Proportionate universalism to reduce health inequalities: an agile scope of the secondary literature

Next update: Update not planned

Contact for queries and feedback

Introduction

Health inequalities remain a major challenge, with people who have fewer resources often experiencing poorer health and shorter lives. Proportionate universalism offers services to everyone, but with extra support for those who need it most, aiming to improve population health and reduce unfair gaps across the social gradient.

This scoping review focused on adult public health and behaviour‑change interventions. We aimed to identify which interventions applied proportionate universalism, describe where and how the principle was put into practice, and summarise its effect on reducing health inequalities.

Main points

How up to date is this evidence?

We conducted the searches in March 2023 and applied no date limits. This summary reflects the evidence available up to that date.

What we found

• No robust secondary research directly evaluated interventions applying proportionate universalism to reduce adult health inequalities.
• One scoping review (2020) mapped definitions and use of the principle (55 studies) but did not assess effectiveness. It found few interventions explicitly using proportionate universalism and noted challenges in applying proportionality and identifying need.
• Due to limited secondary evidence, we screened primary studies. Of four full‑text papers, three UK studies met criteria (quality not appraised). Overall, there is very limited primary evidence testing effectiveness in adults.
• A UK study on free, universal off‑peak exercise classes found no higher participation in deprived groups, and lower retention in the most deprived 20%. A linked cost analysis suggested possible value for money but noted strong limits in design and data.
• A quasi‑experiment in Glasgow on neighbourhood renewal funding showed larger mental‑health gains in higher‑investment areas, though it targeted only deprived areas and was not a strict proportional universalism model.
• Evidence across studies was limited by design constraints, area‑level measurement, moderate response rates, and uncertainty about how closely interventions reflected the principle.

What this means

• This review does not assess whether proportionate universalism “works” as a principle. Instead, it maps where the approach has been applied in real‑world programmes and highlights what existing research can and cannot tell us. Evidence was limited, and it is likely that some interventions apply the principle without naming it, so we cannot draw firm conclusions about effectiveness.
• Further research could take a more targeted approach by searching for specific interventions or outcomes linked to reducing inequalities, or by focusing on particular settings such as adult community programmes. Work on children and family services may also be useful if in scope. Given the limited evidence and the likelihood that some relevant studies were not captured, any use of proportionate universalism should be piloted, adapted to local context, and carefully evaluated.

Technical information

We aimed to give a broad overview of the evidence by summarising what the original authors reported, without re‑interpreting their findings. We extracted key factors from relevant systematic reviews and, where needed, from primary studies, and summarised them briefly in this report. Because our searches focused on terms related to “proportionate universalism,” we may have missed programmes that applied the principle without naming it. If a specific factor is important for your work, we recommend consulting the original studies to judge how well their findings apply to your context. This is a short summary; full details of the search, inclusion criteria, and synthesis approach are available in the full report.

Glossary

Proportionate Universalism: An approach to healthcare and public health that combines universal access to services with a scale and intensity of care that is tailored to the level of need or disadvantage.

Health Inequalities: Avoidable differences in health outcomes between groups or populations – such as differences in how long we live, or the age at which we get preventable diseases or health conditions. For example, differences linked to income, education, work, housing, or where people live.

Social Gradient: The idea that there is a direct, step-by-step correlation between a person’s socioeconomic position (income, education, occupation) and their health outcomes i.e., health usually improves at each step up the social ladder, and people with more resources tend to have better health and longer lives and vice versa.

Scoping Review: A type of evidence review that maps what research exists on a particular topic or research area, rather than testing how well something works. It helps map the available evidence on a topic, clarify concepts as well as identify gaps in research.

Primary Study: An original research investigation where researchers collect and analyse data directly (for example, surveys, interviews, or experiments), rather than summarising other studies.

Secondary Research: Research method that involves the synthesis, analysis, and interpretation of existing data or literature previously collected by others, rather than collecting new, primary data.

Deprivation: In the context of health and social care in Wales, deprivation goes beyond simple poverty (low income). It refers to a widespread, multi-faceted lack of access to essential resources and opportunities that are necessary to maintain a standard of living that supports good health.

Pilot study or piloting: Testing a programme on a small scale first to see whether the components of the main study can all work together and how well it would work in a local context. Also known as “feasibility study”, “feasibility test”, “pilot experiment” or “pilot trial”.

Stakeholders

Iain Bell, Director of Knowledge and Research, Public Health Wales