How “upstream-downstream” metaphor helps us

The upstream-downstream metaphor helps to choose the most cost-effective public health interventions. This post curate peer-reviewed articles of which the main focus is the “upstream-downstream” metaphor.

1. The upstream-downstream metaphor to reduce health inequalities

In this article Naoimh, E. McMahon , a big fan of the upstream-downstream story, reviews literature published until June 2020 about how the upstream-downstream metaphor has helped us to frame action to reduce health inequalities. I am summarising here her findings;

  • Critique the “downstream problem framing”
  • Recommend “upstream” policies and programmes
    • Industry regulation – e.g. smoke-free legislations
    • Increase in minimum wages
    • Programmes to change social norms and power relations
  • Promote “upstream” approaches
    • Programes to promote political literacy and advocacy
    • To apply place-based action such as actions of local departments, city counciles etc.
  • Apply the metaphor to guide the implementation process.

The full text is available for free.

Link to the article:

In her previous article published on the Critical Public Health Journal, she describes how England researchers interpret the “upstream-downstream” parable.

In Naoimh’s two blog posts, she clearly dissects the upstream-downsstream metapor. In one post she focuses on what do we mean when we talk about “upstream” actions with regard to reducing health inequalities. In the second post, she delves into the question of why the metaphor does not always work as expected.

2. Concepts and issues in public health: Culture, Physchology, and the Ecological approach

This article discusses several upstream and midstream interventions; for example, education as a midstream intervention. It is excellent up to date summary of the upstream -midstream approaches.

Its full text is available as a PDF.


3. How some effective interventions increase health inequality

Theo Lorenc from the London School of Hygiene and Tropical Medicine details how some although effective increase health inequalities between socio-economic groups. The commonest ones include “downstream” interventions and media campaigns. In contrast, “upstream interventions” such as fiscal methods such as an increase in tobacco pricing, resource provision, structural workplace interventions reduce health inequalities between socio-economic groups.

Its full text is available as a PDF.


4. How health eudcators move “upstream” in this COVID 19 pandemic

Amy J. Schultz et al. argue in this article how health educators in Michigan can contribute to moving “upstream” to address the COVID19. Although they have published the article in May 2020 on the Health Education and Behavior journal, their suggestions become a strong advocacy role to push through the “upstream” agenda.

Its full text is available as a PDF.


5. Upstream versus downstream interventions to reduce dietary sodium intake

Simon Capewell and Chris Kypridemos in this American Journal of Public Health journal article compare upstream and downstream strategies aimed at achieving the recommended daily dietary sodium levels of us. They consider individual, worksite, and community interventions as “downstream” interventions. In contrast, policies aimed at the reformulation (mandatory as against voluntary) of processed food, food labelling, and medical campaigns are considered “upstream” methods. We can find “upstream” examples from Finland, Japan, and the UK.

Its full text is available through this link:

6. Proximal versus distal and downstream versus upstream

This 2008 Nancy Kreiger’ in her thought-provoking article argues to abolish proximal-distal nexus from public health discourse. The reason I added to this list is that she equals proximal to downstream approaches and distal to upstream ones. This discussion broadens our thinking about upstream-downstream thinking.

The full text is available through this link;

7. Upstream versus downstream climate strategies

This article panel written by JoƫlForamitti et al. apply upstream-downstream metaphor into climate policies. The authors differentiate strategies under three streams: Upstream, midstream, and downstream.

Stream levelWhere regulatory measures are applied
Upstream strategiesSource level: where oil extraction and import occurs
Midstream strategieswhere the oils are refined and transported
Downstream strategiesWhere the actual emissions occur

Access to the full text is available through this link:


Author: Prasantha De Silva

A specialist in Community Medicine board-certified in Sri Lanka and a research analyst in Canada

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