Abstract
The current healthcare landscape does not produce equitable outcomes for people with gout, particularly Māori and Pacific Peoples. In the management of gout, traditionally, the focus has been on assessing the effectiveness of specific interventions. Enhancing gout management requires a broader understanding not only of the effectiveness of interventions but also of the contexts and mechanisms that cause their effectiveness (or lack-thereof). This shift in emphasis is crucial for producing equitable outcomes, and meeting the diverse needs of people with gout.
Although there is good evidence indicating that structural barriers to healthcare contribute to the disparity between intended and actual equitable treatment and management of gout, there is limited evidence to inform the development of interventions targeting these structural barriers for people with gout. This thesis aimed to address this through two Critical Realist studies conducted within the context of Aotearoa New Zealand. Informed by the ontological and epistemological tenets of Critical Realism, the aim of this thesis was to move beyond assessing whether equitable best-practice gout management is effective, towards uncovering the underlying mechanisms and contextual factors that influence its success or failure.
The first study was a Hybrid Critical Realist Synthesis. In this Synthesis, existing literature was used to build and refine theoretical models to understand how and why certain contexts and mechanisms have worked in the past. The realist synthesis identified two overarching program theories: access to care and education. These theories demonstrated how social structures operated to produce outcomes in gout interventions. This is important for intervention design because if interventions do not address these structural forces, inequitable gout outcomes will continue to be produced and re-produced.
The second study was a Critical Realist Case Study, which aimed to understand how and why the gap between intended and actual equitable best-practice gout management occurred in two Hospitals in Aotearoa New Zealand. The results of this study findings revealed that in Aotearoa New Zealand, Colonisation influenced resource allocation in Primary and Secondary Care, thereby impacting access to care for people with gout, resulting in inequitable service utilisation patterns. The analysis of the Case Study results revealed that these events could be linked to underlying social systems that were present not only within the individual Hospital Cases but also throughout Aotearoa New Zealand as a whole.
Overall, the findings of this thesis indicate that visible and invisible contexts and mechanisms have ontologically real causal effects on gout management. When people with gout cannot access care due to inequitable resource allocation policies, often rooted in Colonial social structures, inequitable gout management is perpetuated. This underscores the systemic nature of inequities in the management of gout, highlighting the need for scientific methods and interventions that address the political and social determinants of health in a comprehensive way.