Levelling up health: A practical, evidence-based framework for reducing health inequalities

There are substantial inequalities in health across society which have been exacerbated by the COVID-19 pandemic. The UK government have committed to a programme of levelling-up to address geographical inequalities. Here we undertake rapid review of the evidence base on interventions to reduce such health inequalities and developed a practical, evidence-based framework to ‘level up’ health across the country. This paper overviews a rapid review undertaken to develop a framework of guiding principles to guide policy. To that end and based on an initial theory, we searched one electrotonic database (MEDLINE) from 2007 to July 2021 to identify published umbrella reviews and undertook an internet search to identify relevant systematic reviews, primary studies, and grey literature. Titles and abstracts were screened according to the eligibility criteria. Key themes were extracted from the included studies and synthesised into an overarching framework of guiding principles in consultation with an expert panel. Included studies were cross checked with the initial theoretical domains and further searching undertaken to fill any gaps. We identified 16 published umbrella reviews (covering 667 individual studies), 19 grey literature publications, and 15 key systematic reviews or primary studies. Based on these studies, we develop a framework applicable at national, regional and local level which consisted of five principles - 1) healthy-by-default and easy to use initiatives; 2) long-term, multi-sector action; 3) locally designed focus; 4) targeting disadvantaged communities; and 5) matching of resources to need. Decision-makers working on policies to level up health should be guided by these five principles.


Introduction
Health inequalities -the systematic differences in health between social groups, places, or across the socio-economic gradient -exist both within and across all countries [1]. Since 2020, we have witnessed a rapid compounding of these existing health inequalities due to the COVID-19 pandemic. Unequal outcomes are being documented across the globe, particularly for disadvantaged and marginalised groups such as those with low socioeconomic status, migrant or minority ethnic groups [2][3][4]. In England, deaths in the most deprived areas of the country are double those in the least deprived and up to three times higher in minority ethnic groups [2,5]. The true impact on inequalities is expected to be much greater due to the long-term economic repercussions of the pandemic including increased unemployment, food and housing insecurity, debt, and poverty [6], which are likely to disproportionally affect people living in areas of higher deprivation and minority ethnic groups [7].
Governments around the world are seeking to address societal inequalities. Before the pandemic, the UK Government committed to a programme of 'Levelling Up' to help left behind areas and regions to recover and prosper to the same extent as other parts of the country. The programme, galvanised by the inequalities from the pandemic, includes investing £830million to transform high streets in 57 local areas, £10million to support improvement for local authorities with lower educational outcomes, £18million to expand the opportunities areas programme to help vulnerable and disadvantaged young people into work, and moving 22 000 civil services roles outside London and the South East [8]. To support the programme, a new No.10/Cabinet Office Level Up Unit was established and a Levelling Up White Paper [9] was published in February 2022. Health has always been a key part of the levelling up agenda, but details have not yet been forthcoming.
While there is a strong literature on reducing health inequalities [10][11][12][13], none is framed from a 'levelling up' health approach. Key evidence-based principles are urgently needed to inform the levelling up for health programme. Therefore, this study set out to conduct a policy-focused rapid review of the research literature to develop a practical, evidence-based framework to level up health by area which can be implemented by a diversity of actors (e.g., governments or non-profits) and across a diversity of scales (e.g., local or national) and contexts (e.g., different countries).

Search strategy
The purpose was not to undertake a systematic review, identifying every study relating to health inequalities, but rather a rapid review to identify high-level evidence. We aimed to identify patterns in the literature to develop overarching principles to guide policy, rather than identifying a list of discrete interventions. We sought principles which would be true in most contexts and at different levels (e.g national, regional and local), acknowledging that these would be patterns in the literature rather than rules. To navigate the breadth of inequalities literature, we developed an initial theory of factors that influence geographical health inequalities (detailed in Appendix 1) developed by the research team, in consultation with an expert and a public panel and based on existing research [14]. The expert panel consisted of six people representing local authorities, think tanks, royal colleagues, and academia. There were two meetings of the expert panel in addition to commenting on the initial project outline and final report. To further contain the scope, we focused primarily, but not exclusively, on umbrella reviews (i.e. reviews of reviews), in additional to grey literature.
In collaboration with an experienced information scientist and librarian (IK) and based on the initial theory, we searched one electronic database (MEDLINE) from 2007 to July 2021 using the search strategy detailed in Appendix 2 to identify all the published health inequalities umbrella reviews. One researcher (AL) screened titles and abstracts according to an inclusion/exclusion criteria and a second researcher (JB) checked them; disagreements were resolved through discussion with a third author (JF).

Inclusion criteria
• Umbrella reviews • Interventions with a place-based approach to levelling up or aiming to reduce geographical health inequalities • Studies based in high income countries as defined by the World Bank • Studies with a comprehensive search strategy and quality assessment process • Studies published in English • Studies with any health-related outcome (e.g., morbidity, mortality, heath care access, health related practices)

Exclusion criteria
• Studies published before 2007 covered by our previous review [13].
• Conference abstracts, commentaries, opinion pieces, editorials • Studies not examining health inequalities by socio-economic status, geography, or area measures • Scoping or mapping reviews or reviews only of associations (i.e., those which do not describe interventions) • Studies which have been superseded by a more up to date review We undertook a broad grey literature search using the key words health inequalities and levelling up health, in an internet search engine (Google) and targeted websites (Kings Fund, Health Foundation, Institute of Health Equity). Grey literature documents were reviewed to identify those which address interventions to reduce socio-economic inequalities or actions to support levelling up. To identify any further key literature, we conducted a snowball search: 1) a review of the references and sources used in these documents; and 2) citation follow-up of reviews included from the broader search above. The grey literature search identified key reviews and primary studies which were included (e.g. evaluation of the previous English health inequalities strategy). Included studies were compared to the initial theory and further targeted searching undertaken to fill any gaps (e.g. welfare).
Data extraction was carried out by one researcher (AL) and checked for accuracy by a second researcher (JB). Data was extracted regarding the aim, domains covered, and key findings for published studies. Data were then mapped against the initial theory of geographic inequalities. Next, two researchers (FD and JF) synthesised the literature via an inductive process to identify themes related to effective reductions in health inequalities. Theme headings were brought together to create a framework of guiding principles highlighting how actions to level up might reduce health inequalities. The framework was iteratively refined by the wider research team and expert panel. Due to time constraints, no formal quality assessment was undertaken.

A practical, evidence-based framework to levelling up health
Five key themes were identified and combined into an evidencebased framework of principles which highlights the need to flatten the health gradient (i.e., level up) while simultaneously improving the health of all (see Fig. 2). The five principles are 1) healthy-by-default and easy to use initiatives; 2) long-term, multi-sector action; 3) locally designed focus; 4) targeting disadvantaged communities; and 5) matching of resources to need. All the principles are supported by a robust evidence base (see Table 2) and are applicable at a national, regional, and local level. They are overlapping, rather than mutually exclusive, and should be implemented in conjunction with each other.

Healthy-by-default and easy to use initiatives
Evidence from 11 studies (4 umbrella reviews and 7 systematic reviews) indicated the importance of healthy-by-default and easy to use initiatives which change the conditions to make health-positive choices easier. For example, changing food purchasing conditions through a combination of taxing unhealthy foods and subsidising healthy foods was consistently documented as an intervention type most likely to reduce health inequalities [17,50,60]. The efficacy of easy to engage with interventions was especially highlighted in comparison to downstream, information-giving interventions which were the most likely to widen inequalities in a variety of outcomes related to diet, weight, cholesterol levels, and folate intake [17,60]. Easy to use programmes were more likely to address inequalities, for example by providing the resources needed to engage in health promoting behaviours [17,28]; providing fluoride toothpaste for home use and daily toothbrushing supervision for 5-year-olds led to a reduction in dental health inequalties [17].

Long-term, multi-sector action
Long-term, multi-sector action was supported by evidence from 6 studies (4 umbrella reviews and 2 systematic reviews). In an assessment of housing and neighbourhood interventions, researchers found that a reduction in health inequalities may not have been observed for some interventions due to the reality that disadvantaged populations face many barriers [15]. An intervention aimed at one determinant alone (housing) is unlikely to be effective when individuals are still impacted by others (e.g., working conditions or access to healthy foods). Housing interventions were most likely to be effective in improving health and reducing inequalities when there were multiple interventions targeting several social determinants of health [15]. Systematic and umbrella reviews of physical activity and healthy eating interventions also show that interventions are more likely to reduce inequalities if they are more intensive, multi-component, address multiple barriers to healthy behaviours, and are based in a range of settings from schools and workplaces to churches and community centres [28,60]. Analyses of welfare states, macroeconomic conditions, and social security policies have found that different policies across all these domains are associated with health inequality [18,53].

Locally designed focus
An evidence base of 5 studies (4 umbrella reviews and 1 systematic review) demonstrated increased efficacy and reduced inequalities for programmes which are tailored to local contexts across various domains such as improving child immunisation rates and parenting interventions [29,52]. Including community-based infrastructure developments was associated with more sustainable physical activity interventions, maintaining increased adult physical activity levels, and reduced inequalities [28]. An umbrella review of community pharmacy-based interventions found that previously unvaccinated individuals were a third more likely to receive the influenza immunisation outside of traditional working day hours [30]. The success of peer-support programmes is also indicative of the potential for locally designed services to reduce health inequalities more effectively by adapting to the particular contexts of communities [59].

Targeting disadvantaged communities
There was evidence from 6 studies (4 umbrella reviews and 2 systematic reviews) that universally applied programmes which do not also target disadvantaged communities or account for their particular needs, assets, and barriers to health are less effective in reducing health inequalities and may even widen them [17,56,61]. This was observed in school-based interventions, immunisation campaigns, national media campaigns, and workplace physical activity interventions. Housing improvement interventions with the largest effects and reductions in inequalities were aimed at vulnerable and low-income groups [15,27]. Provision of benefits to disadvantaged groups may also reduce health inequalities, such as food subsidy programmes for women of low-socioeconomic status which reduced inequalities in mean birthweight and food/nutrient uptake [17].

Matching of resources to need
Two studies assessing the UK Health Inequalities Strategy of 1997-2010 highlighted the importance of allocating resources according to need. This type of funding formula was integrated in the English health inequalities strategy implemented between 1997 and 2010. A time trend analysis of the health inequalities strategy found an

Regional Context
Public Health England (2018) [47] (National) Which service or policy mechanisms, models or approaches, have been shown to be effective or ineffective at reducing inequalities in access to health and social care services?
Report A briefing document that aimed to summarise best available evidence on the interventions, models and approaches to reduce inequalities in access to health and social care services.

N/A Policy and politics England
Public Health England (2018) [48] (National) Which service or policy mechanisms, models or approaches, have been shown to be effective or ineffective at reducing the inequalities that older people experience?
Report A briefing document that aimed to summarise best available evidence on service delivery mechanisms, models or approaches that have been shown to be effective or ineffective at reducing the inequalities that older people experience.

N/A Policy and politics England
Public Health England (2018) [49] (National) Which service or policy mechanisms, models or approaches, have been shown to be effective at reducing educational inequalities in early years?
Report A briefing document that aimed to summarise best available evidence on service delivery mechanisms, models or approaches that have been shown to be effective at reducing educational inequalities in early years.

N/A Policy and politics England
Public Health England (2018) [33] (National)   associated decline in geographically unequal life expectancies compared to increasing inequality both before and after the strategy's implementation [63]. The gap in male and female life expectancy in between the most deprived local authorities and the rest of England was smaller in 2012 by 1.2 and 0.6 years smaller, respectively, than would have been the case if trends in inequalities before strategy implementation had continued [63]. Another study found that allocation of NHS resources proportionate to geographic needwith more deprived areas receiving more resourceswas associated with decreased inequalities in mortality amenable to healthcare [62]. For each £1.00 of new resources allocated to deprived areas there was a greater absolute improvement in mortality amenable to healthcare compared to each £1.00 of new resources allocated to affluent areas [62].

Statement of principle findings
Here we present a practical, evidence-based framework of guiding principles to help level up health: 1) healthy-by-default and easy to use initiatives; 2) long-term, multi-sector action; 3) locally designed focus; 4) targeting disadvantaged communities; and 5) matching of resources to need. The principles are designed to collectively inform national, regional, and local policy and services.

What the findings mean
Progress on closing the gap is possible. The previous UK crossgovernment health inequalities programme reduced the socio-economic gap in life expectancy by six months and improved overall life expectancyboth levelling up and improving overall population health [63]. It also resulted in a reduction in the infant mortality inequalities and healthcare-amenable mortality, demonstrating that with commitment and resources meaningful change is possible [62,63]. This was only achieved through sustained, multi-component, and cross-government action over more than 10 years.
The principles described in this framework are upstream and focused on both structural changes and locally based-community engagement given the complex relationships between health outcomes, the social determinants of health, and human agency [65,66]. Until now, there has been a tendency to start with upstream factors but end up with downstream policies focused on behaviour change, such as untargeted information publicity campaigns, which may actually widen inequalities [67,68]. This so-called lifestyle drift occurs because it is easier to offer services and deliver programmes focused on providing information and warning of risks, than addressing the social structures that dictate the health of places and individuals [68]. This also likely skews the evidence base as behavioural interventions are easier to measure in short term programmes and thus are more likely to be included in the evidence base, documented as successful, and repeated. Top-down interventions which assume a one-size-fits-all approach and fail to engage with local communities are also likely to increase inequalities. Our review stresses the need to avoid these tendencies.
Health inequalities have arisen over decades, if not centuries, and have multiple different facets, but tend to have the same root cause: an unequal distribution of the wider determinants of health. There is no one initiative or programme that will address this unequal distribution of resources, opportunity, wealth, education, and power, but rather a multi-level, multi-component programme sustained over the long term is needed. In the framework, we have avoided highlighting specific domains, such as housing, welfare, employment, or education, but rather identified the guiding principles and transferrable evidence which could be applied in any government department, local authority, public health body, or NHS organisation. This is because levelling up health requires an equity-in-all approach with every sector at every level doing what they can.

Comparison with previous literature
The principles contained within our framework are supported by other reports. Public Health England's Place-Based Approaches to Reducing Inequalities recognises the complex causes of health inequalities and provides guidelines for different sectors to work together, implement multi-component interventions, and use of local data [69]. Our framework also aligns with the 2010 Marmot Review Fair Society, Healthy Lives principles which places a heavy focus on addressing the social determinants of health and acting through proportionate universalism (i.e., making services universally available but directed towards disadvantaged populations) [70]. This review and framework do not point towards specific health issues or determinants to prioritise in addressing health inequalities, which has already been examined in the literature, rather it has assessed the principles of efficacy which appear to carry over across many levels, types, and domains of action to reduce inequalities.  No. of included reviews

Domains covered Evidence
Healthy-by-default and easy to use initiatives Thomson (2018) [17] 29 SRs (150 studies) Tobacco, alcohol, nutrition, reproductive health, infectious disease control, the environment, workplace regulations • 2 studies found USA food stamp (subsidy) programme had positive impacts on foetal survival and weight gain during pregnancy of low-income populations. • 9 studies 10-20% increased intake of targeted foods or nutrients of participants in food subsidy programme • 4 studies of taxes on unhealthy foods and drink showed positive equity effects on diet outcomes • 1 SR found significant drop in casualties in the more deprived areas, compared to the less deprived areas from speed limit interventions. • 1 study found reduced absolute inequalities in dental caries between the most affluent and least affluent areas associated with intervention that provided fluoridated toothpaste and daily toothbrushing supervision for 5-year-olds. • 2 studies found evidence that fiscal incentive schemes (maternity allowance, childcare benefits) may decrease inequalities in vaccination rates. Eyles (2012) [50] 32 studies Nutrition and diet • 11 out of 14 studies reporting impacts by SES found prohealth and pro-equity outcomes for food taxes and subsidies (although many note that taxes would be regressive with more financial burden on low-income individuals). McGill (2015) [60] 36 studies Nutrition and diet • 10 of 18 "price" interventions were likely to reduce inequalities by improving healthy eating outcomes more for individuals of low SES, particularly when interventions were a combination of taxes and subsidies with all 6 respective studies reducing inequalities. • 4 of 6 "place" interventions reduced inequalities and none widened them. • 8 of 19 "person" (individual-based information and education) interventions widened inequalities. Cauchi (2016) [25] 63 SRs Childhood obesity • 48 studies with positive outcomes reported the following effective environmental strategies: improving overall school food environment (nutrition standards, reformulating school lunches, removing vending machines/banning sale of sugar sweetened beverages/snacks high in fat, sugar, or salt), purchasing new PE/sports equipment, daily formal physical activity sessions, providing free or low-cost fruit, making playgrounds available for physical activity after school hours, providing free/low-cost water, providing healthy breakfasts at school, substituting sweetened beverages, reducing screen time at home. Beauchamp (2014) [54] 14 studies Obesity • 5 of 6 interventions with a positive equity impact included structural changes to support behaviour change, 5 had a wide reach (3 community-based and 2 school-based), and all were multi-year in duration. • 4 of 5 interventions with no beneficial impact among lower SES groups had low structural changes and 1 had moderate amounts of structural change, 3 were very short term (2-10 weeks), and 4 were based solely on information delivery. Durand (2014) [55] 19 studies Shared decision-making • 5 of 7 studies differentiating outcome by disadvantage/ literacy levels reduced disparities in knowledge, decisional conflict, uncertainty and treatment preferences suggesting SDM interventions could narrow health disparities by promoting skills/resources needed to engage in SDM. Moore (2015) [61] 20 studies Universal school-based interventions on health behaviours • Of 4 education-based interventions, 1 widened inequalities and 3 had a neutral effect. • Of 4 environmental interventions, 1 reduced inequalities and 3 had a neutral effect. • Interventions combining education and environmental change had mixed results. Carey (2019) [20] 6 studies Personalisation schemes • Accessing and benefiting from schemes based on personalisation requires high levels of skills and resources at the individual level. • Identified factors associated with better outcomes in personalisation schemes were higher levels of economic, cultural, social, and symbolic capital in the forms of education, being employed, having capable networks and support, knowledge and skills in navigating complex systems, household income, knowledge of where to access information and the capacity to self-manage individual budgets. Cairns (2015) [56] 18 studies Obesity • 0 of 11 counselling or advice-based interventions reduced inequalities in obesity.
(continued on next page) No. of included reviews

Domains covered Evidence
Craike (2018) [28] 17 SRs Physical activity • 1 SR found that 2 of 4 universal policies showed a positive equity impact on children's physical activity levels: provincial school physical education policy requiring students to take physical education to graduate from secondary school and a children's fitness tax credit. Haby (2016) [24] 15 SRs, 7 economic evaluations Agriculture, food, nutrition • 1 SR reported on health inequality impact found reduction in health inequalities from balancing taxes on unhealthy foods with subsidies on healthy food.

Long-term, multisector action
Gibson (2011) [15] 5 SRs (130 studies) Housing and neighbourhood conditions • 1 SR (72 studies) found highest efficacy in interventions aimed at multiple pathways (rehousing and changes to: indoor equipment or furniture; respondents' knowledge or behaviour; community norms or collective behaviour; housing policy or regulatory practices, and health practitioners' behaviour) and which are ecological (target multiple levels (i.e. individuals, households, housing and neighbourhoods)). Craike (2018) [28] 17 SRs Physical activity • 3 reviews on children found that physical activity interventions, particularly those that were school-based and multicomponent were likely to be effective.

Macroeconomic determinants
• High quality SR showed evidence of pro-equity impact from taxing tobacco and moderate quality SR found mixed, but mostly positive impact on reductions in preterm births among mothers with low education and black mothers. Supported by findings of 4 other lower quality reviews. • 3 reviews (low quality) found some association between unemployment insurance and reduced inequalities and better health outcomes. • 4 reviews (moderate to low quality) on gendered health inequalities found positive equity impacts from the dualearner policy model and welfare conditions reducing job precarity. • 2 reviews (moderate quality) found pro-equity impacts of occupational health and safety regulations such as preventing toxin exposures. Simpson (2021) [53] 38 studies Social security policy and mental health • 14 of 21 studies on expansionary policies (increased benefit amount or access) improved mental health; 4 studies evaluated inequalities of which 2 reduced inequalities and 2 had no impact. • 11 of 17 studies on contractionary policies (decreased benefit amount or access) worsened mental health; 10 evaluated inequalities which widened in 3, narrowed in 2, and had mixed or no effects in 5. Macintyre (2020) [21] 15 SRs (1720 studies)

Adolescent health
• Evidence for market regulation impact in SR on youth smoking found 7 (of 38) studies showed positive impact on inequalities, 16 showed neutral effects, 12 negative impact, 4 mixed and 1 unclear. Taxation/increasing the price of cigarettes had the most evidence for positive equity impact.

Locally designed focus
Cauchi (  • 3 studies documented a widening of socio-economic inequalities from mass media intervention for pre-conception folic acid use from the national campaign (which persisted for 3 years), but not in the local campaign. The studies showed worsening health inequality effects in terms of folate uptake by education level, and the prevalence of neural tube defects by ethnicity. • 1 SR found that the Expanded Food and Nutrition Education Program (EFNEP) -a federal community outreach programme targeted at low-income familiesincreased fruit and vegetable consumption and had a positive effect on health inequalities. • 2 studies found interventions targeted toward disadvantaged groups increased screening ratesparticularly amongst lower socio-economic groups. • 4 studies found positive effects of 'reminder and recall' systems when targeted at disadvantaged groups, but that universal systems had no effect on reducing inequalities in vaccine uptake rates. 7 studies found a combination of targeted and universal immunisations improved health outcomes for indigenous populations. • 1 study found complex interventions targeted interventions were effective in encouraging child-hood vaccination when specifically targeted at lower SES groups of younger children. Cairns (2015) [56] 18 SRs Obesity • 2 RCTs (strong/moderate quality) demonstrated reduced inequalities in physical activity interventions targeted at low-income workers. • 1 observational study (moderate quality) showed increased inequalities from a universally delivered workplace physical activity intervention. Bird (2018) [27] 17 SRs Built and natural environment • 1 SR found provision of affordable and diverse housing was found to be associated with higher or increased physical activity, primarily walking and perceived safety among those from low-income groups. • 9 SRs reported that provision of affordable housing to vulnerable individuals with specific needs (those living with intellectual disability, substance users, individuals experiencing homelessness, and those living with a chronic condition) was associated higher or improved social, behavioural, physical and mental health-related outcomes. Gibson (2011) [15] 5 SRs (130 studies) Housing and neighbourhood conditions • 30 studies found warmth and energy efficiency interventions had the clearest positive impacts on health. Interventions that reported the largest effects were targeted at vulnerable groups, including those with existing health conditions and the elderly. Durand (2014) [55] 19 studies Shared decision-making • 3 studies suggested that despite knowledge levels being lower in disadvantaged groups pre-intervention, disparities between groups tended to disappear post-intervention, particularly when the intervention was adapted to disadvantaged groups' needs (e.g. low literacy).

Matching of resources to need
Barr (2017) [62] NHS resource allocation

Strengths and limitations
This rapid review assessed evidence from a broad range of umbrella reviews, systematic reviews, primary studies, and grey literature which covered a variety of domains related to health inequalities. This methodology enabled high-level analysis of principles which might impact levelling up health efforts. For the first time, this report brings together a set of practical principles for acting to level up health based on an expansive evidence base. Furthermore, the framework is applicable at many levels from national to local governments and across sectors from non-profit organisations to community institutions. As the principles are broad in scope, they can be applied to any effort to reduce health inequalities and are not constrained by any one domain. The framework is also highly relevant to policy making. Drawing upon an expert panel during the design and interpretation of the research increases the quality.
This review was limited by a general gap in data availability and evaluation of how interventions impact health inequalities. As a rapid review with many levels of included evidence, there was likely a varying degree of quality research included which may have impacted assessment of the evidence base overall. Additionally, some literature may have been missed due to the nature of rapid methodology used. While no formal quality assessment of the included studies was undertaken it was noted in the literature that: many umbrella and systematic reviews did not differentiate results by level of disadvantage; there was a lacking consensus on how to define and measure disadvantage resulting in an incomplete picture of health inequality and leaving unaddressed the nuances of varied health inequality pathways and how intersecting vulnerabilities may be compounded; and there were many shorter-term evaluations reviewed which might not have captured the true impact of interventions. However, the purpose of the review was not to identify and appraise discrete interventions, but rather to identify general patterns in the data to guide policy making. To this end, these limitations are likely to have less of an impact compared to a traditional systematic review.

Research and policy recommendations
The literature on inequalities remains imbalanced on describing the problem of inequalities rather than finding solutions. More detailed research is needed on specific programme and policy impacts and via what mechanisms they reduce inequalities. Future research should collect more robust data assessing how intervention impact is distributed across different levels and types of disadvantage. Further research is needed to examine the extent to which the UK levelling up programme aligns with these guiding principles.
Policy-makers should focus on long-term, collaborative and crossgovernment strategies; the ambition to level up health will not be achieved in one electoral cycle. Efforts to address health inequalities across and within countries will require action from different actors and sectors to address the multiple wider determinants of health. National and local policies to level up should be informed and checked against these evidence-based levelling up for health principles, for example within the health inequalities impact assessment process [71]. The government should prioritise those interventions, such as widespread fluoridation of water and pollution reduction, which create healthier conditions for all. Local community engagement is fundamental. This requires building long-term relationships and trust with communities, and ensuring representation reflects the diversity of each community. Bespoke initiatives for communities facing specific issues are needed alongside universal initiatives ensuring that resources, such as funding, staff time or estates, are allocated proportionate to need is imperative to levelling up.

Conclusions
The pandemic has exposed and exacerbated health inequalities. It is paramount that action is taken to reduce health inequalities, closing the gap between those who experience good and poor health while also improving health for all. Here we present a framework of guiding principles based on a high-level rapid review of the evidence to inform levelling up health. These five principles are 1) healthy-by-default and easy to use initiatives; 2) long-term, multi-sector action; 3) locally designed focus; 4) targeting disadvantaged communities; and 5) matching of resources to need. These principles can and should be applied to the efforts of recovering from and rebuilding after the pandemic and more research is needed to assess the extent to which health inequalities actions align to this framework.

Funding
This research was externally commissioned by Public Health England.

Declaration of competing interest
The authors declare that they have no known competing financial  (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21). This explained 85% of the total reduction of absolute inequality in mortality amenable to healthcare during this time. interests or personal relationships that could have appeared to influence the work reported in this paper. 49 34 and 48 430648 50 ((communit* or citizen* or public* or minorit* ethnic* or stakeholder* or population* or neighbourhood or neighbourhood) adj5 (engag* or develop* or empower* or involv* or participat* or collaborat* or consult* or partner* or forum* or panel* or jury or champion*)