Between the clinic and the community: a qualitative study of logics of action on social determinants of health in general practices serving disadvantaged communities

Background
Persistent socioeconomic inequalities in health remain a major public health challenge. Although the social determinants of health (SDOH) are widely recognised as foundational drivers of health inequities, translating structural understandings into sustained system-level action remains difficult. Primary care is increasingly positioned as a key site for advancing health equity; however, practitioners’ orientations toward SDOH vary and are shaped by institutional, organisational, and ideological contexts. This study examines how general practices operationalise action on SDOH when provided with dedicated resources and flexibility to respond within socioeconomically disadvantaged settings.

Methods
This qualitative study explored the implementation of CareDEEP, a 12-month initiative within the Deep End Network of North East North Cumbria (England), which provided funding and peer support to general practices serving highly deprived populations. Ten practices designed and implemented locally determined initiatives addressing SDOH. Drawing on realist-informed qualitative analysis, we examined how contextual configurations shaped practice responses. Data included monitoring reports, observational data from peer meetings, and interviews with participating staff. Analysis was informed by theoretical frameworks on SDOH discourses (Raphael) and functional, analytical, and structural approaches to action (Brassolotto et al.).

Results
Practices demonstrated distinct but patterned “logics of action” in how SDOH were interpreted and addressed. These ranged from functionally oriented service-level responses to more analytically or structurally framed initiatives. The orientation adopted was shaped by interacting contextual factors, including workforce capacity, leadership, prior exposure to health inequality work, organisational pressures, and local partnership infrastructure.

Conclusions
General practice can function as a site of public health implementation for action on SDOH, but responses are mediated by contextual, including ideological, factors. Interventions seeking to support structural engagement in primary care must attend not only to resources but also to the organisational and discursive conditions shaping practitioner reasoning. Understanding these logics of action is critical for designing policies that strengthen primary care’s contribution to health equity.