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Thinking Upstream: A 25-Year Retrospective and Conceptual Model Aimed at Reducing Health Inequities

Butterfield, Patricia G. PhD, RN, FAAN

doi: 10.1097/ANS.0000000000000161
Original Articles

Thinking upstream was first introduced into the nursing vernacular in 1990 with the goal of advancing broad and context-rich perspectives of health. Initially invoked as conceptual framing language, upstream precepts were subsequently adopted and adapted by a generation of thoughtful nursing scholars. Their work reduced health inequities by redirecting actions further up etiologic pathways and by emphasizing economic, political, and environmental health determinants. US health care reform has fostered a much broader adoption of upstream language in policy documents. This article includes a semantic exploration of thinking upstream and a new model, the Butterfield Upstream Model for Population Health (BUMP Health).

Washington State University College of Nursing, Spokane.

Correspondence: Patricia G. Butterfield, PhD, RN, FAAN, Washington State University College of Nursing, 103 East Spokane Falls Blvd, Spokane, WA 99202 (

The author benefited greatly from the input of 3 gifted scholars who reviewed the manuscript; they are Dr Julie Postma, Dr Betty Bekemeier, and Ms Sarah Valentine-Maher. Their wisdom and encouragement were invaluable.

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

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