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The large losses and inequities in health and wellbeing due to harmful commodities such as tobacco, alcohol, unhealthy food and beverages, and gambling products are well-established.[[1–5]] Acknowledging the sophisticated means by which industries producing these commodities exploit consumers, and the political economy of globalisation, Kickbusch et al. define the term “commercial determinants of health” (CDoH) as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health”.[[6]] Through CDoH, corporations exert power and influence by shaping the societal norms and environments in which people live, grow up, work, play and socialise.[[7,8]] Harmful products are normalised and consumer choices are shaped for the benefit of corporate profits. Along with the socio-economic determinants of health, racism and colonisation, CDoH are important upstream drivers of health loss and inequities in New Zealand.

The health sector has an important role to play in reducing and preventing the influence and impact of CDoH. The final report of the New Zealand Health and Disability System Review states: “there is a need for much more concerted action at national, regional and local levels to address the CDoH”.[[9]] Responding effectively to the CDoH can help achieve the aims of the New Zealand public health system, i.e., to protect, promote and improve the health of all New Zealanders; to achieve equity in health outcomes among New Zealand’s population groups; and to build towards pae ora (healthy futures) for all New Zealanders.[[10]]

Given a lack of guidance on how the health sector can effectively address CDoH, the aim of this study was to develop and apply a theoretical framework to assess the rigour of a district health organisation’s response to CDoH.

Methods

The multi-method study was conducted in 2021 at Counties Manukau Health (CM Health) in three phases, guided by the Institute for Health Improvement’s “Plan-Do-Study-Act” cycle.[[11]] In Phase one (“Plan”), a theoretical framework was developed describing CDoH and how to respond, based on two focused literature reviews and applying principles of Te Tiriti o Waitangi—the Treaty which established the relationship between Māori, the Indigenous people of New Zealand, and the British Crown. Phase two (“Do”) involved using the framework to assess CM Health’s response to CDoH based on policy document review and perspectives of key informants. In Phase three (“Study”), the framework was refined and recommendations for strengthening the response, in a future “Act” phase, were formulated.

The first literature review aimed to summarise key CDoH mechanisms and strategies. Publications were included in the review if they included a conceptual theory or framework describing what CDoH are and how they exert influence. General background or discussion articles were excluded. MEDLINE electronic database was searched using the search terms “commercial or corporat* AND determinant* AND health or disease*”, and was limited to English language publications from 2000 to May 2021. Grey literature (using Google) and snowball searching was conducted. Data from included articles were summarised in table and narrative form. Key aspects of interest included definition of CDoH, type of evidence, mechanisms of influence, and outcomes.

The second literature review aimed to summarise evidence about how health sector organisations can respond to CDoH. A relevant scoping review by Mialon and colleagues published in 2020[[12]] identified ways to manage the influence of CDoH in the context of public health policy, research and practice. The search strategy in this article was replicated for the period 2019–2021. Expert advice was sought, and Google searching carried out to identify relevant grey literature. Data were summarised in table and narrative form, with a focus on recommended mechanisms, relevant to the health sector, for responding to CDoH.

For the document review, the CM Health intranet, including the document directory and department pages, was searched for relevant policy, procedure and guideline documents. Documents were reviewed against the “response” section of the framework (shown in Figure 1).

Next, a qualitative study explored the perspectives of three key stakeholder groups: CM Health employees, academics/experts on the topic, and people in community organisations. The 12 participants, recruited through a purposive sampling strategy, included four Māori and three Pasifika participants. The sample size was chosen for pragmatic reasons, and the concept of data saturation was not deployed in this study.[[13]] Participants were provided with a participant information sheet and gave written, informed consent. Semi-structured interviews (conducted by KM) were audio-recorded and later transcribed by a commercial transcription service. Topics explored were outlined in an interview guide and included: 1) perceptions of the visibility of CDoH; 2) perceptions of the current response to CDoH; 3) suggestions for how CM Health could strengthen the response; and 4) thoughts and feedback on the theoretical framework under development. Thematic analysis of data (KM and SS) used a constructivist approach[[14]] and involved close reading of transcripts, coding of text, categorisation of codes and interpretation of ideas, comparison within and across key stakeholder groups, and development of themes.

Ethics approval was granted by the Auckland Health Research Ethics Committee (reference AH21918) and locality approval by the CM Health Research Office.

Results

Phase 1: development of theoretical framework

This section describes findings from the literature reviews that, together with application of Te Tiriti of Waitangi principles and refinement based on input from key informants, resulted in the framework shown in Figure 1.

Literature review: key CDoH mechanisms and strategies

Of 678 records identified, 28 were potentially relevant based on abstracts, and full texts were reviewed. Nine articles fulfilled the eligibility criteria and were included in the review (Appendix 1).[[6,15–22]] All articles were descriptive in nature, included conceptual frameworks, and acknowledged impacts and consequences of CDoH. Outcomes described were broad and included political, cultural, social, environmental and health effects. Two articles took a nuanced approach to outcomes, allowing recognition of both positive and negative impacts by corporations.[[16,18]]

In general, articles described CDoH as being enmeshed within broad political, economic and regulatory environments, allowing CDoH to operate and promote corporate growth.[[6,15,16,18–20]] Four articles explored the concept of power, which was described as influencing decision making in three ways: 1) direct influence in decision making; 2) indirect influence on agenda setting and limiting choices (e.g., keeping controversial topics off the agenda); and 3) invisible power i.e., shaping public opinion and influencing norms and ideas.[[15,18–20]] Two articles described broad “vehicles of power” through which harmful commodity industries exert their influence: political environment, preference shaping, knowledge environment, legal and extra-legal environment.[[15,19]] Overall, the power exerted by corporations was described as prevailing over public health governance and regulatory measures.[[6,15,16,18,20]]

Five articles described specific strategies used by industries.[[6,15,16,18,20]]  Strategies included: participation in decision making and lobbying;[[ 6,15,16,18,20]] marketing and advertising to enhance the appeal of harmful commodities, and shaping the broader narrative about their acceptability and normalisation of consumption in everyday life;[[ 6,15,16,18,20]] product modification and extensive supply chains;[[ 6,15,16,18,20]] corporate social responsibility practices to enhance public perceptions of corporations, while allowing marketing to be delivered;[[ 6,15,16]] sponsorship/donations, funding of research and medical conferences/education to enable corporate control over decision making and the research process;[[ 15,16,20]] and revolving door arrangements (where an individual moves between the commercial and public sectors, bringing their influence into their new position or gathering confidential information to take back to the industry) as a means to exert influence.[[15,18]]

Literature review: response to CDoH in healthcare organisations

No relevant articles were found in the updated search (2019–2021). In addition to Mialon et al,[[12]] two journal articles[[23,24]] and two World Health Organization (WHO) documents (i.e., Framework Convention on Tobacco Control[[25]] and Framework for Engagement with Non-state Actors[[26]]) were identified through grey literature searching (Appendix 2). Key points summarising how health organisations can effectively respond to CDoH were incorporated into the framework (Figure 1).

Te Tiriti o Waitangi

Application of Te Tiriti o Waitangi is fundamental to responding to CDoH in New Zealand. The first iteration of the theoretical framework was guided by the Hauora principles—tino rangatiratanga, partnership, active protection, equity, and options.[[27,28]] We envisioned these principles being applied across the five “response” actions, ensuring shared power in active pro-equity decision making about responses to CDoH.

Figure 1: Framework summarising commercial determinants of health and how to respond in a local district health setting.

Phase 2: assessment of CM Health’s response to CDoH

Collectively, the policy document review and stakeholder interviews provided a multi-faceted overview of CM Health’s response to CDoH.

Policy document review

CM Health has a suite of policies (see Table 1) that guide management—including decision making and transparency—of corporate interactions and conflict of interest (COI). The organisation applies the State Services Commission Code of Conduct[[29]] and has a code of conduct policy that applies to all employees.

A comprehensive COI policy provides guidance on the identification, disclosure, and management of COI and aims to “protect the integrity of CM Health and its employees by helping to ensure that employees perform their duties in a fair and unbiased manner and that decisions are made unaffected by private interests or personal gain”. COI is also considered in other policies related to human resources, procurement processes and research. COI and gift registers are maintained by departments.

The Corporate Relationships Policy outlines principles and considerations when establishing relationships with external organisations. It states that “associations should be avoided with external organisations whose values, practices, products, or branding are or appear to be in conflict with the stated vision, aims, objectives or policies of CM Health.”

A range of policies address the impacts of harmful commodity industries and support healthy environments. CM Health has a smokefree policy (which includes vaping), an alcohol position statement, and follows the National Healthy Food and Drink Policy.

This policy review did not find specific documentation of responses to CDoH which apply Te Tiriti o Waitangi.

Thematic analysis of key informant interviews

Three themes were developed based on interpretation of interviewees’ perceptions of the current situation (including visibility of CDoH and responses to CDoH) and opportunities for strengthening the response. Code categories and quotes that illustrate meaning are described in Tables 2, 3 and 4.

Theme 1: disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers

Key informants described high visibility of adverse health outcomes and experiences of harm. They expressed frustration and anger at the injustice of the current situation, and they perceived the health system (as well as the public sector and Government more broadly) as failing people and communities, particularly Māori, Pasifika, and socio-economically deprived communities. Despite the scale of impacts, it was felt that CDoH as drivers of harm are not acknowledged or well understood. It is paradoxical that CDoH are “invisible” due to normalisation in society when they appear to be everywhere once you become more aware of them: “how can you not see it? It’s just so everywhere” (Community member, #12). We need to increase awareness and recognise “that commercial determinants are key drivers of ill health…it’s just as important as recognising the broader social determinants [of health]” (Topic expert, #5).

Theme 2: power imbalance between harmful commodity industries and communities

Participants spoke about corporates having large resources and influence, including in the political sphere. In comparison, people across communities and the health sector have shared concerns about “fighting” against many barriers and change being hard and slow, despite much effort. One participant described how it felt coming before a District Licensing Committee to object to an alcohol licence application: “I got absolutely slaughtered by lawyers representing the applicant…it was like community objectors were nothing more than a hindrance” (Community member #8). A common perspective among participants was that the power of corporates who sell harmful products should be restricted and that CM Health could do more to contribute to this, both locally—e.g., improving healthy food choices in the hospital—as well as nationally, by advocating for stronger regulations of harmful products.

Theme 3: need for a robust, values-based, Tiriti-aligned response to CDoH

All participants thought that while CM Health was responding well in some regards (e.g., implementing the National Healthy Food & Beverage Policy), the overall response to CDoH needs to be strengthened, within the organisation as well as more broadly in the public sector and Government. Decisions should be based on our values, with Te Tiriti o Waitangi as the foundation and health and wellbeing as key priorities. It is important to consider the alignment (or not) of values when engaging with corporate entities and to ensure transparency of interactions and identification of COI. Community participants strongly supported the need to value knowledge and initiatives of community and population groups, including Māori, Pasifika and young people, and to collaborate for greater collective impact.

View Tables 1–4.

Phase 3: refinement of framework and next steps

The framework was refined based on testing it with, and feedback from, key informants. Overall, they strongly supported the concept and thought it was important to assess and address the health sector response to CDoH. There was broad support for the proposed descriptions of how Te Tiriti o Waitangi would apply in this setting. The approach, initially developed based on the Waitangi Tribunal Hauora report and the guidance on incorporating Te Tiriti o Waitangi into the health system from the Ministry of Health,[[27,28]] was further developed based on feedback. Interviewees highlighted the broader context of colonisation and racism leading to unequal treatment by unhealthy commodity industries, and this was incorporated into the framework (Figure 1).

Next steps supported by the literature and recommended by key informants included: raising awareness within CM Health and the community of the CDoH and the impact of harmful commodity industries; strengthening organisational policies relevant to CDoH including those related to interactions with harmful commodity industries and ensuring alignment with Te Tiriti o Waitangi; developing an organisation-wide position statement on CDoH; reviewing and strengthening COI policies, supporting community initiatives and action; and working collaboratively with others towards evidence-based policy and legislation which support healthy environments.

Discussion

This paper describes the development and use of a theoretical framework for assessing a health organisation’s response to CDoH. The framework describes the strategies used by harmful commodity industries and how to respond to these, in the context of a health organisation setting. Assessment of CM Health’s response to CDoH through policy document review and key informant interviews found that although there are many relevant policies, including those concerning corporate relationships and COI, there are opportunities to strengthen the content of policies (e.g., alignment with Te Tiriti o Waitangi) and processes involved in implementing them (e.g., raising awareness about them and increased transparency of their application). Three key themes were identified based on key informants’ perceptions of the current response and opportunities for strengthening the response: 1) disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers; 2) power imbalance between harmful commodity industries and communities; and 3) need for a robust, values-based, Tiriti-aligned response to CDoH.

From one iteration of using the framework, it appears it is able to be practically applied. However, our experience is that, in isolation, a document review is unlikely to provide a complete view. We think policy review should ideally be combined with key informant interviews to provide a more complete assessment of a health organisation’s response to CDoH.

Strengths of this research include its basis in theory and evidence related to CDoH, and the use of a range of methods (i.e., literature review, document review and key informant interviews) that were appropriate for the research aim and exploratory nature. Key informant interviews provided rich data for thematic analysis, including from Māori and Pasifika participants, whose inclusion was prioritised in the purposeful sampling method.

There are also some limitations with this study. Firstly, for practical and resourcing reasons, the scale of the study was small, involving focussed literature reviews and a relatively small number of key informants. The document review considered policies, but not processes related to them such as implementation. This was mitigated by seeking input on policy process aspects from key informants. Secondly, the authors acknowledge that in qualitative analysis there is the potential for bias due to framing and interpretations that are shaped by the researchers’ assumptions, experiences, and personal beliefs,[[30]] and that a different interpretation and development of key themes may have occurred if undertaken by different researchers. Research rigour could have been improved by involving more people in the research process and incorporating formal research reflexivity practices. Thirdly, although it was possible to get valuable insights by its application in one organisational setting, the framework should be considered as developmental, and would benefit from further testing and refinement.

CDoH as a field of global health research has expanded over the last decade and has mostly focussed on the drivers and mechanisms through which corporations exert their influence. As described earlier in the results section, just a small number of published papers address how to respond to CDoH, and there is a gap in research and guidance about responding at a local, organisational level. The authors are not aware of other published literature exploring this concept in a health organisation setting. The global Governance, Ethics, and Conflicts of Interest in Public Health (GECI-PH) network, launched in 2018, has identified the need for frameworks, policies and tools that can be used to manage the influence of private sector actors on public health policy, research, and practice.[[31]] The framework and approach for assessment developed in this study could be used for such a purpose in health and other public sector organisations in New Zealand. It can also be used as a starting point for conversations within organisations about CDoH, their impact, and how organisations should respond. The next step indicated by this research is the implementation of a strengthened response to CDoH. Future research should address implementation issues and explore factors that are likely to enable success, such as leadership, organisational readiness, appropriate resourcing, and capability within the organisation (including legal expertise).

This paper highlights the powerful influence exerted by harmful commodity industries through CDoH, and how these drive adverse health and wellbeing impacts experienced by people and communities. The health sector has an important role to play in redressing the power imbalance that exists between harmful commodity industries and people, whānau and communities. Responses include raising awareness about CDoH, supporting community initiatives and actions, and contributing to and advocating for evidence-based policy and legislation that restrict the power of harmful industries and support healthy environments and communities. Recommended responses also include raising awareness within organisations of organisational polices that exist to mitigate adverse impacts of CDoH; reviewing and strengthening policies related to COI and ensuring these cover both personal and commercial interests; and reviewing and strengthening policies, processes and systems to support a more transparent and values-based approach to identify and manage corporate interactions, engagements and relationships.

There is an opportunity for such responses to CDoH to be addressed within the new health entities created in the current New Zealand health reforms. The Pae Ora (Healthy Futures) Bill states that the health sector should protect and promote people’s health and wellbeing, which includes undertaking preventative measures and addressing the wider determinants of health. While it is important to acknowledge progress already made in responding to CDoH, such as in the area of tobacco control (underpinned by the Framework Convention on Tobacco Control and Smokefree legislation), there is much work to be done across health and other public sectors to realise the enormous potential for gains in health, wellbeing and equity outcomes through applying a more pro-active, systematic and sophisticated response to the CDoH.

View Appendices.

Summary

Abstract

Aim

To develop and apply a theoretical framework to assess the rigour of a district health organisation’s response to the commercial determinants of health (CDoH).

Method

The multi-method study incorporated literature reviews of CDoH strategies and ways in which organisations can respond; policy document review; and 12 qualitative, semi-structured, key informant interviews.

Results

A theoretical framework was developed summarising CDoH and potential responses. The organisation has relevant policies, including those concerning corporate relationships and conflict of interest; however, there are opportunities to strengthen policy content and processes. Key themes were identified based on key informants’ perceptions: 1) disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers of these impacts; 2) power imbalance between harmful commodity industries and communities; and 3) need for a robust, values-based, Tiriti-aligned response to CDoH.

Conclusion

The health sector has an important role to play in redressing the power imbalance between harmful commodity industries and communities. Responses include: raising awareness about CDoH; strengthening policies related to interactions with corporations, and in particular considering alignment of values; supporting community actions; and advocating for legislative changes which restrict the power of harmful industries and support healthy environments and communities.

Author Information

Sarah Sharpe: Public Health Physician, Population Health Directorate, Te Whatu Ora Counties Manukau, Auckland, New Zealand. Karen McIlhone: Public Health Registrar, National Screening Unit, Te Whatu Ora, Auckland, New Zealand. Summer Hawke, Manager Population Health Programmes, Population Health Directorate, Te Whatu Ora Counties Manukau, Auckland, New Zealand. Shanthi Ameratunga: Senior Researcher, Population Health Directorate, Te Whatu Ora Counties Manukau, Auckland; Honorary Professor, School of Population Health, The University of Auckland, Auckland, New Zealand.

Acknowledgements

We would like to acknowledge and thank the twelve participants of the qualitative research component, Dr Nicki Jackson (who provided early advice on the project plan) and Dr Gary Jackson (who reviewed the project report). The project was funded by Counties Manukau Health.

Correspondence

Sarah Sharpe: Population Health Team, Te Whatu Ora Counties Manukau, Middlemore Hospital, 100 Hospital Road, Auckland 2025, New Zealand.

Correspondence Email

sarah.sharpe@middlemore.co.nz

Competing Interests

Nil.

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2) Shield K, Manthey J, Rylett M, Probst C, Wettlaufer A, Parry CDH, et al. National, regional, and global burdens of disease from 2000 to 2016 attributable to alcohol use: a comparative risk assessment study. Lancet Public Health. 2020;5(1):e51-e61.

3) Connor J, Kydd R, Shield K, Rehm J. The burden of disease and injury attributable to alcohol in New Zealanders under 80 years of age: marked disparities by ethnicity and sex. N Z Med J. 2015;128(1409):15-28.

4) Kelly S, Swinburn B. Childhood obesity in New Zealand. N Z Med J. 2015;128(1417):6-7.

5) Browne M, Greer N, Kolandai-Matchett K, Rawat V, Langham E, Rockloff M, Palmer Du Preez K, Abbott M. Measuring the Burden of Gambling Harm in New Zealand. Central Queensland University and Auckland University of Technology, 2017.

6) Kickbusch I, Allen L, Franz C. The commercial determinants of health. Lancet Glob Health. 2016;4(12):e895-e6.

7) Mialon M. An overview of the commercial determinants of health. Global Health. 2020;16(1):74.

8) de Lacy-Vawdon C, Livingstone C. Defining the commercial determinants of health: a systematic review. BMC Public Health. 2020;20(1):1022.

9) Health and Disability System Review. Health and Disability System Review - Final Report - Pūrongo Whakamutunga. Wellington: HDSR, 2020.

10) New Zealand Parliament. Pae Ora (Healthy Futures) Bill 2022 [9 May 2022]. Available from: https://legislation.govt.nz/bill/government/2021/0085/latest/LMS575405.html.

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12) Mialon M, Vandevijvere S, Carriedo-Lutzenkirchen A, Bero L, Gomes F, Petticrew M, et al. Mechanisms for addressing and managing the influence of corporations on public health policy, research and practice: a scoping review. BMJ Open. 2020;10(7):e034082.

13) Braun V, Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qualitative Research in Sport, Exercise, and Health. 2019;13(2):201-16.

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15) Madureira Lima J, Galea S. Corporate practices and health: a framework and mechanisms. Global Health. 2018;14(1):21.

16) Rochford C, Tenneti N, Moodie R. Reframing the impact of business on health: the interface of corporate, commercial, political and social determinants of health. BMJ Glob Health. 2019;4(4):e001510.

17) Freudenberg N, Galea S. Corporate practices. In: Galea S, editor. Macrosocial Determinants of Population Health. New York: Springer; 2007.

18) Baum FE, Sanders DM, Fisher M, Anaf J, Freudenberg N, Friel S, et al. Assessing the health impact of transnational corporations: its importance and a framework. Global Health. 2016;12(1):27.

19) Jamieson L, Gibson B, Thomson WM. Oral Health Inequalities and the Corporate Determinants of Health: A Commentary. Int J Environ Res Public Health. 2020;17(18).

20) Wood B, Baker P, Sacks G. Conceptualising the Commercial Determinants of Health Using a Power Lens: A Review and Synthesis of Existing Frameworks. Int J Health Policy Manag. 2021.

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22) Buse K, Tanaka S, Hawkes S. Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of non-communicable diseases and identifying options for reducing risk exposure. Global Health. 2017;13(1):34.

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The large losses and inequities in health and wellbeing due to harmful commodities such as tobacco, alcohol, unhealthy food and beverages, and gambling products are well-established.[[1–5]] Acknowledging the sophisticated means by which industries producing these commodities exploit consumers, and the political economy of globalisation, Kickbusch et al. define the term “commercial determinants of health” (CDoH) as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health”.[[6]] Through CDoH, corporations exert power and influence by shaping the societal norms and environments in which people live, grow up, work, play and socialise.[[7,8]] Harmful products are normalised and consumer choices are shaped for the benefit of corporate profits. Along with the socio-economic determinants of health, racism and colonisation, CDoH are important upstream drivers of health loss and inequities in New Zealand.

The health sector has an important role to play in reducing and preventing the influence and impact of CDoH. The final report of the New Zealand Health and Disability System Review states: “there is a need for much more concerted action at national, regional and local levels to address the CDoH”.[[9]] Responding effectively to the CDoH can help achieve the aims of the New Zealand public health system, i.e., to protect, promote and improve the health of all New Zealanders; to achieve equity in health outcomes among New Zealand’s population groups; and to build towards pae ora (healthy futures) for all New Zealanders.[[10]]

Given a lack of guidance on how the health sector can effectively address CDoH, the aim of this study was to develop and apply a theoretical framework to assess the rigour of a district health organisation’s response to CDoH.

Methods

The multi-method study was conducted in 2021 at Counties Manukau Health (CM Health) in three phases, guided by the Institute for Health Improvement’s “Plan-Do-Study-Act” cycle.[[11]] In Phase one (“Plan”), a theoretical framework was developed describing CDoH and how to respond, based on two focused literature reviews and applying principles of Te Tiriti o Waitangi—the Treaty which established the relationship between Māori, the Indigenous people of New Zealand, and the British Crown. Phase two (“Do”) involved using the framework to assess CM Health’s response to CDoH based on policy document review and perspectives of key informants. In Phase three (“Study”), the framework was refined and recommendations for strengthening the response, in a future “Act” phase, were formulated.

The first literature review aimed to summarise key CDoH mechanisms and strategies. Publications were included in the review if they included a conceptual theory or framework describing what CDoH are and how they exert influence. General background or discussion articles were excluded. MEDLINE electronic database was searched using the search terms “commercial or corporat* AND determinant* AND health or disease*”, and was limited to English language publications from 2000 to May 2021. Grey literature (using Google) and snowball searching was conducted. Data from included articles were summarised in table and narrative form. Key aspects of interest included definition of CDoH, type of evidence, mechanisms of influence, and outcomes.

The second literature review aimed to summarise evidence about how health sector organisations can respond to CDoH. A relevant scoping review by Mialon and colleagues published in 2020[[12]] identified ways to manage the influence of CDoH in the context of public health policy, research and practice. The search strategy in this article was replicated for the period 2019–2021. Expert advice was sought, and Google searching carried out to identify relevant grey literature. Data were summarised in table and narrative form, with a focus on recommended mechanisms, relevant to the health sector, for responding to CDoH.

For the document review, the CM Health intranet, including the document directory and department pages, was searched for relevant policy, procedure and guideline documents. Documents were reviewed against the “response” section of the framework (shown in Figure 1).

Next, a qualitative study explored the perspectives of three key stakeholder groups: CM Health employees, academics/experts on the topic, and people in community organisations. The 12 participants, recruited through a purposive sampling strategy, included four Māori and three Pasifika participants. The sample size was chosen for pragmatic reasons, and the concept of data saturation was not deployed in this study.[[13]] Participants were provided with a participant information sheet and gave written, informed consent. Semi-structured interviews (conducted by KM) were audio-recorded and later transcribed by a commercial transcription service. Topics explored were outlined in an interview guide and included: 1) perceptions of the visibility of CDoH; 2) perceptions of the current response to CDoH; 3) suggestions for how CM Health could strengthen the response; and 4) thoughts and feedback on the theoretical framework under development. Thematic analysis of data (KM and SS) used a constructivist approach[[14]] and involved close reading of transcripts, coding of text, categorisation of codes and interpretation of ideas, comparison within and across key stakeholder groups, and development of themes.

Ethics approval was granted by the Auckland Health Research Ethics Committee (reference AH21918) and locality approval by the CM Health Research Office.

Results

Phase 1: development of theoretical framework

This section describes findings from the literature reviews that, together with application of Te Tiriti of Waitangi principles and refinement based on input from key informants, resulted in the framework shown in Figure 1.

Literature review: key CDoH mechanisms and strategies

Of 678 records identified, 28 were potentially relevant based on abstracts, and full texts were reviewed. Nine articles fulfilled the eligibility criteria and were included in the review (Appendix 1).[[6,15–22]] All articles were descriptive in nature, included conceptual frameworks, and acknowledged impacts and consequences of CDoH. Outcomes described were broad and included political, cultural, social, environmental and health effects. Two articles took a nuanced approach to outcomes, allowing recognition of both positive and negative impacts by corporations.[[16,18]]

In general, articles described CDoH as being enmeshed within broad political, economic and regulatory environments, allowing CDoH to operate and promote corporate growth.[[6,15,16,18–20]] Four articles explored the concept of power, which was described as influencing decision making in three ways: 1) direct influence in decision making; 2) indirect influence on agenda setting and limiting choices (e.g., keeping controversial topics off the agenda); and 3) invisible power i.e., shaping public opinion and influencing norms and ideas.[[15,18–20]] Two articles described broad “vehicles of power” through which harmful commodity industries exert their influence: political environment, preference shaping, knowledge environment, legal and extra-legal environment.[[15,19]] Overall, the power exerted by corporations was described as prevailing over public health governance and regulatory measures.[[6,15,16,18,20]]

Five articles described specific strategies used by industries.[[6,15,16,18,20]]  Strategies included: participation in decision making and lobbying;[[ 6,15,16,18,20]] marketing and advertising to enhance the appeal of harmful commodities, and shaping the broader narrative about their acceptability and normalisation of consumption in everyday life;[[ 6,15,16,18,20]] product modification and extensive supply chains;[[ 6,15,16,18,20]] corporate social responsibility practices to enhance public perceptions of corporations, while allowing marketing to be delivered;[[ 6,15,16]] sponsorship/donations, funding of research and medical conferences/education to enable corporate control over decision making and the research process;[[ 15,16,20]] and revolving door arrangements (where an individual moves between the commercial and public sectors, bringing their influence into their new position or gathering confidential information to take back to the industry) as a means to exert influence.[[15,18]]

Literature review: response to CDoH in healthcare organisations

No relevant articles were found in the updated search (2019–2021). In addition to Mialon et al,[[12]] two journal articles[[23,24]] and two World Health Organization (WHO) documents (i.e., Framework Convention on Tobacco Control[[25]] and Framework for Engagement with Non-state Actors[[26]]) were identified through grey literature searching (Appendix 2). Key points summarising how health organisations can effectively respond to CDoH were incorporated into the framework (Figure 1).

Te Tiriti o Waitangi

Application of Te Tiriti o Waitangi is fundamental to responding to CDoH in New Zealand. The first iteration of the theoretical framework was guided by the Hauora principles—tino rangatiratanga, partnership, active protection, equity, and options.[[27,28]] We envisioned these principles being applied across the five “response” actions, ensuring shared power in active pro-equity decision making about responses to CDoH.

Figure 1: Framework summarising commercial determinants of health and how to respond in a local district health setting.

Phase 2: assessment of CM Health’s response to CDoH

Collectively, the policy document review and stakeholder interviews provided a multi-faceted overview of CM Health’s response to CDoH.

Policy document review

CM Health has a suite of policies (see Table 1) that guide management—including decision making and transparency—of corporate interactions and conflict of interest (COI). The organisation applies the State Services Commission Code of Conduct[[29]] and has a code of conduct policy that applies to all employees.

A comprehensive COI policy provides guidance on the identification, disclosure, and management of COI and aims to “protect the integrity of CM Health and its employees by helping to ensure that employees perform their duties in a fair and unbiased manner and that decisions are made unaffected by private interests or personal gain”. COI is also considered in other policies related to human resources, procurement processes and research. COI and gift registers are maintained by departments.

The Corporate Relationships Policy outlines principles and considerations when establishing relationships with external organisations. It states that “associations should be avoided with external organisations whose values, practices, products, or branding are or appear to be in conflict with the stated vision, aims, objectives or policies of CM Health.”

A range of policies address the impacts of harmful commodity industries and support healthy environments. CM Health has a smokefree policy (which includes vaping), an alcohol position statement, and follows the National Healthy Food and Drink Policy.

This policy review did not find specific documentation of responses to CDoH which apply Te Tiriti o Waitangi.

Thematic analysis of key informant interviews

Three themes were developed based on interpretation of interviewees’ perceptions of the current situation (including visibility of CDoH and responses to CDoH) and opportunities for strengthening the response. Code categories and quotes that illustrate meaning are described in Tables 2, 3 and 4.

Theme 1: disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers

Key informants described high visibility of adverse health outcomes and experiences of harm. They expressed frustration and anger at the injustice of the current situation, and they perceived the health system (as well as the public sector and Government more broadly) as failing people and communities, particularly Māori, Pasifika, and socio-economically deprived communities. Despite the scale of impacts, it was felt that CDoH as drivers of harm are not acknowledged or well understood. It is paradoxical that CDoH are “invisible” due to normalisation in society when they appear to be everywhere once you become more aware of them: “how can you not see it? It’s just so everywhere” (Community member, #12). We need to increase awareness and recognise “that commercial determinants are key drivers of ill health…it’s just as important as recognising the broader social determinants [of health]” (Topic expert, #5).

Theme 2: power imbalance between harmful commodity industries and communities

Participants spoke about corporates having large resources and influence, including in the political sphere. In comparison, people across communities and the health sector have shared concerns about “fighting” against many barriers and change being hard and slow, despite much effort. One participant described how it felt coming before a District Licensing Committee to object to an alcohol licence application: “I got absolutely slaughtered by lawyers representing the applicant…it was like community objectors were nothing more than a hindrance” (Community member #8). A common perspective among participants was that the power of corporates who sell harmful products should be restricted and that CM Health could do more to contribute to this, both locally—e.g., improving healthy food choices in the hospital—as well as nationally, by advocating for stronger regulations of harmful products.

Theme 3: need for a robust, values-based, Tiriti-aligned response to CDoH

All participants thought that while CM Health was responding well in some regards (e.g., implementing the National Healthy Food & Beverage Policy), the overall response to CDoH needs to be strengthened, within the organisation as well as more broadly in the public sector and Government. Decisions should be based on our values, with Te Tiriti o Waitangi as the foundation and health and wellbeing as key priorities. It is important to consider the alignment (or not) of values when engaging with corporate entities and to ensure transparency of interactions and identification of COI. Community participants strongly supported the need to value knowledge and initiatives of community and population groups, including Māori, Pasifika and young people, and to collaborate for greater collective impact.

View Tables 1–4.

Phase 3: refinement of framework and next steps

The framework was refined based on testing it with, and feedback from, key informants. Overall, they strongly supported the concept and thought it was important to assess and address the health sector response to CDoH. There was broad support for the proposed descriptions of how Te Tiriti o Waitangi would apply in this setting. The approach, initially developed based on the Waitangi Tribunal Hauora report and the guidance on incorporating Te Tiriti o Waitangi into the health system from the Ministry of Health,[[27,28]] was further developed based on feedback. Interviewees highlighted the broader context of colonisation and racism leading to unequal treatment by unhealthy commodity industries, and this was incorporated into the framework (Figure 1).

Next steps supported by the literature and recommended by key informants included: raising awareness within CM Health and the community of the CDoH and the impact of harmful commodity industries; strengthening organisational policies relevant to CDoH including those related to interactions with harmful commodity industries and ensuring alignment with Te Tiriti o Waitangi; developing an organisation-wide position statement on CDoH; reviewing and strengthening COI policies, supporting community initiatives and action; and working collaboratively with others towards evidence-based policy and legislation which support healthy environments.

Discussion

This paper describes the development and use of a theoretical framework for assessing a health organisation’s response to CDoH. The framework describes the strategies used by harmful commodity industries and how to respond to these, in the context of a health organisation setting. Assessment of CM Health’s response to CDoH through policy document review and key informant interviews found that although there are many relevant policies, including those concerning corporate relationships and COI, there are opportunities to strengthen the content of policies (e.g., alignment with Te Tiriti o Waitangi) and processes involved in implementing them (e.g., raising awareness about them and increased transparency of their application). Three key themes were identified based on key informants’ perceptions of the current response and opportunities for strengthening the response: 1) disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers; 2) power imbalance between harmful commodity industries and communities; and 3) need for a robust, values-based, Tiriti-aligned response to CDoH.

From one iteration of using the framework, it appears it is able to be practically applied. However, our experience is that, in isolation, a document review is unlikely to provide a complete view. We think policy review should ideally be combined with key informant interviews to provide a more complete assessment of a health organisation’s response to CDoH.

Strengths of this research include its basis in theory and evidence related to CDoH, and the use of a range of methods (i.e., literature review, document review and key informant interviews) that were appropriate for the research aim and exploratory nature. Key informant interviews provided rich data for thematic analysis, including from Māori and Pasifika participants, whose inclusion was prioritised in the purposeful sampling method.

There are also some limitations with this study. Firstly, for practical and resourcing reasons, the scale of the study was small, involving focussed literature reviews and a relatively small number of key informants. The document review considered policies, but not processes related to them such as implementation. This was mitigated by seeking input on policy process aspects from key informants. Secondly, the authors acknowledge that in qualitative analysis there is the potential for bias due to framing and interpretations that are shaped by the researchers’ assumptions, experiences, and personal beliefs,[[30]] and that a different interpretation and development of key themes may have occurred if undertaken by different researchers. Research rigour could have been improved by involving more people in the research process and incorporating formal research reflexivity practices. Thirdly, although it was possible to get valuable insights by its application in one organisational setting, the framework should be considered as developmental, and would benefit from further testing and refinement.

CDoH as a field of global health research has expanded over the last decade and has mostly focussed on the drivers and mechanisms through which corporations exert their influence. As described earlier in the results section, just a small number of published papers address how to respond to CDoH, and there is a gap in research and guidance about responding at a local, organisational level. The authors are not aware of other published literature exploring this concept in a health organisation setting. The global Governance, Ethics, and Conflicts of Interest in Public Health (GECI-PH) network, launched in 2018, has identified the need for frameworks, policies and tools that can be used to manage the influence of private sector actors on public health policy, research, and practice.[[31]] The framework and approach for assessment developed in this study could be used for such a purpose in health and other public sector organisations in New Zealand. It can also be used as a starting point for conversations within organisations about CDoH, their impact, and how organisations should respond. The next step indicated by this research is the implementation of a strengthened response to CDoH. Future research should address implementation issues and explore factors that are likely to enable success, such as leadership, organisational readiness, appropriate resourcing, and capability within the organisation (including legal expertise).

This paper highlights the powerful influence exerted by harmful commodity industries through CDoH, and how these drive adverse health and wellbeing impacts experienced by people and communities. The health sector has an important role to play in redressing the power imbalance that exists between harmful commodity industries and people, whānau and communities. Responses include raising awareness about CDoH, supporting community initiatives and actions, and contributing to and advocating for evidence-based policy and legislation that restrict the power of harmful industries and support healthy environments and communities. Recommended responses also include raising awareness within organisations of organisational polices that exist to mitigate adverse impacts of CDoH; reviewing and strengthening policies related to COI and ensuring these cover both personal and commercial interests; and reviewing and strengthening policies, processes and systems to support a more transparent and values-based approach to identify and manage corporate interactions, engagements and relationships.

There is an opportunity for such responses to CDoH to be addressed within the new health entities created in the current New Zealand health reforms. The Pae Ora (Healthy Futures) Bill states that the health sector should protect and promote people’s health and wellbeing, which includes undertaking preventative measures and addressing the wider determinants of health. While it is important to acknowledge progress already made in responding to CDoH, such as in the area of tobacco control (underpinned by the Framework Convention on Tobacco Control and Smokefree legislation), there is much work to be done across health and other public sectors to realise the enormous potential for gains in health, wellbeing and equity outcomes through applying a more pro-active, systematic and sophisticated response to the CDoH.

View Appendices.

Summary

Abstract

Aim

To develop and apply a theoretical framework to assess the rigour of a district health organisation’s response to the commercial determinants of health (CDoH).

Method

The multi-method study incorporated literature reviews of CDoH strategies and ways in which organisations can respond; policy document review; and 12 qualitative, semi-structured, key informant interviews.

Results

A theoretical framework was developed summarising CDoH and potential responses. The organisation has relevant policies, including those concerning corporate relationships and conflict of interest; however, there are opportunities to strengthen policy content and processes. Key themes were identified based on key informants’ perceptions: 1) disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers of these impacts; 2) power imbalance between harmful commodity industries and communities; and 3) need for a robust, values-based, Tiriti-aligned response to CDoH.

Conclusion

The health sector has an important role to play in redressing the power imbalance between harmful commodity industries and communities. Responses include: raising awareness about CDoH; strengthening policies related to interactions with corporations, and in particular considering alignment of values; supporting community actions; and advocating for legislative changes which restrict the power of harmful industries and support healthy environments and communities.

Author Information

Sarah Sharpe: Public Health Physician, Population Health Directorate, Te Whatu Ora Counties Manukau, Auckland, New Zealand. Karen McIlhone: Public Health Registrar, National Screening Unit, Te Whatu Ora, Auckland, New Zealand. Summer Hawke, Manager Population Health Programmes, Population Health Directorate, Te Whatu Ora Counties Manukau, Auckland, New Zealand. Shanthi Ameratunga: Senior Researcher, Population Health Directorate, Te Whatu Ora Counties Manukau, Auckland; Honorary Professor, School of Population Health, The University of Auckland, Auckland, New Zealand.

Acknowledgements

We would like to acknowledge and thank the twelve participants of the qualitative research component, Dr Nicki Jackson (who provided early advice on the project plan) and Dr Gary Jackson (who reviewed the project report). The project was funded by Counties Manukau Health.

Correspondence

Sarah Sharpe: Population Health Team, Te Whatu Ora Counties Manukau, Middlemore Hospital, 100 Hospital Road, Auckland 2025, New Zealand.

Correspondence Email

sarah.sharpe@middlemore.co.nz

Competing Interests

Nil.

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The large losses and inequities in health and wellbeing due to harmful commodities such as tobacco, alcohol, unhealthy food and beverages, and gambling products are well-established.[[1–5]] Acknowledging the sophisticated means by which industries producing these commodities exploit consumers, and the political economy of globalisation, Kickbusch et al. define the term “commercial determinants of health” (CDoH) as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health”.[[6]] Through CDoH, corporations exert power and influence by shaping the societal norms and environments in which people live, grow up, work, play and socialise.[[7,8]] Harmful products are normalised and consumer choices are shaped for the benefit of corporate profits. Along with the socio-economic determinants of health, racism and colonisation, CDoH are important upstream drivers of health loss and inequities in New Zealand.

The health sector has an important role to play in reducing and preventing the influence and impact of CDoH. The final report of the New Zealand Health and Disability System Review states: “there is a need for much more concerted action at national, regional and local levels to address the CDoH”.[[9]] Responding effectively to the CDoH can help achieve the aims of the New Zealand public health system, i.e., to protect, promote and improve the health of all New Zealanders; to achieve equity in health outcomes among New Zealand’s population groups; and to build towards pae ora (healthy futures) for all New Zealanders.[[10]]

Given a lack of guidance on how the health sector can effectively address CDoH, the aim of this study was to develop and apply a theoretical framework to assess the rigour of a district health organisation’s response to CDoH.

Methods

The multi-method study was conducted in 2021 at Counties Manukau Health (CM Health) in three phases, guided by the Institute for Health Improvement’s “Plan-Do-Study-Act” cycle.[[11]] In Phase one (“Plan”), a theoretical framework was developed describing CDoH and how to respond, based on two focused literature reviews and applying principles of Te Tiriti o Waitangi—the Treaty which established the relationship between Māori, the Indigenous people of New Zealand, and the British Crown. Phase two (“Do”) involved using the framework to assess CM Health’s response to CDoH based on policy document review and perspectives of key informants. In Phase three (“Study”), the framework was refined and recommendations for strengthening the response, in a future “Act” phase, were formulated.

The first literature review aimed to summarise key CDoH mechanisms and strategies. Publications were included in the review if they included a conceptual theory or framework describing what CDoH are and how they exert influence. General background or discussion articles were excluded. MEDLINE electronic database was searched using the search terms “commercial or corporat* AND determinant* AND health or disease*”, and was limited to English language publications from 2000 to May 2021. Grey literature (using Google) and snowball searching was conducted. Data from included articles were summarised in table and narrative form. Key aspects of interest included definition of CDoH, type of evidence, mechanisms of influence, and outcomes.

The second literature review aimed to summarise evidence about how health sector organisations can respond to CDoH. A relevant scoping review by Mialon and colleagues published in 2020[[12]] identified ways to manage the influence of CDoH in the context of public health policy, research and practice. The search strategy in this article was replicated for the period 2019–2021. Expert advice was sought, and Google searching carried out to identify relevant grey literature. Data were summarised in table and narrative form, with a focus on recommended mechanisms, relevant to the health sector, for responding to CDoH.

For the document review, the CM Health intranet, including the document directory and department pages, was searched for relevant policy, procedure and guideline documents. Documents were reviewed against the “response” section of the framework (shown in Figure 1).

Next, a qualitative study explored the perspectives of three key stakeholder groups: CM Health employees, academics/experts on the topic, and people in community organisations. The 12 participants, recruited through a purposive sampling strategy, included four Māori and three Pasifika participants. The sample size was chosen for pragmatic reasons, and the concept of data saturation was not deployed in this study.[[13]] Participants were provided with a participant information sheet and gave written, informed consent. Semi-structured interviews (conducted by KM) were audio-recorded and later transcribed by a commercial transcription service. Topics explored were outlined in an interview guide and included: 1) perceptions of the visibility of CDoH; 2) perceptions of the current response to CDoH; 3) suggestions for how CM Health could strengthen the response; and 4) thoughts and feedback on the theoretical framework under development. Thematic analysis of data (KM and SS) used a constructivist approach[[14]] and involved close reading of transcripts, coding of text, categorisation of codes and interpretation of ideas, comparison within and across key stakeholder groups, and development of themes.

Ethics approval was granted by the Auckland Health Research Ethics Committee (reference AH21918) and locality approval by the CM Health Research Office.

Results

Phase 1: development of theoretical framework

This section describes findings from the literature reviews that, together with application of Te Tiriti of Waitangi principles and refinement based on input from key informants, resulted in the framework shown in Figure 1.

Literature review: key CDoH mechanisms and strategies

Of 678 records identified, 28 were potentially relevant based on abstracts, and full texts were reviewed. Nine articles fulfilled the eligibility criteria and were included in the review (Appendix 1).[[6,15–22]] All articles were descriptive in nature, included conceptual frameworks, and acknowledged impacts and consequences of CDoH. Outcomes described were broad and included political, cultural, social, environmental and health effects. Two articles took a nuanced approach to outcomes, allowing recognition of both positive and negative impacts by corporations.[[16,18]]

In general, articles described CDoH as being enmeshed within broad political, economic and regulatory environments, allowing CDoH to operate and promote corporate growth.[[6,15,16,18–20]] Four articles explored the concept of power, which was described as influencing decision making in three ways: 1) direct influence in decision making; 2) indirect influence on agenda setting and limiting choices (e.g., keeping controversial topics off the agenda); and 3) invisible power i.e., shaping public opinion and influencing norms and ideas.[[15,18–20]] Two articles described broad “vehicles of power” through which harmful commodity industries exert their influence: political environment, preference shaping, knowledge environment, legal and extra-legal environment.[[15,19]] Overall, the power exerted by corporations was described as prevailing over public health governance and regulatory measures.[[6,15,16,18,20]]

Five articles described specific strategies used by industries.[[6,15,16,18,20]]  Strategies included: participation in decision making and lobbying;[[ 6,15,16,18,20]] marketing and advertising to enhance the appeal of harmful commodities, and shaping the broader narrative about their acceptability and normalisation of consumption in everyday life;[[ 6,15,16,18,20]] product modification and extensive supply chains;[[ 6,15,16,18,20]] corporate social responsibility practices to enhance public perceptions of corporations, while allowing marketing to be delivered;[[ 6,15,16]] sponsorship/donations, funding of research and medical conferences/education to enable corporate control over decision making and the research process;[[ 15,16,20]] and revolving door arrangements (where an individual moves between the commercial and public sectors, bringing their influence into their new position or gathering confidential information to take back to the industry) as a means to exert influence.[[15,18]]

Literature review: response to CDoH in healthcare organisations

No relevant articles were found in the updated search (2019–2021). In addition to Mialon et al,[[12]] two journal articles[[23,24]] and two World Health Organization (WHO) documents (i.e., Framework Convention on Tobacco Control[[25]] and Framework for Engagement with Non-state Actors[[26]]) were identified through grey literature searching (Appendix 2). Key points summarising how health organisations can effectively respond to CDoH were incorporated into the framework (Figure 1).

Te Tiriti o Waitangi

Application of Te Tiriti o Waitangi is fundamental to responding to CDoH in New Zealand. The first iteration of the theoretical framework was guided by the Hauora principles—tino rangatiratanga, partnership, active protection, equity, and options.[[27,28]] We envisioned these principles being applied across the five “response” actions, ensuring shared power in active pro-equity decision making about responses to CDoH.

Figure 1: Framework summarising commercial determinants of health and how to respond in a local district health setting.

Phase 2: assessment of CM Health’s response to CDoH

Collectively, the policy document review and stakeholder interviews provided a multi-faceted overview of CM Health’s response to CDoH.

Policy document review

CM Health has a suite of policies (see Table 1) that guide management—including decision making and transparency—of corporate interactions and conflict of interest (COI). The organisation applies the State Services Commission Code of Conduct[[29]] and has a code of conduct policy that applies to all employees.

A comprehensive COI policy provides guidance on the identification, disclosure, and management of COI and aims to “protect the integrity of CM Health and its employees by helping to ensure that employees perform their duties in a fair and unbiased manner and that decisions are made unaffected by private interests or personal gain”. COI is also considered in other policies related to human resources, procurement processes and research. COI and gift registers are maintained by departments.

The Corporate Relationships Policy outlines principles and considerations when establishing relationships with external organisations. It states that “associations should be avoided with external organisations whose values, practices, products, or branding are or appear to be in conflict with the stated vision, aims, objectives or policies of CM Health.”

A range of policies address the impacts of harmful commodity industries and support healthy environments. CM Health has a smokefree policy (which includes vaping), an alcohol position statement, and follows the National Healthy Food and Drink Policy.

This policy review did not find specific documentation of responses to CDoH which apply Te Tiriti o Waitangi.

Thematic analysis of key informant interviews

Three themes were developed based on interpretation of interviewees’ perceptions of the current situation (including visibility of CDoH and responses to CDoH) and opportunities for strengthening the response. Code categories and quotes that illustrate meaning are described in Tables 2, 3 and 4.

Theme 1: disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers

Key informants described high visibility of adverse health outcomes and experiences of harm. They expressed frustration and anger at the injustice of the current situation, and they perceived the health system (as well as the public sector and Government more broadly) as failing people and communities, particularly Māori, Pasifika, and socio-economically deprived communities. Despite the scale of impacts, it was felt that CDoH as drivers of harm are not acknowledged or well understood. It is paradoxical that CDoH are “invisible” due to normalisation in society when they appear to be everywhere once you become more aware of them: “how can you not see it? It’s just so everywhere” (Community member, #12). We need to increase awareness and recognise “that commercial determinants are key drivers of ill health…it’s just as important as recognising the broader social determinants [of health]” (Topic expert, #5).

Theme 2: power imbalance between harmful commodity industries and communities

Participants spoke about corporates having large resources and influence, including in the political sphere. In comparison, people across communities and the health sector have shared concerns about “fighting” against many barriers and change being hard and slow, despite much effort. One participant described how it felt coming before a District Licensing Committee to object to an alcohol licence application: “I got absolutely slaughtered by lawyers representing the applicant…it was like community objectors were nothing more than a hindrance” (Community member #8). A common perspective among participants was that the power of corporates who sell harmful products should be restricted and that CM Health could do more to contribute to this, both locally—e.g., improving healthy food choices in the hospital—as well as nationally, by advocating for stronger regulations of harmful products.

Theme 3: need for a robust, values-based, Tiriti-aligned response to CDoH

All participants thought that while CM Health was responding well in some regards (e.g., implementing the National Healthy Food & Beverage Policy), the overall response to CDoH needs to be strengthened, within the organisation as well as more broadly in the public sector and Government. Decisions should be based on our values, with Te Tiriti o Waitangi as the foundation and health and wellbeing as key priorities. It is important to consider the alignment (or not) of values when engaging with corporate entities and to ensure transparency of interactions and identification of COI. Community participants strongly supported the need to value knowledge and initiatives of community and population groups, including Māori, Pasifika and young people, and to collaborate for greater collective impact.

View Tables 1–4.

Phase 3: refinement of framework and next steps

The framework was refined based on testing it with, and feedback from, key informants. Overall, they strongly supported the concept and thought it was important to assess and address the health sector response to CDoH. There was broad support for the proposed descriptions of how Te Tiriti o Waitangi would apply in this setting. The approach, initially developed based on the Waitangi Tribunal Hauora report and the guidance on incorporating Te Tiriti o Waitangi into the health system from the Ministry of Health,[[27,28]] was further developed based on feedback. Interviewees highlighted the broader context of colonisation and racism leading to unequal treatment by unhealthy commodity industries, and this was incorporated into the framework (Figure 1).

Next steps supported by the literature and recommended by key informants included: raising awareness within CM Health and the community of the CDoH and the impact of harmful commodity industries; strengthening organisational policies relevant to CDoH including those related to interactions with harmful commodity industries and ensuring alignment with Te Tiriti o Waitangi; developing an organisation-wide position statement on CDoH; reviewing and strengthening COI policies, supporting community initiatives and action; and working collaboratively with others towards evidence-based policy and legislation which support healthy environments.

Discussion

This paper describes the development and use of a theoretical framework for assessing a health organisation’s response to CDoH. The framework describes the strategies used by harmful commodity industries and how to respond to these, in the context of a health organisation setting. Assessment of CM Health’s response to CDoH through policy document review and key informant interviews found that although there are many relevant policies, including those concerning corporate relationships and COI, there are opportunities to strengthen the content of policies (e.g., alignment with Te Tiriti o Waitangi) and processes involved in implementing them (e.g., raising awareness about them and increased transparency of their application). Three key themes were identified based on key informants’ perceptions of the current response and opportunities for strengthening the response: 1) disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers; 2) power imbalance between harmful commodity industries and communities; and 3) need for a robust, values-based, Tiriti-aligned response to CDoH.

From one iteration of using the framework, it appears it is able to be practically applied. However, our experience is that, in isolation, a document review is unlikely to provide a complete view. We think policy review should ideally be combined with key informant interviews to provide a more complete assessment of a health organisation’s response to CDoH.

Strengths of this research include its basis in theory and evidence related to CDoH, and the use of a range of methods (i.e., literature review, document review and key informant interviews) that were appropriate for the research aim and exploratory nature. Key informant interviews provided rich data for thematic analysis, including from Māori and Pasifika participants, whose inclusion was prioritised in the purposeful sampling method.

There are also some limitations with this study. Firstly, for practical and resourcing reasons, the scale of the study was small, involving focussed literature reviews and a relatively small number of key informants. The document review considered policies, but not processes related to them such as implementation. This was mitigated by seeking input on policy process aspects from key informants. Secondly, the authors acknowledge that in qualitative analysis there is the potential for bias due to framing and interpretations that are shaped by the researchers’ assumptions, experiences, and personal beliefs,[[30]] and that a different interpretation and development of key themes may have occurred if undertaken by different researchers. Research rigour could have been improved by involving more people in the research process and incorporating formal research reflexivity practices. Thirdly, although it was possible to get valuable insights by its application in one organisational setting, the framework should be considered as developmental, and would benefit from further testing and refinement.

CDoH as a field of global health research has expanded over the last decade and has mostly focussed on the drivers and mechanisms through which corporations exert their influence. As described earlier in the results section, just a small number of published papers address how to respond to CDoH, and there is a gap in research and guidance about responding at a local, organisational level. The authors are not aware of other published literature exploring this concept in a health organisation setting. The global Governance, Ethics, and Conflicts of Interest in Public Health (GECI-PH) network, launched in 2018, has identified the need for frameworks, policies and tools that can be used to manage the influence of private sector actors on public health policy, research, and practice.[[31]] The framework and approach for assessment developed in this study could be used for such a purpose in health and other public sector organisations in New Zealand. It can also be used as a starting point for conversations within organisations about CDoH, their impact, and how organisations should respond. The next step indicated by this research is the implementation of a strengthened response to CDoH. Future research should address implementation issues and explore factors that are likely to enable success, such as leadership, organisational readiness, appropriate resourcing, and capability within the organisation (including legal expertise).

This paper highlights the powerful influence exerted by harmful commodity industries through CDoH, and how these drive adverse health and wellbeing impacts experienced by people and communities. The health sector has an important role to play in redressing the power imbalance that exists between harmful commodity industries and people, whānau and communities. Responses include raising awareness about CDoH, supporting community initiatives and actions, and contributing to and advocating for evidence-based policy and legislation that restrict the power of harmful industries and support healthy environments and communities. Recommended responses also include raising awareness within organisations of organisational polices that exist to mitigate adverse impacts of CDoH; reviewing and strengthening policies related to COI and ensuring these cover both personal and commercial interests; and reviewing and strengthening policies, processes and systems to support a more transparent and values-based approach to identify and manage corporate interactions, engagements and relationships.

There is an opportunity for such responses to CDoH to be addressed within the new health entities created in the current New Zealand health reforms. The Pae Ora (Healthy Futures) Bill states that the health sector should protect and promote people’s health and wellbeing, which includes undertaking preventative measures and addressing the wider determinants of health. While it is important to acknowledge progress already made in responding to CDoH, such as in the area of tobacco control (underpinned by the Framework Convention on Tobacco Control and Smokefree legislation), there is much work to be done across health and other public sectors to realise the enormous potential for gains in health, wellbeing and equity outcomes through applying a more pro-active, systematic and sophisticated response to the CDoH.

View Appendices.

Summary

Abstract

Aim

To develop and apply a theoretical framework to assess the rigour of a district health organisation’s response to the commercial determinants of health (CDoH).

Method

The multi-method study incorporated literature reviews of CDoH strategies and ways in which organisations can respond; policy document review; and 12 qualitative, semi-structured, key informant interviews.

Results

A theoretical framework was developed summarising CDoH and potential responses. The organisation has relevant policies, including those concerning corporate relationships and conflict of interest; however, there are opportunities to strengthen policy content and processes. Key themes were identified based on key informants’ perceptions: 1) disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers of these impacts; 2) power imbalance between harmful commodity industries and communities; and 3) need for a robust, values-based, Tiriti-aligned response to CDoH.

Conclusion

The health sector has an important role to play in redressing the power imbalance between harmful commodity industries and communities. Responses include: raising awareness about CDoH; strengthening policies related to interactions with corporations, and in particular considering alignment of values; supporting community actions; and advocating for legislative changes which restrict the power of harmful industries and support healthy environments and communities.

Author Information

Sarah Sharpe: Public Health Physician, Population Health Directorate, Te Whatu Ora Counties Manukau, Auckland, New Zealand. Karen McIlhone: Public Health Registrar, National Screening Unit, Te Whatu Ora, Auckland, New Zealand. Summer Hawke, Manager Population Health Programmes, Population Health Directorate, Te Whatu Ora Counties Manukau, Auckland, New Zealand. Shanthi Ameratunga: Senior Researcher, Population Health Directorate, Te Whatu Ora Counties Manukau, Auckland; Honorary Professor, School of Population Health, The University of Auckland, Auckland, New Zealand.

Acknowledgements

We would like to acknowledge and thank the twelve participants of the qualitative research component, Dr Nicki Jackson (who provided early advice on the project plan) and Dr Gary Jackson (who reviewed the project report). The project was funded by Counties Manukau Health.

Correspondence

Sarah Sharpe: Population Health Team, Te Whatu Ora Counties Manukau, Middlemore Hospital, 100 Hospital Road, Auckland 2025, New Zealand.

Correspondence Email

sarah.sharpe@middlemore.co.nz

Competing Interests

Nil.

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