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

Mcmahon, Naoimh orcid iconORCID: 0000-0001-6319-2263 (2019) Working ‘upstream’ to reduce health inequalities: A Foucauldian discourse analysis. Doctoral thesis, University of Central Lancashire.

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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 counter-discourse, 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.

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