For citation purposes: Bosma H. Social epidemiology: Shuttling between upstream and downstream: A personal and narrative review. OA Epidemiology 2014 Mar 22;2(1):5.


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Social epidemiology: Shuttling between upstream and downstream: A personal and narrative review.

H Bosma

Authors affiliations

(1) Maastricht University, CAPHRI, Social Medicine, P.O. Box 616, 6200 MD Maastricht, the Netherlands

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This paper is a personal and narrative review of social epidemiology as a field of research in its own right, studying the substantial, persistent and widening gaps in health between lower and higher socioeconomic status groups. It portrays social epidemiology as a discipline studying how upstream, environmental factors (e.g. social stratification) influence health via downstream, individual factors (e.g. smoking or personality), how downstream factors (e.g. genetic factors or personality) might be just as fundamental as upstream factors in generating later socioeconomic differences in health, and how downstream factors almost never exist in a social vacuum. This review describes five themes in social epidemiology, two main perspectives on the explanation of socioeconomic differences in health, and some confusing findings regarding (natural) interventions in the United Kingdom and the Scandinavian countries. It portrays social epidemiology as a discipline that needs to shuttle back and forth between upstream and downstream factors for a full understanding of why socioeconomic differences in health exist and to find better tools to tackle the refractory health inequalities. It is a personal review, as I not only use my own work to illustrate the line of thought, but, having worked in the field for more than two decades, also permit myself a few personal reflections and comments.


People in lower socioeconomic positions have higher risks of disease and premature mortality than their better-off counterparts. The problem is persistent and even worsening. Social epidemiology is portrayed as a challenging field of research where some questions have been answered, but new questions continue to be raised. To advance the field of research, social epidemiology can no longer dismiss individual (downstream) factors as potentially equally fundamental influences on people’s life-courses. Simultaneously, contextualisation (e.g. of health behaviours) remains important, particularly in the current era dominated by an emphasis on individual responsibility.

Licensee OA Publishing London 2014. Creative Commons Attribution License (CC-BY)