific groups of patients as bearers of ‘culture’ and ‘ethnicity’, which in turn explains their perceived (in)appropriate healthcare behavior [44, 53]. With a linear construction of adherence (knowledge-motivation-adherence), the focus is placed on the decontextualized patient and thus not on the social practices in which standardized treatment is formed, activated, and performed. In this manner, the very construction of adherence becomes problematic, as it shifts responsibility onto staff and patients, obscuring the marginalization embedded in standardized treatment. We will now explore these marginalizing effects by elaborating on the connections between our findings and existing literature.

Marginalizing effects of standardized treatment

Standardized treatment is based on the best available evidence, which also relies on portraying research methods and treatments as objective and independent of the recipient. Consequently, the role that healthcare plays in the space of providing access to marginalized people remains largely invisible [54]. However, there has been increased attention to the lack of minoritized representation in clinical trials [55, 56]. This historical lack of diversity has meant that standardized treatments are largely based on evidence from trials involving predominantly young white males [57]. This has not only influenced standardized treatment but medicine in general. Consequently, there is an increased awareness and exposure of the implicit Eurocentrism, whiteness and androcentrism of standardized treatment and modern medicine. Despite the aim of standardized treatment to provide equal, objective, and evidence-based healthcare, we find through our abductive analysis that the proactive elements of the standardized treatment described within ERAS pathways are not unbiased elements in clinical practice. The four active elements of (preoperative) information, nutrition, early mobilization, and pain management are most often framed as responsibilities to be achieved by patients. Examining how nonadherent behavior is constructed in this context reveals an underlying norm, in which the foundations of modern, standardized healthcare implicitly play a role. Making this norm the focus of analysis reveals the marginalizing processes embedded in standardized treatment.

First, in the analysis of pain management, there is a vast amount of research showing how the pain of racially and ethnically minoritized patients is undermined and undertreated in healthcare [58–61]. From a historical perspective, (not) expressing pain can be linked to a white, Eurocentric, male norm in which ideologies of stoicism became the normalized emotion [43]. The idea of ‘ethnic pain’ is based on racist assumptions that have been criticized in Danish healthcare [62]. Ethnicity and pain behavior become entangled, ultimately leading to the delegitimization of ethnically minoritized patients’ pain experiences, which is further placed within the sphere of nonadherent behavior.

Secondly, in the analysis of nutritional guidelines, food intake is only achievable if patients eat pre-calculated and pre-ordered hospital food. Eating homemade food does not fit within the organizational structures that underpin ERAS pathways. To explain nonadherent behavior, the staff drew on essentialist understandings of culture. Culture as a concept has been heavily debated as it often leads to the othering of racially and ethnically minoritized citizens in Western society, politics and health research [44, 51, 63, 64]. In this manner, culture becomes an othering concept to explain behavior that is perceived as inappropriate and problematic [44, 53]. Implicitly, these ideas are linked to postcolonial discourses of ‘the culture’ of minoritized patients as inferior, which also plays a role in comments by staff. The explanations of the staff can be understood in terms of what Alpers et al. (2019) have suggested to be non-nutritive aspects of food among ethnically minoritized patients, labeled food culture [65]. The food culture of ethnically minoritized patients is then placed in opposition to adhering to the nutritional food intake of the majoritized patients. The Eurocentric underpinnings of food provided by the hospital are not included in these explanations. Instead, the food culture of the minoritized becomes an essentialist explanation that is consequently seen as a hindrance to adhering to the standard.

Third, early mobilization is understood in relation to tenets of individualism and self-responsibility, which are perceived as not applying to ethnically minoritized patients, due to collectivist notions that are explained as interfering with the requirements of ERAS. Positioning ethnically minoritized patients as collectivists was connected to positive associations of care but also to nonadherence during standardized treatment.

Finally, when patients did not understand the premise within preplanned guidelines from the outset, staff often explained this through essentialist understandings of perceived low compliance. Such explanations were positioned in opposition to the behavior of ethnic Danes, which is implicitly framed through whiteness [66, 67]. As mentioned, this explanation functions as a racial marker, reinforcing a normative point of comparison. When staff discussed participation, they reflected on a potential underrepresentation of minoritized groups in patient seminars and same-day surgery programs. This warrants further exploration, as other studies of orthopedic procedures have shown lower utilization by minoritized groups [68, 69].

Overall, our analysis reveals agency in standardized treatment by pointing out the implicit biases and norms that are incorporated into how proactive elements are designed, perceived and best achieved. This leads to the promotion of specific adherent behavior while simultaneously marginalizing other health behaviors. For ethnically minoritized patients, we find these marginalizing processes to be closely connected to ethnic markers, as patients encounter different expectations and preconceptions from staff depending on their names, appearance, religion, and language [6]. Further, these markers intersect with other social categories, such as gender and socio-economic status [17]. This intersectional practice affects patients who are placed in the margins of healthcare, as they have to work hard towards creating legitimacy in access to healthcare. These processes create overwork and can be understood within the realm of marginalizing and othering processes in which essentialized behavior is linked to ideas of ethnicity [14]. To grasp these structural processes, we shift our focus from health disparities towards health inequities.

Health inequities in standardized treatment based on perceived ethnicity

Health interventions aiming to reduce inequalities in standardized treatment and in healthcare in general have often had a linear focus on individual patient-staff encounters consisting of educating the healthcare staff (minimizing bias through competency training) and changing the behavior of patients (to increase adherence). However, the efficiency of such interventions lacks evidence, which has been connected to the non-inclusion of structural aspects, such as socio-politics, healthcare education, organizational requirements and patients’ lived experiences [15, 49, 70, 71]. While standardized treatment has undoubtedly improved the care and treatment of patients in general, we argue that the neutralization of the pathways themselves risks concealing the effect that is also embedded in standardized treatment, where implicit bias creates processes of marginalization. We have found these processes in the foundation of the pathways; in how ethnicity and race are described in research and clinical practice; in how adherence is constructed; and in how minoritized patients are portrayed (see Table 1).

Table 1.

Shows how ethnic health inequities are produced in standardized treatment by highlighting central concepts (Column 1), describing the theoretical underpinnings and use in literature (Column 2) and showing how these concepts and Understandings have implications in clinical practice based on our findings (Column 3)

Productions of ethnic health inequities in standardized treatment
Main concepts	Theoretical conceptualizations	Findings in clinical practice
Foundation of pathways	Lack of diversity in clinical trials	The pathways themselves remain unquestioned and neutralized They conceal the implicit bias that is also embedded in standardized treatment
	Lack of diversity among researchers
	Healthcare based on Eurocentric norms
	Pathways portrayed as unbiased, objective, and neutral
Adherence	Presented as a solution to decrease ethnic and racial disparities	The responsibility of, and explanation for, non-adherent behavior is placed upon the patients
	Decontextualized from patients’ lived experiences and structures of healthcare
	Action towards adherence is a matter of choice and will
	To increase adherence is through increasing information
Ethnicity	Often used and portrayed as an independent and objective variable	Ethnicity become essentialized and minoritized patients are given cultural, exaggerated and collectivist traits Is the explanation for non-adherent behavior Stereotypes patients of ethnically minoritized backgrounds
	Highlighted as central to disparities
	Understood through essentialized and fixed attributes
	Connected to culture
	Belonging to ‘the other’
Ethnic disparities	Systematic differences in health between different ethnic groups	Disparities are to be solved in individual healthcare encounters
	Cannot explain the cause of disparities

The argument for adherence seems to be that the more staff and patients adhere to protocols, the more patient outcomes will automatically improve. However, to contend with the complexities of health inequities require us to de-neutralize standardized treatment and explore how health inequities are manifested and normalized within the pathways themselves. Equity-oriented healthcare shifts the focus of intervention from the behavior of the ‘disadvantaged’ to the system that produces unmerited advantage and disadvantage [1]. This focus lifts the gaze from an individualized approach to instead engage actively with the inclusion of organizational structures, policies, and processes. Following other scholars, we therefore argue for an urgent need to incorporate health inequities into health research, policy, treatment and care, including standardized protocols [1].

Research limitations

The limitations of this study include the national context, and the departments included. Ethnography enables in-depth analysis of rich data that includes observations, conversations, and interactions, but in this study, it was also limited by the fact that the data came from two hospitals in one region of Denmark, which might affect generalizability outside this geographical area. Secondly, although only orthopedic departments were included in this study, the findings are not limited to orthopedic contexts but are relevant across different healthcare settings and medical specialties that provide standardized treatment. Finally, the national context of Denmark might limit the transferability to other healthcare systems.

Conclusion

Standardized treatment is portrayed as a neutral and objective concept and has gained traction as a means to mitigate health disparities. However, when patients do not meet the requirements of standardized pathways, it is often explained and explored in literature through a linear understanding of (non)adherence. In this study, we show how staff draw on concepts of culture, collectivism, ethnicity, and lack of stoicism to explain the nonadherent behavior of ethnically minoritized patients in standardized treatment. The desire to provide treatment and care to all patients becomes entangled with current linear, essentialized, stereotypical, and decontextualized understandings and conceptualizations of ethnicity as it intersects with notions of health behavior, health disparities, and (non)adherence. Through an equity lens, we show how these marginalizing and othering processes are produced in standardized treatment. We argue that current conceptualizations obscure the agency of standardized treatment in relation to marginalizing effects while simultaneously positioning healthcare staff as biased, responsible and at a loss.

Author contributions

This study was a collaboration between all authors. NH collected the empirical data and initiated the idea for the analysis and manuscript. NH made the first draft. All authors (NH, MH, TL) have developed the full analysis and contributed to the manuscript including results and discussion. All authors (NH, MH, TL) have read, commented, and approved the final manuscript.

Funding

Open access funding provided by Copenhagen University.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

An ethnographic study is not considered as health science research by the Regional Ethical Review Board and was not notifiable. Nonetheless, the study was registered with Regional Ethical Review Board (H-20072465). The study was approved by the Danish Data Protection Authority (P-2020‐1068). We obtained informed consent to participate from all the participants. The study adheres to the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.