Abstract:Strengthening HIV prevention remains an urgent global health priority. The problem is that 'advancement' in HIV prevention often stands for the development of biomedical technologies or interventions. Theories and practices of health promotion have been advocating a shift from a biological/medical preventive focus to a more social one; from the level of individuals to organisations, communities and broader social policy. It seems, however, that in practice a real shift in the desired direction remains an elusi… Show more
“…In contrast, where authors centred the importance of economic inequality in driving health inequalities, 18 , 27–29 ‘upstream’ policies were those which involved redistribution and ‘fundamental social reform’ 29 to raise the incomes of low-wage workers, improve education and employment opportunities, and provide a safety net against poverty. 28 Lastly, for those authors who centred the role of social norms and power relations in shaping personal autonomy and risk exposure, 17 , 30 ‘upstream’ programmes were those which could be explicitly linked to a broader political project of, for example, achieving gender equity through wider social change. The example of microfinance initiatives was provided to illustrate how such programmes may work at the intersection of social and economic inequalities.…”
Section: Resultsmentioning
confidence: 99%
“…The example of microfinance initiatives was provided to illustrate how such programmes may work at the intersection of social and economic inequalities. 30 While these authors focused on the rationale for specific policies/programmes, others used the metaphor to argue for ways of working needed for such actions to be realized.…”
Background
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.
Methods
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.
Results
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.
Conclusions
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.
“…In contrast, where authors centred the importance of economic inequality in driving health inequalities, 18 , 27–29 ‘upstream’ policies were those which involved redistribution and ‘fundamental social reform’ 29 to raise the incomes of low-wage workers, improve education and employment opportunities, and provide a safety net against poverty. 28 Lastly, for those authors who centred the role of social norms and power relations in shaping personal autonomy and risk exposure, 17 , 30 ‘upstream’ programmes were those which could be explicitly linked to a broader political project of, for example, achieving gender equity through wider social change. The example of microfinance initiatives was provided to illustrate how such programmes may work at the intersection of social and economic inequalities.…”
Section: Resultsmentioning
confidence: 99%
“…The example of microfinance initiatives was provided to illustrate how such programmes may work at the intersection of social and economic inequalities. 30 While these authors focused on the rationale for specific policies/programmes, others used the metaphor to argue for ways of working needed for such actions to be realized.…”
Background
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.
Methods
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.
Results
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.
Conclusions
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.
“…This is discussed by Gilbert, who claims that There is no doubt that if the ultimate goal is to affect the ‘social’ in the epidemic, public health efforts need to focus on integrated and relevant ‘structural interventions’ along the continuum of the disease trajectory that correspond with the main drivers of the epidemic. 3 ( 2012 :74) …”
Section: Discussionmentioning
confidence: 99%
“…1 (a)) as well as the wider framework of forces shaping the manifestations of stigma ( Fig. 1 (b)) based on the social-ecological model (Gilbert 2012 ). 4 Fig.…”
Although stigma and its relationship to health and disease is not a new phenomenon, it has not been a major feature in the public discourse until the emergence of HIV. The range of negative responses associated with the epidemic placed stigma on the public agenda and drew attention to its complexity as a phenomenon and concept worthy of further investigation. Despite the consensus that stigma is one of the major contributors to the rapid spread of HIV and the frequent use of the term in the media and among people in the street, the exact meaning of ‘stigma’ remains ambiguous. The aim of this paper is to briefly re-visit some of the scholarly deliberations and further interrogate their relevance in explaining HIV-related stigma evidenced in South Africa. In conclusion a model is presented. Its usefulness – or explanatory potential – is that it attempts to provide a comprehensive framework that offers insights into the individual as well as the social/structural components of HIV-related stigma in a particular context. As such, it has the potential to provide more nuanced understandings as well as to alert us to knowledge-gaps in the process.
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