Fundamental causation and candidacy: Harnessing explanatory frames to better understand how structural determinants of health inequalities shape disengagement from primary healthcare

IF 4.9 2区医学 Q1 PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH

Social Science & Medicine Pub Date : 2025-04-04 DOI:10.1016/j.socscimed.2025.118043

Mhairi Mackenzie , David Baruffati , Calum Lindsay , Kate O'Donnell , David Ellis , Sharon Simpson , Geoffrey Wong , Michelle Major , Andrea Williamson

{"title":"Fundamental causation and candidacy: Harnessing explanatory frames to better understand how structural determinants of health inequalities shape disengagement from primary healthcare","authors":"Mhairi Mackenzie , David Baruffati , Calum Lindsay , Kate O'Donnell , David Ellis , Sharon Simpson , Geoffrey Wong , Michelle Major , Andrea Williamson","doi":"10.1016/j.socscimed.2025.118043","DOIUrl":null,"url":null,"abstract":"<div><div>This paper aims to better understand how structural determinants of health inequalities shape disengagement from healthcare for vulnerable groups across a range of social conditions. Using a sub-sample (N = 20) from a qualitative interview UK study of those missing from primary-care, it illuminates how structural drivers of health inequalities operate at organisational and practice levels to weaken engagement with primary-care. Finding ways of better analysing and demonstrating the causal chains between structural determinants and patterns of disengagement is important because previous research has shown that practitioner and policy understanding of structural determination, an important precursor for mitigatory action, is not always sufficient, and research on healthcare utilisation can itself be weak in investigating structures of inequality.</div><div>We address this deductively by testing a novel combination of Link and Phelan's Fundamental Cause Theory and Dixon-Woods and colleagues' Candidacy framework. Combining elements of these frameworks compensates for identified gaps in each. We demonstrate how Candidacy can be strengthened through incorporating more systematic theorisation of structural processes and that the more abstract arguments of fundamental (structural) causes can be made concrete via Candidacy's focus on inequalities in patients' access to, and utilisation of, healthcare. We also argue that both theories are enhanced by including Metzl and Hansen's concept of ‘structural competency’ as a potential mitigatory mechanism operating between fundamental causes and patient engagement.</div></div>","PeriodicalId":49122,"journal":{"name":"Social Science & Medicine","volume":"374 ","pages":"Article 118043"},"PeriodicalIF":4.9000,"publicationDate":"2025-04-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Social Science & Medicine","FirstCategoryId":"3","ListUrlMain":"https://www.sciencedirect.com/science/article/pii/S0277953625003739","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH","Score":null,"Total":0}

引用次数: 0

Abstract

This paper aims to better understand how structural determinants of health inequalities shape disengagement from healthcare for vulnerable groups across a range of social conditions. Using a sub-sample (N = 20) from a qualitative interview UK study of those missing from primary-care, it illuminates how structural drivers of health inequalities operate at organisational and practice levels to weaken engagement with primary-care. Finding ways of better analysing and demonstrating the causal chains between structural determinants and patterns of disengagement is important because previous research has shown that practitioner and policy understanding of structural determination, an important precursor for mitigatory action, is not always sufficient, and research on healthcare utilisation can itself be weak in investigating structures of inequality.

We address this deductively by testing a novel combination of Link and Phelan's Fundamental Cause Theory and Dixon-Woods and colleagues' Candidacy framework. Combining elements of these frameworks compensates for identified gaps in each. We demonstrate how Candidacy can be strengthened through incorporating more systematic theorisation of structural processes and that the more abstract arguments of fundamental (structural) causes can be made concrete via Candidacy's focus on inequalities in patients' access to, and utilisation of, healthcare. We also argue that both theories are enhanced by including Metzl and Hansen's concept of ‘structural competency’ as a potential mitigatory mechanism operating between fundamental causes and patient engagement.

查看原文本刊更多论文

基本因果关系和候选资格：利用解释性框架更好地理解卫生不平等的结构性决定因素如何影响脱离初级卫生保健

本文旨在更好地理解健康不平等的结构性决定因素如何在一系列社会条件下影响弱势群体脱离医疗保健。使用来自英国一项关于初级保健缺失者的定性访谈研究的子样本（N = 20），它阐明了卫生不平等的结构性驱动因素如何在组织和实践层面上运作，从而削弱了对初级保健的参与。找到更好地分析和证明结构决定因素与脱离接触模式之间的因果链的方法是很重要的，因为以前的研究表明，从业者和政策对结构决定的理解（缓解行动的重要前兆）并不总是充分的，而且关于医疗保健利用的研究本身在调查不平等结构方面可能很薄弱。我们通过测试Link和Phelan的基本原因理论和Dixon-Woods及其同事的候选资格框架的新组合来演绎解决这个问题。将这些框架的元素结合起来，可以弥补每个框架中已确定的差距。我们展示了如何通过结合结构过程的更系统的理论化来加强候选资格，并且通过候选资格关注患者获得和利用医疗保健的不平等，可以使基本（结构）原因的更抽象的论点具体化。我们还认为，通过将Metzl和Hansen的“结构能力”概念作为在根本原因和患者参与之间运行的潜在缓解机制，这两种理论都得到了加强。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

求助全文

约1分钟内获得全文求助全文

来源期刊

Social Science & Medicine PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH-

CiteScore

9.10

自引率

5.60%

发文量

762

审稿时长

38 days

期刊介绍： Social Science & Medicine provides an international and interdisciplinary forum for the dissemination of social science research on health. We publish original research articles (both empirical and theoretical), reviews, position papers and commentaries on health issues, to inform current research, policy and practice in all areas of common interest to social scientists, health practitioners, and policy makers. The journal publishes material relevant to any aspect of health from a wide range of social science disciplines (anthropology, economics, epidemiology, geography, policy, psychology, and sociology), and material relevant to the social sciences from any of the professions concerned with physical and mental health, health care, clinical practice, and health policy and organization. We encourage material which is of general interest to an international readership.