“They are nae worrying about it… so …what’s the point in asking?”: a qualitative study of candidacy for early CKD care in areas of multiple deprivation

“They are nae worrying about it… so …what’s the point in asking?”: a qualitative study of candidacy for early CKD care in areas of multiple deprivation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “They are nae worrying about it… so …what’s the point in asking?”: a qualitative study of candidacy for early CKD care in areas of multiple deprivation Buse Keskindag, Tom Blakeman, Audrey Hughes, Samira Bell, Mike Melvin, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9021068/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Chronic kidney disease (CKD) is common, associated with substantial comorbidity and strong socioeconomic gradients. Early CKD care focuses on preventing disease progression and reducing cardiovascular risk. However, inequities in access to CKD care are most pronounced early in the disease course, a critical window for equitable population-level prevention within primary care. Understanding how these inequities arise within primary care, where early identification and management largely occur, is therefore essential. This study explored how people living with CKD in deprived areas of Scotland, a setting characterised by marked health inequalities, establish candidacy for early kidney care at a point when prevention should begin but is often lacking. Methods: A qualitative study informed by critical realism combined semi-structured interviews with 38 adults with CKD (predominantly Stage 3 and primarily managed in primary care) and focus groups or interviews with 23 primary care professionals (N = 61). Participants were drawn from the most deprived 40% of neighbourhoods across three Scottish health boards, ensuring variation in CKD stage, diagnosis timing, professional role, and urban-rural setting. Data were analysed using reflexive thematic analysis informed by the Candidacy Framework. Results: Early kidney care for working-age adults living in deprived areas is often delayed, with CKD detected when personal resources, including time, finances, and support, are already stretched. Diagnosis is typically explained briefly, if at all, leading to uncertainty about its significance and next steps. Communication and care vary widely, with many patients relying on personal persistence to navigate fragmented healthcare systems. Care frequently depends on professional discretion, with uneven community and voluntary resources bridging gaps in care. These patterns reflect structural constraints rather than individual disengagement. Conclusion: Early kidney care in communities experiencing deprivation represents a constrained preventive window within primary care. The “triple invisibility” of early CKD, at population, system, and symptom levels, undermines sustained engagement at the point when intervention is most effective. Strengthening equitable prevention requires service-level redesign and workforce models that embed kidney health within routine cardiometabolic care, address structural constraints in deprived areas, and integrate physical and psychosocial risk management. Trial registration: Not applicable. chronic kidney disease primary care health inequalities prevention candidacy social determinants qualitative research Figures Figure 1 Contributions to the Literature Text box 1. Contributions to the Literature Provides qualitative insight into how working-age adults and primary care professionals in deprived areas experience and negotiate early CKD care. Demonstrates how primary care capacity constraints shape inequitable access to progression-preventing interventions. Shows how socioeconomic precarity interacts with workforce pressures to limit preventive continuity. Identifies “triple invisibility” (population-, system-, and symptom-level) as a mechanism weakening sustained engagement. Offers direction for strengthening equitable prevention within universal primary care systems. Background Inequities in health and healthcare are a major challenge in Scotland (United Kingdom; UK), which has among the lowest life expectancy in Western Europe and a widening gap between the most and least deprived areas over the last decade (Health Foundation, 2022). Within universal healthcare systems, primary care is the principal platform for population-level prevention. Increasing workload, workforce shortages and rising clinical complexity place strain on the NHS’s capacity to deliver preventive care, particularly for people with complex health and care needs (Baird et al., 2016; Hobbs et al., 2016; Fisher et al., 2024). Recent Scottish reforms aim to strengthen multidisciplinary support and data systems in primary care (Scottish Government, 2025; Scottish Government, 2023; ALLIANCE, 2025), yet these ambitions remain difficult to realise in routine practice. In high-workload settings, performance metrics that prioritise measurable targets over continuity and communication may further disadvantage deprived populations (RCGPS, 2024). In such contexts, chronic illness care strategies can inadvertently reinforce inequalities (Jefferson et al., 2022; Lowrie et al., 2017). Chronic kidney disease (CKD) affects around one in ten adults in the UK (KRUK, 2023), with substantial morbidity (Francis et al., 2024; Tuttle et al., 2019), and is projected to become the fifth leading cause of death globally by 2050 (GBD Chronic Kidney Disease Collaboration, 2020; Herrington et al., 2026). The international KDIGO classification system explicitly stratifies staging of CKD according to risks of all-cause mortality, cardiovascular events, and kidney-specific outcomes, including progression to kidney failure and acute kidney injury (AKI) (KDIGO, 2024). CKD staging integrates underlying cause with assessment of albuminuria and estimated glomerular filtration rate (eGFR), with monitoring and management guided by combined risk category (shown in Additional File 1). CKD is typically managed within multimorbidity care, including hypertension and diabetes (MacRae et al., 2021), with early detection and management focused on slowing disease progression and reducing cardiovascular risk in line with KDIGO guidance (KDIGO, 2024). Reduced kidney function (eGFR) or albuminuria may be present without symptoms and are usually detected only through blood or urine testing (KDIGO, 2024). Because the UK does not screen the general population, detection depends on risk-based or opportunistic monitoring in primary care, yet awareness remains low even where testing occurs (Francis et al., 2024). National guidance recommends regular kidney checks for people with diabetes, hypertension or cardiovascular disease, with abnormal results confirmed, staged and investigated (NICE, 2021). In practice, responsibilities vary across teams, and early abnormalities are not always clearly communicated or recorded, contributing to under-recognition (Daker-White et al., 2015). Nephrologists and CKD nurses typically become involved only when progression risk is high, including significant albuminuria, suspected renal disease, severely reduced kidney function (stage 4) or established kidney failure (stage 5) (NICE, 2021). Earlier stages, including mild to moderate kidney impairment, are usually managed entirely in primary care. Although effective risk-stratified pharmacological therapies (EMPA-KIDNEY Collaborative Group, 2022) and lifestyle interventions (Heiwe and Jacobson, 2011; Garofalo et al., 2018) exist, timely use depends not only on detection but on interpretation and clinical action. Together, these gaps shape who becomes aware of CKD early - and who does not - reproducing inequalities in access to early kidney care, defined here as the identification, communication and management of CKD in its earlier stages. Evidence from Scotland shows that people in deprived areas experience higher burdens of multimorbidity, later CKD presentation (first identified at a stage requiring referral) and poorer outcomes, including earlier death (Sawhney et al., 2023; 2024; Cowan et al., 2025), reflecting structural limits on time, continuity and preventive engagement within primary care. Financial insecurity, limited transport and housing precarity further restrict illness recognition and the capacity to seek and sustain care (Sawhney et al., 2024). Yet little is known about how these conditions shape people’s entry into early kidney care and the interactions through which access is negotiated. Understanding how people’s circumstances shape their ability to seek and sustain kidney health is essential for designing interventions that reduce inequalities. The Action Plan for Scotland commits to reducing social and geographic inequalities in CKD through earlier detection and equitable monitoring (KRUK, 2024), but realising these aims requires understanding how candidacy for early care unfolds within constraints of time, continuity, trust and broader structural determinants (Marmot, 2010). Although treatment burden and organisational barriers have been described for older people with advanced CKD (Hounkpatin et al., 2020; Roberti et al., 2018), little is known about how working-age adults living in deprived areas experience early kidney care. One framework that helps explain how access is shaped by social and organisational conditions is the Candidacy Framework (Dixon-Woods et al., 2005). It has been applied in studies of chronic and clinically mediated conditions where symptom ambiguity and structural disadvantage influence how people come to be recognised - and to recognise themselves - as eligible for care (Koehn et al., 2024; Sinnott et al., 2024; Mackenzie, 2025). Early CKD care shares these characteristics: identification is typically incidental and clinically mediated rather than symptom-led, and opportunities for early engagement are constrained by socioeconomic and organisational pressures (Daker-White et al., 2015). The Candidacy Framework has therefore been used in this study to understand how early kidney care is accessed and navigated from the perspectives of working-age adults living in areas of multiple deprivation (i.e., disadvantage across income, employment and service access domains) in Scotland and the primary care professionals who support them. Methods Study design This qualitative study, conducted between July 2024 and May 2025, explored experiences of early kidney care among working-age adults living with CKD and the primary-care professionals who support them in socioeconomically deprived areas of Scotland. Reporting followed the COREQ checklist (Tong et al., 2007) and was informed by a critical-realist orientation recognising the interplay of structure and agency (Haigh et al., 2019). The study was co-designed and conducted in partnership with patients, public contributors, and professionals, following GRIPP2 Short Form guidance (Staniszewska et al., 2017); full details are provided in Additional file 2. Study sites Participants were recruited across three Scottish health boards - NHS Grampian (north-east), NHS Fife (east), and NHS Greater Glasgow and Clyde (west) - selected to reflect geographical and socioeconomic variation in CKD service provision. Additionally, a Scotland-wide community/self-referral route was available, enabling eligible patients from beyond the three participating health boards to take part, which resulted in one participant from outside the three boards. Participant recruitment continued until information power was achieved to meet analytic depth (Malterud et al., 2016). Information power was considered across the study aim, sample specificity, quality of dialogue, theoretical engagement, and the analytic strategy employed, informing judgments about sample adequacy rather than relying on numerical thresholds (Malterud et al., 2016). A study is considered to have adequate information power when the sample is well aligned with the study aim, the participants have relevant experience, the data are of high quality, and the analytic approach allows for in-depth, reflexive interpretation. Patients’ eligibility and recruitment Eligible patients were aged 18-65, aware of a chronic kidney disease (CKD) diagnosis or a sustained acute kidney injury (AKI) requiring ongoing kidney monitoring, confirmed by their GP records, and living within the most deprived 40% of neighbourhoods in Scotland (Scottish Index of Multiple Deprivation [SIMD] quintiles 1-2). Awareness of diagnosis was required to ensure meaningful engagement and to avoid inadvertent disclosure (Daker-White, 2015). Eligible patients were identified through medical record screening using routinely recorded diagnostic codes, age and postcode, and were invited via NHS Research Scotland (NRS) Primary Care Networks, nephrology clinics and community organisations. Most NHS participants were identified through primary care records. Recruitment was based on the most recent recorded CKD stage (or self-reported where records were unavailable); where NHS consent was provided, medical record extracts confirmed CKD stage and most recent estimated glomerular filtration rate (eGFR). Of 297 study invitations issued by post across the three boards (106 Greater Glasgow & Clyde, 56 Fife, 135 Grampian), 28 primary care patients participated. In secondary care, nephrology staff invited eligible patients during scheduled appointments; of 14 who expressed interest, nine took part. Community outreach through Kidney Research UK, the Grampian Kidney Patient Association and the Scottish Kidney Federation yielded 10 responses, with one meeting eligibility criteria and subsequently recruited. Approximately 12% of invited individuals participated. Rather than aiming for statistical representativeness, the sample provided contextual and experiential diversity across CKD stages, ages and socioeconomic backgrounds aligned with the study aims. Thirty-eight individuals (n = 38) living with kidney disease in socioeconomically deprived areas participated in the study. Of those with available postcode data, 27% resided in SIMD Quintile 1 and 64% in Quintile 2; an additional ~9% had deprivation status verified by the NRS Primary Care Network but not disclosed to the research team. Most participants were recruited from large urban areas, with a smaller number from accessible rural areas and small towns, reflecting the geographic distribution of the Scottish population. Most participants had a stage 3 CKD diagnosis and, within this group, stage 3a (mild to moderate reduction in kidney function) was more common than stage 3b. Smaller numbers were at earlier stages of mild kidney function reduction or at more advanced stages of kidney function decline, and one participant had sustained an AKI. Nearly all participants reported multiple physical health comorbidities. Detailed participant characteristics are presented in Additional file 3. Professionals’ eligibility and recruitment Eligible professionals were general practitioners, practice nurses, pharmacists, and reception/administrative staff working in practices serving socioeconomically deprived populations, including “Deep End” general practices (surgeries serving Scotland’s most disadvantaged communities). Professionals were invited via digital flyers distributed through NRS coordinators and practice networks. In total, 23 professionals participated (from 27 who expressed interest): 15 GPs, six practice nurses and two community pharmacists, spanning urban and rural contexts. Data collection Semi-structured interviews and focus groups were conducted by trained and experienced qualitative researchers, primarily by BK, with two patient interviews conducted by MRD, using topic guides co-designed with patient and public partners, piloted and refined iteratively (Additional file 4). Patients took part in one-to-one, semi-structured interviews conducted by telephone (n=30), online (n=4), or in person on university premises (n=4), typically lasting 41-72 minutes. Professionals participated in online focus groups (four groups of three to four participants, ~90 minutes) or, where scheduling was difficult, one-to-one interviews (~60 minutes; n=9). Participants were offered interpreter support; one patient interview was conducted in a language other than English at the participant’s request by a bilingual interviewer. No additional non-English interviews were requested. Interviewers had no prior clinical relationship with participants. Participants were informed of the researchers’ roles, study aims, and interest in understanding access to early kidney care in areas experiencing deprivation. All sessions were audio-recorded, professionally transcribed, anonymised, and accuracy-checked. Structured field notes captured contextual details, cross-site differences, and reflexive observations informing ongoing analysis. No repeat interviews were conducted. At the start of each patient interview, a brief questionnaire captured demographics (e.g. age, gender, postcode, employment) and kidney status at diagnosis and currently. For NHS-recruited participants, kidney health information was verified from medical records by NHS Research Scotland Primary Care Network coordinators and the recruiting nephrologist (or delegated clinician) and, with participants’ consent, securely shared with the clinical team member or the project researcher. All clinical information shared with the research team was pseudo-anonymised and transferred via secure NHS channels. To reduce barriers to participation, all participants received easy-read study information and were offered a choice of written, online, or verbal consent covering participation, recording, and use of anonymised quotations. Patients received a £25 shopping voucher, and professionals were reimbursed £97 per hour (directly or via general practices), in line with NIHR payment guidance (National Institute for Health and Care Research, 2021) and ethical arguments for fair recognition under sustained workload pressure (Bower et al., 2009). Researcher reflexivity The team brought complementary disciplinary and practice perspectives, including counselling psychology, general practice, nephrology, clinical epidemiology, health psychology and implementation research. During fortnightly analytic meetings, researchers presented new data extracts and emerging interpretations, which were discussed collectively with patient and public contributors and clinical team members to challenge assumptions and refine analytic decisions. These cross-disciplinary discussions supported sustained reflexivity, alongside memo-writing and explicit attention to researcher positionality throughout data collection and analysis. Additional one-to-one input from lived-experience contributors further strengthened interpretive rigour. Methodological oversight for use of the Candidacy Framework was provided by a medical sociologist. Data analysis Transcripts were analysed using reflexive thematic analysis (RTA) (Braun and Clarke, 2019) within a critical realist frame (Haigh et al., 2019). A critical realism approach recognises that phenomena such as access to care are shaped by underlying social structures, while being known through participants’ lived accounts. It guided attention to both participants’ experiences and the generative mechanisms influencing engagement with kidney care, allowing analysis to account for the interaction between individual circumstances and broader organisational and systemic contexts. RTA proceeded through six iterative phases: (1) familiarisation, (2) systematic inductive coding, (3) theme generation, (4) theme reviewing, (5) defining and naming themes, and (6) reporting (Braun and Clarke, 2019). This approach emphasises researcher reflexivity by recognising the active role of the researcher in knowledge production, prioritises analytic depth and interpretive richness over consensus between coders, and involves an iterative process of theme development in which themes are generated, reviewed, and refined through sustained engagement with the data rather than assessed through inter-rater reliability. Themes were developed inductively and subsequently interpreted through the domains of the Candidacy Framework (Dixon-Woods et al., 2005), which has been widely applied to theorise access to primary care (Sinnott et al., 2024). The Framework’s domains consist of seven overlapping stages representing candidacy for a health service. We developed an additional cross-cutting meta-theme ( precarity shaping the conditions for early kidney care ) rather than forcing a fit. Because early CKD is associated with non-specific symptoms and is often detected incidentally, identification was clinically mediated rather than patient-led, with sense-making occurring after disclosure and shaped by multimorbidity; candidacy domains are therefore presented in an empirically informed order (Table 1). Detailed coding trees for both study subpopulations (patients and primary care professionals) are available in Additional file 5. NVivo (R1 2020) supported organisation; in line with RTA, we prioritised reflexive, dialogic sense-making over inter-rater reliability. Themes were built collaboratively with patient partners, checked across subgroups and negative cases, and documented in analytic memos and debriefs. Sampling sufficiency was assessed using the principle of information power (Malterud et al., 2016), based on the relevance, richness and diversity of data in relation to the study aim. Table 1. Definitions of candidacy domains in this study. Candidacy domain Definition Identification and early sense-making of kidney disease How CKD is detected and initially interpreted as important or negligible within routine multimorbidity care, focusing on how patients and professionals recognise and make sense of kidney disease in everyday practice. Appearing in services - primary care encounters How kidney disease was communicated and voiced in clinical encounters, and how interactions shaped whether patients felt recognised, reassured, or dismissed. Navigating kidney disease-related care and support The practical work patients undertook to pursue kidney-related follow-up within primary care-led systems after identification - including arranging appointments, attending tests, and seeking practical or social support where needed to make care feasible. Permeability of primary care healthcare services How the design and organisation of general primary care services enabled or constrained access to kidney-related care, including appointment systems, administrative interfaces, digital routes, geography, and follow-up practices. Adjudications of candidacy How professionals judged, prioritised, and acted on patients’ eligibility or capacity for care in the context of multimorbidity and deprivation. Offers and resistance to kidney care How offers of kidney care were made, interpreted, and taken up or deferred, shaped by trust, understanding, perceived relevance, and practical feasibility within constrained contexts. Operating conditions shaping candidacy in kidney care How system-level contexts - including workload, resources, incentives, and policy - shaped the consistency, continuity, and responsiveness of kidney care, influencing who was prioritised and supported over time. Precarity shaping the conditions for early kidney care ¥ How socioeconomic precarity and health-related vulnerability, shaped by structural conditions, influenced patients’ capacity to engage with kidney care before and after diagnosis. ¥ a cross-cutting inductive meta-theme, reflecting experiences that extended beyond the seven candidacy domains. Results Findings are presented in an empirically informed order that reflects how early kidney care unfolded in practice. The first six sections report how kidney disease was negotiated within primary care systems during its earlier phases, from detection and interpretation through access, professional decision-making, and responses to care. We begin with identification and early sense-making, as CKD was typically detected incidentally through routine primary care activity rather than through patient-led symptom recognition. We then report how kidney disease featured within primary care encounters, where its significance was negotiated amid multimorbidity and time-limited consultations, followed by navigation, capturing the work patients undertook to pursue kidney-related follow-up and support. Subsequent sections examine the permeability of primary care services, professional adjudications of candidacy - operating across identification and offers of care - and patients’ responses to these offers as organisational processes. We conclude with two domains describing influences that shape these processes: operating conditions (NHS system-level influences) and socioeconomic precarity and health-related vulnerability, shaped by structural conditions, that influence patients’ capacity to engage. Together, these contextualise candidacy across the pathway. An analytic representation of these processes is shown in Fig. 1. Identification and early sense-making of kidney disease Primary care professionals described CKD identification as largely opportunistic, emerging through routine blood tests rather than symptoms: “ We get very, very few patients presenting acutely unwell with acute kidney injuries ” (FG_2, GP). Detection typically occurred during reviews for other long-term conditions such as diabetes, hypertension, thyroid disorders, or pregnancy complications: “ They were doing blood tests for another condition… and that’s where the kidney function showed as being low ” (PC05001). For patients, this often meant the diagnosis arrived unexpectedly, with limited understanding of why blood or urine tests had been undertaken or what the findings were intended to assess. Professionals viewed identification as both a technical and interpretive process. Some followed local renal protocols, while others referred to national guidance such as NICE or SIGN, noting that thresholds and calculators could be “ not very user-friendly ” (FG_3, GP). Most described CKD as best integrated within existing multimorbidity reviews rather than through dedicated clinics: “ You don’t need another whole clinic… you maybe just need to add an ACR onto the bloods you are doing ” (FG_4, GP). Others used practice audits, such as the “triple whammy” medication review, to prevent avoidable harm. These accounts positioned identification within routine chronic disease management rather than as a distinct event. For patients, identification was less about clinical detection and more about making sense of early, often non-specific (attributable to other co-existing health problems) or absent symptoms, resulting in kidney disease being experienced as ‘invisible’. Many lacked prior knowledge of kidneys or their function: “ I wasn’t very knowledgeable about kidney disease, so I didn’t really know what it meant ” (C01001). Reactions ranged from shock and disbelief to mild concern or resignation. Some were startled that a chronic disease could be discovered incidentally: “ It was a shock to the system because I had always thought I was fit and healthy ” (C01001). Others accepted it with little alarm: “ It does sit at the back of your mind… but it’s not something I dwell on ” (PC03022). Appearing in services - primary care encounters First conversations about kidney function were often led by practice nurses or pharmacists during reviews for other conditions, positioning them at the frontline of disclosure. CKD diagnosis was a key moment of appearance, marked by uncertainty about what the findings meant and whether further action was needed. Some patients were unsure if they had ever received a formal diagnosis: “ Up to date, my GPs etc have never been concerned I’m having problems with my kidneys… nobody’s really said anything ” (PC02026). Others only discovered their condition indirectly: “ They told me because I was borderline for kidney disease… that was the first time I knew anything about it ” (PC01001). In some cases, the information was presented so casually that it did not register as significant: “ When I was told about this, it was made very little of… I wouldn’t say I was given that impression at all ” (PC05001). This uncertainty was reinforced by how kidney disease was positioned relative to other health priorities. Several patients and professionals described kidney disease as a secondary concern, overshadowed by other chronic conditions such as diabetes or hypertension. One patient participant reflected that “ the kidneys have become a secondary thing... I was quite happy pedalling along ” (PC2001), while clinicians often prioritised managing comorbidities first: “ If they are coming for their annual hypertension review... they might not be aware of the CKD that they’ve got related to that ” (FG_4, pharmacist). This framing reinforced uncertainty about the significance of CKD and contributed to patients interpreting silence or reassurance as a sign that nothing more needed to be done. Against this background, the way results were communicated at this stage determined whether patients viewed themselves as needing further care or assumed nothing more was required. Some recalled being given medication without explanation - “ They just palmed me off with medication ” (PC01003) - while others described feeling confused and anxious as a result of not knowing what their results meant: “ The kidney count… is quite low… once you hit 50 you hit a bit more serious waters… nobody has discussed any of that with me ” (PC05001). In time-pressured settings, clinicians tended to soften or abbreviate disclosure - “ The kidneys are just getting a bit slower… ” (FG_2, GP) - while those with greater continuity favoured directness: “ Maybe I’ve made it a bit too reassuring… maybe my letter should actually be saying, ‘You really need to look after yourself! ’” (FG_3, GP). These differing approaches influenced how candidacy was voiced and heard, often leaving patients uncertain about whether they truly had a diagnosis, how serious it was, and what, if anything, they should do next. Emotional responses ranged from passive trust to frustration and anxiety: “ I kind of feel angry… I don’t know really what else I can say about it; it’s just the whole information - no support, no nothing ” (PC01001). Uncertainty and reassurance also shaped how patients engaged with services afterwards. For some, reassurance discouraged further enquiry: “ They are nae worrying about it… so I just think, well what’s the point in asking? ” (PC02057). Others recognised their own hesitation: “ I haven’t really had it explained to me… but to be honest, that’s partly my problem, I haven’t really asked enough ” (PC04002). Information was often contingent on active questioning: “ If I hadn’t asked what it [a blood test] was for, I wouldn’t have been told ” (PC03001). For some, more detail encouraged self-management - “If I get that wee bit more information, then I can make adjustments” (PC06023). Professionals linked these patterns to social context. In deprived areas, patients were perceived as less likely to attend and more likely to present late: “ These patients with poor socioeconomic status… they’ll also have all of the comorbidities… so your non-attenders will go higher ” (FG_2, GP). Engagement was often framed as personal responsibility: “ They do get another recall… but we don’t go about texting and saying they have not come ” (FG_3, GP). Several professionals expressed frustration at these limits: “ We can only educate and invite them in as much as we can… apart from going to their door and dragging them in, I’m not really too sure what else you can do ” (FG_2, GP). Navigating kidney disease-related care and support Navigating kidney-disease-related care was often contingent not only on clinical need but on the practical and social resources available to patients. Some struggled with the cost of even basic travel: “ I don’t drive or anything like that, so I usually just walk or I get the bus. I can’t afford to travel by bus, I normally just have to walk ” (PC01002). Others relied on friends or careful budgeting: “ My friend drives me about, so it makes it easier ” (PC02060); “ Appointments are made a month in advance, so that gives me enough time to leave money aside ” (PC0234). Attending appointments could itself be costly and difficult: “ I dinna hae [don’t have] the money to put petrol in .” (PC02057). For those in work, appointments and blood tests required trade-offs: “ I may need to take time off… that means I either lose pay or annual leave ” (PC01001), though some had more support: “I’m very grateful… they are aware that I’m likely to be absent from work ” (CO01001). Patients also described variation in practical and emotional support around appointments. Some prepared in advance and brought a relative: “ I normally write doon whit [down what] I want to ask… I like [my daughter] to be there ” (PC0234). Others went alone: “ Usually on my own… I don’t think I ever have [had anyone with me] ” (PC01001). Financial strain compounded the difficulties of navigating care. “ The benefits I get, it’s never enough to get me by a whole month… I have to budget a lot ” (SC01005). For some, deprivation was severe: “ I’m only living off ten pound a month… I have to go down to the foodbanks. They give me salty foods, so I have no option but to eat them ” (PC01002). Applications for welfare benefits were described as emotionally draining and often unsuccessful, with patients doubting whether kidney disease even qualified as a disability: “ Kidney disease doesn’t fall into that [disability] category ” (PC01002). Professionals observed how poverty directly undermined medical advice: “ He eats what is given [by the foodbank]… tinned food that’s sugar-laden, salt-laden ” (HCP0201, GP). Healthcare professionals also reflected that people living in deprived circumstances often faced complex social and health problems that outweighed kidney care priorities: “ So if I was to ask them what was important to them, managing their chronic kidney disease is probably not even on the radar ” (FG_4, pharmacist). Confidence in navigating health systems reflected how clearly information was provided and understood. Some experienced referrals as abrupt or poorly explained: “ I think I was just referred… it just happened ” (SC01005). Patients under hospital follow-up reported clearer pathways: “ I call 111… If they advise me go to the hospital… I do that ” (SC01002). Those managed mainly in primary care were more hesitant, contacting the GP only if symptoms were present or burdensome: “ I wouldn’t be phoning the doctor just to discuss the fact that I’m feeling anxious ” (PC010013). In the absence of guidance, some turned to the internet and felt overwhelmed: “ You start the information gathering process and quickly learn… you don’t know what is actually right or wrong ” (PC03022). Professionals recognised these barriers, noting inconsistent information provision. Leaflets remained the default, particularly for people who did not go online: “ A lot of our patients don’t go online… they prefer written things ” (FG_1, GP). Yet CKD-specific resources were scarce: “ We have lots of leaflets on diabetes… but I don’t think we do have any [for kidneys] ” (FG_3, nurse). Long, generic leaflets were considered unhelpful (FG_2, GP). NHS websites were sometimes signposted, but professionals doubted their reach: “ There might be stuff online… but I don’t know… there’s certainly a massive lack of awareness ” (FG_2, GP). In multilingual contexts, reliance on interpreters was routine: “ Most of the patients that come in will come in with some sort of interpreter… or we just have one in-house on the phones, so we have adapted ” (FG_2, GP). Across accounts, the availability of structured psychosocial and wider support - such as link workers or social prescribing - was uneven. Rural general practices sometimes reported more consistent access than urban ones, where waiting times were longer and eligibility was narrower. Some patients were unsure what help existed: “ Just help with taxi fares or a transport pick-up… I’m not sure if it happens here ” (PC0234). Others drew on charities or peer groups for advice and connection: “ I was made aware of a couple of charities… that were quite good for insights and support groups ” (SC01002); “ There’s a community there… people going through similar things that I can ask ” (CO01001). Clinicians recognised the contribution of third-sector organisations but found them difficult to keep track of: “ There are wonderful third-sector organisations… but it’s very hard to keep your finger on the pulse… funding changes, times change ” (HCP0101, GP). For underserved groups, the challenge was not only whether services existed but whether they were reachable in practice: “ How do they get that education… or even be able to access it? ” (FG_2, nurse). Permeability of primary care healthcare services Because early CKD care is largely delivered through routine primary care rather than specialist renal services, the permeability of general primary care systems strongly shaped how participants accessed and experienced kidney-related care. For many patients, getting an appointment felt difficult unless initiated by the practice: “ To get an appointment on your own is very difficult… but if they want you down for something, they’ll fit you in ” (PC03001). Rigid scheduling often clashed with everyday life. One patient working in childcare explained: “ I work in a nursery and we are asked… that we try and pick times that are outwith school hours, which is not always easy ” (PC010013). By contrast, blood test appointments with nurses were described as easier: “ It is relatively easy to book an appointment… to see the nurse ” (PC03022). Professionals confirmed that service design and timing shaped who could attend. Annual health checks were hard to fit around work: “ They find it hard in practice because of the inflexibility around opening times ” (FG_4, pharmacist). Others expected same-day access and were frustrated by the limited number of urgent slots: “ If you’re not well, you expect an appointment… there is often a mismatch between patient expectation and what is available ” (HCP0201, GP). The medical reception interface was a consistent point of tension. Patients disliked sharing sensitive details with non-clinical staff: “ Fit [what] I find quite disillusionin’ [disillusioning] is when you phone up and the receptionist wants to ken yer life [know everything about your problem]… I’ll tell the doctor what’s wrong with me… but I’m nae tellin [I’m not telling you] you because you’re the receptionist ” (PC02001). Professionals also described reception staff as gatekeepers, with practices experimenting with re-labelling the role as “ care co-ordinator ” (HCP0401, nurse). Access was further shaped by housing and digital precarity. Frequent house moves or neighbourhood instability meant appointment letters sometimes never arrived: “ People sometimes move house quite a lot… their mail goes missing… they might not be at that house because they’ve moved ” (HCP1301, GP). Text-based reminders helped some, but for others, access was as fragile as a phone top-up: “ They might not be able to receive the text message because they’ve ran out of credits that week… they don’t have any money on their phone ” (HCP1301, GP). Geography and infrastructure also influenced permeability. Accounts from both patients and professionals illustrated how access was uneven and continually negotiated. Some living in small villages reported easy access: “ My doctor’s surgery… answer very, very quickly. I think it’s because it’s a very small village - we are really lucky ” (PC03001). Others in rural areas described physical and communication barriers: “ We get flooded roads, and sometimes we just don’t get our letters… it would be a nuisance if I received a letter late and had missed it through no fault of my own ” (SC01002). Clinicians echoed this, noting patient resistance when asked to travel to off-site hubs: “ You’re essentially telling them… ‘Up you go to xxx or down you go into the centre of town’… they’re like, ‘Well, I’m at a GP because I’m in a zone. Why are you moving me out of zone? ’” (FG_3, GP). In these cases, what appeared to be small system efficiencies often created new barriers for those already managing complex lives. When patients did not attend, clinicians described a spectrum of follow-up work, from multiple calls and texts to, in high-risk cases, police welfare checks: “ If it’s a high-risk patient, then we’ll often go an extra mile to track them down… might even get the police to go and see them ” (FG_1, GP). Small rural surgeries were sometimes able to respond more flexibly, while inner-city practices struggled under stretched appointment systems. Adjudications of candidacy by health professionals What mattered most to patients in professionals’ adjudications was being listened to, taken seriously, and given clear explanations - qualities most often experienced in hospital-based nephrology clinics. These settings allowed longer more conversational appointments where professionals validated concerns and offered reassurance: “ The doctor asks me open-ended questions and gives me the chance to explain how I’m feeling ” (CO01001). Early reassurance and proactive action strengthened confidence: “ He automatically went to speak to a professional in the kidney field ” (PC01003). Clear explanations and reliable follow-up further reinforced trust: “ My consultant will explain… then I’ll get a letter and a full explanation in the post ” (CO01001). Even small acts of explanation mattered: “ Rather than just saying your kidney function is X… reassure that there are support tools out there ” (CO01001). By contrast, these qualities were often missing in primary care, where short appointments limited discussion and left patients uncertain: “ I just really wished the GP… if they’d maybe explained what it was that was raised and how it can affect my bodily function ” (PC03001). Others described encounters that felt cursory or alienating, particularly for those without the perceived literacy, confidence or support to question judgements. Some experienced care as “ a box-ticking exercise… I couldn’t ask any questions ” (CO01001). For patients with multimorbidity or mobility challenges, time-limited appointments in general practices amplified barriers: “ By the time I get to the room… it’s time for me to leave ” (PC04053). Blunt communication, even when accurate, could feel distancing: “ The doctor said to me that, yeah, he would expect the kidney function that he’d seen in my test results, would expect a seventy-year-old man to have those results. I felt like that was quite blunt ” (CO01001). Others reported little or no explanation: “ I just need somebody to explain what’s wrong with me… plus advice on how to delay this kidney infection or whatever it is ” (PC01001). Silence was often interpreted as inaction: “ If there was something that could be done about it, they would have said something ” (PC03018), implying that recognition frequently occurred only once the disease had already progressed. For some, silence itself became a judgement, interpreted as a quiet signal that nothing more could be offered: “ If there was something that could be done about it, they would have said something ” (PC03018). While for patients, adjudication was about tone, explanation and respect shaping their sense of being taken seriously, professionals described it as more about judging what patients could realistically manage in the context of deprivation, multimorbidity and difficult life circumstances. In these settings, clinicians often took on more of the follow-up work themselves, anticipating that patients might struggle to do so. As one GP explained: “ You won’t leave it with the patient to follow something up… a lot of the time you’ll anticipate that and be a bit proactive at our end… you try to put more nets in place for the patient ” (FG_1, GP). Instead of expecting patients to self-manage, practices phoned repeatedly, wrote extra instructions on prescriptions, or involved carers and pharmacists. “ They can’t differentiate… they wouldn’t be able to tell you the difference between a lot of their medications ” (FG_1, GP). “ It always takes a bit of detective work ,” another GP shared, describing a patient whose care was coordinated closely with his wife; when no carer was present, things were “ much more chaotic ” (FG_1, GP). In some accounts, better-resourced teams were described as having scope for proactive recall and tailored plans, whereas in thinner systems, more responsibility appeared to rest with patients. These adjudications also extended to lifestyle change. Professionals recognised the impact of deprivation and sought to provide personalised care that prioritised patient needs. They also acknowledged that some patients might achieve little change due to complex social and health circumstances. Clinicians contrasted the generic, instruction-based approach often used in routine reviews with more responsive, motivational conversations: “You don’t want to be doing everything at once… but maybe have a conversation about, ‘If there’s one thing you could change… what would it be?’ ” (FG_3, GP). Even small gains were treated as meaningful: “ Just getting the weight down by a couple of kilos… that’s a success ” (FG_3, practice nurse). Yet CKD was seen as harder to adjudicate than diabetes or hypertension because there was little visible improvement to offer. As one GP put it, “ You have to make these changes not for positive improvement, but just to make things less bad ” (FG_2, GP). Another described the difficulty of patient expectations: “ What can I do about that, doctor? ” to which the honest but unsatisfying reply was, “ Keep taking those pills… and hope for the best ” (FG_2, GP). Where continuity allowed, clinicians described more scope to revisit, calibrate, and encourage. Offers and resistance to kidney care In primary care, patient participants reported experiencing routine kidney monitoring as a formality rather than meaningful care. Annual reviews were described as administrative obligations, detached from everyday life with a long-term condition. “ Every time you go… you have to bring a urine sample… I don’t think I’ve received any [kidney] care for anything like that ” (PC02035). Others wanted more dialogue: “ I just think it needs to be a little bit more personalised… there’s no real chat with a doctor unless you are ill-ill ” (PC010013). Professionals confirmed that offers of care were not fixed but shaped locally. Some practices held back appointment slots for working patients or those who struggled to get through on the day: “ Patients can pre-book appointments, but we try and reserve those for people who are working or who have got a genuine reason why they couldn’t phone on the day ” (HCP0101, GP). For patients with complex needs, double appointments were offered informally: “ Anyone that is vulnerable or has a lot going on, we give them double appointments ” (HCP0101, GP). Such offers depended on local knowledge and staff discretion rather than formal policy, and patients noticed the difference between places where such flexibility existed and places where it did not. Communication of results revealed further contrasts. Patients in renal clinics reported clear explanation and choice: “ They’ve always explained it to me… they ask you if you’d like to know ” (SC01002). In primary care, results were described as opaque or delegated: “ They just said that this level is slightly off… there’s been no conversation about it ” (PC03001). Being asked to call reception was a source of frustration: “ Why on earth am I phoning you for results? Surely somebody medically qualified should be answering the questions ” (PC02051). Professionals acknowledged these problems and described informal workarounds. One nurse annotated blood results with ranges and CKD stages to support understanding: “ I write next to it what the normals are… and the stages of it ” (HCP0401, practice nurse). She sometimes offered her email to patients who found it hard to get through by phone. “ Trying to get through to us can be quite difficult… so they can always e-mail in ” (HCP0401, practice nurse). These adjustments made care more tangible, but they were piecemeal and dependent on individual initiative; in teams with fewer staff or higher turnover, such extras were harder to sustain. Self-management support was another point where offers and resistance emerged in primary care. Patients often felt guidance was lacking: “They’ve never told me anything like that. ‘You shouldn’t drink that or you shouldn’t eat that’… they’ve never discussed anything like that with me” (PC02057). Others valued written resources as something to return to after consultations: “You leave, and that’s when you’ve got all the questions… having something you can read at your leisure is a definite plus” (PC01003). Yet for those with limited literacy, written materials were of little use: “ It’s more difficult for me to read by myself and not fully understand… there’s no one to ask what it’s talking about” (SC01005). Professionals described repeatedly revisiting lifestyle advice in the hope of catching patients at the right moment: “ We re-broach everything… just trying to engage people” (FG_3, practice nurse). Disclosure also varied with context. “They’ve been at the GP, not necessarily told the truth, and then they come to the nurse and it all comes out” (FG_3, practice nurse). Where continuity and nurse-led reviews were stable, patients described more usable offers; where staffing and access were less stable, offers were thinner and resistance seemingly greater. Continuity was a persistent concern for patients who described seeing different GPs at each visit: “ Every time you go it’s some different doctor… you’ve got to go through the same story every time ” (PC2005). Fragmentation disrupted trust and sometimes created risk: “The antibiotics that I was given aren’t safe for kidneys… they actually cause more damage” (PC01002). Missed follow-up compounded this: “ ’You’ve got high levels of protein’… and to be honest, I’ve not heard anything since ” (PC02026). Some responded with withdrawal: “ I’ve got so little faith in my GP… to go back just feels slightly pointless ” (PC05001). Professionals acknowledged the unevenness of recall and management of missingness: “ Every practice does it slightly differently… sometimes nothing happens, they just get invited again the following year ” (FG_4, GP). Pharmacists sometimes picked up gaps in reviews or used prescriptions to encourage attendance by providing a limited supply of medication: “ I’ll reauthorise it so they can get six months’ worth… and then after that I really do need them to attend for bloods ” (FG_4, pharmacist). In some health boards, these systems were reportedly more consistent; elsewhere, they relied on individual clinicians and workarounds. Despite frustration and withdrawal, many patients continued to engage with their care through routine monitoring, medication and lifestyle adjustments. “ I have to get a check… to continue giving me my prescription ” (PC03001). “ I look for a really healthy diet now… that’s all I’m really doing ” (PC01001). “ My morning always starts off with tablets… they’re trying to control my blood pressure to control the kidney function ” (CO01001). Yet professionals also noted that some patients resisted offers, not from disinterest but from concern about legitimacy: “ People don’t like to bother doctors or their practice unless they feel really unwell… I hear that all the time: ‘I didn’t want to bother you because I know how busy you are. It didn’t seem important, I feel okay ’” (HCP1301, GP). Professionals also highlighted that transportation difficulties and financial constraints often act as barriers to patient engagement: “ We’ve got patients in our practice who can’t afford the bus to come down… they can’t afford the taxi ” (FG_2, GP). Accounts also hinted at variation, with some participants describing steadier staffing and clearer recall as enabling engagement, while in stretched urban practices, others spoke of holding back, judging their needs did not warrant taking up scarce slots. Operating conditions shaping candidacy in kidney care For patients living with CKD in areas of deprivation, access to care was shaped not only by their own efforts but by the conditions under which services operated - the timing of appointments, the availability of staff, and the responsiveness of follow-up. Routine monitoring in primary care was often experienced as procedural, with responsibility for contact left unclear: “ I wasn’t given any kind of information on who I can go to ” (PC01002). Appointments were often too short to allow meaningful dialogue, with participants expressing a preference for longer consultations: “ A twenty-minute appointment… so that you’ve got time to ask questions ” (PC01001). Others described struggling to secure face-to-face consultations: “ They won’t actually physically see you ” (PC01001). Patients often acknowledged system pressures - “ They are probably requiring more staff, extra resources ” (PC04001) - but recognition of strain did not reduce the frustration of inaccessibility. Still, not all encounters were negative. Pharmacists were seen as approachable and responsive: “ The pharmacist is really good… she will come and speak to you ” (PC01001). National policy also mattered. The removal of prescription charges was described not just as convenience but as an enabler of adherence: “ Since the government made prescriptions free… that doesn’t affect me getting my medication at all ” (PC02005). For others, digital tools were helpful: “We’re very lucky… they do respond within a day to this form” (PC03001). Automated text reminders were welcomed by one interviewee: “ They give me a text two days beforehand ” (PC0234). Some contrasted inner-city practices as harder to access than smaller rural surgeries, hinting at how local context shaped follow-up. Healthcare professionals described the same conditions from the vantage point of constraint. In deprived areas, shortages of staff and services were repeatedly cited: “ On the other side of practices, being in special measures, not having enough staff. So, you have a whole lot of different structural things that are going on ” (FG_4, GP). As another GP put it: “ We’re all trying our best to do the best for everyone, but it just doesn’t feel like there’s enough resource available to get round everyone… we probably are leaving some people behind ” (FG_3, GP). Even seemingly small service losses - such as no longer loaning blood pressure monitors or the absence of district nurses or social care workers - were seen to have a disproportionate impact on patients with multimorbidity. “ I think, inevitably, we are leaving behind some. We know we are… it’s those who are in the most deprived sections of society that are getting the least good healthcare ” (FG_2, GP). Digital infrastructure was described as patchy. Apps were widely used for asthma and diabetes, but CKD was said to be “ very niche compared to the wider market for it ” (FG_2, GP). Language barriers added another layer: “ It’s difficult for some people who English is not their first language to register at the practice… so they’re trying to make that a bit more accessible ” (FG_1, GP). What for some was framed as innovation or efficiency was, for others, experienced as exclusion. Policy shifts were also seen as influential. Several GPs pointed to the removal of CKD from the Quality and Outcomes Framework (QoF) as a turning point: “ eGFR and lab analysis came around the same point as the introduction of QoF in 2003-2004… It was incentivised and became an important target… now it’s been removed from the GP contract in Scotland ” (FG_4, GP). Without this incentive, recall systems became harder to sustain, especially in practices already under strain. Wider support also varied by place. “ It’s better in the shire… social care will routinely be involved… but we don’t have that, unfortunately, in the city ” (FG_1, GP). Where services did exist, they were not always straightforward to use. One team reported that they also practised as social prescribers: “ We don’t have an actual clinic. We just have a group of us… nurse, GP, pharmacist… so we made a folder on the drive with Sleepio and things like that… so there’s different headings for each topic ” (FG_3, practice nurse). Communication with renal teams was likewise uneven. Some valued comprehensive letters: “ Their letters are really comprehensive… they flag up actions for the GP at the start, which is really helpful ” (FG_1, GP). Others described professional-to-professional communication systems that felt anonymous: “ We’ve got this alleged system… where you’re supposed to write an advice letter… I’ve never done that with renal. There’s this feeling of anonymisation and not knowing… you might recognise names, but you don’t know who people are ” (FG_2, GP). In short, the links between primary and secondary care were fragile and variable. Within practices, CKD work was spread across nurses, pharmacists and advanced nurse practitioners. “ Most of the meaningful interventions I’d say would probably be non-GP these days ” (FG_4, GP). While efficient, this sometimes clashed with patient expectations: “ They felt that they were totally being fobbed off… they weren’t very satisfied sometimes when they walked in and I was there ” (FG_4, pharmacist). Professionals noted that CKD care often relied on informal champions: “ You really need somebody that’s going to champion it… whether that’s diabetes or CKD… then it becomes a wee bit by osmosis, influencing others’ practices ” (FG_4, pharmacist). Without such champions, CKD was at risk of being overshadowed by other conditions. Access to training was also described as limited: “ We don’t get PLT [Protected Learning Time] any more… even out-of-hours things you often can’t attend because you’re still at work ” (FG_2, GP). Preventive care was frequently squeezed: “I get ten minutes for each of my patients… there’s so much I would love to help them with… but I’ve got to move on” (HCP0201, GP). Pharmacists, with more discretion, sometimes carved out longer reviews: “Maybe I’m a wee bit better at being able to protect my time… I can create fifteen or thirty minutes to review somebody if they are really complicated” (FG_4, pharmacist). Considering system and local challenges in primary care, professionals highlighted that current healthcare provision fails to meet the needs of patients with deprived circumstances. Precarity shaping the conditions for early kidney care Participants’ accounts showed that socioeconomic and emotional precarity often predated awareness of kidney disease and shaped how its later identification and management were negotiated in practice. Ongoing pressures related to work, finances, housing, and mental health influenced participants’ capacity to prioritise kidney health, attend appointments, seek clarification, and remain engaged with services, forming the context in which candidacy for early kidney care developed. Physical fatigue, chronic pain, and declining function disrupted employment from Stage 4 onwards, though some Stage 3 participants also described early signs that affected their ability to work. Many reduced their hours, going from full-time to part-time: “ I used to work full-time … but again, that was too much, so I had to come down to two mornings a week ” (PC02057). Another described the exhausting cycle of justifying kidney health needs to their employer: “ three occupational health reports… letters from my doctors… there’s only so much I can do ” (PC06023). Concerns about future employment arose even in Stage 3: “ I had no option but to hand in my notice… and I do worry… it may also affect that next job as well ” (PC01002). Financial strain was a recurring theme, compounded by low income and, in some cases, unstable housing. This strain became especially pronounced in Stage 4 CKD, with one participant describing a cascading collapse of support: “ All these things just happened and crashed from underneath me... I was homeless… I had no job… and myself and my partner did split up, so I was away from my children ” (SC01006). Even earlier in the disease course, the cost of self-management - attending appointments, following dietary advice, maintaining routines - was financially burdensome. As one participant put it: “ Kidney disease financially is expensive… making things [food] from scratch can be more costly ” (PC01002). Multiple health issues compounded the burden: “ trying to keep on top of ” health issues while “ always on the go ” (PC02026). Emotional strain was also a consistent background feature across accounts, described not as occasional distress but as persistent low mood, frustration, and mental fatigue - “ I’ve found myself to be a little bit more moody and cranky… I think it’s just mainly to do with the mental health that comes with the kidney disease ” (PC01002). Others described a shift of baseline: “ My moods in general, I’m just low - constantly low mood ” (PC06023). This was particularly common among those managing multiple conditions alongside social or financial pressures. Some withheld how they felt to avoid worrying others: “ I keep myself to myself… I don’t put my health issues onto my children ” (PC04053). Others noticed changes in how they related to people: “ Very short-tempered. Tetchy. Feel as if I’m arguing with people quite a lot ” (PC06023). In people with severely decreased kidney function or established kidney failure, the emotional and physical demands of illness took a toll on intimate relationships: “ I just can’t get out of my bed… I feel sorry for my husband ” (PC02057). At that point, some described reaching a crisis point: “ I was suicidal. I looked at throwing myself in the Aberdeen harbour… I didn’t know where to turn ” (SC01006). That same patient participant later noted receiving support through primary care: “ I was put back on antidepressants to help my suicidal thoughts… and now I feel a lot stronger ” (SC01006). Others sought mental health support outside the NHS: “ I do see a counsellor on a weekly basis… I talk to them about how I’m feeling mentally ” (CO01001). Discussion Summary of findings Consistent with prior quantitative evidence of later CKD identification in deprived areas (Sawhney et al., 2024), our qualitative findings show that, for working-age adults, “early” kidney care is often structurally late - typically initiated only once disease is already advanced and personal resources are depleted - thereby limiting capacity to engage in preventive action. Although incidental detection is characteristic of early CKD, it is explained briefly, if at all, leaving patients uncertain about its seriousness and what action is required. Conversations about kidney health vary in clarity and tone, shaping whether people understand themselves as needing ongoing care or interpret reassurance as closure. Many struggle to navigate complex and fragmented systems, where appointments, referrals, and follow-up depend on persistence, timing, and personal means. Professional assessments are similarly constrained by uncertainty, limited support, and the constant need to prioritise amid multimorbidity and system strain. Offers of care are uneven, sometimes softened or deferred, and their usefulness depends on continuity and relationships rather than standardised processes. Much care relies on discretionary effort - extra calls, annotated results, and active test-chasing - while community resources such as link workers and voluntary organisations bridge the gap between clinical advice and daily life. While these efforts often sustain care under pressure, they also render access uneven, as follow-up becomes contingent on individual initiative and local capacity rather than embedded systems. Interpretation: candidacy under constraint Viewed through the Candidacy Framework (Dixon-Woods et al., 2005), whether and how people enter early kidney care depends on continual negotiation with services, shaped by time, trust, and capacity. Eligibility and engagement depend on how people’s daily lives align - or fail to align - with the organisation of primary care (Cummins et al., 2007; Strazdins et al., 2011). In this context, late detection and inconsistent follow-up reflect not a lack of motivation but the structural conditions that constrain recognition, help-seeking, and sustained engagement. As one participant reflected, “ They are nae worrying about it… so .. well what’s the point in asking? ” (PC02057). This illustrates what we term candidacy under constraint - where patients internalise limited professional concern as a cue that their condition is not a priority, disengaging not from apathy but from an awareness of system strain. Both patients and professionals work to sustain care within these constraints, often relying on discretionary effort and local relationships to bridge systemic gaps. Together, these local negotiations reveal the broader logic of the Inverse Care Law - first articulated by Hart (1971), extended to prevention (Macintyre, 2007), and still evident in contemporary systems (Cookson et al., 2021) - where those with the greatest need face the most limited capacity for timely care. Seen through the lens of candidacy as socially structured access, relational mechanisms - trust, continuity and communication - are not optional interpersonal features but core conditions shaping service permeability (Ladds et al., 2023; Sinnott et al., 2024). These mechanisms operate within wider structural constraints, where workforce capacity, organisational priorities and socioeconomic conditions shape both daily life and service delivery. Recent Scottish evidence indicates that such pressures persist despite policy commitments to equity (Bogie et al., 2025). In practice, primary care capacity remains a key constraint, with staffing pressures and turnover narrowing opportunities for testing, follow-up and timely diagnosis (Audit Scotland, 2025). National initiatives aimed at addressing social and health inequalities will depend on sustained workforce time and community capacity to translate policy into practice. Implications: equitable early kidney care These findings help explain why kidney health remains under-prioritised within non-communicable disease strategies. At a population level, early stages of kidney disease have limited public health visibility, reflected in routine data sources and their relative absence from national dashboards. At a system level, kidney disease lacks the enhanced services and incentives afforded to conditions such as diabetes and cardiovascular disease in primary care. At an individual level, early CKD is largely asymptomatic or characterised by non-specific symptoms, further limiting recognition and salience. Together, this “triple invisibility”, at population, system, and symptom levels, weakens candidacy for early kidney care and constrains preventive action. Viewing CKD as a biomedical-psychosocial juncture reframes early kidney care as both detection and action. The question is not only how to detect disease earlier, but how to create the conditions that make early action possible. Ensuring capacity for early kidney care within an overstretched health system is essential to prevent inequities from widening. This requires protected opportunities for early detection, timely communication, and structured follow-up before disease progression limits prevention. It also requires institutional recognition that time, continuity, and trust are core conditions for equitable care rather than optional extras. Action across primary and community settings should safeguard consultation time, ensure that test results are communicated clearly with agreed next steps, and embed navigation for social and practical needs such as transport, employment, housing, digital access, and psychosocial support. Although kidney function tests are among the most frequently performed investigations in UK primary care (Hobbs et al., 2016), our findings highlight ongoing challenges in how patients and professionals interpret and act on results. Clear framing of blood and urine testing within annual reviews - emphasising kidney health and shared next steps - may reduce softened or protective communication practices that inadvertently contribute to partial or non-disclosure of CKD (Deliyanidis et al., 2024; Daker-White et al., 2015). Strengthening these temporal and relational aspects of care may help early detection translate into sustained engagement and reinforce prevention as a shared, enduring capacity (Ladds et al., 2023). Future research should build on this work through co-design with people affected by CKD, primary care teams, and community partners to develop and test integrated models of care that embed appropriately framed conversations about kidney health into routine practice, address the service constraints identified here, and enable earlier and more equitable action. These findings also connect to the emerging concept of cardiovascular–kidney–metabolic (CKM) syndrome, which recognises cardiovascular disease, chronic kidney disease, and metabolic disorders as part of a linked continuum of biological and social risk (Ndumele et al., 2023). The CKM model emphasises staged risk assessment and prevention at the earliest identifiable stages of cardiometabolic risk, incorporating kidney function and albuminuria testing within integrated care pathways. Importantly, it situates social and structural determinants of health - including socioeconomic position, stress exposure, and access to care - as part of the causal pathway rather than as external context. Our findings complement this perspective by clarifying what translating integrated risk recognition into sustained preventive action would require in practice, particularly in deprived areas. Achieving the CKM ambition will depend on addressing the organisational and relational constraints identified here - limited time, fragile continuity, and uneven community capacity - through workforce models that integrate kidney health across routine cardiovascular and metabolic encounters. In doing so, prevention can move from aspiration to implementation, enabling earlier and more equitable action within real-world service conditions. Implications: theory Our findings extend recent refinements of candidacy in use and scope (Koehn et al., 2024; Mackenzie, 2025) by showing that, in early CKD, clinical rather than patient-led identification initiates the candidacy process, requiring an empirically adapted ordering of the early domains to reflect how participants encountered care in practice. We further show that socioeconomic precarity and organisational strain are embedded within, and operate across, candidacy domains, structuring capacity to appear in services, navigate care pathways, and engage with offers of care. These processes were bidirectional and contingent on disease severity: while precarity shaped candidacy most strongly before and at early recognition, progression of CKD often intensified existing socioeconomic and emotional strain, further constraining engagement. Multimorbidity additionally distributed attention and priority across conditions, shaping how kidney disease was interpreted and adjudicated by professionals. Taken together, these insights complement existing work by positioning candidacy more explicitly within the structural determinants shaping access to asymptomatic and clinically mediated conditions. Strengths and limitations This study’s key strengths include the multi-site design across three Scottish boards and the focus on a working-age and lived experience of area deprivation (i.e. a seldom-heard population); this is complemented by accessibility-minded recruitment (easy-read materials, flexible modes), dual perspectives (patients and professionals), and theory-informed analysis underpinned by substantive patient, public and professional engagement. The present qualitative study did not sample across the full socioeconomic gradient, which would have enabled systematic examination of how structural mechanisms operate across levels of socioeconomic advantage and disadvantage. However, previous quantitative analysis using linked population-level data has demonstrated clear socioeconomic gradients in CKD-related outcomes, with greater mortality and poorer health indicators among people experiencing higher levels of deprivation (Sawhney et al., 2024). The current study, therefore, focused on an in-depth exploration of how these inequalities are experienced and negotiated in practice among those known, from linked population-level data, to face constrained access to care, reflecting a complementary qualitative emphasis on mechanism and process. This study is situated within the context of Scotland’s NHS, which represents a methodological consideration; however, convergence with UK-wide evidence on primary care during the austerity era (Nuffield Trust, 2024) supports the transferability of the findings. In addition, participants were sampled according to eGFR-based CKD staging rather than full KDIGO risk classification, incorporating albuminuria, which may have provided additional nuance in how CKD is considered and discussed for individuals with higher albuminuria despite mild or moderately reduced kidney function. However, as albuminuria is not consistently recorded in primary care, sampling on this basis would likely have introduced systematic exclusion and difficult-to-interpret accounts, undermining analytic coherence. Conclusions Early kidney care in communities experiencing deprivation represents a structurally constrained preventive window in which biological risk intersects with lived social conditions shaping opportunities for action. In the absence of population, system and symptom visibility, prevention becomes dependent on discretionary effort and individual capacity at the point when intervention is most effective. Access and engagement therefore emerge as processes of candidacy negotiated within limited time, continuity and system capacity, revealing how organisational and social structures, rather than individual motivation, reproduce inequities even within universal healthcare. Strengthening equitable prevention requires community-linked primary care models that embed social and structural determinants within care design, consistent with integrated cardio-renal-metabolic approaches that situate prevention and inequity within the causal pathway. Abbreviations CKD: chronic kidney disease AKI: acute kidney injury SIMD: Scottish Index of Multiple Deprivation eGFR: estimated glomerular filtration rate ACR: albumin-to-creatinine ratio NHS: National Health Service NRS: NHS Research Scotland RTA: reflexive thematic analysis GRIPP2: Guidance for Reporting Involvement of Patients and the Public COREQ: Consolidated criteria for reporting qualitative research KDIGO: Kidney Disease: Improving Global Outcomes QoF: Quality and Outcomes Framework Declarations Ethics approval and consent to participate All study procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki. The study was approved by Health and Social Care Research Ethics Committee A (reference 24/NI/0037). Written, verbal, or online informed consent was obtained from all participants for participation in interviews or focus groups, for audio-recording, and for the use of anonymised quotations in research outputs and publications. Patient participants were additionally invited to provide optional consent for access to relevant medical records relating to kidney health status. All participants were additionally invited to provide optional consent for future contact regarding ethically approved studies and for receipt of a lay summary of the study findings. Ongoing verbal consent was reconfirmed at the start of each interview and focus group. Interviews and focus groups were audio-recorded, transcribed verbatim, and anonymised prior to analysis, with field notes also anonymised prior to analysis. Audio and text files were stored securely in password-protected folders in accordance with UK data protection regulations. Consent for publication Not applicable. No identifiable individual data are presented in this article. Availability of data and materials A complete qualitative coding framework with a hierarchical coding tree is available via the University of Aberdeen PURE repository. Competing interests TB is also funded by the NIHR Greater Manchester Patient Safety Research Collaboration (Grant NIHR204295). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health and Care Research, or the Department of Health and Social Care. SB has received consulting fees from AstraZeneca, GSK, Stada UK, and Novo Nordisk, and research support from AstraZeneca. These relationships are outside the scope of the present study. The remaining authors declare that they have no competing interests. Funding This research, conducted as part of the Kidney Inequalities: Needs, Data, Experiences, Response (KINDER) study, was supported by the Scottish Government Chief Scientist Office (grant HIPS/23/17). The funders had no role in study design, data collection, analysis, interpretation, or the decision to submit the manuscript for publication. Author contributions SS was the Chief Investigator. MRD led this study, with TB’s support. MRD, SS, TB and AH contributed to study conceptualisation and funding acquisition. BK and MRD led project administration. Site engagement was undertaken by SB, BJ and SS. Participant-facing materials were co-designed by MRD, BK, AH, MMe and FN. Participant recruitment, data collection and data analysis were led by BK. Interpretation and validation of findings were undertaken by MRD, BK, TB, AH, SB, MMe, FN, MG, BJ, MMa, NSR, EC, PC and SS. MRD and BK drafted the original manuscript. All authors contributed to manuscript review and editing. MMa provided specialist methodological guidance. All authors read and approved the final manuscript and are accountable for the work. Acknowledgements We thank NHS Research Scotland (NRS) Primary Care Networks, especially Amanda Cardy and a research governance manager, Louise King, for her support in our efforts to improve study accessibility. We are deeply grateful to all participants, our advisory group, and our patient and public partners for their generous contributions throughout the project. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any Author Accepted Manuscript version arising from this submission. Authors’ information MRD is an Advanced Research Fellow and qualitative health researcher specialising in health services research and equity-focused implementation science; she is also an accredited community-based counsellor. BK is a Postdoctoral Researcher with a background in health psychology and expertise in qualitative health research. SS and PC are clinical academic nephrologists with a focus on population kidney health and deprivation-related inequalities. TB and BJ are academic general practitioners with expertise in multimorbidity and primary care service organisation. SB is a clinical epidemiologist specialising in chronic disease outcomes. MMa is a Professor of Medical Sociology with expertise in structural determinants of health and health inequalities. NSR and EC are academic researchers contributing to chronic disease and health services research. AH, MG and FN are Patient and Public Involvement contributors. Additional file 5: Qualitative coding framework and full coding tree. Available via the University of Aberdeen PURE repository: https://abdn.elsevierpure.com/en/datasets/kinder-qualitative-study-coding-trees/ References ALLIANCE. Long Term Conditions Framework: consultation response. The Health and Social Care Alliance Scotland; 2025. Available from: https://www.alliance-scotland.org.uk/wp-content/uploads/2025/07/Long-Term-Conditions-Framework-ALLIANCE-Response.pdf Audit Scotland. General practice: progress since the 2018 General Medical Services contract. Edinburgh: Audit Scotland; 2025. Available from: General practice: Progress since the 2018 General Medical Services contract Baird B, Charles A, Honeyman M, Maguire D, Das P. Understanding pressures in general practice. London: King’s Fund; 2016. Available from: https://assets.kingsfund.org.uk/f/256914/x/62ae34157d/understanding_pressures_general_practice_2016.pdf Barnard R, Spooner S, Hubmann M, Checkland K, Campbell J, Swinglehurst D. The hidden work of general practitioners: an ethnography. Soc Sci Med . 2024;350:116922. Bogie J, van Dijk M, Bezzina C, Lunan C, Henderson D, Mercer SW, Blane DN. Equity, workload, and general practice under strain in deprived communities. Br J Gen Pract . 2025;75(757):e549-e558. Bower P, Wallace P, Ward E, Graffy J, Miller J, Delaney B, et al. Improving recruitment to health research in primary care. Fam Pract . 2009;26(5):391-7. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health . 2019;11(4):589-97. Cookson R, Doran T, Asaria M, Gupta I, Mujica FP. The inverse care law re-examined: a global perspective. Lancet . 2021;397(10276):828-38. Cowan E, Bell S, Black C, Blakeman T, Fraser S, Hughes A, et al. Deprivation and limitations in daily life in new onset kidney disease: a population study. Clin Kidney J . 2025; 19 (1): sfaf397. Cummins S, Curtis S, Diez-Roux AV, Macintyre S. Understanding and representing “place” in health research: a relational approach. Soc Sci Med . 2007;65(9):1825-38. Daker-White G, Rogers A, Kennedy A, et al. Non-disclosure of chronic kidney disease in primary care and the limits of instrumental rationality in chronic illness self-management. Soc Sci Med . 2015;131:31-9. Deliyanidis S, Stiefel FC, Bourquin C, Michaud L. Focus on the blind spots of clinician–patient interactions: a critical narrative review of collusion in medical settings. J Health Psychol . 2024;30(8):1751-67. Dixon-Woods M, Kirk D, Agarwal S, Annandale E, Arthur T, Harvey J, et al. Vulnerability and access to healthcare: a critical interpretive review. Soc Sci Med . 2005;61(12):2620–31. EMPA-KIDNEY Collaborative Group. Empagliflozin in patients with chronic kidney disease. N Engl J Med . 2022;388:117–27. Fisher R, Loftus L, Holdroyd I, Ford J. Fairer funding for general practice in England: what’s the problem, why is it so hard to fix, and what should the government do? London: Nuffield Trust & Health Equity Evidence Centre; 2024. Available from: https://www.nuffieldtrust.org.uk/resource/fairer-funding-for-general-practice-in-england Francis A, Harhay MN, Ong ACM, Tummalapalli SL, Ortiz A, Fogo AB, et al. Chronic kidney disease and the global public health agenda. Nat Rev Nephrol . 2024;20(7):473-85. GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet . 2020;395(10225):709-33. Garofalo C, Borrelli S, Provenzano M, De Stefano T, Vita C, Chiodini P, et al. Dietary salt restriction in chronic kidney disease: a meta-analysis of randomized clinical trials. Nutrients . 2018;10(6):732. Haigh F, Kemp L, Bazeley P, Haigh N. Developing a critical realist-informed framework to explain how the human rights and social determinants of health relationship works. BMC Public Health . 2019;19:7760. Health Foundation. Health inequalities in Scotland: an independent review. London: Health Foundation; 2022. Available from: https://www.health.org.uk/health-inequalities-in-scotland-an-independent-review Heiwe S, Jacobson SH. Exercise training for adults with chronic kidney disease. Cochrane Database Syst Rev . 2011;(10):CD003236. Herrington WG, Judge PK, Grams ME, Wanner C, et al. Chronic kidney disease. Lancet . 2026;407(10523):90-104. Hobbs FDR, Bankhead C, Mukhtar T, Stevens S, Perera-Salazar R, Holt T, et al. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007-14. Lancet . 2016;387(10035):2323-30. Hounkpatin HO, Sang E, Price S, Okoye O, et al. Change in burden and experiences of treatment burden among people with kidney disease: a longitudinal qualitative study. BMJ Open . 2020;10(12):e041097. Jefferson L, Golder S, Heathcote C, Avila AC, Dale V, Essex H, et al. GP wellbeing during the COVID-19 pandemic: a systematic review. Br J Gen Pract . 2022. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024 Apr;105(4S):S117-314. Khan A. GP workload and patient safety: the balancing act. Br J Gen Pract . 2024;73(733):459-61. Kidney Research UK. Kidney disease: a UK public health emergency - the health economics of kidney disease to 2033. Peterborough: Kidney Research UK; 2023. Available from: Economics-of-Kidney-Disease-full-report_accessible.pdf Kidney Research UK. Chronic kidney disease: an action plan for Scotland. Peterborough: Kidney Research UK; 2024. Available at: https://www.kidneyresearchuk.org/wp-content/uploads/2024/11/KRUK-Chronic-Kidney-Disease-Scottish-Action-Plan.pdf Koehn S, Hunkeler E, Lee V, Wallace B. Candidacy and chronic disease management among marginalised older adults. Soc Sci Med . 2024;330:115949. Ladds E, Majeed A, Greenhalgh T. A contemporary ontology of continuity in general practice. Soc Sci Med . 2023;326:115958. Levesque J-F, Harris MF, Russell G. Patient-centred access to healthcare: conceptual framework. Int J Equity Health . 2013;12:18. Lowrie R, Mair FS, Greenlaw N. Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data. BMJ Open . 2017;7(3):e012270. Mackenzie M, Baruffati D, Lindsay C, O’Donnell K, Ellis D, Simpson S, et al. Fundamental causation and candidacy: harnessing explanatory frames to better understand how structural determinants of health inequalities shape disengagement from primary healthcare. Soc Sci Med . 2025;374:118043. MacRae C, Mercer SW, Guthrie B, Henderson D. Comorbidity in chronic kidney disease: a large cross-sectional study of prevalence in Scottish primary care. BMC Primary Care. 2021;71(704):e243-e249. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res . 2016;26(13):1753-60. Marmot M. Fair society, healthy lives: the Marmot Review . London: Institute of Health Equity; 2010. Available from: https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review National Institute for Health and Care Excellence. Chronic kidney disease: assessment and management (NG203). London: NICE; 2021. Available from: https://www.nice.org.uk/guidance/ng203 National Institute for Health and Care Research. Payment guidance for researchers and professionals. NIHR; 2021. Available from: https://www.learningforinvolvement.org.uk/wp-content/uploads/2021/12/Payment-guidance-for-researchers-and-professionals-Dec-2021.pdf Ndumele CE, Greenland P, Van Gaalen J, et al. Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association. Circulation . 2023;149:e1-e35. Roberti J, Cummings A, Myall M, Harvey J, Lippiett K, Hunt K, et al. Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies. BMJ Open . 2018;8(9):e023507. Royal College of General Practitioners Scotland. The Scottish GP workforce and socioeconomic health inequalities. Edinburgh: RCGP Scotland; 2024. Available from: https://www.rcgp.org.uk/getmedia/263e368d-1dc2-4ac8-9180-05d9da9158bb/Scottish-GP-Workforce-Socioeconomic-Health-Inequalities.pdf Sawhney S, et al. Care processes and outcomes of deprivation across the clinical course of kidney disease: findings from a high-income country with universal healthcare. Nephrol Dial Transplant . 2023;38(5):1170–9. Sawhney S, et al. Individual and neighbourhood-level social and deprivation factors impact kidney health in the GLOMMS-CORE study. Kidney Int . 2024;106(5):928-42. Scottish Government. Delivering value-based health and care: a vision for Scotland. Edinburgh: Scottish Government; 2023. Available from: https://www.gov.scot/publications/delivering-value-based-health-care-vision-scotland Scottish Government. Primary care improvement plans: implementation progress summary (March 2025). Edinburgh: Scottish Government; 2025. Available from: https://www.gov.scot/publications/primary-care-improvement-plans-implementation-progress-summary-march-2025 Sinnott C, Ansari A, Price E, Fisher R, Beech J, Alderwick H, et al. Understanding access to general practice through the lens of candidacy: a critical review of the literature. Br J Gen Pract . 2024;74(747):e683-e694. Staniszewska S, Brett J, Simera I, Seers K, Mockford C, Goodlad S, et al. GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. BMJ . 2017;358:j3453. Strazdins L, Griffin AL, Broom DH, Banwell C, Korda RJ, Dixon J, et al. Time scarcity: another health inequality? Soc Sci Med . 2011;72(9):1349-58. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care . 2007;19(6):349-57. Tuttle KR, Alicic RZ, Duru OK, Jones CR, Daratha KB, Nicholas SB, et al. Clinical characteristics of and risk factors for chronic kidney disease among adults and children: an analysis of the CURE-CKD registry. JAMA Netw Open . 2019;2(12):e1918169. Additional Declarations Competing interest reported. TB is also funded by the NIHR Greater Manchester Patient Safety Research Collaboration (Grant NIHR204295). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health and Care Research, or the Department of Health and Social Care. SB has received consulting fees from AstraZeneca, GSK, Stada UK, and Novo Nordisk, and research support from AstraZeneca. These relationships are outside the scope of the present study. The remaining authors declare that they have no competing interests. Supplementary Files Additionalfile1.docx Additional file 1: KDIGO chronic kidney disease (CKD) risk heat map. Visual classification framework integrating estimated glomerular filtration rate (eGFR) and albuminuria categories to stratify CKD severity and risk of progression and adverse outcomes. Adapted from KDIGO clinical practice guidelines. Additionalfile2.docx Additional file 2: Patient, Public and Professional Involvement (PPPI) statement. Description of the rationale, design, conduct and impact of patient, public and professional involvement across study phases. Additionalfile3.docx Additional file 3: Participant characteristics (patients). Summary table describing demographic and clinical characteristics of patient participants included in the qualitative study. Additionalfile4.docx Additional file 4: Topic guides for qualitative data collection. Interview and focus group topic guides used with patients and professionals. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Apr, 2026 Reviews received at journal 30 Mar, 2026 Reviews received at journal 12 Mar, 2026 Reviewers agreed at journal 09 Mar, 2026 Reviewers agreed at journal 07 Mar, 2026 Reviewers agreed at journal 06 Mar, 2026 Reviewers invited by journal 05 Mar, 2026 Editor invited by journal 04 Mar, 2026 Editor assigned by journal 04 Mar, 2026 Submission checks completed at journal 04 Mar, 2026 First submitted to journal 03 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9021068","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603066634,"identity":"9154f216-a699-4e47-866a-781074f819a3","order_by":0,"name":"Buse Keskindag","email":"","orcid":"","institution":"University of Aberdeen","correspondingAuthor":false,"prefix":"","firstName":"Buse","middleName":"","lastName":"Keskindag","suffix":""},{"id":603066635,"identity":"078c5e41-72c2-4116-a26f-14a3bfb55b3a","order_by":1,"name":"Tom Blakeman","email":"","orcid":"","institution":"University of 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14:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9021068/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9021068/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104546599,"identity":"f77c0375-807a-4002-97d6-d699748ad53b","added_by":"auto","created_at":"2026-03-13 07:27:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4761647,"visible":true,"origin":"","legend":"\u003cp\u003eAnalytic representation of candidacy for early kidney care in areas of multiple deprivation.\u003c/p\u003e\n\u003cp\u003eThe figure illustrates how candidacy for kidney care is negotiated through organisational processes (blue pathways), from identification and sense-making to offers and responses, with non-linear movement that may involve revisiting earlier points. Processes are grouped for interpretive clarity as early¹, mid-process², and later responses³; these groupings are descriptive rather than sequential. Organisational processes are shaped by two cross-cutting influences –primary care operating conditions and structurally shaped socioeconomic precarity and health-related vulnerability experienced by patients – which contextualise candidacy across the pathway rather than constituting discrete steps.\u003c/p\u003e","description":"","filename":"KINDERfig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9021068/v1/7e0b8bf49f36c9af97b2b0fc.jpg"},{"id":105727700,"identity":"538623fe-f02f-49fd-961a-6684ffbb9e18","added_by":"auto","created_at":"2026-03-30 11:00:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6132054,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9021068/v1/275e0f67-2392-416e-8d89-575732d3c0c4.pdf"},{"id":104546633,"identity":"b42fb38d-90dd-4507-9504-8ad8a8a172af","added_by":"auto","created_at":"2026-03-13 07:27:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18911,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional file 1:\u003c/strong\u003e \u003cstrong\u003eKDIGO chronic kidney disease (CKD) risk heat map.\u003c/strong\u003e\u003cbr\u003e\nVisual classification framework integrating estimated glomerular filtration rate (eGFR) and albuminuria categories to stratify CKD severity and risk of progression and adverse outcomes. Adapted from KDIGO clinical practice guidelines.\u003c/p\u003e","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9021068/v1/0a8edb5a6d9e815d4cd59105.docx"},{"id":104546598,"identity":"a42775f6-ceab-4d91-8ed4-6eb543c0ec3c","added_by":"auto","created_at":"2026-03-13 07:27:01","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":34740,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional file 2:\u003c/strong\u003e \u003cstrong\u003ePatient, Public and Professional Involvement (PPPI) statement.\u003c/strong\u003e\u003cbr\u003e\nDescription of the rationale, design, conduct and impact of patient, public and professional involvement across study phases.\u003c/p\u003e","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-9021068/v1/9e6c4e8870cdfb14fb71a60d.docx"},{"id":104546592,"identity":"ba8e7363-d838-4bf7-b22b-7e2bf3f4758f","added_by":"auto","created_at":"2026-03-13 07:26:59","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":46364,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional file 3:\u003c/strong\u003e \u003cstrong\u003eParticipant characteristics (patients).\u003c/strong\u003e\u003cbr\u003e\nSummary table describing demographic and clinical characteristics of patient participants included in the qualitative study.\u003c/p\u003e","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-9021068/v1/e883614cffd719cfca9031f4.docx"},{"id":104546634,"identity":"b0f4b0bc-73df-47eb-a57c-fafb1ddc99da","added_by":"auto","created_at":"2026-03-13 07:27:06","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":45128,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional file 4:\u003c/strong\u003e \u003cstrong\u003eTopic guides for qualitative data collection.\u003c/strong\u003e\u003cbr\u003e\nInterview and focus group topic guides used with patients and professionals.\u003c/p\u003e","description":"","filename":"Additionalfile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-9021068/v1/c7ef5f6163c924642dee6a80.docx"}],"financialInterests":"Competing interest reported. TB is also funded by the NIHR Greater Manchester Patient Safety Research Collaboration (Grant NIHR204295). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health and Care Research, or the Department of Health and Social Care.\n\nSB has received consulting fees from AstraZeneca, GSK, Stada UK, and Novo Nordisk, and research support from AstraZeneca. These relationships are outside the scope of the present study.\n\nThe remaining authors declare that they have no competing interests.","formattedTitle":"“They are nae worrying about it… so …what’s the point in asking?”: a qualitative study of candidacy for early CKD care in areas of multiple deprivation","fulltext":[{"header":"Contributions to the Literature","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eText box 1. Contributions to the Literature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eProvides qualitative insight into how working-age adults and primary care professionals in deprived areas experience and negotiate early CKD care.\u003c/li\u003e\n \u003cli\u003eDemonstrates how primary care capacity constraints shape inequitable access to progression-preventing interventions.\u003c/li\u003e\n \u003cli\u003eShows how socioeconomic precarity interacts with workforce pressures to limit preventive continuity.\u003c/li\u003e\n \u003cli\u003eIdentifies \u0026ldquo;triple invisibility\u0026rdquo; (population-, system-, and symptom-level) as a mechanism weakening sustained engagement.\u003c/li\u003e\n \u003cli\u003eOffers direction for strengthening equitable prevention within universal primary care systems.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Background","content":"\u003cp\u003eInequities in health and healthcare are a major challenge in Scotland (United Kingdom; UK), which has among the lowest life expectancy in Western Europe and a widening gap between the most and least deprived areas over the last decade (Health Foundation, 2022). Within universal healthcare systems, primary care is the principal platform for population-level prevention. Increasing workload, workforce shortages and rising clinical complexity place strain on the NHS\u0026rsquo;s capacity to deliver preventive care, particularly for people with complex health and care needs (Baird et al., 2016; Hobbs et al., 2016; Fisher et al., 2024). Recent Scottish reforms aim to strengthen multidisciplinary support and data systems in primary care (Scottish Government, 2025; Scottish Government, 2023; ALLIANCE, 2025), yet these ambitions remain difficult to realise in routine practice. In high-workload settings, performance metrics that prioritise measurable targets over continuity and communication may further disadvantage deprived populations (RCGPS, 2024). In such contexts, chronic illness care strategies can inadvertently reinforce inequalities (Jefferson et al., 2022; Lowrie et al., 2017).\u003c/p\u003e\n\u003cp\u003eChronic kidney disease (CKD) affects around one in ten adults in the UK (KRUK, 2023), with substantial morbidity (Francis et al., 2024; Tuttle et al., 2019), and is projected to become the fifth leading cause of death globally by 2050 (GBD Chronic Kidney Disease Collaboration, 2020; Herrington et al., 2026). The international KDIGO classification system explicitly stratifies staging of CKD according to risks of all-cause mortality, cardiovascular events, and kidney-specific outcomes, including progression to kidney failure and acute kidney injury (AKI) (KDIGO, 2024). CKD staging integrates underlying cause with assessment of albuminuria and estimated glomerular filtration rate (eGFR), with monitoring and management guided by combined risk category (shown in Additional File 1). CKD is typically managed within multimorbidity care, including hypertension and diabetes (MacRae et al., 2021), with early detection and management focused on slowing disease progression and reducing cardiovascular risk in line with KDIGO guidance (KDIGO, 2024).\u003c/p\u003e\n\u003cp\u003eReduced kidney function (eGFR) or albuminuria may be present without symptoms and are usually detected only through blood or urine testing (KDIGO, 2024). Because the UK does not screen the general population, detection depends on risk-based or opportunistic monitoring in primary care, yet awareness remains low even where testing occurs (Francis et al., 2024). National guidance recommends regular kidney checks for people with diabetes, hypertension or cardiovascular disease, with abnormal results confirmed, staged and investigated (NICE, 2021). In practice, responsibilities vary across teams, and early abnormalities are not always clearly communicated or recorded, contributing to under-recognition (Daker-White et al., 2015). Nephrologists and CKD nurses typically become involved only when progression risk is high, including significant albuminuria, suspected renal disease, severely reduced kidney function (stage 4) or established kidney failure (stage 5) (NICE, 2021). Earlier stages, including mild to moderate kidney impairment, are usually managed entirely in primary care. Although effective risk-stratified pharmacological therapies (EMPA-KIDNEY Collaborative Group, 2022) and lifestyle interventions (Heiwe and Jacobson, 2011; Garofalo et al., 2018) exist, timely use depends not only on detection but on interpretation and clinical action. Together, these gaps shape who becomes aware of CKD early - and who does not - reproducing inequalities in access to early kidney care, defined here as the identification, communication and management of CKD in its earlier stages.\u003c/p\u003e\n\u003cp\u003eEvidence from Scotland shows that people in deprived areas experience higher burdens of multimorbidity, later CKD presentation (first identified at a stage requiring referral) and poorer outcomes, including earlier death (Sawhney et al., 2023; 2024; Cowan et al., 2025), reflecting structural limits on time, continuity and preventive engagement within primary care. Financial insecurity, limited transport and housing precarity further restrict illness recognition and the capacity to seek and sustain care (Sawhney et al., 2024). Yet little is known about how these conditions shape people\u0026rsquo;s entry into early kidney care and the interactions through which access is negotiated. Understanding how people\u0026rsquo;s circumstances shape their ability to seek and sustain kidney health is essential for designing interventions that reduce inequalities. The Action Plan for Scotland commits to reducing social and geographic inequalities in CKD through earlier detection and equitable monitoring (KRUK, 2024), but realising these aims requires understanding how candidacy for early care unfolds within constraints of time, continuity, trust and broader structural determinants (Marmot, 2010). Although treatment burden and organisational barriers have been described for older people with advanced CKD (Hounkpatin et al., 2020; Roberti et al., 2018), little is known about how working-age adults living in deprived areas experience early kidney care.\u003c/p\u003e\n\u003cp\u003eOne framework that helps explain how access is shaped by social and organisational conditions is the Candidacy Framework (Dixon-Woods et al., 2005). It has been applied in studies of chronic and clinically mediated conditions where symptom ambiguity and structural disadvantage influence how people come to be recognised - and to recognise themselves - as eligible for care (Koehn et al., 2024; Sinnott et al., 2024; Mackenzie, 2025). Early CKD care shares these characteristics: identification is typically incidental and clinically mediated rather than symptom-led, and opportunities for early engagement are constrained by socioeconomic and organisational pressures (Daker-White et al., 2015). The Candidacy Framework has therefore been used in this study to understand how early kidney care is accessed and navigated from the perspectives of working-age adults living in areas of multiple deprivation (i.e., disadvantage across income, employment and service access domains) in Scotland and the primary care professionals who support them.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eThis qualitative study, conducted between July 2024 and May 2025, explored experiences of early kidney care among working-age adults living with CKD and the primary-care professionals who support them in socioeconomically deprived areas of Scotland. Reporting followed the COREQ checklist (Tong et al., 2007) and was informed by a critical-realist orientation recognising the interplay of structure and agency (Haigh et al., 2019). The study was co-designed and conducted in partnership with patients, public contributors, and professionals, following GRIPP2 Short Form guidance (Staniszewska et al., 2017); full details are provided in Additional file 2.\u003c/p\u003e\n\u003ch2\u003eStudy sites\u003c/h2\u003e\n\u003cp\u003eParticipants were recruited across three Scottish health boards - NHS Grampian (north-east), NHS Fife (east), and NHS Greater Glasgow and Clyde (west) - selected to reflect geographical and socioeconomic variation in CKD service provision. Additionally, a Scotland-wide community/self-referral route was available, enabling eligible patients from beyond the three participating health boards to take part, which resulted in one participant from outside the three boards.\u003c/p\u003e\n\u003cp\u003eParticipant recruitment continued until information power was achieved to meet analytic depth (Malterud et al., 2016). Information power was considered across the study aim, sample specificity, quality of dialogue, theoretical engagement, and the analytic strategy employed, informing judgments about sample adequacy rather than relying on numerical thresholds (Malterud et al., 2016). A study is considered to have adequate information power when the sample is well aligned with the study aim, the participants have relevant experience, the data are of high quality, and the analytic approach allows for in-depth, reflexive interpretation. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePatients\u0026rsquo; eligibility and recruitment\u003c/h2\u003e\n\u003cp\u003eEligible patients were aged 18-65, aware of a chronic kidney disease (CKD) diagnosis or a sustained acute kidney injury (AKI) requiring ongoing kidney monitoring, confirmed by their GP records, and living within the most deprived 40% of neighbourhoods in Scotland (Scottish Index of Multiple Deprivation [SIMD] quintiles 1-2). Awareness of diagnosis was required to ensure meaningful engagement and to avoid inadvertent disclosure (Daker-White, 2015).\u003c/p\u003e\n\u003cp\u003eEligible patients were identified through medical record screening using routinely recorded diagnostic codes, age and postcode, and were invited via NHS Research Scotland (NRS) Primary Care Networks, nephrology clinics and community organisations. Most NHS participants were identified through primary care records. Recruitment was based on the most recent recorded CKD stage (or self-reported where records were unavailable); where NHS consent was provided, medical record extracts confirmed CKD stage and most recent estimated glomerular filtration rate (eGFR). Of 297 study invitations issued by post across the three boards (106 Greater Glasgow \u0026amp; Clyde, 56 Fife, 135 Grampian), 28 primary care patients participated. In secondary care, nephrology staff invited eligible patients during scheduled appointments; of 14 who expressed interest, nine took part. Community outreach through Kidney Research UK, the Grampian Kidney Patient Association and the Scottish Kidney Federation yielded 10 responses, with one meeting eligibility criteria and subsequently recruited. Approximately 12% of invited individuals participated. Rather than aiming for statistical representativeness, the sample provided contextual and experiential diversity across CKD stages, ages and socioeconomic backgrounds aligned with the study aims.\u003c/p\u003e\n\u003cp\u003eThirty-eight individuals (n = 38) living with kidney disease in socioeconomically deprived areas participated in the study. Of those with available postcode data, 27% resided in SIMD Quintile 1 and 64% in Quintile 2; an additional ~9% had deprivation status verified by the NRS Primary Care Network but not disclosed to the research team. Most participants were recruited from large urban areas, with a smaller number from accessible rural areas and small towns, reflecting the geographic distribution of the Scottish population.\u0026nbsp;Most participants had a stage 3 CKD diagnosis and, within this group, stage 3a (mild to moderate reduction in kidney function) was more common than stage 3b. Smaller numbers were at earlier stages of mild kidney function reduction or at more advanced stages of kidney function decline, and one participant had sustained an AKI. Nearly all participants reported multiple physical health comorbidities. Detailed participant characteristics are presented in Additional file 3.\u003c/p\u003e\n\u003cp\u003eProfessionals\u0026rsquo; eligibility and recruitment\u003c/p\u003e\n\u003cp\u003eEligible professionals were general practitioners, practice nurses, pharmacists, and reception/administrative staff working in practices serving socioeconomically deprived populations, including \u0026ldquo;Deep End\u0026rdquo; general practices (surgeries serving Scotland\u0026rsquo;s most disadvantaged communities). Professionals were invited via digital flyers distributed through NRS coordinators and practice networks. In total, 23 professionals participated (from 27 who expressed interest): 15 GPs, six practice nurses and two community pharmacists, spanning urban and rural contexts.\u003c/p\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003cp\u003eSemi-structured interviews and focus groups were conducted by trained and experienced qualitative researchers, primarily by BK, with two patient interviews conducted by MRD, using topic guides co-designed with patient and public partners, piloted and refined iteratively (Additional file 4). Patients took part in one-to-one, semi-structured interviews conducted by telephone (n=30), online (n=4), or in person on university premises (n=4), typically lasting 41-72 minutes. Professionals participated in online focus groups (four groups of three to four participants, ~90 minutes) or, where scheduling was difficult, one-to-one interviews (~60 minutes; n=9). Participants were offered interpreter support; one patient interview was conducted in a language other than English at the participant\u0026rsquo;s request by a bilingual interviewer. No additional non-English interviews were requested. Interviewers had no prior clinical relationship with participants. Participants were informed of the researchers\u0026rsquo; roles, study aims, and interest in understanding access to early kidney care in areas experiencing deprivation. All sessions were audio-recorded, professionally transcribed, anonymised, and accuracy-checked. Structured field notes captured contextual details, cross-site differences, and reflexive observations informing ongoing analysis. No repeat interviews were conducted.\u003c/p\u003e\n\u003cp\u003eAt the start of each patient interview, a brief questionnaire captured demographics (e.g. age, gender, postcode, employment) and kidney status at diagnosis and currently. For NHS-recruited participants, kidney health information was verified from medical records by NHS Research Scotland Primary Care Network coordinators and the recruiting nephrologist (or delegated clinician) and, with participants\u0026rsquo; consent, securely shared with the clinical team member or the project researcher. All clinical information shared with the research team was pseudo-anonymised and transferred via secure NHS channels.\u003c/p\u003e\n\u003cp\u003eTo reduce barriers to participation, all participants received easy-read study information and were offered a choice of written, online, or verbal consent covering participation, recording, and use of anonymised quotations. Patients received a \u0026pound;25 shopping voucher, and professionals were reimbursed \u0026pound;97 per hour (directly or via general practices), in line with NIHR payment guidance (National Institute for Health and Care Research, 2021) and ethical arguments for fair recognition under sustained workload pressure (Bower et al., 2009).\u003c/p\u003e\n\u003ch2\u003eResearcher reflexivity\u003c/h2\u003e\n\u003cp\u003eThe team brought complementary disciplinary and practice perspectives, including counselling psychology, general practice, nephrology, clinical epidemiology, health psychology and implementation research. During fortnightly analytic meetings, researchers presented new data extracts and emerging interpretations, which were discussed collectively with patient and public contributors and clinical team members to challenge assumptions and refine analytic decisions. These cross-disciplinary discussions supported sustained reflexivity, alongside memo-writing and explicit attention to researcher positionality throughout data collection and analysis. Additional one-to-one input from lived-experience contributors further strengthened interpretive rigour. Methodological oversight for use of the Candidacy Framework was provided by a medical sociologist.\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eTranscripts were analysed using reflexive thematic analysis (RTA) (Braun and Clarke, 2019) within a critical realist frame (Haigh et al., 2019). A critical realism approach recognises that phenomena such as access to care are shaped by underlying social structures, while being known through participants\u0026rsquo; lived accounts. It guided attention to both participants\u0026rsquo; experiences and the generative mechanisms influencing engagement with kidney care, allowing analysis to account for the interaction between individual circumstances and broader organisational and systemic contexts. RTA proceeded through six iterative phases: (1) familiarisation, (2) systematic inductive coding, (3) theme generation, (4) theme reviewing, (5) defining and naming themes, and (6) reporting (Braun and Clarke, 2019). This approach emphasises researcher reflexivity by recognising the active role of the researcher in knowledge production, prioritises analytic depth and interpretive richness over consensus between coders, and involves an iterative process of theme development in which themes are generated, reviewed, and refined through sustained engagement with the data rather than assessed through inter-rater reliability. Themes were developed inductively and subsequently interpreted through the domains of the Candidacy Framework (Dixon-Woods et al., 2005), which has been widely applied to theorise access to primary care (Sinnott et al., 2024). The Framework\u0026rsquo;s domains consist of seven overlapping stages representing candidacy for a health service. We developed an additional cross-cutting meta-theme (\u003cem\u003eprecarity shaping the conditions for early kidney care\u003c/em\u003e) rather than forcing a fit. Because early CKD is associated with non-specific symptoms and is often detected incidentally, identification was clinically mediated rather than patient-led, with sense-making occurring after disclosure and shaped by multimorbidity; candidacy domains are therefore presented in an empirically informed order\u0026nbsp;(Table 1). Detailed coding trees for both study subpopulations (patients and primary care professionals) are available in Additional file 5. NVivo (R1 2020) supported organisation; in line with RTA, we prioritised reflexive, dialogic sense-making over inter-rater reliability. Themes were built collaboratively with patient partners, checked across subgroups and negative cases, and documented in analytic memos and debriefs. Sampling sufficiency was assessed using the principle of information power (Malterud et al., 2016), based on the relevance, richness and diversity of data in relation to the study aim.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Definitions of candidacy domains in this study.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCandidacy domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 431px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIdentification and early sense-making of kidney disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 431px;\"\u003e\n \u003cp\u003eHow CKD is detected and initially interpreted as important or negligible within routine multimorbidity care, focusing on how patients and professionals recognise and make sense of kidney disease in everyday practice.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAppearing in services - primary care encounters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 431px;\"\u003e\n \u003cp\u003eHow kidney disease was communicated and voiced in clinical encounters, and how interactions shaped whether patients felt recognised, reassured, or dismissed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNavigating kidney disease-related care and support\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 431px;\"\u003e\n \u003cp\u003eThe practical work patients undertook to pursue kidney-related follow-up within primary care-led systems after identification - including arranging appointments, attending tests, and seeking practical or social support where needed to make care feasible.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePermeability of primary care healthcare services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 431px;\"\u003e\n \u003cp\u003eHow the design and organisation of general primary care services enabled or constrained access to kidney-related care, including appointment systems, administrative interfaces, digital routes, geography, and follow-up practices.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjudications of candidacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 431px;\"\u003e\n \u003cp\u003eHow professionals judged, prioritised, and acted on patients\u0026rsquo; eligibility or capacity for care in the context of multimorbidity and deprivation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOffers and resistance to kidney care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 431px;\"\u003e\n \u003cp\u003eHow offers of kidney care were made, interpreted, and taken up or deferred, shaped by trust, understanding, perceived relevance, and practical feasibility within constrained contexts.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperating conditions shaping candidacy in kidney care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 431px;\"\u003e\n \u003cp\u003eHow system-level contexts - including workload, resources, incentives, and policy - shaped the consistency, continuity, and responsiveness of kidney care, influencing who was prioritised and supported over time.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrecarity shaping the conditions for early kidney care\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 431px;\"\u003e\n \u003cp\u003eHow socioeconomic precarity and health-related vulnerability, shaped by structural conditions, influenced patients\u0026rsquo; capacity to engage with kidney care before and after diagnosis.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e\u0026yen;\u003c/sup\u003e a cross-cutting inductive meta-theme, reflecting experiences that extended beyond the seven candidacy domains.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFindings are presented in an empirically informed order that reflects how early kidney care unfolded in practice. The first six sections report how kidney disease was negotiated within primary care systems during its earlier phases, from detection and interpretation through access, professional decision-making, and responses to care. We begin with identification and early sense-making, as CKD was typically detected incidentally through routine primary care activity rather than through patient-led symptom recognition. We then report how kidney disease featured within primary care encounters, where its significance was negotiated amid multimorbidity and time-limited consultations, followed by navigation, capturing the work patients undertook to pursue kidney-related follow-up and support. Subsequent sections examine the permeability of primary care services, professional adjudications of candidacy - operating across identification and offers of care - and patients\u0026rsquo; responses to these offers as organisational processes. We conclude with two domains describing influences that shape these processes: operating conditions (NHS system-level influences) and socioeconomic precarity and health-related vulnerability, shaped by structural conditions, that influence patients\u0026rsquo; capacity to engage. Together, these contextualise candidacy across the pathway. An analytic representation of these processes is shown in Fig. 1.\u003c/p\u003e\n\u003ch2\u003eIdentification and early sense-making of kidney disease\u003c/h2\u003e\n\u003cp\u003ePrimary care professionals described CKD identification as largely opportunistic, emerging through routine blood tests rather than symptoms: \u0026ldquo;\u003cem\u003eWe get very, very few patients presenting acutely unwell with acute kidney injuries\u003c/em\u003e\u0026rdquo; (FG_2, GP). Detection typically occurred during reviews for other long-term conditions such as diabetes, hypertension, thyroid disorders, or pregnancy complications: \u0026ldquo;\u003cem\u003eThey were doing blood tests for another condition\u0026hellip; and that\u0026rsquo;s where the kidney function showed as being low\u003c/em\u003e\u0026rdquo; (PC05001). For patients, this often meant the diagnosis arrived unexpectedly, with limited understanding of why blood or urine tests had been undertaken or what the findings were intended to assess.\u003c/p\u003e\n\u003cp\u003eProfessionals viewed identification as both a technical and interpretive process. Some followed local renal protocols, while others referred to national guidance such as NICE or SIGN, noting that thresholds and calculators could be \u0026ldquo;\u003cem\u003enot very user-friendly\u003c/em\u003e\u0026rdquo; (FG_3, GP). Most described CKD as best integrated within existing multimorbidity reviews rather than through dedicated clinics: \u0026ldquo;\u003cem\u003eYou don\u0026rsquo;t need another whole clinic\u0026hellip; you maybe just need to add an ACR onto the bloods you are doing\u003c/em\u003e\u0026rdquo; (FG_4, GP). Others used practice audits, such as the \u0026ldquo;triple whammy\u0026rdquo; medication review, to prevent avoidable harm. These accounts positioned identification within routine chronic disease management rather than as a distinct event.\u003c/p\u003e\n\u003cp\u003eFor patients, identification was less about clinical detection and more about making sense of early, often non-specific (attributable to other co-existing health problems) or absent symptoms, resulting in kidney disease being experienced as \u0026lsquo;invisible\u0026rsquo;. Many lacked prior knowledge of kidneys or their function: \u0026ldquo;\u003cem\u003eI wasn\u0026rsquo;t very knowledgeable about kidney disease, so I didn\u0026rsquo;t really know what it meant\u003c/em\u003e\u0026rdquo; (C01001). Reactions ranged from shock and disbelief to mild concern or resignation. Some were startled that a chronic disease could be discovered incidentally: \u0026ldquo;\u003cem\u003eIt was a shock to the system because I had always thought I was fit and healthy\u003c/em\u003e\u0026rdquo; (C01001). Others accepted it with little alarm: \u0026ldquo;\u003cem\u003eIt does sit at the back of your mind\u0026hellip; but it\u0026rsquo;s not something I dwell on\u003c/em\u003e\u0026rdquo; (PC03022).\u003c/p\u003e\n\u003ch2\u003eAppearing in services - primary care encounters\u003c/h2\u003e\n\u003cp\u003eFirst conversations about kidney function were often led by practice nurses or pharmacists during reviews for other conditions, positioning them at the frontline of disclosure. CKD diagnosis was a key moment of appearance, marked by uncertainty about what the findings meant and whether further action was needed. Some patients were unsure if they had ever received a formal diagnosis: \u0026ldquo;\u003cem\u003eUp to date, my GPs etc have never been concerned I\u0026rsquo;m having problems with my kidneys\u0026hellip; nobody\u0026rsquo;s really said anything\u003c/em\u003e\u0026rdquo; (PC02026). Others only discovered their condition indirectly: \u0026ldquo;\u003cem\u003eThey told me because I was borderline for kidney disease\u0026hellip; that was the first time I knew anything about it\u003c/em\u003e\u0026rdquo; (PC01001). In some cases, the information was presented so casually that it did not register as significant: \u0026ldquo;\u003cem\u003eWhen I was told about this, it was made very little of\u0026hellip; I wouldn\u0026rsquo;t say I was given that impression at all\u003c/em\u003e\u0026rdquo; (PC05001).\u003c/p\u003e\n\u003cp\u003eThis uncertainty was reinforced by how kidney disease was positioned relative to other health priorities. Several patients and professionals described kidney disease as a secondary concern, overshadowed by other chronic conditions such as diabetes or hypertension. One patient participant reflected that \u0026ldquo;\u003cem\u003ethe kidneys have become a secondary thing... I was quite happy pedalling along\u003c/em\u003e\u0026rdquo; (PC2001), while clinicians often prioritised managing comorbidities first: \u0026ldquo;\u003cem\u003eIf they are coming for their annual hypertension review... they might not be aware of the CKD that they\u0026rsquo;ve got related to that\u003c/em\u003e\u0026rdquo; (FG_4, pharmacist). This framing reinforced uncertainty about the significance of CKD and contributed to patients interpreting silence or reassurance as a sign that nothing more needed to be done.\u003c/p\u003e\n\u003cp\u003eAgainst this background, the way results were communicated at this stage determined whether patients viewed themselves as needing further care or assumed nothing more was required. Some recalled being given medication without explanation - \u0026ldquo;\u003cem\u003eThey just palmed me off with medication\u003c/em\u003e\u0026rdquo; (PC01003) - while others described feeling confused and anxious as a result of not knowing what their results meant: \u0026ldquo;\u003cem\u003eThe kidney count\u0026hellip; is quite low\u0026hellip; once you hit 50 you hit a bit more serious waters\u0026hellip; nobody has discussed any of that with me\u003c/em\u003e\u0026rdquo; (PC05001). In time-pressured settings, clinicians tended to soften or abbreviate disclosure - \u0026ldquo;\u003cem\u003eThe kidneys are just getting a bit slower\u0026hellip;\u003c/em\u003e\u0026rdquo; (FG_2, GP) - while those with greater continuity favoured directness: \u0026ldquo;\u003cem\u003eMaybe I\u0026rsquo;ve made it a bit too reassuring\u0026hellip; maybe my letter should actually be saying, \u0026lsquo;You really need to look after yourself!\u003c/em\u003e\u0026rsquo;\u0026rdquo; (FG_3, GP). These differing approaches influenced how candidacy was voiced and heard, often leaving patients uncertain about whether they truly had a diagnosis, how serious it was, and what, if anything, they should do next. Emotional responses ranged from passive trust to frustration and anxiety: \u0026ldquo;\u003cem\u003eI kind of feel angry\u0026hellip; I don\u0026rsquo;t know really what else I can say about it; it\u0026rsquo;s just the whole information - no support, no nothing\u003c/em\u003e\u0026rdquo; (PC01001).\u003c/p\u003e\n\u003cp\u003eUncertainty and reassurance also shaped how patients engaged with services afterwards. For some, reassurance discouraged further enquiry: \u0026ldquo;\u003cem\u003eThey are nae worrying about it\u0026hellip; so I just think, well what\u0026rsquo;s the point in asking?\u003c/em\u003e\u0026rdquo; (PC02057). Others recognised their own hesitation: \u0026ldquo;\u003cem\u003eI haven\u0026rsquo;t really had it explained to me\u0026hellip; but to be honest, that\u0026rsquo;s partly my problem, I haven\u0026rsquo;t really asked enough\u003c/em\u003e\u0026rdquo; (PC04002). Information was often contingent on active questioning: \u0026ldquo;\u003cem\u003eIf I hadn\u0026rsquo;t asked what it [a blood test] was for, I wouldn\u0026rsquo;t have been told\u003c/em\u003e\u0026rdquo; (PC03001). For some, more detail encouraged self-management - \u0026ldquo;If I get that wee bit more information, then I can make adjustments\u0026rdquo; (PC06023). Professionals linked these patterns to social context. In deprived areas, patients were perceived as less likely to attend and more likely to present late: \u0026ldquo;\u003cem\u003eThese patients with poor socioeconomic status\u0026hellip; they\u0026rsquo;ll also have all of the comorbidities\u0026hellip; so your non-attenders will go higher\u003c/em\u003e\u0026rdquo; (FG_2, GP). Engagement was often framed as personal responsibility: \u0026ldquo;\u003cem\u003eThey do get another recall\u0026hellip; but we don\u0026rsquo;t go about texting and saying they have not come\u003c/em\u003e\u0026rdquo; (FG_3, GP). Several professionals expressed frustration at these limits: \u0026ldquo;\u003cem\u003eWe can only educate and invite them in as much as we can\u0026hellip; apart from going to their door and dragging them in, I\u0026rsquo;m not really too sure what else you can do\u003c/em\u003e\u0026rdquo; (FG_2, GP).\u003c/p\u003e\n\u003ch2\u003eNavigating kidney disease-related care and support\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNavigating kidney-disease-related care was often contingent not only on clinical need but on the practical and social resources available to patients. Some struggled with the cost of even basic travel: \u0026ldquo;\u003cem\u003eI don\u0026rsquo;t drive or anything like that, so I usually just walk or I get the bus. I can\u0026rsquo;t afford to travel by bus, I normally just have to walk\u003c/em\u003e\u0026rdquo; (PC01002). Others relied on friends or careful budgeting: \u0026ldquo;\u003cem\u003eMy friend drives me about, so it makes it easier\u003c/em\u003e\u0026rdquo; (PC02060); \u0026ldquo;\u003cem\u003eAppointments are made a month in advance, so that gives me enough time to leave money aside\u003c/em\u003e\u0026rdquo; (PC0234). Attending appointments could itself be costly and difficult: \u0026ldquo;\u003cem\u003eI dinna hae [don\u0026rsquo;t have] the money to put petrol in\u003c/em\u003e.\u0026rdquo; (PC02057). For those in work, appointments and blood tests required trade-offs: \u0026ldquo;\u003cem\u003eI may need to take time off\u0026hellip; that means I either lose pay or annual leave\u003c/em\u003e\u0026rdquo; (PC01001), though some had more support: \u003cem\u003e\u0026ldquo;I\u0026rsquo;m very grateful\u0026hellip; they are aware that I\u0026rsquo;m likely to be absent from work\u003c/em\u003e\u0026rdquo; (CO01001). Patients also described variation in practical and emotional support around appointments. Some prepared in advance and brought a relative: \u0026ldquo;\u003cem\u003eI normally write doon whit [down what] I want to ask\u0026hellip; I like [my daughter] to be there\u003c/em\u003e\u0026rdquo; (PC0234). Others went alone: \u0026ldquo;\u003cem\u003eUsually on my own\u0026hellip; I don\u0026rsquo;t think I ever have [had anyone with me]\u003c/em\u003e\u0026rdquo; (PC01001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinancial strain compounded the difficulties of navigating care. \u0026ldquo;\u003cem\u003eThe benefits I get, it\u0026rsquo;s never enough to get me by a whole month\u0026hellip; I have to budget a lot\u003c/em\u003e\u0026rdquo; (SC01005). For some, deprivation was severe: \u0026ldquo;\u003cem\u003eI\u0026rsquo;m only living off ten pound a month\u0026hellip; I have to go down to the foodbanks. They give me salty foods, so I have no option but to eat them\u003c/em\u003e\u0026rdquo; (PC01002). Applications for welfare benefits were described as emotionally draining and often unsuccessful, with patients doubting whether kidney disease even qualified as a disability: \u0026ldquo;\u003cem\u003eKidney disease doesn\u0026rsquo;t fall into that [disability] category\u003c/em\u003e\u0026rdquo; (PC01002). Professionals observed how poverty directly undermined medical advice: \u0026ldquo;\u003cem\u003eHe eats what is given [by the foodbank]\u0026hellip; tinned food that\u0026rsquo;s sugar-laden, salt-laden\u003c/em\u003e\u0026rdquo; (HCP0201, GP). Healthcare professionals also reflected that people living in deprived circumstances often faced complex social and health problems that outweighed kidney care priorities: \u0026ldquo;\u003cem\u003eSo if I was to ask them what was important to them, managing their chronic kidney disease is probably not even on the radar\u003c/em\u003e\u0026rdquo; (FG_4, pharmacist).\u003c/p\u003e\n\u003cp\u003eConfidence in navigating health systems reflected how clearly information was provided and understood. Some experienced referrals as abrupt or poorly explained: \u0026ldquo;\u003cem\u003eI think I was just referred\u0026hellip; it just happened\u003c/em\u003e\u0026rdquo; (SC01005). Patients under hospital follow-up reported clearer pathways: \u0026ldquo;\u003cem\u003eI call 111\u0026hellip; If they advise me go to the hospital\u0026hellip; I do that\u003c/em\u003e\u0026rdquo; (SC01002). Those managed mainly in primary care were more hesitant, contacting the GP only if symptoms were present or burdensome: \u0026ldquo;\u003cem\u003eI wouldn\u0026rsquo;t be phoning the doctor just to discuss the fact that I\u0026rsquo;m feeling anxious\u003c/em\u003e\u0026rdquo; (PC010013). In the absence of guidance, some turned to the internet and felt overwhelmed: \u0026ldquo;\u003cem\u003eYou start the information gathering process and quickly learn\u0026hellip; you don\u0026rsquo;t know what is actually right or wrong\u003c/em\u003e\u0026rdquo; (PC03022). Professionals recognised these barriers, noting inconsistent information provision. Leaflets remained the default, particularly for people who did not go online: \u0026ldquo;\u003cem\u003eA lot of our patients don\u0026rsquo;t go online\u0026hellip; they prefer written things\u003c/em\u003e\u0026rdquo; (FG_1, GP). Yet CKD-specific resources were scarce: \u0026ldquo;\u003cem\u003eWe have lots of leaflets on diabetes\u0026hellip; but I don\u0026rsquo;t think we do have any [for kidneys]\u003c/em\u003e\u0026rdquo; (FG_3, nurse). Long, generic leaflets were considered unhelpful (FG_2, GP). NHS websites were sometimes signposted, but professionals doubted their reach: \u0026ldquo;\u003cem\u003eThere might be stuff online\u0026hellip; but I don\u0026rsquo;t know\u0026hellip; there\u0026rsquo;s certainly a massive lack of awareness\u003c/em\u003e\u0026rdquo; (FG_2, GP). In multilingual contexts, reliance on interpreters was routine: \u0026ldquo;\u003cem\u003eMost of the patients that come in will come in with some sort of interpreter\u0026hellip; or we just have one in-house on the phones, so we have adapted\u003c/em\u003e\u0026rdquo; (FG_2, GP).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcross accounts, the availability of structured psychosocial and wider support - such as link workers or social prescribing - was uneven. Rural general practices sometimes reported more consistent access than urban ones, where waiting times were longer and eligibility was narrower. Some patients were unsure what help existed: \u0026ldquo;\u003cem\u003eJust help with taxi fares or a transport pick-up\u0026hellip; I\u0026rsquo;m not sure if it happens here\u003c/em\u003e\u0026rdquo; (PC0234). Others drew on charities or peer groups for advice and connection: \u0026ldquo;\u003cem\u003eI was made aware of a couple of charities\u0026hellip; that were quite good for insights and support groups\u003c/em\u003e\u0026rdquo; (SC01002); \u0026ldquo;\u003cem\u003eThere\u0026rsquo;s a community there\u0026hellip; people going through similar things that I can ask\u003c/em\u003e\u0026rdquo; (CO01001). Clinicians recognised the contribution of third-sector organisations but found them difficult to keep track of: \u0026ldquo;\u003cem\u003eThere are wonderful third-sector organisations\u0026hellip; but it\u0026rsquo;s very hard to keep your finger on the pulse\u0026hellip; funding changes, times change\u003c/em\u003e\u0026rdquo; (HCP0101, GP). For underserved groups, the challenge was not only whether services existed but whether they were reachable in practice: \u0026ldquo;\u003cem\u003eHow do they get that education\u0026hellip; or even be able to access it?\u003c/em\u003e\u0026rdquo; (FG_2, nurse).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePermeability of primary care healthcare services\u003c/h2\u003e\n\u003cp\u003eBecause early CKD care is largely delivered through routine primary care rather than specialist renal services, the permeability of general primary care systems strongly shaped how participants accessed and experienced kidney-related care. For many patients, getting an appointment felt difficult unless initiated by the practice: \u0026ldquo;\u003cem\u003eTo get an appointment on your own is very difficult\u0026hellip; but if they want you down for something, they\u0026rsquo;ll fit you in\u003c/em\u003e\u0026rdquo; (PC03001). Rigid scheduling often clashed with everyday life. One patient working in childcare explained: \u0026ldquo;\u003cem\u003eI work in a nursery and we are asked\u0026hellip; that we try and pick times that are outwith school hours, which is not always easy\u003c/em\u003e\u0026rdquo; (PC010013). By contrast, blood test appointments with nurses were described as easier: \u0026ldquo;\u003cem\u003eIt is relatively easy to book an appointment\u0026hellip; to see the nurse\u003c/em\u003e\u0026rdquo; (PC03022). Professionals confirmed that service design and timing shaped who could attend. Annual health checks were hard to fit around work: \u0026ldquo;\u003cem\u003eThey find it hard in practice because of the inflexibility around opening times\u003c/em\u003e\u0026rdquo; (FG_4, pharmacist). Others expected same-day access and were frustrated by the limited number of urgent slots: \u0026ldquo;\u003cem\u003eIf you\u0026rsquo;re not well, you expect an appointment\u0026hellip; there is often a mismatch between patient expectation and what is available\u003c/em\u003e\u0026rdquo; (HCP0201, GP).\u003c/p\u003e\n\u003cp\u003eThe medical reception interface was a consistent point of tension. Patients disliked sharing sensitive details with non-clinical staff: \u0026ldquo;\u003cem\u003eFit [what] I find quite disillusionin\u0026rsquo; [disillusioning] is when you phone up and the receptionist wants to ken yer life [know everything about your problem]\u0026hellip; I\u0026rsquo;ll tell the doctor what\u0026rsquo;s wrong with me\u0026hellip; but I\u0026rsquo;m nae tellin [I\u0026rsquo;m not telling you] you because you\u0026rsquo;re the receptionist\u003c/em\u003e\u0026rdquo; (PC02001). Professionals also described reception staff as gatekeepers, with practices experimenting with re-labelling the role as \u0026ldquo;\u003cem\u003ecare co-ordinator\u003c/em\u003e\u0026rdquo; (HCP0401, nurse). Access was further shaped by housing and digital precarity. Frequent house moves or neighbourhood instability meant appointment letters sometimes never arrived: \u0026ldquo;\u003cem\u003ePeople sometimes move house quite a lot\u0026hellip; their mail goes missing\u0026hellip; they might not be at that house because they\u0026rsquo;ve moved\u003c/em\u003e\u0026rdquo; (HCP1301, GP). Text-based reminders helped some, but for others, access was as fragile as a phone top-up: \u0026ldquo;\u003cem\u003eThey might not be able to receive the text message because they\u0026rsquo;ve ran out of credits that week\u0026hellip; they don\u0026rsquo;t have any money on their phone\u003c/em\u003e\u0026rdquo; (HCP1301, GP).\u003c/p\u003e\n\u003cp\u003eGeography and infrastructure also influenced permeability. Accounts from both patients and professionals illustrated how access was uneven and continually negotiated. Some living in small villages reported easy access: \u0026ldquo;\u003cem\u003eMy doctor\u0026rsquo;s surgery\u0026hellip; answer very, very quickly. I think it\u0026rsquo;s because it\u0026rsquo;s a very small village - we are really lucky\u003c/em\u003e\u0026rdquo; (PC03001). Others in rural areas described physical and communication barriers: \u0026ldquo;\u003cem\u003eWe get flooded roads, and sometimes we just don\u0026rsquo;t get our letters\u0026hellip; it would be a nuisance if I received a letter late and had missed it through no fault of my own\u003c/em\u003e\u0026rdquo; (SC01002). Clinicians echoed this, noting patient resistance when asked to travel to off-site hubs: \u0026ldquo;\u003cem\u003eYou\u0026rsquo;re essentially telling them\u0026hellip; \u0026lsquo;Up you go to xxx or down you go into the centre of town\u0026rsquo;\u0026hellip; they\u0026rsquo;re like, \u0026lsquo;Well, I\u0026rsquo;m at a GP because I\u0026rsquo;m in a zone. Why are you moving me out of zone?\u003c/em\u003e\u0026rsquo;\u0026rdquo; (FG_3, GP). In these cases, what appeared to be small system efficiencies often created new barriers for those already managing complex lives. When patients did not attend, clinicians described a spectrum of follow-up work, from multiple calls and texts to, in high-risk cases, police welfare checks: \u0026ldquo;\u003cem\u003eIf it\u0026rsquo;s a high-risk patient, then we\u0026rsquo;ll often go an extra mile to track them down\u0026hellip; might even get the police to go and see them\u003c/em\u003e\u0026rdquo; (FG_1, GP). Small rural surgeries were sometimes able to respond more flexibly, while inner-city practices struggled under stretched appointment systems.\u003c/p\u003e\n\u003ch2\u003eAdjudications of candidacy by health professionals\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWhat mattered most to patients in professionals\u0026rsquo; adjudications was being listened to, taken seriously, and given clear explanations - qualities most often experienced in hospital-based nephrology clinics. These settings allowed longer more conversational appointments where professionals validated concerns and offered reassurance: \u0026ldquo;\u003cem\u003eThe doctor asks me open-ended questions and gives me the chance to explain how I\u0026rsquo;m feeling\u003c/em\u003e\u0026rdquo; (CO01001). Early reassurance and proactive action strengthened confidence: \u0026ldquo;\u003cem\u003eHe automatically went to speak to a professional in the kidney field\u003c/em\u003e\u0026rdquo; (PC01003). Clear explanations and reliable follow-up further reinforced trust: \u0026ldquo;\u003cem\u003eMy consultant will explain\u0026hellip; then I\u0026rsquo;ll get a letter and a full explanation in the post\u003c/em\u003e\u0026rdquo; (CO01001). Even small acts of explanation mattered: \u0026ldquo;\u003cem\u003eRather than just saying your kidney function is X\u0026hellip; reassure that there are support tools out there\u003c/em\u003e\u0026rdquo; (CO01001). By contrast, these qualities were often missing in primary care, where short appointments limited discussion and left patients uncertain: \u0026ldquo;\u003cem\u003eI just really wished the GP\u0026hellip; if they\u0026rsquo;d maybe explained what it was that was raised and how it can affect my bodily function\u003c/em\u003e\u0026rdquo; (PC03001).\u003c/p\u003e\n\u003cp\u003eOthers described encounters that felt cursory or alienating, particularly for those without the perceived literacy, confidence or support to question judgements. Some experienced care as \u0026ldquo;\u003cem\u003ea box-ticking exercise\u0026hellip; I couldn\u0026rsquo;t ask any questions\u003c/em\u003e\u0026rdquo; (CO01001). For patients with multimorbidity or mobility challenges, time-limited appointments in general practices amplified barriers: \u0026ldquo;\u003cem\u003eBy the time I get to the room\u0026hellip; it\u0026rsquo;s time for me to leave\u003c/em\u003e\u0026rdquo; (PC04053). Blunt communication, even when accurate, could feel distancing: \u0026ldquo;\u003cem\u003eThe doctor said to me that, yeah, he would expect the kidney function that he\u0026rsquo;d seen in my test results, would expect a seventy-year-old man to have those results. I felt like that was quite blunt\u003c/em\u003e\u0026rdquo; (CO01001). Others reported little or no explanation: \u0026ldquo;\u003cem\u003eI just need somebody to explain what\u0026rsquo;s wrong with me\u0026hellip; plus advice on how to delay this kidney infection or whatever it is\u003c/em\u003e\u0026rdquo; (PC01001). \u003cstrong\u003eSilence was often interpreted as inaction: \u0026ldquo;\u003cem\u003eIf there was something that could be done about it, they would have said something\u003c/em\u003e\u0026rdquo; (PC03018), implying that recognition frequently occurred only once the disease had already progressed.\u003c/strong\u003e For some, silence itself became a judgement, interpreted as a quiet signal that nothing more could be offered: \u0026ldquo;\u003cem\u003eIf there was something that could be done about it, they would have said something\u003c/em\u003e\u0026rdquo; (PC03018).\u003c/p\u003e\n\u003cp\u003eWhile for patients, adjudication was about tone, explanation and respect shaping their sense of being taken seriously, professionals described it as more about judging what patients could realistically manage in the context of deprivation, multimorbidity and difficult life circumstances. In these settings, clinicians often took on more of the follow-up work themselves, anticipating that patients might struggle to do so. As one GP explained: \u0026ldquo;\u003cem\u003eYou won\u0026rsquo;t leave it with the patient to follow something up\u0026hellip; a lot of the time you\u0026rsquo;ll anticipate that and be a bit proactive at our end\u0026hellip; you try to put more nets in place for the patient\u003c/em\u003e\u0026rdquo; (FG_1, GP). Instead of expecting patients to self-manage, practices phoned repeatedly, wrote extra instructions on prescriptions, or involved carers and pharmacists. \u0026ldquo;\u003cem\u003eThey can\u0026rsquo;t differentiate\u0026hellip; they wouldn\u0026rsquo;t be able to tell you the difference between a lot of their medications\u003c/em\u003e\u0026rdquo; (FG_1, GP). \u0026ldquo;\u003cem\u003eIt always takes a bit of detective work\u003c/em\u003e,\u0026rdquo; another GP shared, describing a patient whose care was coordinated closely with his wife; when no carer was present, things were \u0026ldquo;\u003cem\u003emuch more chaotic\u003c/em\u003e\u0026rdquo; (FG_1, GP). In some accounts, better-resourced teams were described as having scope for proactive recall and tailored plans, whereas in thinner systems, more responsibility appeared to rest with patients.\u003c/p\u003e\n\u003cp\u003eThese adjudications also extended to lifestyle change. Professionals recognised the impact of deprivation and sought to provide personalised care that prioritised patient needs. They also acknowledged that some patients might achieve little change due to complex social and health circumstances. Clinicians contrasted the generic, instruction-based approach often used in routine reviews with more responsive, motivational conversations: \u003cem\u003e\u0026ldquo;You don\u0026rsquo;t want to be doing everything at once\u0026hellip; but maybe have a conversation about, \u0026lsquo;If there\u0026rsquo;s one thing you could change\u0026hellip; what would it be?\u0026rsquo;\u003c/em\u003e\u0026rdquo; (FG_3, GP). Even small gains were treated as meaningful: \u0026ldquo;\u003cem\u003eJust getting the weight down by a couple of kilos\u0026hellip; that\u0026rsquo;s a success\u003c/em\u003e\u0026rdquo; (FG_3, practice nurse). Yet CKD was seen as harder to adjudicate than diabetes or hypertension because there was little visible improvement to offer. As one GP put it, \u0026ldquo;\u003cem\u003eYou have to make these changes not for positive improvement, but just to make things less bad\u003c/em\u003e\u0026rdquo; (FG_2, GP). Another described the difficulty of patient expectations: \u0026ldquo;\u003cem\u003eWhat can I do about that, doctor?\u003c/em\u003e\u0026rdquo; to which the honest but unsatisfying reply was, \u0026ldquo;\u003cem\u003eKeep taking those pills\u0026hellip; and hope for the best\u003c/em\u003e\u0026rdquo; (FG_2, GP). Where continuity allowed, clinicians described more scope to revisit, calibrate, and encourage.\u003c/p\u003e\n\u003ch2\u003eOffers and resistance to kidney care\u003c/h2\u003e\n\u003cp\u003eIn primary care, patient participants reported experiencing routine kidney monitoring as a formality rather than meaningful care. Annual reviews were described as administrative obligations, detached from everyday life with a long-term condition. \u0026ldquo;\u003cem\u003eEvery time you go\u0026hellip; you have to bring a urine sample\u0026hellip; I don\u0026rsquo;t think I\u0026rsquo;ve received any [kidney] care for anything like that\u003c/em\u003e\u0026rdquo; (PC02035). Others wanted more dialogue: \u0026ldquo;\u003cem\u003eI just think it needs to be a little bit more personalised\u0026hellip; there\u0026rsquo;s no real chat with a doctor unless you are ill-ill\u003c/em\u003e\u0026rdquo; (PC010013). Professionals confirmed that offers of care were not fixed but shaped locally. Some practices held back appointment slots for working patients or those who struggled to get through on the day: \u0026ldquo;\u003cem\u003ePatients can pre-book appointments, but we try and reserve those for people who are working or who have got a genuine reason why they couldn\u0026rsquo;t phone on the day\u003c/em\u003e\u0026rdquo; (HCP0101, GP). For patients with complex needs, double appointments were offered informally: \u0026ldquo;\u003cem\u003eAnyone that is vulnerable or has a lot going on, we give them double appointments\u003c/em\u003e\u0026rdquo; (HCP0101, GP). Such offers depended on local knowledge and staff discretion rather than formal policy, and patients noticed the difference between places where such flexibility existed and places where it did not.\u003c/p\u003e\n\u003cp\u003eCommunication of results revealed further contrasts. Patients in renal clinics reported clear explanation and choice: \u0026ldquo;\u003cem\u003eThey\u0026rsquo;ve always explained it to me\u0026hellip; they ask you if you\u0026rsquo;d like to know\u003c/em\u003e\u0026rdquo; (SC01002). In primary care, results were described as opaque or delegated: \u0026ldquo;\u003cem\u003eThey just said that this level is slightly off\u0026hellip; there\u0026rsquo;s been no conversation about it\u003c/em\u003e\u0026rdquo; (PC03001). Being asked to call reception was a source of frustration: \u0026ldquo;\u003cem\u003eWhy on earth am I phoning you for results? Surely somebody medically qualified should be answering the questions\u003c/em\u003e\u0026rdquo; (PC02051). Professionals acknowledged these problems and described informal workarounds. One nurse annotated blood results with ranges and CKD stages to support understanding: \u0026ldquo;\u003cem\u003eI write next to it what the normals are\u0026hellip; and the stages of it\u003c/em\u003e\u0026rdquo; (HCP0401, practice nurse). She sometimes offered her email to patients who found it hard to get through by phone. \u0026ldquo;\u003cem\u003eTrying to get through to us can be quite difficult\u0026hellip; so they can always e-mail in\u003c/em\u003e\u0026rdquo; (HCP0401, practice nurse). These adjustments made care more tangible, but they were piecemeal and dependent on individual initiative; in teams with fewer staff or higher turnover, such extras were harder to sustain.\u003c/p\u003e\n\u003cp\u003eSelf-management support was another point where offers and resistance emerged in primary care. Patients often felt guidance was lacking: \u003cem\u003e\u0026ldquo;They\u0026rsquo;ve never told me anything like that. \u0026lsquo;You shouldn\u0026rsquo;t drink that or you shouldn\u0026rsquo;t eat that\u0026rsquo;\u0026hellip; they\u0026rsquo;ve never discussed anything like that with me\u0026rdquo;\u0026nbsp;\u003c/em\u003e(PC02057). Others valued written resources as something to return to after consultations: \u003cem\u003e\u0026ldquo;You leave, and that\u0026rsquo;s when you\u0026rsquo;ve got all the questions\u0026hellip; having something you can read at your leisure is a definite plus\u0026rdquo;\u003c/em\u003e (PC01003). Yet for those with limited literacy, written materials were of little use: \u0026ldquo;\u003cem\u003eIt\u0026rsquo;s more difficult for me to read by myself and not fully understand\u0026hellip; there\u0026rsquo;s no one to ask what it\u0026rsquo;s talking about\u0026rdquo;\u003c/em\u003e (SC01005). Professionals described repeatedly revisiting lifestyle advice in the hope of catching patients at the right moment: \u0026ldquo;\u003cem\u003eWe re-broach everything\u0026hellip; just trying to engage people\u0026rdquo;\u003c/em\u003e (FG_3, practice nurse). Disclosure also varied with context. \u003cem\u003e\u0026ldquo;They\u0026rsquo;ve been at the GP, not necessarily told the truth, and then they come to the nurse and it all comes out\u0026rdquo;\u003c/em\u003e (FG_3, practice nurse). Where continuity and nurse-led reviews were stable, patients described more usable offers; where staffing and access were less stable, offers were thinner and resistance seemingly greater.\u003c/p\u003e\n\u003cp\u003eContinuity was a persistent concern for patients who described seeing different GPs at each visit: \u0026ldquo;\u003cem\u003eEvery time you go it\u0026rsquo;s some different doctor\u0026hellip; you\u0026rsquo;ve got to go through the same story every time\u003c/em\u003e\u0026rdquo; (PC2005). Fragmentation disrupted trust and sometimes created risk: \u0026ldquo;The antibiotics that I was given aren\u0026rsquo;t safe for kidneys\u0026hellip; they actually cause more damage\u0026rdquo; (PC01002). Missed follow-up compounded this: \u0026ldquo;\u003cem\u003e\u0026rsquo;You\u0026rsquo;ve got high levels of protein\u0026rsquo;\u0026hellip; and to be honest, I\u0026rsquo;ve not heard anything since\u003c/em\u003e\u0026rdquo; (PC02026). Some responded with withdrawal: \u0026ldquo;\u003cem\u003eI\u0026rsquo;ve got so little faith in my GP\u0026hellip; to go back just feels slightly pointless\u003c/em\u003e\u0026rdquo; (PC05001). Professionals acknowledged the unevenness of recall and management of missingness: \u0026ldquo;\u003cem\u003eEvery practice does it slightly differently\u0026hellip; sometimes nothing happens, they just get invited again the following year\u003c/em\u003e\u0026rdquo; (FG_4, GP). Pharmacists sometimes picked up gaps in reviews or used prescriptions to encourage attendance by providing a limited supply of medication: \u0026ldquo;\u003cem\u003eI\u0026rsquo;ll reauthorise it so they can get six months\u0026rsquo; worth\u0026hellip; and then after that I really do need them to attend for bloods\u003c/em\u003e\u0026rdquo; (FG_4, pharmacist). In some health boards, these systems were reportedly more consistent; elsewhere, they relied on individual clinicians and workarounds.\u003c/p\u003e\n\u003cp\u003eDespite frustration and withdrawal, many patients continued to engage with their care through routine monitoring, medication and lifestyle adjustments. \u0026ldquo;\u003cem\u003eI have to get a check\u0026hellip; to continue giving me my prescription\u003c/em\u003e\u0026rdquo; (PC03001). \u0026ldquo;\u003cem\u003eI look for a really healthy diet now\u0026hellip; that\u0026rsquo;s all I\u0026rsquo;m really doing\u003c/em\u003e\u0026rdquo; (PC01001). \u0026ldquo;\u003cem\u003eMy morning always starts off with tablets\u0026hellip; they\u0026rsquo;re trying to control my blood pressure to control the kidney function\u003c/em\u003e\u0026rdquo; (CO01001). Yet professionals also noted that some patients resisted offers, not from disinterest but from concern about legitimacy: \u0026ldquo;\u003cem\u003ePeople don\u0026rsquo;t like to bother doctors or their practice unless they feel really unwell\u0026hellip; I hear that all the time: \u0026lsquo;I didn\u0026rsquo;t want to bother you because I know how busy you are. It didn\u0026rsquo;t seem important, I feel okay\u003c/em\u003e\u0026rsquo;\u0026rdquo; (HCP1301, GP). Professionals also highlighted that transportation difficulties and financial constraints often act as barriers to patient engagement: \u0026ldquo;\u003cem\u003eWe\u0026rsquo;ve got patients in our practice who can\u0026rsquo;t afford the bus to come down\u0026hellip; they can\u0026rsquo;t afford the taxi\u003c/em\u003e\u0026rdquo; (FG_2, GP). Accounts also hinted at variation, with some participants describing steadier staffing and clearer recall as enabling engagement, while in stretched urban practices, others spoke of holding back, judging their needs did not warrant taking up scarce slots.\u003c/p\u003e\n\u003ch2\u003eOperating conditions shaping candidacy in kidney care\u003c/h2\u003e\n\u003cp\u003eFor patients living with CKD in areas of deprivation, access to care was shaped not only by their own efforts but by the conditions under which services operated - the timing of appointments, the availability of staff, and the responsiveness of follow-up. Routine monitoring in primary care was often experienced as procedural, with responsibility for contact left unclear: \u0026ldquo;\u003cem\u003eI wasn\u0026rsquo;t given any kind of information on who I can go to\u003c/em\u003e\u0026rdquo; (PC01002). Appointments were often too short to allow meaningful dialogue, with participants expressing a preference for longer consultations: \u0026ldquo;\u003cem\u003eA twenty-minute appointment\u0026hellip; so that you\u0026rsquo;ve got time to ask questions\u003c/em\u003e\u0026rdquo; (PC01001). Others described struggling to secure face-to-face consultations: \u0026ldquo;\u003cem\u003eThey won\u0026rsquo;t actually physically see you\u003c/em\u003e\u0026rdquo; (PC01001). Patients often acknowledged system pressures - \u0026ldquo;\u003cem\u003eThey are probably requiring more staff, extra resources\u003c/em\u003e\u0026rdquo; (PC04001) - but recognition of strain did not reduce the frustration of inaccessibility. Still, not all encounters were negative. Pharmacists were seen as approachable and responsive: \u0026ldquo;\u003cem\u003eThe pharmacist is really good\u0026hellip; she will come and speak to you\u003c/em\u003e\u0026rdquo; (PC01001). National policy also mattered. The removal of prescription charges was described not just as convenience but as an enabler of adherence: \u0026ldquo;\u003cem\u003eSince the government made prescriptions free\u0026hellip; that doesn\u0026rsquo;t affect me getting my medication at all\u003c/em\u003e\u0026rdquo; (PC02005). For others, digital tools were helpful: \u0026ldquo;We\u0026rsquo;re very lucky\u0026hellip; they do respond within a day to this form\u0026rdquo; (PC03001). Automated text reminders were welcomed by one interviewee: \u0026ldquo;\u003cem\u003eThey give me a text two days beforehand\u003c/em\u003e\u0026rdquo; (PC0234). Some contrasted inner-city practices as harder to access than smaller rural surgeries, hinting at how local context shaped follow-up.\u003c/p\u003e\n\u003cp\u003eHealthcare professionals described the same conditions from the vantage point of constraint. In deprived areas, shortages of staff and services were repeatedly cited: \u0026ldquo;\u003cem\u003eOn the other side of practices, being in special measures, not having enough staff. So, you have a whole lot of different structural things that are going on\u003c/em\u003e\u0026rdquo; (FG_4, GP). As another GP put it: \u0026ldquo;\u003cem\u003eWe\u0026rsquo;re all trying our best to do the best for everyone, but it just doesn\u0026rsquo;t feel like there\u0026rsquo;s enough resource available to get round everyone\u0026hellip; we probably are leaving some people behind\u003c/em\u003e\u0026rdquo; (FG_3, GP). Even seemingly small service losses - such as no longer loaning blood pressure monitors or the absence of district nurses or social care workers - were seen to have a disproportionate impact on patients with multimorbidity. \u0026ldquo;\u003cem\u003eI think, inevitably, we are leaving behind some. We know we are\u0026hellip; it\u0026rsquo;s those who are in the most deprived sections of society that are getting the least good healthcare\u003c/em\u003e\u0026rdquo; (FG_2, GP). Digital infrastructure was described as patchy. Apps were widely used for asthma and diabetes, but CKD was said to be \u0026ldquo;\u003cem\u003every niche compared to the wider market for it\u003c/em\u003e\u0026rdquo; (FG_2, GP). Language barriers added another layer: \u0026ldquo;\u003cem\u003eIt\u0026rsquo;s difficult for some people who English is not their first language to register at the practice\u0026hellip; so they\u0026rsquo;re trying to make that a bit more accessible\u003c/em\u003e\u0026rdquo; (FG_1, GP). What for some was framed as innovation or efficiency was, for others, experienced as exclusion.\u003c/p\u003e\n\u003cp\u003ePolicy shifts were also seen as influential. Several GPs pointed to the removal of CKD from the Quality and Outcomes Framework (QoF) as a turning point: \u0026ldquo;\u003cem\u003eeGFR and lab analysis came around the same point as the introduction of QoF in 2003-2004\u0026hellip; It was incentivised and became an important target\u0026hellip; now it\u0026rsquo;s been removed from the GP contract in Scotland\u003c/em\u003e\u0026rdquo; (FG_4, GP). Without this incentive, recall systems became harder to sustain, especially in practices already under strain. Wider support also varied by place. \u0026ldquo;\u003cem\u003eIt\u0026rsquo;s better in the shire\u0026hellip; social care will routinely be involved\u0026hellip; but we don\u0026rsquo;t have that, unfortunately, in the city\u003c/em\u003e\u0026rdquo; (FG_1, GP). Where services did exist, they were not always straightforward to use. One team reported that they also practised as social prescribers: \u0026ldquo;\u003cem\u003eWe don\u0026rsquo;t have an actual clinic. We just have a group of us\u0026hellip; nurse, GP, pharmacist\u0026hellip; so we made a folder on the drive with Sleepio and things like that\u0026hellip; so there\u0026rsquo;s different headings for each topic\u003c/em\u003e\u0026rdquo; (FG_3, practice nurse). Communication with renal teams was likewise uneven. Some valued comprehensive letters: \u0026ldquo;\u003cem\u003eTheir letters are really comprehensive\u0026hellip; they flag up actions for the GP at the start, which is really helpful\u003c/em\u003e\u0026rdquo; (FG_1, GP). Others described professional-to-professional communication systems that felt anonymous: \u0026ldquo;\u003cem\u003eWe\u0026rsquo;ve got this alleged system\u0026hellip; where you\u0026rsquo;re supposed to write an advice letter\u0026hellip; I\u0026rsquo;ve never done that with renal. There\u0026rsquo;s this feeling of anonymisation and not knowing\u0026hellip; you might recognise names, but you don\u0026rsquo;t know who people are\u003c/em\u003e\u0026rdquo; (FG_2, GP). In short, the links between primary and secondary care were fragile and variable.\u003c/p\u003e\n\u003cp\u003eWithin practices, CKD work was spread across nurses, pharmacists and advanced nurse practitioners. \u0026ldquo;\u003cem\u003eMost of the meaningful interventions I\u0026rsquo;d say would probably be non-GP these days\u003c/em\u003e\u0026rdquo; (FG_4, GP). While efficient, this sometimes clashed with patient expectations: \u0026ldquo;\u003cem\u003eThey felt that they were totally being fobbed off\u0026hellip; they weren\u0026rsquo;t very satisfied sometimes when they walked in and I was there\u003c/em\u003e\u0026rdquo; (FG_4, pharmacist). Professionals noted that CKD care often relied on informal champions: \u0026ldquo;\u003cem\u003eYou really need somebody that\u0026rsquo;s going to champion it\u0026hellip; whether that\u0026rsquo;s diabetes or CKD\u0026hellip; then it becomes a wee bit by osmosis, influencing others\u0026rsquo; practices\u003c/em\u003e\u0026rdquo; (FG_4, pharmacist). Without such champions, CKD was at risk of being overshadowed by other conditions. Access to training was also described as limited: \u0026ldquo;\u003cem\u003eWe don\u0026rsquo;t get PLT [Protected Learning Time] any more\u0026hellip; even out-of-hours things you often can\u0026rsquo;t attend because you\u0026rsquo;re still at work\u003c/em\u003e\u0026rdquo; (FG_2, GP). Preventive care was frequently squeezed: \u003cem\u003e\u0026ldquo;I get ten minutes for each of my patients\u0026hellip; there\u0026rsquo;s so much I would love to help them with\u0026hellip; but I\u0026rsquo;ve got to move on\u0026rdquo;\u003c/em\u003e (HCP0201, GP). Pharmacists, with more discretion, sometimes carved out longer reviews: \u003cem\u003e\u0026ldquo;Maybe I\u0026rsquo;m a wee bit better at being able to protect my time\u0026hellip; I can create fifteen or thirty minutes to review somebody if they are really complicated\u0026rdquo;\u003c/em\u003e (FG_4, pharmacist). \u0026nbsp;Considering system and local challenges in primary care, professionals highlighted that current healthcare provision fails to meet the needs of patients with deprived circumstances.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePrecarity shaping the conditions for early kidney care\u003c/h2\u003e\n\u003cp\u003eParticipants\u0026rsquo; accounts showed that socioeconomic and emotional precarity often predated awareness of kidney disease and shaped how its later identification and management were negotiated in practice. Ongoing pressures related to work, finances, housing, and mental health influenced participants\u0026rsquo; capacity to prioritise kidney health, attend appointments, seek clarification, and remain engaged with services, forming the context in which candidacy for early kidney care developed. Physical fatigue, chronic pain, and declining function disrupted employment from Stage 4 onwards, though some Stage 3 participants also described early signs that affected their ability to work. Many reduced their hours, going from full-time to part-time: \u0026ldquo;\u003cem\u003eI used to work full-time \u0026hellip; but again, that was too much, so I had to come down to two mornings a week\u003c/em\u003e\u0026rdquo; (PC02057). Another described the exhausting cycle of justifying kidney health needs to their employer: \u0026ldquo;\u003cem\u003ethree occupational health reports\u0026hellip; letters from my doctors\u0026hellip; there\u0026rsquo;s only so much I can do\u003c/em\u003e\u0026rdquo; (PC06023). Concerns about future employment arose even in Stage 3: \u0026ldquo;\u003cem\u003eI had no option but to hand in my notice\u0026hellip; and I do worry\u0026hellip; it may also affect that next job as well\u003c/em\u003e\u0026rdquo; (PC01002). Financial strain was a recurring theme, compounded by low income and, in some cases, unstable housing. This strain became especially pronounced in Stage 4 CKD, with one participant describing a cascading collapse of support: \u0026ldquo;\u003cem\u003eAll these things just happened and crashed from underneath me... I was homeless\u0026hellip; I had no job\u0026hellip; and myself and my partner did split up, so I was away from my children\u003c/em\u003e\u0026rdquo; (SC01006). Even earlier in the disease course, the cost of self-management - attending appointments, following dietary advice, maintaining routines - was financially burdensome. As one participant put it: \u0026ldquo;\u003cem\u003eKidney disease financially is expensive\u0026hellip; making things [food] from scratch can be more costly\u003c/em\u003e\u0026rdquo; (PC01002). Multiple health issues compounded the burden: \u0026ldquo;\u003cem\u003etrying to keep on top of\u003c/em\u003e\u0026rdquo; health issues while \u0026ldquo;\u003cem\u003ealways on the go\u003c/em\u003e\u0026rdquo; (PC02026).\u003c/p\u003e\n\u003cp\u003eEmotional strain was also a consistent background feature across accounts, described not as occasional distress but as persistent low mood, frustration, and mental fatigue - \u0026ldquo;\u003cem\u003eI\u0026rsquo;ve found myself to be a little bit more moody and cranky\u0026hellip; I think it\u0026rsquo;s just mainly to do with the mental health that comes with the kidney disease\u003c/em\u003e\u0026rdquo; (PC01002). Others described a shift of baseline: \u0026ldquo;\u003cem\u003eMy moods in general, I\u0026rsquo;m just low - constantly low mood\u003c/em\u003e\u0026rdquo; (PC06023). This was particularly common among those managing multiple conditions alongside social or financial pressures. Some withheld how they felt to avoid worrying others: \u0026ldquo;\u003cem\u003eI keep myself to myself\u0026hellip; I don\u0026rsquo;t put my health issues onto my children\u003c/em\u003e\u0026rdquo; (PC04053). Others noticed changes in how they related to people: \u0026ldquo;\u003cem\u003eVery short-tempered. Tetchy. Feel as if I\u0026rsquo;m arguing with people quite a lot\u003c/em\u003e\u0026rdquo; (PC06023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn people with severely decreased kidney function or established kidney failure, the emotional and physical demands of illness took a toll on intimate relationships: \u0026ldquo;\u003cem\u003eI just can\u0026rsquo;t get out of my bed\u0026hellip; I feel sorry for my husband\u003c/em\u003e\u0026rdquo; (PC02057). \u0026nbsp;At that point, some described reaching a crisis point: \u0026ldquo;\u003cem\u003eI was suicidal. I looked at throwing myself in the Aberdeen harbour\u0026hellip; I didn\u0026rsquo;t know where to turn\u003c/em\u003e\u0026rdquo; (SC01006). That same patient participant later noted receiving support through primary care: \u0026ldquo;\u003cem\u003eI was put back on antidepressants to help my suicidal thoughts\u0026hellip; and now I feel a lot stronger\u003c/em\u003e\u0026rdquo; (SC01006). Others sought mental health support outside the NHS: \u0026ldquo;\u003cem\u003eI do see a counsellor on a weekly basis\u0026hellip; I talk to them about how I\u0026rsquo;m feeling mentally\u003c/em\u003e\u0026rdquo; (CO01001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch2\u003eSummary of findings\u003c/h2\u003e\n\u003cp\u003eConsistent with prior quantitative evidence of later CKD identification in deprived areas (Sawhney et al., 2024), our qualitative findings show that, for working-age adults, \u0026ldquo;early\u0026rdquo; kidney care is often structurally late - typically initiated only once disease is already advanced and personal resources are depleted - thereby limiting capacity to engage in preventive action. Although incidental detection is characteristic of early CKD, it is explained briefly, if at all, leaving patients uncertain about its seriousness and what action is required. Conversations about kidney health vary in clarity and tone, shaping whether people understand themselves as needing ongoing care or interpret reassurance as closure. Many struggle to navigate complex and fragmented systems, where appointments, referrals, and follow-up depend on persistence, timing, and personal means. Professional assessments are similarly constrained by uncertainty, limited support, and the constant need to prioritise amid multimorbidity and system strain. Offers of care are uneven, sometimes softened or deferred, and their usefulness depends on continuity and relationships rather than standardised processes. Much care relies on discretionary effort - extra calls, annotated results, and active test-chasing - while community resources such as link workers and voluntary organisations bridge the gap between clinical advice and daily life. While these efforts often sustain care under pressure, they also render access uneven, as follow-up becomes contingent on individual initiative and local capacity rather than embedded systems.\u003c/p\u003e\n\u003ch2\u003eInterpretation: candidacy under constraint\u003c/h2\u003e\n\u003cp\u003eViewed through the Candidacy Framework (Dixon-Woods et al., 2005), whether and how people enter early kidney care depends on continual negotiation with services, shaped by time, trust, and capacity. Eligibility and engagement depend on how people\u0026rsquo;s daily lives align - or fail to align - with the organisation of primary care (Cummins et al., 2007; Strazdins et al., 2011). In this context, late detection and inconsistent follow-up reflect not a lack of motivation but the structural conditions that constrain recognition, help-seeking, and sustained engagement. As one participant reflected, \u0026ldquo;\u003cem\u003eThey are nae worrying about it\u0026hellip; so .. well what\u0026rsquo;s the point in asking?\u003c/em\u003e\u0026rdquo; (PC02057). This illustrates what we term candidacy under constraint - where patients internalise limited professional concern as a cue that their condition is not a priority, disengaging not from apathy but from an awareness of system strain. Both patients and professionals work to sustain care within these constraints, often relying on discretionary effort and local relationships to bridge systemic gaps. Together, these local negotiations reveal the broader logic of the Inverse Care Law - first articulated by Hart (1971), extended to prevention (Macintyre, 2007), and still evident in contemporary systems (Cookson et al., 2021) - where those with the greatest need face the most limited capacity for timely care.\u003c/p\u003e\n\u003cp\u003eSeen through the lens of candidacy as socially structured access, relational mechanisms - trust, continuity and communication - are not optional interpersonal features but core conditions shaping service permeability (Ladds et al., 2023; Sinnott et al., 2024). These mechanisms operate within wider structural constraints, where workforce capacity, organisational priorities and socioeconomic conditions shape both daily life and service delivery. Recent Scottish evidence indicates that such pressures persist despite policy commitments to equity (Bogie et al., 2025). In practice, primary care capacity remains a key constraint, with staffing pressures and turnover narrowing opportunities for testing, follow-up and timely diagnosis (Audit Scotland, 2025). National initiatives aimed at addressing social and health inequalities will depend on sustained workforce time and community capacity to translate policy into practice.\u003c/p\u003e\n\u003ch2\u003eImplications: equitable early kidney care\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThese findings help explain why kidney health remains under-prioritised within non-communicable disease strategies. At a population level, early stages of kidney disease have limited public health visibility, reflected in routine data sources and their relative absence from national dashboards. At a system level, kidney disease lacks the enhanced services and incentives afforded to conditions such as diabetes and cardiovascular disease in primary care. At an individual level, early CKD is largely asymptomatic or characterised by non-specific symptoms, further limiting recognition and salience. Together, this \u0026ldquo;triple invisibility\u0026rdquo;, at population, system, and symptom levels, weakens candidacy for early kidney care and constrains preventive action.\u003c/p\u003e\n\u003cp\u003eViewing CKD as a biomedical-psychosocial juncture reframes early kidney care as both detection and action. The question is not only how to detect disease earlier, but how to create the conditions that make early action possible. Ensuring capacity for early kidney care within an overstretched health system is essential to prevent inequities from widening. This requires protected opportunities for early detection, timely communication, and structured follow-up before disease progression limits prevention. It also requires institutional recognition that time, continuity, and trust are core conditions for equitable care rather than optional extras. Action across primary and community settings should safeguard consultation time, ensure that test results are communicated clearly with agreed next steps, and embed navigation for social and practical needs such as transport, employment, housing, digital access, and psychosocial support. Although kidney function tests are among the most frequently performed investigations in UK primary care (Hobbs et al., 2016), our findings highlight ongoing challenges in how patients and professionals interpret and act on results. Clear framing of blood and urine testing within annual reviews - emphasising kidney health and shared next steps - may reduce softened or protective communication practices that inadvertently contribute to partial or non-disclosure of CKD (Deliyanidis et al., 2024; Daker-White et al., 2015). Strengthening these temporal and relational aspects of care may help early detection translate into sustained engagement and reinforce prevention as a shared, enduring capacity (Ladds et al., 2023). Future research should build on this work through co-design with people affected by CKD, primary care teams, and community partners to develop and test integrated models of care that embed appropriately framed conversations about kidney health into routine practice, address the service constraints identified here, and enable earlier and more equitable action.\u003c/p\u003e\n\u003cp\u003eThese findings also connect to the emerging concept of cardiovascular\u0026ndash;kidney\u0026ndash;metabolic (CKM) syndrome, which recognises cardiovascular disease, chronic kidney disease, and metabolic disorders as part of a linked continuum of biological and social risk (Ndumele et al., 2023). The CKM model emphasises staged risk assessment and prevention at the earliest identifiable stages of cardiometabolic risk, incorporating kidney function and albuminuria testing within integrated care pathways. Importantly, it situates social and structural determinants of health - including socioeconomic position, stress exposure, and access to care - as part of the causal pathway rather than as external context. Our findings complement this perspective by clarifying what translating integrated risk recognition into sustained preventive action would require in practice, particularly in deprived areas. Achieving the CKM ambition will depend on addressing the organisational and relational constraints identified here - limited time, fragile continuity, and uneven community capacity - through workforce models that integrate kidney health across routine cardiovascular and metabolic encounters. In doing so, prevention can move from aspiration to implementation, enabling earlier and more equitable action within real-world service conditions.\u003c/p\u003e\n\u003ch2\u003eImplications: theory\u003c/h2\u003e\n\u003cp\u003eOur findings extend recent refinements of candidacy in use and scope (Koehn et al., 2024; Mackenzie, 2025) by showing that, in early CKD, clinical rather than patient-led identification initiates the candidacy process, requiring an empirically adapted ordering of the early domains to reflect how participants encountered care in practice. We further show that socioeconomic precarity and organisational strain are embedded within, and operate across, candidacy domains, structuring capacity to appear in services, navigate care pathways, and engage with offers of care. These processes were bidirectional and contingent on disease severity: while precarity shaped candidacy most strongly before and at early recognition, progression of CKD often intensified existing socioeconomic and emotional strain, further constraining engagement. Multimorbidity additionally distributed attention and priority across conditions, shaping how kidney disease was interpreted and adjudicated by professionals. Taken together, these insights complement existing work by positioning candidacy more explicitly within the structural determinants shaping access to asymptomatic and clinically mediated conditions.\u003c/p\u003e\n\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\n\u003cp\u003eThis study\u0026rsquo;s key strengths include the multi-site design across three Scottish boards and the focus on a working-age and lived experience of area deprivation (i.e. a seldom-heard population); this is complemented by accessibility-minded recruitment (easy-read materials, flexible modes), dual perspectives (patients and professionals), and theory-informed analysis underpinned by substantive patient, public and professional engagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe present qualitative study did not sample across the full socioeconomic gradient, which would have enabled systematic examination of how structural mechanisms operate across levels of socioeconomic advantage and disadvantage. However, previous quantitative analysis using linked population-level data has demonstrated clear socioeconomic gradients in CKD-related outcomes, with greater mortality and poorer health indicators among people experiencing higher levels of deprivation (Sawhney et al., 2024). The current study, therefore, focused on an in-depth exploration of how these inequalities are experienced and negotiated in practice among those known, from linked population-level data, to face constrained access to care, reflecting a complementary qualitative emphasis on mechanism and process.\u003c/p\u003e\n\u003cp\u003eThis study is situated within the context of Scotland\u0026rsquo;s NHS, which represents a methodological consideration; however, convergence with UK-wide evidence on primary care during the austerity era (Nuffield Trust, 2024) supports the transferability of the findings. In addition, participants were sampled according to eGFR-based CKD staging rather than full KDIGO risk classification, incorporating albuminuria, which may have provided additional nuance in how CKD is considered and discussed for individuals with higher albuminuria despite mild or moderately reduced kidney function. However, as albuminuria is not consistently recorded in primary care, sampling on this basis would likely have introduced systematic exclusion and difficult-to-interpret accounts, undermining analytic coherence.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eEarly kidney care in communities experiencing deprivation represents a structurally constrained preventive window in which biological risk intersects with lived social conditions shaping opportunities for action. In the absence of population, system and symptom visibility, prevention becomes dependent on discretionary effort and individual capacity at the point when intervention is most effective. Access and engagement therefore emerge as processes of candidacy negotiated within limited time, continuity and system capacity, revealing how organisational and social structures, rather than individual motivation, reproduce inequities even within universal healthcare. Strengthening equitable prevention requires community-linked primary care models that embed social and structural determinants within care design, consistent with integrated cardio-renal-metabolic approaches that situate prevention and inequity within the causal pathway.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCKD: chronic kidney disease\u003c/p\u003e\n\u003cp\u003eAKI: acute kidney injury\u003c/p\u003e\n\u003cp\u003eSIMD: Scottish Index of Multiple Deprivation\u003c/p\u003e\n\u003cp\u003eeGFR: estimated glomerular filtration rate\u003c/p\u003e\n\u003cp\u003eACR: albumin-to-creatinine ratio\u003c/p\u003e\n\u003cp\u003eNHS: National Health Service\u003c/p\u003e\n\u003cp\u003eNRS: NHS Research Scotland\u003c/p\u003e\n\u003cp\u003eRTA: reflexive thematic analysis\u003c/p\u003e\n\u003cp\u003eGRIPP2: Guidance for Reporting Involvement of Patients and the Public\u003c/p\u003e\n\u003cp\u003eCOREQ: Consolidated criteria for reporting qualitative research\u003c/p\u003e\n\u003cp\u003eKDIGO: Kidney Disease: Improving Global Outcomes\u003c/p\u003e\n\u003cp\u003eQoF: Quality and Outcomes Framework\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eAll study procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki. The study was approved by Health and Social Care Research Ethics Committee A (reference 24/NI/0037). Written, verbal, or online informed consent was obtained from all participants for participation in interviews or focus groups, for audio-recording, and for the use of anonymised quotations in research outputs and publications. Patient participants were additionally invited to provide optional consent for access to relevant medical records relating to kidney health status. All participants were additionally invited to provide optional consent for future contact regarding ethically approved studies and for receipt of a lay summary of the study findings. Ongoing verbal consent was reconfirmed at the start of each interview and focus group. Interviews and focus groups were audio-recorded, transcribed verbatim, and anonymised prior to analysis, with field notes also anonymised prior to analysis. Audio and text files were stored securely in password-protected folders in accordance with UK data protection regulations.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable. No identifiable individual data are presented in this article.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eA complete qualitative coding framework with a hierarchical coding tree is available via the University of Aberdeen PURE repository.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eTB is also funded by the NIHR Greater Manchester Patient Safety Research Collaboration (Grant NIHR204295). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health and Care Research, or the Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003eSB has received consulting fees from AstraZeneca, GSK, Stada UK, and Novo Nordisk, and research support from AstraZeneca.\u0026nbsp;These relationships are outside the scope of the present study.\u003c/p\u003e\n\u003cp\u003eThe remaining authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research, conducted as part of the Kidney Inequalities: Needs, Data, Experiences, Response (KINDER) study, was supported by the Scottish Government Chief Scientist Office (grant HIPS/23/17). The funders had no role in study design, data collection, analysis, interpretation, or the decision to submit the manuscript for publication.\u003c/p\u003e\n\u003ch2\u003eAuthor contributions\u003c/h2\u003e\n\u003cp\u003eSS was the Chief Investigator. MRD led this study, with TB\u0026rsquo;s support. MRD, SS, TB and AH contributed to study conceptualisation and funding acquisition. BK and MRD led project administration. Site engagement was undertaken by SB, BJ and SS. Participant-facing materials were co-designed by MRD, BK, AH, MMe and FN. Participant recruitment, data collection and data analysis were led by BK. Interpretation and validation of findings were undertaken by MRD, BK, TB, AH, SB, MMe, FN, MG, BJ, MMa, NSR, EC, PC and SS. MRD and BK drafted the original manuscript. All authors contributed to manuscript review and editing. MMa provided specialist methodological guidance. All authors read and approved the final manuscript and are accountable for the work.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe thank NHS Research Scotland (NRS) Primary Care Networks, especially Amanda Cardy and a research governance manager, Louise King, for her support in our efforts to improve study accessibility. We are deeply grateful to all participants, our advisory group, and our patient and public partners for their generous contributions throughout the project. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any Author Accepted Manuscript version arising from this submission.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; information\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eMRD is an Advanced Research Fellow and qualitative health researcher specialising in health services research and equity-focused implementation science; she is also an accredited community-based counsellor. BK is a Postdoctoral Researcher with a background in health psychology and expertise in qualitative health research. SS and PC are clinical academic nephrologists with a focus on population kidney health and deprivation-related inequalities. TB and BJ are academic general practitioners with expertise in multimorbidity and primary care service organisation. SB is a clinical epidemiologist specialising in chronic disease outcomes. MMa is a Professor of Medical Sociology with expertise in structural determinants of health and health inequalities. NSR and EC are academic researchers contributing to chronic disease and health services research. AH, MG and FN are Patient and Public Involvement contributors.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAdditional file 5:\u003c/strong\u003e \u003cstrong\u003eQualitative coding framework and full coding tree.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Available via the University of Aberdeen PURE repository: https://abdn.elsevierpure.com/en/datasets/kinder-qualitative-study-coding-trees/\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eALLIANCE. Long Term Conditions Framework: consultation response. The Health and Social Care Alliance Scotland; 2025. Available from: https://www.alliance-scotland.org.uk/wp-content/uploads/2025/07/Long-Term-Conditions-Framework-ALLIANCE-Response.pdf\u003c/li\u003e\n\u003cli\u003eAudit Scotland. General practice: progress since the 2018 General Medical Services contract. Edinburgh: Audit Scotland; 2025. Available from: General practice: Progress since the 2018 General Medical Services contract\u003c/li\u003e\n\u003cli\u003eBaird B, Charles A, Honeyman M, Maguire D, Das P. Understanding pressures in general practice. London: King\u0026rsquo;s Fund; 2016. Available from: https://assets.kingsfund.org.uk/f/256914/x/62ae34157d/understanding_pressures_general_practice_2016.pdf\u003c/li\u003e\n\u003cli\u003eBarnard R, Spooner S, Hubmann M, Checkland K, Campbell J, Swinglehurst D. The hidden work of general practitioners: an ethnography. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2024;350:116922.\u003c/li\u003e\n\u003cli\u003eBogie J, van Dijk M, Bezzina C, Lunan C, Henderson D, Mercer SW, Blane DN. Equity, workload, and general practice under strain in deprived communities. \u003cem\u003eBr J Gen Pract\u003c/em\u003e. 2025;75(757):e549-e558. \u003c/li\u003e\n\u003cli\u003eBower P, Wallace P, Ward E, Graffy J, Miller J, Delaney B, et al. Improving recruitment to health research in primary care. \u003cem\u003eFam Pract\u003c/em\u003e. 2009;26(5):391-7.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. \u003cem\u003eQual Res Sport Exerc Health\u003c/em\u003e. 2019;11(4):589-97.\u003c/li\u003e\n\u003cli\u003eCookson R, Doran T, Asaria M, Gupta I, Mujica FP. The inverse care law re-examined: a global perspective. \u003cem\u003eLancet\u003c/em\u003e. 2021;397(10276):828-38.\u003c/li\u003e\n\u003cli\u003eCowan E, Bell S, Black C, Blakeman T, Fraser S, Hughes A, et al. Deprivation and limitations in daily life in new onset kidney disease: a population study. \u003cem\u003eClin Kidney J\u003c/em\u003e. 2025; 19 (1): sfaf397. \u003c/li\u003e\n\u003cli\u003eCummins S, Curtis S, Diez-Roux AV, Macintyre S. Understanding and representing \u0026ldquo;place\u0026rdquo; in health research: a relational approach. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2007;65(9):1825-38.\u003c/li\u003e\n\u003cli\u003eDaker-White G, Rogers A, Kennedy A, et al. Non-disclosure of chronic kidney disease in primary care and the limits of instrumental rationality in chronic illness self-management. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2015;131:31-9.\u003c/li\u003e\n\u003cli\u003eDeliyanidis S, Stiefel FC, Bourquin C, Michaud L. Focus on the blind spots of clinician\u0026ndash;patient interactions: a critical narrative review of collusion in medical settings. \u003cem\u003eJ Health Psychol\u003c/em\u003e. 2024;30(8):1751-67.\u003c/li\u003e\n\u003cli\u003eDixon-Woods M, Kirk D, Agarwal S, Annandale E, Arthur T, Harvey J, et al. Vulnerability and access to healthcare: a critical interpretive review. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2005;61(12):2620\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eEMPA-KIDNEY Collaborative Group. Empagliflozin in patients with chronic kidney disease. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2022;388:117\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eFisher R, Loftus L, Holdroyd I, Ford J. Fairer funding for general practice in England: what\u0026rsquo;s the problem, why is it so hard to fix, and what should the government do? London: Nuffield Trust \u0026amp; Health Equity Evidence Centre; 2024. Available from: https://www.nuffieldtrust.org.uk/resource/fairer-funding-for-general-practice-in-england\u003c/li\u003e\n\u003cli\u003eFrancis A, Harhay MN, Ong ACM, Tummalapalli SL, Ortiz A, Fogo AB, et al. Chronic kidney disease and the global public health agenda. \u003cem\u003eNat Rev Nephrol\u003c/em\u003e. 2024;20(7):473-85.\u003c/li\u003e\n\u003cli\u003eGBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. \u003cem\u003eLancet\u003c/em\u003e. 2020;395(10225):709-33.\u003c/li\u003e\n\u003cli\u003eGarofalo C, Borrelli S, Provenzano M, De Stefano T, Vita C, Chiodini P, et al. Dietary salt restriction in chronic kidney disease: a meta-analysis of randomized clinical trials. \u003cem\u003eNutrients\u003c/em\u003e. 2018;10(6):732. \u003c/li\u003e\n\u003cli\u003eHaigh F, Kemp L, Bazeley P, Haigh N. Developing a critical realist-informed framework to explain how the human rights and social determinants of health relationship works. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2019;19:7760.\u003c/li\u003e\n\u003cli\u003eHealth Foundation. Health inequalities in Scotland: an independent review. London: Health Foundation; 2022. Available from: https://www.health.org.uk/health-inequalities-in-scotland-an-independent-review\u003c/li\u003e\n\u003cli\u003eHeiwe S, Jacobson SH. Exercise training for adults with chronic kidney disease. Cochrane \u003cem\u003eDatabase Syst Rev\u003c/em\u003e. 2011;(10):CD003236. \u003c/li\u003e\n\u003cli\u003eHerrington WG, Judge PK, Grams ME, Wanner C, et al. Chronic kidney disease. \u003cem\u003eLancet\u003c/em\u003e. 2026;407(10523):90-104.\u003c/li\u003e\n\u003cli\u003eHobbs FDR, Bankhead C, Mukhtar T, Stevens S, Perera-Salazar R, Holt T, et al. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007-14. \u003cem\u003eLancet\u003c/em\u003e. 2016;387(10035):2323-30.\u003c/li\u003e\n\u003cli\u003eHounkpatin HO, Sang E, Price S, Okoye O, et al. Change in burden and experiences of treatment burden among people with kidney disease: a longitudinal qualitative study. \u003cem\u003eBMJ Open\u003c/em\u003e. 2020;10(12):e041097.\u003c/li\u003e\n\u003cli\u003eJefferson L, Golder S, Heathcote C, Avila AC, Dale V, Essex H, et al. GP wellbeing during the COVID-19 pandemic: a systematic review. \u003cem\u003eBr J Gen Pract\u003c/em\u003e. 2022.\u003c/li\u003e\n\u003cli\u003eKidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024 Apr;105(4S):S117-314. \u003c/li\u003e\n\u003cli\u003eKhan A. GP workload and patient safety: the balancing act. \u003cem\u003eBr J Gen Pract\u003c/em\u003e. 2024;73(733):459-61.\u003c/li\u003e\n\u003cli\u003eKidney Research UK. Kidney disease: a UK public health emergency - the health economics of kidney disease to 2033. Peterborough: Kidney Research UK; 2023. Available from: Economics-of-Kidney-Disease-full-report_accessible.pdf\u003c/li\u003e\n\u003cli\u003eKidney Research UK. Chronic kidney disease: an action plan for Scotland. Peterborough: Kidney Research UK; 2024. Available at: https://www.kidneyresearchuk.org/wp-content/uploads/2024/11/KRUK-Chronic-Kidney-Disease-Scottish-Action-Plan.pdf\u003c/li\u003e\n\u003cli\u003eKoehn S, Hunkeler E, Lee V, Wallace B. Candidacy and chronic disease management among marginalised older adults. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2024;330:115949.\u003c/li\u003e\n\u003cli\u003eLadds E, Majeed A, Greenhalgh T. A contemporary ontology of continuity in general practice. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2023;326:115958.\u003c/li\u003e\n\u003cli\u003eLevesque J-F, Harris MF, Russell G. Patient-centred access to healthcare: conceptual framework. \u003cem\u003eInt J Equity Health\u003c/em\u003e. 2013;12:18.\u003c/li\u003e\n\u003cli\u003eLowrie R, Mair FS, Greenlaw N. Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data. \u003cem\u003eBMJ Open\u003c/em\u003e. 2017;7(3):e012270.\u003c/li\u003e\n\u003cli\u003eMackenzie M, Baruffati D, Lindsay C, O\u0026rsquo;Donnell K, Ellis D, Simpson S, et al. Fundamental causation and candidacy: harnessing explanatory frames to better understand how structural determinants of health inequalities shape disengagement from primary healthcare. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2025;374:118043.\u003c/li\u003e\n\u003cli\u003eMacRae C, Mercer SW, Guthrie B, Henderson D. Comorbidity in chronic kidney disease: a large cross-sectional study of prevalence in Scottish primary care. BMC Primary Care. 2021;71(704):e243-e249.\u003c/li\u003e\n\u003cli\u003eMalterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. \u003cem\u003eQual Health Res\u003c/em\u003e. 2016;26(13):1753-60.\u003c/li\u003e\n\u003cli\u003eMarmot M. \u003cem\u003eFair society, healthy lives: the Marmot Review\u003c/em\u003e. London: Institute of Health Equity; 2010. Available from: https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review \u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence. Chronic kidney disease: assessment and management (NG203). London: NICE; 2021. Available from: https://www.nice.org.uk/guidance/ng203\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Research. Payment guidance for researchers and professionals. NIHR; 2021. Available from: https://www.learningforinvolvement.org.uk/wp-content/uploads/2021/12/Payment-guidance-for-researchers-and-professionals-Dec-2021.pdf\u003c/li\u003e\n\u003cli\u003eNdumele CE, Greenland P, Van Gaalen J, et al. Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association. \u003cem\u003eCirculation\u003c/em\u003e. 2023;149:e1-e35.\u003c/li\u003e\n\u003cli\u003eRoberti J, Cummings A, Myall M, Harvey J, Lippiett K, Hunt K, et al. Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies. \u003cem\u003eBMJ Open\u003c/em\u003e. 2018;8(9):e023507.\u003c/li\u003e\n\u003cli\u003eRoyal College of General Practitioners Scotland. The Scottish GP workforce and socioeconomic health inequalities. Edinburgh: RCGP Scotland; 2024. Available from: https://www.rcgp.org.uk/getmedia/263e368d-1dc2-4ac8-9180-05d9da9158bb/Scottish-GP-Workforce-Socioeconomic-Health-Inequalities.pdf\u003c/li\u003e\n\u003cli\u003eSawhney S, et al. Care processes and outcomes of deprivation across the clinical course of kidney disease: findings from a high-income country with universal healthcare. \u003cem\u003eNephrol Dial Transplant\u003c/em\u003e. 2023;38(5):1170\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSawhney S, et al. Individual and neighbourhood-level social and deprivation factors impact kidney health in the GLOMMS-CORE study. \u003cem\u003eKidney Int\u003c/em\u003e. 2024;106(5):928-42.\u003c/li\u003e\n\u003cli\u003eScottish Government. Delivering value-based health and care: a vision for Scotland. Edinburgh: Scottish Government; 2023. Available from: https://www.gov.scot/publications/delivering-value-based-health-care-vision-scotland\u003c/li\u003e\n\u003cli\u003eScottish Government. Primary care improvement plans: implementation progress summary (March 2025). Edinburgh: Scottish Government; 2025. Available from: https://www.gov.scot/publications/primary-care-improvement-plans-implementation-progress-summary-march-2025 \u003c/li\u003e\n\u003cli\u003eSinnott C, Ansari A, Price E, Fisher R, Beech J, Alderwick H, et al. Understanding access to general practice through the lens of candidacy: a critical review of the literature. \u003cem\u003eBr J Gen Pract\u003c/em\u003e. 2024;74(747):e683-e694.\u003c/li\u003e\n\u003cli\u003eStaniszewska S, Brett J, Simera I, Seers K, Mockford C, Goodlad S, et al. GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. \u003cem\u003eBMJ\u003c/em\u003e. 2017;358:j3453.\u003c/li\u003e\n\u003cli\u003eStrazdins L, Griffin AL, Broom DH, Banwell C, Korda RJ, Dixon J, et al. Time scarcity: another health inequality? \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2011;72(9):1349-58.\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. \u003cem\u003eInt J Qual Health Care\u003c/em\u003e. 2007;19(6):349-57.\u003c/li\u003e\n\u003cli\u003eTuttle KR, Alicic RZ, Duru OK, Jones CR, Daratha KB, Nicholas SB, et al. Clinical characteristics of and risk factors for chronic kidney disease among adults and children: an analysis of the CURE-CKD registry. \u003cem\u003eJAMA Netw Open\u003c/em\u003e. 2019;2(12):e1918169.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"chronic kidney disease, primary care, health inequalities, prevention, candidacy, social determinants, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-9021068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9021068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eChronic kidney disease (CKD) is common, associated with substantial comorbidity and strong socioeconomic gradients. Early CKD care focuses on preventing disease progression and reducing cardiovascular risk. However, inequities in access to CKD care are most pronounced early in the disease course, a critical window for equitable population-level prevention within primary care. Understanding how these inequities arise within primary care, where early identification and management largely occur, is therefore essential. This study explored how people living with CKD in deprived areas of Scotland, a setting characterised by marked health inequalities, establish candidacy for early kidney care at a point when prevention should begin but is often lacking.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eA qualitative study informed by critical realism combined semi-structured interviews with 38 adults with CKD (predominantly Stage 3 and primarily managed in primary care) and focus groups or interviews with 23 primary care professionals (N = 61). Participants were drawn from the most deprived 40% of neighbourhoods across three Scottish health boards, ensuring variation in CKD stage, diagnosis timing, professional role, and urban-rural setting. Data were analysed using reflexive thematic analysis informed by the Candidacy Framework.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Early kidney care for working-age adults living in deprived areas is often delayed, with CKD detected when personal resources, including time, finances, and support, are already stretched. Diagnosis is typically explained briefly, if at all, leading to uncertainty about its significance and next steps. Communication and care vary widely, with many patients relying on personal persistence to navigate fragmented healthcare systems. Care frequently depends on professional discretion, with uneven community and voluntary resources bridging gaps in care. These patterns reflect structural constraints rather than individual disengagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Early kidney care in communities experiencing deprivation represents a constrained preventive window within primary care. The “triple invisibility” of early CKD, at population, system, and symptom levels, undermines sustained engagement at the point when intervention is most effective. Strengthening equitable prevention requires service-level redesign and workforce models that embed kidney health within routine cardiometabolic care, address structural constraints in deprived areas, and integrate physical and psychosocial risk management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"“They are nae worrying about it… so …what’s the point in asking?”: a qualitative study of candidacy for early CKD care in areas of multiple deprivation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 07:26:12","doi":"10.21203/rs.3.rs-9021068/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-01T08:04:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T20:02:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-12T11:08:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118463365620118655571200621676894825357","date":"2026-03-09T09:13:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69803749456173813944063201766052144384","date":"2026-03-07T10:31:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44012581230681945626022582648089073023","date":"2026-03-06T20:26:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-06T02:05:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-04T14:02:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-04T09:41:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-04T09:41:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2026-03-03T13:55:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c91f14ac-4457-4fda-a6c4-bdf1e1d68c15","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T06:53:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 07:26:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9021068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9021068","identity":"rs-9021068","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}