Equity Beyond Entry: A Capability Approach to Understanding Widening Participation in Medical Education

Research Context

This study is situated in Scotland, where widening participation policies are nationally coordinated but locally implemented. Here, the term widening participation encompasses a broad range of circumstances associated with underrepresentation in higher education, including, for example, coming from a low-income household, eligibility for free school meals, attending a school with a low progression rate into higher education, holding refugee or asylum seeker status, having experience of the care system, or being estranged from family. While broader UK literature often includes minoritised ethnic groups under the widening participation umbrella, this is not a standalone criterion in Scotland. However, recognising the intersectional nature of disadvantage, this study includes individuals from minority ethnic backgrounds.

Across the UK, widening participation initiatives typically involve targeted outreach programmes, contextual admissions, foundation or gateway programmes, and additional academic and pastoral support to improve access and retention. How these initiatives are defined, prioritised, and operationalised varies between institutions [34].

While the context of this study is specific to Scottish medical education, the structural barriers identified – financial precarity, cultural exclusion, and the hidden curricula – resonate across international contexts. The findings, therefore, offer broader insights for global efforts to diversify the medical profession and create environments in which all students can thrive.

Research paradigm

We adopted a qualitative design informed by a constructivist paradigm, which views reality as socially constructed and shaped by individual experiences [35]. We co-created knowledge with participants through interaction, interpretation, and reflexivity, recognising how context, social structures, and individual perspectives influence students’ experiences. We chose this paradigm to explore the interplay between agency and structural constraint, which is central to both widening participation and the capability approach. Although critical paradigms more explicitly foreground power and inequality, constructivism enabled us to engage with both subjective meaning-making and broader institutional context. Throughout the study, we examined how participants’ narratives reflected and negotiated structural realities.

Researcher reflexivity and positionality

Consistent with reflexive thematic analysis, we recognised our active role in shaping knowledge. The lead researcher (AS), a senior resident doctor and postgraduate research student, is a first-generation university graduate from a socioeconomically deprived background. She conducted all interviews and led the analysis. Her shared background with participants enhanced rapport and interpretive depth, but also introduced potential bias, which she addressed through reflexive journaling and regular supervisory discussions.

The supervisory team comprised: DH, a Professor of Psychometrics; JH, a Professor of Social Science in Medicine; LM, a Professor of Transplant Surgery and former Dean of Admissions and Widening Participation; and VT, a Consultant Physician and Associate Director of Medical Education for Scholarship with no prior experience in widening participation. Their diverse disciplinary and professional perspectives challenged assumptions, refined interpretations, and strengthened analytic depth.

Participants

Data collection

Between March and June 2024, after final examinations, AS conducted sixteen semi-structured interviews in person or via secure online platforms, according to participant preference. We used semi-structured interviews because they provided the flexibility to explore individual meanings while maintaining a consistent focus on key topics. This approach aligned with our constructivist paradigm and reflexive thematic analysis, enabling participants to shape the direction of discussion and articulate experiences in their own terms. It also allowed us to probe how personal, social, and institutional factors influenced students’ capabilities and sense of agency, consistent with the capability approach.

We developed the interview guide (Appendix 2) from the existing literature on widening participation and medical student experience, drawing on studies addressing access barriers, identity, belonging, and structural inequality. We piloted the guide with two widening participation students not involved in the main study, leading to minor revisions that clarified wording, emphasised structural influences, and reordered questions to build rapport before exploring identity and belonging.

AS audio-recorded, transcribed and anonymised all interviews, assigning pseudonyms chosen or approved by participants. A master key linking pseudonyms to real names was encrypted and stored separately.

We invited participants to review their transcripts and redact data before analysis to maintain agency over their narratives. We did not conduct member checking, as this is not typically aligned with the epistemological foundations of reflexive thematic analysis.

AS approached interviews reflexively, aware that her dual identity as a widening participation graduate and medical educator could feel both familiar and authoritative. She mitigated power imbalances and created a safe, non-judgmental space for open dialogue.

Data analysis

We analysed data using reflexive thematic analysis, as outlined by Braun and Clarke [36]. This approach, aligned with our constructivist paradigm, views meaning as co-constructed through interpretation and reflexivity and recognises the researcher’s active role in shaping, rather than discovering, themes.

We followed Braun and Clarke’s six phases: 1) data familiarisation; 2) initial coding; 3) developing preliminary themes; 4) reviewing and refining themes; 5) defining and naming themes; and 6) producing the final report. We moved iteratively across stages, guided by both the data and emerging theoretical insights.

We used the capability approach to foreground opportunity, constraint, agency, and valued outcomes. During coding and theme development, we examined how participants described the interplay of resources, conversion factors, capabilities, functionings, and agency, attending to latent meanings, social positioning, and structural contexts. This approach enabled us to move from descriptive codes (e.g., teacher discouragement, financial hardship) to interpretive themes (e.g., capability to aspire, capability to succeed), illustrating how structural and social conditions shaped students’ real freedoms. We retained and examined contradictory or divergent accounts as critical counterpoints, revealing the heterogeneity of experiences among widening participation students and the uneven operation of conversion factors across contexts.

Ethical approval

We obtained ethical approval from the Medical Education Ethics Committee at the University of Edinburgh, with subsequent approval from other participating institutions.

The capability to aspire: Recognition and misrecognition

Aspiration is a socially situated capability shaped by recognition and institutional conversion factors. For many participants, schools did not cultivate this capability but constrained it, often through subtle or overt sociocultural bias. Teachers and careers advisers – key institutional gatekeepers – were frequently described as discouraging or dismissive when students expressed interest in medicine.

Elsie recalled:

In capability terms, this reflects a failure of institutional recognition, which restricts the conversion of aspiration into action and reproduces social hierarchies about who medicine is ‘for.’

Leah’s experience with a careers adviser illustrated how classed assumptions narrowed aspirational horizons:

Here, restrictive social conversion curtailed the capability to aspire by constraining what was imaginable, diverting students toward roles aligned with deficit-based assumptions.

Andrew described a broader culture of low expectations:

For participants, ambition often began in spaces where medicine was unacknowledged or discouraged. This institutional climate produced capability deprivation by undermining recognition as a precursor to aspiration. Students’ ability to resist these pressures represented agency under constraint—a survival strategy that should not be romanticised but understood as a response to structural misrecognition.

The capability to achieve: Educational disadvantage

Although participants had gained entry to medical school, their accounts revealed stark inequities in educational foundations. From a capability perspective, this demonstrates that formal access to education is insufficient; what matters is the ability to convert resources into valued outcomes through enabling conversion factors.

Adam recalled:

Adam had formal access to schooling but lacked the conditions to convert that access into achievement; his real freedom to succeed was constrained by an environment that could not consistently support his learning.

Leah described how high staff turnover led to widespread academic failure:

Her experience highlights that educational achievement is contingent on institutional conversion factors, not just individual effort. The capability approach exposes how structural deprivation is misread as individual deficit, reframing failure as a reflection of inequitable conditions rather than personal inadequacy.

For some, these deficits demanded self-directed learning. Katie explained:

Katie’s experience exemplifies how ‘resilience’ operates as a compensatory conversion factor, masking structural inequity. The burden of ‘working harder’ becomes a hidden requirement for success, unevenly distributed. From a capability standpoint, these inequities transfer the responsibility for achievement from the institution to the student, constraining real freedoms to achieve.

The capability to belong: Cultural and institutional exclusion

Belonging is a socially and institutionally mediated capability—a freedom to participate and be recognised within a community. For many participants, belonging was unequally distributed through the operation of social and cultural conversion factors such as classed norms, linguistic hierarchies, and institutional cultures.

Elsie, who studied at a university close to home, described being mocked by her peers for her regional accent:

Though seemingly minor, such microaggressions revealed institutionalised forms of exclusion. For Elsie, language became a marker of difference, rendering her identity less legitimate and constraining her capability to belong. Despite studying in her hometown, she felt displaced:

Elsie was not marginalised by geography or academic ability, but by the dominant institutional culture in which access did not equate to inclusion.

Val described the cultural distance she felt in peer conversations:

These everyday exchanges reinforced symbolic boundaries and the unequal distribution of social capital, shaping who could fully participate. Belonging thus emerges as a collective capability that depends on institutional conversion factors that affirm or marginalise identities.

The capability to succeed: Financial insecurity

For many participants, success was constrained not by ability but by financial insecurity and inflexible institutional conversion factors. Although formally admitted, students’ real freedoms were curtailed by the need to work, lack of targeted support, and burdensome funding processes.

Nicole highlighted how institutional assumptions overlooked lived realities:

This response reveals a key tension – access to resources does not equate to the capability or agency to use them effectively. From a capability perspective, institutional support must be both available and accessible. Without clear guidance, Nicole was left to manage structural pressures alone, while institutional assumptions framed financial stability as a personal issue.

Leah’s experience underscored how institutional responses to hardship were framed in ways that pathologised need:

The university’s response to Leah’s financial situation failed to address the structural barriers limiting her capability to succeed. The hardship fund was inaccessible due to its invasive process, failing as a conversion factor. Leah’s request for advanced timetabling, a genuine structural solution, would have enabled independent capability and agency. By offering only reactive, short-term solutions, the institution perpetuated deficit narratives and reinforced a sense of capability deprivation.

The capability to advance: Privilege and progression

Although all students accessed the same curriculum, their actual freedom to convert opportunity into advancement varied according to their access to social, cultural, and academic capital. Privilege functioned as an enabling conversion factor, facilitating access to electives, research, and networks that advanced careers.

Ailish explained:

Adam added:

Though capabilities were theoretically equal, Ailish and Adam’s functionings differed because enabling conversion factors were unequally distributed. While their friends effortlessly gained access to opportunities, Ailish and Adam had to navigate these barriers independently, relying on personal conversion factors, such as motivation and resilience, expending additional effort for the same outcome.

Freya reflected on confidence as a socially conditioned form of agency:

Confidence here emerges not as a personality trait but as a socially-generated capability, shaped by upbringing and expectation. The uneven distribution of networks, confidence, and insider knowledge demonstrates how privilege mediates students’ capabilities and agency to advance. From a capability standpoint, advancement depends not only on the availability of opportunities but also on the conversion factors that determine who can act upon them.

Taken together, these findings illustrate that widening participation in medical education extends far beyond entry. Across the five capabilities – to aspire, achieve, belong, succeed, and advance – students’ experiences reveal how personal, social, and institutional conversion factors interact to shape what they are genuinely able to do and become. While formal access opens the door, inequitable conversion conditions determine whether participation translates into real freedoms and valued outcomes. Agency often emerged as resistance under constraint rather than evidence of equal opportunity. These findings underscore that achieving equity in medical education requires transforming the structural and cultural conditions of medical training so that capability expansion becomes the true measure of success in widening participation.

Reframing inequity through the capability approach

This study demonstrates that students from widening participation backgrounds face persistent structural barriers that hinder their ability to convert opportunities into genuine capabilities during their medical education. While previous research has identified similar inequities, the novelty of this study lies in applying the capability approach to reconceptualise these challenges as failures of institutional conversion factors that constrain students’ real freedoms to achieve valued outcomes.

By adopting this lens, we move beyond access-based definitions of equity to examine how opportunity is structured, distributed, and converted into real advantage. The capability approach exposes the limits of inclusion narratives that equate equity with access, instead foregrounding institutional responsibility for creating environments that expand capability. Rather than focusing on what widening participation students are perceived to lack, we foreground what institutions fail to meaningfully provide.

Our analysis extends previous applications of the capability approach, demonstrating its analytic power to uncover context-specific mechanisms of constraint and adaptation. Participants varied in how they negotiated structural barriers: some exercised their agency by actively engaging mentors or creating self-directed opportunities, while others were restricted by financial or cultural constraints. This variability highlights how capabilities are relational and contingent, shaped through interaction between agency and the conversion factors that enable or restrict it.

This framework also challenges the widespread valorisation of resilience. Within a capability perspective, resilience is better understood as agency under constraint – an adaptive, often exhausting response to capability deprivation rather than an index of strength. The extraordinary efforts students make to overcome institutional shortcomings both obscure systemic inequity and individualise the responsibility for success.

Overall, the capability approach provides a critical and theoretically coherent framework for understanding how students navigate unequal conditions. It shifts attention from individual attributes to the institutional and structural processes that expand or restrict capability, reframing equity as the expansion of students’ real freedoms and agency to thrive. This theoretical application constitutes the study’s primary contribution to medical education scholarship, demonstrating the utility of the capability approach as a framework for diagnosing and addressing persistent inequities in access, belonging, and progression. In doing so, this study extends the capability approach beyond its prior applications in health and higher education, demonstrating its explanatory power for understanding the structural dynamics of equity in medical training.

Situating findings in an international context

Our findings contribute to global debates on equity in medical education by highlighting the limitations of access-focused models and the need for sustained structural support across the educational continuum. Participants emphasised that meaningful inclusion required not only gaining access to medical school, but having the institutional conversion factors – such as mentorship, financial stability, inclusive pedagogy, and predictable timetables – necessary to sustain participation and achievement. These insights are particularly relevant in contexts where widening participation continues to be evaluated through narrow metrics of enrolment rather than capability expansion.

The capability approach provides a comparative and transferable framework for assessing substantive equity across systems. By asking whether students have the real freedom and agency to achieve valued outcomes, it directs attention beyond formal opportunity to the conditions that determine whether those opportunities can be realised. Whether in quota-based or meritocratic systems, a capability-informed perspective redefines fairness not as equal access, but as the equal ability to convert access into opportunity.

This framing also offers a practical policy lens: equity efforts should be judged not by who enters medical school, but by who is supported to thrive, progress, and advance. Future research could explore how national contexts shape the conversion factors that constrain or enable underrepresented students, and how institutions can adapt their practices to expand students’ capabilities and agency. In this way, our study offers both a contextualised insight into Scottish medical education and a transferable conceptual contribution to international discussions on how medical schools can move from formal access to substantive equity.

Institutional critique

Participants consistently identified institutional shortcomings in career guidance and financial support as significant barriers to equitable participation. While grounded in perceptions rather than auditable data, the consistency of these accounts suggests systemic weaknesses in how medical schools enable students to translate formal resources into real opportunities.

Financial support mechanisms were frequently described as opaque, bureaucratic, or stigmatising. Although hardship funds existed, their design and delivery failed as enabling conversion factors, undermined by intrusive eligibility checks and poor communication. In capability terms, financial resources were available but not accessible, thus were ineffective in enabling opportunities.

Similarly, students described a lack of inclusive and transparent career guidance. Those without inherited professional networks or insider knowledge often relied on informal advice or personal initiative to navigate complex postgraduate pathways, creating an uneven playing field for career development. This gap constrained students’ capability to advance, reinforcing existing inequalities and limiting agency.

These findings underscore the requirement for institutional resources that are not only available but genuinely accessible, navigable, and responsive to students’ lived realities. Future research should examine how institutional supports operate as enabling or restrictive conversion factors and identify strategies that transform institutional processes from nominal provision into genuine capability enhancement.

Strengths and Limitations