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What shapes local health system actors’ thinking and action on social inequalities in health? A meta‑ethnography

Social Theory & Health

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Local health systems are increasingly tasked to play a more central role in driving action to reduce social inequalities in health. Past experience, however, has demonstrated the challenge of reorienting health system actions towards prevention and the wider determinants of health. In this review, I use meta-ethnographic methods to synthesise findings from eleven qualitative research studies that have examined how ambitions to tackle social inequalities in health take shape within local health systems. The resulting line-of-argument illustrates how such inequalities continue to be problematised in narrow and reductionist ways to fit both with pre-existing conceptions of health, and the institutional practices which shape thinking and action. Instances of health system actors adopting a more social view of inequalities, and taking a more active role in influencing the social and structural determinants of health, were attributed to the beliefs and values of system leaders, and their ability to push-back against dominant discourses and institutional norms. This synthesised account provides an additional layer of understanding about the specific challenges experienced by health workforces when tasked to address this complex and enduring problem, and provides essential insights for understanding the success and shortcomings of future cross-sectoral efforts to tackle social inequalities in health.

Working ‘upstream’ to reduce social inequalities in health: a qualitative study of how partners in an applied health research collaboration interpret the metaphor

Critical Public Health 

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Evidence suggests that despite the popularity and influence of key health equity concepts, they often fail to shift the thinking and actions of health workforces towards the social and structural determinants of health inequalities. These findings tend to be attributed to institutional constraints, along with the role of influential discourses which promote a focus on individuals and behaviours. However, questions have also been raised about the clarity and utility of the concepts themselves, and the extent to which the language they use works (or indeed fails to work) in reorienting thinking and action. The purpose of this study was to explore how partners in an applied health research collaboration in England interpreted the popular ‘upstream-downstream’ story, and what it means to work ‘upstream’ to reduce health inequalities. Where participants were not familiar with its academic or technical usage, the story was taken to be a metaphor for prevention generally, or it prompted a root cause analysis of the more discrete ways in which inequalities were encountered in participants’ research or work. Even in instances where participants did hold more socio-political perspectives, these were often not evoked by the metaphor itself. Two of the 18 participants were unable to equate the metaphor with particular actions or ways of working, while others found it to be a poor fit with how they understood inequalities. The study findings illustrate and explain the challenges that arise when technical metaphors from the health equity literature are opened-up to interpretation by wider audiences.

Framing action to reduce health inequalities: what is argued for through use of the ‘upstream-downstream’ metaphor?

Journal of Public Health

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Public 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.


An 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.


All 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.


The 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.

Working ‘upstream’ to reduce health inequalities: A Foucauldian discourse analysis

If you have a lot of spare time, you're welcome to go to source and read my thesis. You'll find it if you click here. The content might appear slightly different to the published articles which reflects both space constraints in journals and (hopefully) better and clearer arguments. 


There has been a long-standing concern to reduce health inequalities between different social groups. While primarily understood as arising from the inequitable distribution of power, wealth, and resources, in recent years dominant scientific and political discourses have resulted in health inequalities being understood as a problem of individual behaviour. In response, a number of counter-discourses have emerged which seek to reorient efforts away from tackling these symptoms of the problem, to work once again at the level of root causes. In this thesis, I conduct an in-depth analysis of one of these counter-discourses, the upstream parable, to examine how it operates in research and practice. Employing a form of discourse analysis underpinned by the ideas of Michel Foucault, I examine how the idea of working ‘upstream’ is articulated in a sample of peer-reviewed articles, and how it is interpreted by a sample of people working to reduce health inequalities in the North West of England. I demonstrate that there are many different ways of constructing the problem of health inequalities, and that the upstream counterdiscourse, rather than resulting in a reframing of the problem, is in fact interpreted in light of existing perspectives. This finding illustrates the malleability of the discourse, and serves to challenge the extent to which it can operate to successfully reframe the problem of health inequalities, and reorient efforts to work at root causes. In this thesis, I make an original contribution to knowledge by going beyond a critique of dominant perspectives to provide original insights about how an established counter-discourse, in the field of health inequalities, operates in practice. I identify shortcomings of the discourse, and make recommendations for how ideas which appear in the academic literature, could be employed more fruitfully in practice to reorient efforts to work at the root causes of this intractable problem.

Full publications list

I'm just including my most recent publications from my own research on this page. 

For a full list of other work in which I've been involved click here.

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