Defining the commercial determinants of health: a systematic review

Recently, research addressing social determinants of health (SDoH), following formative work by Marmot and colleagues [1], has focused on identifying, describing, and beginning to address underlying social causes of population ill-health. However, SDoH approaches have yet to achieve far-reaching population health improvements. Globally, an unprecedented burden from non-communicable diseases (NCDs) has developed [2]. NCDs are amongst the most pressing contemporary challenges to human health, affecting both high-income and low- and middle-income countries alike, contributing to the double-burden of disease [3].

NCDs are often termed ‘lifestyle diseases’ given their origins in behaviors including diet, physical inactivity, alcohol use, and tobacco use [4, 5]. However, these behaviors are increasingly recognized as socially constructed choices heavily influenced by commercial interests [6, 7]. Some call NCDs ‘industrial epidemics’ [8‐12] or ‘profit-’ or ‘corporate-driven diseases’ [12‐17] given the prominent involvement of commercial interests, entities and products. Meanwhile, others describe commercial conditions that influence health as ‘corporate’ or ‘commercial determinants of health’ (CDoH). Some researchers have called for CDoH to be afforded the same priority for disease prevention and research priority as SDoH [5, 9, 18], although some may view CDoH as a subset of SDoH.

Despite increasing references to CDoH in the literature, to date, no systematic synthesis of the CDoH literature base has been produced. This review seeks to address this and distil the current CDoH evidence base. This systematic review aims to:

The working CDoH definition guiding initial stages of this review was that proposed by Kickbusch, Allen and Franz: “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” [19].

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [20]. No protocol has been registered or published elsewhere. Peer-reviewed literature and/or grey literature providing a definition and/or description of the drivers or underlying causes, channels or mechanisms, and/or outcomes associated with CDoH, were included.

Original studies, reviews, commentaries, editorials, discussion papers, books and book chapters, reports, web articles and resources from government and non-government organizations, and conceptual works were included, where they met inclusion criteria. Other works such as newspaper and online news articles, presentations or speeches, and social media posts were excluded. Data could be qualitative, quantitative, or mixed-method.

Papers naming CDoH directly, and/or describing similar concepts such as ‘corporate determinants’ or corporations and associated practices as social determinants of disease, ill-health, or NCDs were included. Whilst there is an expanse of literature that could be categorized as CDoH, including literature that does not name the CDoH or associated terms explicitly, this review sought a narrower framing to focus in literature self-identified as pertaining to CDoH.

CDoH are described as underpinning many global health challenges. The CDoH literature ties together macro-level conditions such as economic and political systems, globalization, trade, power dynamics, corporate structures including rights and responsibilities, and regulatory and accountability approaches, with lower-level activities, structures and relations of corporations and related industry groups. However, much of this literature lacks specificity.

No CDoH definition has been consistently applied in the literature. Many authors fail to provide any definition, seemingly assuming some implicit understanding of CDoH. The apparent discord between three definitions identified, whereby West and Marteau [42] emphasize health outcomes arising from the ‘profit motive’, Kickbusch et al. [19] emphasize the promotion of products and choices detrimental to health, and Kosinska and Ostlin [32] describe the tension between commercial and public health objectives specifically for goods and services, highlights a lack of precision within the CDoH literature. This may reflect the dynamic and reflexive nature of the relationships that constitute commercial influences on health.

Further, the CDoH term is not consistently applied. Some texts refer to corporations as elements of SDoH [6, 25] or disease [43], and to commercial interests as distal, structural, societal factors causing disease and injury [33]. Conceptually, these terms and associated discussions closely reflect CDoH, and texts were accordingly included for review. However, other texts were excluded for failing to utilize CDoH language and/or for failing to acknowledge macro-level conditions and/or associated structures, relations and activities as determinants of health and disease.

Many activities, such as marketing [8, 48, 49], CSR [8, 48], and, CPA [7, 49, 50] have been well-documented for their influence on behaviors and health. However, these have largely been studied in isolation, without considering the broader social, economic and political conditions facilitating them, and, at times, without regard for associated outcomes. Similarly, significant literature describes issues such as trade relations [51, 52], globalization [53, 54], health commercialization [55], conflicts between corporate and human rights [55, 56], and health-harming products [53, 57] without acknowledging these as determinants of health or CDoH specifically. This represents a lacuna in the evidence base.

Whilst CDoH outcomes are mostly described as harms, Millar [15] proposed that some corporate entities ‘do real good’ for the sake of doing good, whilst others highlighted the perception that some industries are not as harmful as others. McKee and Stuckler [34] indicated that corporations can be a ‘force for good or bad’, dependent on their activities and partnerships. These interpretations may suggest that CDoH could be positive or negative, with benefits and harms nuanced and circumstantial. We question whether harm and ill-health are defining consequences of CDoH, or whether there could be scenarios, presently or in future, where commercial determinants could be consistent with public health interests and positively influence health. That is whether, as with SDoH, CDoH occur along a gradient or nuanced spectrum, thereby influencing population health and wellbeing negatively and/or positively depending on the context. Whilst current literature focuses on negative outcomes it is possible that positive CDoH outcomes may eventuate with appropriate intervention and/or context. This warrants further exploration. In particular, this work could consider the CDoH from a systems perspective, recognize the influence of CDoH at various levels, and explore the structures and, most importantly, the reflexive relations that generate environments, conditions and behaviors that shape health and wellbeing. A new CDoH definition that considers these factors may assist in addressing the current lack of precision in the literature base, whilst also going some way to framing responsive and reflexive CDoH interventions in future.

This review documents the macro-level conditions, relations, structures and activities, and consequences constituting CDoH as described in the CDoH literature. That is, literature self-identified as describing CDoH and associated concepts. Given the nascent nature of the CDoH literature, this review provides a timely synthesis of the current state of understanding.

Some limitations apply to this review. The narrow searching frame may have meant that some literature pertaining to peripheral CDoH concepts may not have been captured in this review. Further, the working definition adopted for initial planning may present a potential limitation [19].

Reviewed literature was limited to that published in English only. As such, perspectives from high-income countries frame much of the literature. However, material reviewed also discusses implications for low- and middle-income countries, including understanding and concern for the flow of commercial influences into these countries [5, 14, 16, 19, 23, 26, 28, 34, 38].

There are some inherent limitations to grey literature searching given the volume of results and the ‘filter bubble’, generated by search engines that tailor results to individual search histories and preferences. However, the inclusion of grey literature allowed for a more comprehensive review.

CDoH present an emerging, yet relatively underdeveloped, area of academic interest and concern. There is limited capacity to synthesize substantive findings, as these are not yet developed in the CDoH-specific literature. So far, the literature has largely focused on describing, rather than addressing, harm. As such, approaches to preventing the harms associated with CDoH are largely hypothetical, with some important exclusions including tobacco control efforts. It is anticipated that the literature base will continue to expand over coming years, with future work beginning to explore this further in the context of CDoH specifically.

The CDoH field is of increasing social and public health relevance. Whilst the literature base is in its infancy, it has begun to illustrate the multiple elements constituting CDoH, groups most affected, and resulting diminished population health outcomes. Overall, there is a need for greater specificity in the CDoH literature. As there is no widely accepted CDoH definition in use, evolution of this may be pertinent. Further, CDoH language should be more widely adopted to describe corporate influences on health and mechanisms reinforcing these globally, to better recognize these as significant contributors to global disease. In order to reduce NCDs and improve population wellbeing globally, systematic approaches to identifying, describing, and where necessary disrupting the complex conditions constituting CDoH are needed.