ReviewJournal of public health (Oxford, England)2022
Framing action to reduce health inequalities: what is argued for through use of the 'upstream-downstream' metaphor?
Review in Journal of public health (Oxford, England), 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 21 papers, 2 of them syntheses that pooled it.
What it found
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
21 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- The effect of climate mitigation and adaptation policies on health and health inequalities: a systematic review.The Lancet. Planetary health · 2025Pooled it
- Area-Level Factors of Dental Caries in Children and Adolescents in European Neighborhoods - a Systematic Review.Journal of urban health : bulletin of the New York Academy of Medicine · 2025Pooled it
- World Cafés as a method of identifying cross-sectoral policy solutions to social determinants of health equity in Australia.Health promotion international · 2026Article
- Marginalising prevention during Health Devolution in Greater Manchester? A qualitative study of the perceptions and experiences of public health professionals.Journal of public health (Oxford, England) · 2026Article
- Upstream Interventions to Promote Oral Health and Reduce Oral Health Inequalities: A Scoping Review.Community dentistry and oral epidemiology · 2026Article
- Multilevel influences on family caregiver burden in diabetic foot ulcer care: a qualitative study.BMC nursing · 2026Article
- Commonly cited approaches to reducing health inequalities: a call for more clarity around their definition and underlying assumptions.Journal of epidemiology and community health · 2026Review
- Beyond Risk Prediction: Considering Upstream Universal Suicide Prevention to Decrease Risk and Increase Resilience.Behavioral sciences (Basel, Switzerland) · 2026Review
- Education as an upstream social security intervention: constructing a competency-based talent development framework in health economics.Frontiers in public health · 2026Article
- "Who the hell is upstream pushing them all in?" Reclaiming public health's defining metaphor to counter the commercial determinants of health.PLOS global public health · 2026Article
- Article
- The upstream-downstream tension in the global health classroom.BMJ global health · 2025Article
- PROTOCOL: Co-Responding Police-Mental Health Programs and the Impact on Justice and Social Service Outcomes: A Systematic Review.Campbell systematic reviews · 2025Article
- Exploring the social context of smoking behaviours: insights from stop-smoking advisors in deprived communities in Northwest of England UK.BMC public health · 2025Article
- Considerations for using participatory systems modeling as a tool for implementation mapping in chronic disease prevention.Annals of epidemiology · 2025Article
- A mixed methods exploration of the lifestyle drift concept to support the development of measurement tools.Discover public health · 2025Article
- Identifying opportunities for upstream evaluations relevant to child and maternal health: a UK policy-mapping review.Archives of disease in childhood · 2023Review
- Does resource insecurity drive HIV-related stigma? Associations between food and housing insecurity with HIV-related stigma in cohort of women living with HIV in Canada.Journal of the International AIDS Society · 2022Article
- Upstream interventions to promote oral health and reduce socioeconomic oral health inequalities: a scoping review protocol.BMJ open · 2022Article
- 'It All Kind of Links Really': Young People's Perspectives on the Relationship between Socioeconomic Circumstances and Health.International journal of environmental research and public health · 2022Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
1 author.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundPublic health insights struggle to compete with dominant ideas which frame health inequalities as a problem of individual behaviour. There is consequently a need to critically reflect upon and question the effectiveness of different strategies for framing and communicating key insights. Taking the example of the 'upstream-downstream' metaphor, this literature review contributes to a necessary first step by asking what exactly is being argued for through its use.
methodsAn iterative search strategy was used to identify peer-reviewed articles which could contribute to the review question. A discourse analysis framework informed data extraction and synthesis of 24 articles. Articles were subsequently categorized into groups which reflected the different uses of the metaphor identified.
resultsAll authors used the metaphor to promote a particular causal understanding of health inequalities, leading some to recommend policies and programmes, and others to focus on implementation processes. This seemingly simple metaphor has evolved beyond differentiating 'upstream' from 'downstream' determinants, to communicate an ambitious politically engaged agenda for change.
conclusionsThe metaphor is not without its critics and in light of the complexity of the arguments encapsulated in its use, work is needed to establish if it can, and does, resonate as intended with wider audiences.
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What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.