Advancing Our Ability to Monitor and Address the Population Health Impacts of the Commercial Determinants of Health

Date of Award

Spring 1-1-2025

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Health

First Advisor

Ransome, Yusuf

Abstract

Background: The activities of commercial entities have significant impacts on population health and health equity. These activities and the systems, structures, norms, and values that underpin them are studied in the public health literature through the lens of the commercial determinants of health (CDH). Though research on the CDH has progressed rapidly in the last few years, two critical gaps have yet to be addressed. The first is the need to identify and develop mechanisms to systematically monitor the activities of commercial entities that influence population health. The second is the need to identify, develop, and/or leverage mechanisms that can be used to discourage commercial practices that harm population health and encourage commercial practices that support population health. The research presented in this dissertation was designed to advance progress towards addressing these gaps. Specifically, the aims of this dissertation were to: 1) develop a model and typology of the activities through which commercial entities can influence population health and health equity across industries, 2) adapt this model to the food and beverage (F&B) industry and identify monitoring priorities for this sector, and 3) investigate the extent to which existing Environmental, Social, Governance (ESG) investment frameworks capture the activities of the F&B industry that influence population health and health equity, as one potential mechanism to both monitor and address the CDH. Methods & Results: Chapter 2: We conducted a scoping review and qualitative synthesis of CDH literature (n = 116) to develop a typology of commercial activities that can influence population health and health equity across industries. The resulting Corporate Influences on Population Health (HEALTH-CORP) typology identifies 70 activities through which commercial entities can influence population health, which are categorized across seven domains of corporate influence (e.g., political practices, environmental practices). We developed a model that situates these domains based on their proximity to health outcomes (i.e., distal to proximal) and identified five population groups whose health is affected by commercial activities (e.g., consumers, local communities). Chapter 3: We elicited input from public health professionals and academics (n = 22) to adapt the HEALTH-CORP typology to the F&B industry and identify potential monitoring priorities. Participants rated the importance of measuring each HEALTH-CORP domain on a 4-point scale (from “not important” (0) to “very important” (3)). They also provided written feedback on how to adapt the typology to the F&B industry. We used qualitative and quantitative techniques (e.g., Mann-Whitney U tests) to summarize participants' feedback and investigate subgroup differences in importance ratings. The political practices domain received the highest mean importance rating (M = 2.95, IQR = 0), whereas employment practices received the lowest (M = 2.14, IQR = 2). Importance ratings for the domains of employment practices and practices affecting local communities were significantly higher for individuals reporting current employment in a low-and-middle-income country (LMIC) than those not reporting current employment in an LMIC. We received 324 comments that informed the resulting HEALTH-CORP-FB typology, consisting of 89 F&B industry activities that can influence health (e.g., profiteering, use of child-appealing packaging). Chapter 4: We conducted a framework analysis in which five existing ESG reporting standards and ratings systems were investigated to understand the extent to which they capture the activities of the F&B industry that can influence population health and health equity. The fields from the ESG frameworks (i.e., disclosures, metrics) were compared to the activities in the HEALTH-CORP-FB typology to identify topics already covered by these frameworks and to document where gaps currently exist. The ESG fields for the packaged foods subindustry were then further characterized by three attributes (i.e., relevance, type of business operations, and data type). A total of 1348 ESG fields were mapped to the HEALTH-CORP-FB typology. On average, the ESG frameworks captured 39% of the activities in the typology (range across frameworks: 27-48%). A higher proportion of the activities in the governance, environmental, employment, and economic practices domains were covered by the ESG frameworks (range across domains: 43-87%) than the activities in the products and services, preference and perception-shaping practices, and political practices domains (17-36%). ESG fields corresponding to the latter domains also seemed to measure corporate activities in an inferior way. That is, the products and services, preference and perception-shaping practices, and political practices domains had lower proportions of fields that were considered highly relevant (range across domains: 26-53%) and that measured corporate performance (21-26%) than the ESG fields corresponding to the governance, environmental, employment, and economic practices domains (62-70% and 40-59%, respectively). We propose fields that could be added to existing ESG investment frameworks to improve the extent to which they capture the health impact of this industry (e.g., percent of revenue from food products classified as ultra-processed). Chapter 5: We propose ways in which the CDH field could continue to progress in monitoring and addressing the CDH. Specifically, we identify the lack of accessible, high-quality data as a critical barrier to monitoring corporate practices and discuss how leveraging corporate non-financial reporting may be a means to improve data availability. We then review the strengths and limitations of two relevant agenda-setting exercises (the Sustainable Development Goals and global action to address the social determinants of health) to propose five principles (e.g., prioritization, strategic framing) to guide the development of the World Health Organization’s forthcoming CDH policy recommendations. Conclusions: This dissertation documents the diverse range of activities through which commercial entities can impact population health and health equity in terms of cross-industry practices and practices employed by the F&B industry. The HEALTH-CORP and HEALTH-CORP-FB typologies may be a valuable resource for policymakers and public health professionals. The typologies also offer conceptual infrastructure to facilitate the monitoring of corporate activities that impact population health. Finally, this dissertation lays the necessary groundwork for further consideration of ESG investment criteria as a potential mechanism to monitor and address the activities of the F&B industry that impact population health and health equity. Future work could build on these advances by continuing to investigate these avenues and other mechanisms for monitoring and addressing the CDH (e.g., incorporating teaching on the CDH into the curricula of business schools).

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