Bringing the commercial determinants of health out of the shadows: a review of how the commercial determinants are represented in conceptual frameworks.

BACKGROUND: The term 'commercial determinants of health' (CDOH) is increasingly focussing attention upon the role of tobacco, alcohol and food and beverage companies and others-as important drivers of non-communicable diseases (NCDs). However, the CDOH do not seem to be clearly represented in the most common social determinants of health (SDOH) frameworks. We review a wide range of existing frameworks of the determinants of health to determine whether and how commercial determinants are incorporated into current SDOH thinking. METHODS: We searched for papers and non-academic reports published in English since 2000 describing influences on population health outcomes. We included documents with a formal conceptual framework or diagram, showing the integration of the different determinants. RESULTS: Forty-eight framework documents were identified. Only one explicitly included the CDOH in a conceptual diagram. Ten papers discussed the commercial determinants in some form in the text only and fourteen described negative impacts of commercial determinants in the text. Twelve discussed positive roles for the private sector in producing harmful commodities. Overall, descriptions of commercial determinants are frequently understated, not made explicit, or simply missing. The role of commercial actors as vectors of NCDs is largely absent or invisible in many of the most influential conceptual diagrams. CONCLUSIONS: Our current public health models may risk framing public health problems and solutions in ways that obscure the role that the private sector, in particular large transnational companies, play in shaping the broader environment and individual behaviours, and thus population health outcomes.

Type A behavior pattern and coronary heart disease: Philip Morris's "crown jewel".

The type A behavior pattern (TABP) was described in the 1950s by cardiologists Meyer Friedman and Ray Rosenman, who argued that TABP was an important risk factor for coronary heart disease. This theory was supported by positive findings from the Western Collaborative Group Study and the Framingham Study. We analyzed tobacco industry documents to show that the tobacco industry was a major funder of TABP research, with selected results used to counter concerns regarding tobacco and health. Our findings also help explain inconsistencies in the findings of epidemiological studies of TABP, in particular the phenomenon of initially promising results followed by negative findings. Our analysis suggests that these "decline effects" are partly explained by tobacco industry involvement in TABP research.

Sankey diagrams can clarify 'evidence attrition': A systematic review and meta-analysis of the effectiveness of rapid diagnostic tests for antimicrobial resistance.

OBJECTIVES: To demonstrate, using the example of a new systematic review of rapid diagnostic tests, how Sankey diagrams, alongside the PRISMA guidelines, can (i) facilitate reporting of the quality of the evidence base and (ii) help assess evidence syntheses when studies use heterogeneous outcomes. METHODS: Systematic review and meta-analysis of experimental and observational studies which included at least one prescribing or clinical outcome of RDTs in hospital in-patients. Sub-group analysis was used to assess heterogeneity in summary effect estimates. A Sankey diagram was then used to show the pattern and quality of evidence on RDT outcomes. RESULTS: 57 studies from 14 countries were included. The introduction of RDTs did not significantly reduce in-hospital mortality (RR 0.83, 95% CI 0.60 - 1.15) or length of stay (weighted mean difference = -0.36, 95% CI -1.67 to 0.96). There was high heterogeneity in outcomes. CONCLUSION: There is no clear evidence that the routine use of RDTs for bacterial identification and antibiotic susceptibility testing improves clinical outcomes in hospital in-patients. Sankey diagrams may be a useful further way succinctly to present the pattern and quality of evidence in systematic reviews, especially when it is heterogeneous and not easily amenable to meta-analysis.

The "father of stress" meets "big tobacco": Hans Selye and the tobacco industry.

The concept of stress remains prominent in public health and owes much to the work of Hans Selye (1907-1982), the "father of stress." One of his main allies in this work has never been discussed as such: the tobacco industry. After an analysis of tobacco industry documents, we found that Selye received extensive tobacco industry funding and that his research on stress and health was used in litigation to defend the industry's interests and argue against a causal role for smoking in coronary heart disease and cancer. These findings have implications for assessing the scientific integrity of certain areas of stress research and for understanding corporate influences on public health research, including research on the social determinants of health.

A framework for identifying and mitigating the equity harms of COVID-19 policy interventions.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a global pandemic. Governments have implemented combinations of "lockdown" measures of various stringencies, including school and workplace closures, cancellations of public events, and restrictions on internal and external movements. These policy interventions are an attempt to shield high-risk individuals and to prevent overwhelming countries' healthcare systems, or, colloquially, "flatten the curve." However, these policy interventions may come with physical and psychological health harms, group and social harms, and opportunity costs. These policies may particularly affect vulnerable populations and not only exacerbate pre-existing inequities but also generate new ones. METHODS: We developed a conceptual framework to identify and categorize adverse effects of COVID-19 lockdown measures. We based our framework on Lorenc and Oliver's framework for the adverse effects of public health interventions and the PROGRESS-Plus equity framework. To test its application, we purposively sampled COVID-19 policy examples from around the world and evaluated them for the potential physical, psychological, and social harms, as well as opportunity costs, in each of the PROGRESS-Plus equity domains: Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, and disability). RESULTS: We found examples of inequitably distributed adverse effects for each COVID-19 lockdown policy example, stratified by a low- or middle-income country and high-income country, in every PROGRESS-Plus equity domain. We identified the known policy interventions intended to mitigate some of these adverse effects. The same harms (anxiety, depression, food insecurity, loneliness, stigma, violence) appear to be repeated across many groups and are exacerbated by several COVID-19 policy interventions. CONCLUSION: Our conceptual framework highlights the fact that COVID-19 policy interventions can generate or exacerbate interactive and multiplicative equity harms. Applying this framework can help in three ways: (1) identifying the areas where a policy intervention may generate inequitable adverse effects; (2) mitigating the policy and practice interventions by facilitating the systematic examination of relevant evidence; and (3) planning for lifting COVID-19 lockdowns and policy interventions around the world.

Pregnancy, Fertility, Breastfeeding, and Alcohol Consumption: An Analysis of Framing and Completeness of Information Disseminated by Alcohol Industry-Funded Organizations.

OBJECTIVE: Alcohol use during pregnancy can harm the developing fetus. The exact amount, pattern, and critical period of exposure necessary for harm to occur are unclear, although official guidance often emphasizes precautionary abstention. The impacts on fertility and breastfeeding are also unclear. Information on alcohol and pregnancy is disseminated by the alcohol industry-funded organizations, and there are emerging concerns about its accuracy, suggesting the need for detailed analysis. METHOD: Information on alcohol consumption in relation to fertility, pregnancy, and breastfeeding was extracted from the websites of 23 alcohol industry-funded bodies (e.g., Drinkaware [United Kingdom] and DrinkWise [Australia]), and 19 public health organizations (e.g., Health.gov and NHS Choices). Comparative qualitative and quantitative analysis of the framing and completeness of this information was undertaken. RESULTS: Alcohol industry-funded organizations were statistically significantly less likely than public health websites to provide information on fetal alcohol spectrum disorder and less likely to advise that no amount of alcohol is safe during pregnancy. They were significantly more likely to emphasize uncertainties and less likely to use direct language (e.g., "don't drink"). Some alcohol industry-funded (and no public health) websites appear to use "alternate causation" arguments, similar to those used by the tobacco industry, to argue for causes of alcohol harms in pregnancy other than alcohol. CONCLUSIONS: Alcohol industry-funded websites omit and misrepresent the evidence on key risks of alcohol consumption during pregnancy. This may "nudge" women toward continuing to drink during pregnancy. These findings suggest that alcohol industry-funded bodies may increase risk to pregnant women by disseminating misinformation. The public should be made widely aware of the risks of obtaining health information from alcohol industry-funded sources.

Shifting schedules: the health effects of reorganizing shift work.

BACKGROUND: Approximately one fifth of workers are engaged in some kind of shift work. The harmful effects of shift work on the health and work-life balance of employees are well known. A range of organizational interventions has been suggested to address these negative effects. METHODS: This study undertook the systematic review (following Quality Of Reporting Of Meta [QUORUM] analyses guidelines) of experimental and quasi-experimental studies, from any country (in any language) that evaluated the effects on health and work-life balance of organizational-level interventions that redesign shift work schedules. Twenty-seven electronic databases (medical, social science, economic) were searched. Data extraction and quality appraisal were carried out by two independent reviewers. Narrative synthesis was performed. The review was conducted between October 2005 and November 2006. RESULTS: Twenty-six studies were found relating to a variety of organizational interventions. No one type of intervention was found to be consistently harmful to workers. However, three types were found to have beneficial effects on health and work-life balance: (1) switching from slow to fast rotation, (2) changing from backward to forward rotation, and (3) self-scheduling of shifts. Improvements were usually at little or no direct organizational cost. However, there were concerns about the generalizability of the evidence, and no studies reported on impacts on health inequalities. CONCLUSIONS: This review reinforces the findings of epidemiologic and laboratory-based research by suggesting that certain organizational-level interventions can improve the health of shift workers, their work-life balance, or both. This evidence could be useful when designing interventions to improve the experience of shift work.

What are the health benefits of active travel? A systematic review of trials and cohort studies.

BACKGROUND: Increasing active travel (primarily walking and cycling) has been widely advocated for reducing obesity levels and achieving other population health benefits. However, the strength of evidence underpinning this strategy is unclear. This study aimed to assess the evidence that active travel has significant health benefits. METHODS: The study design was a systematic review of (i) non-randomised and randomised controlled trials, and (ii) prospective observational studies examining either (a) the effects of interventions to promote active travel or (b) the association between active travel and health outcomes. Reports of studies were identified by searching 11 electronic databases, websites, reference lists and papers identified by experts in the field. Prospective observational and intervention studies measuring any health outcome of active travel in the general population were included. Studies of patient groups were excluded. RESULTS: Twenty-four studies from 12 countries were included, of which six were studies conducted with children. Five studies evaluated active travel interventions. Nineteen were prospective cohort studies which did not evaluate the impact of a specific intervention. No studies were identified with obesity as an outcome in adults; one of five prospective cohort studies in children found an association between obesity and active travel. Small positive effects on other health outcomes were found in five intervention studies, but these were all at risk of selection bias. Modest benefits for other health outcomes were identified in five prospective studies. There is suggestive evidence that active travel may have a positive effect on diabetes prevention, which may be an important area for future research. CONCLUSIONS: Active travel may have positive effects on health outcomes, but there is little robust evidence to date of the effectiveness of active transport interventions for reducing obesity. Future evaluations of such interventions should include an assessment of their impacts on obesity and other health outcomes.

Does usage of domestic heating influence internal environmental conditions and health?

BACKGROUND: Housing conditions are recognised as an important determinant of health. In the UK, interventions to improve domestic heating are in place with the expectation that they will improve health. As a component of evaluating such policies, this study assesses whether specific health outcomes are significantly associated with the extent and duration of domestic heating use, either directly or via a possible mediating effect of internal environmental conditions. METHODS: Baseline data from a prospective controlled study evaluating the health effects of a publicly-funded programme of heating improvements in Scotland were used to assess associations among heating use, internal conditions, and three specific health outcomes. RESULTS: There were significant associations (P < 0.01) between measures of heating use and the presence of environmental problems in the home, such as mould and condensation. The presence of such problems was, in turn, found to be significantly predictive of two health outcomes derived from the SF-36 (P < 0.01) and of adult wheezing (P < 0.05). The direction of significant associations was highly consistent: greater levels of heating were associated with reduced likelihood of environmental problems, and the presence of environmental problems was linked to poorer health status. Heating use was not directly associated with the health outcomes considered. CONCLUSIONS: The study findings are consistent with a conceptual model in which health may be influenced by usage patterns of domestic heating, via the mediating effect of poor internal environmental conditions. Since these findings are based on cross-sectional data, interpretation must be carried out cautiously. However, if confirmed by planned future work they have important implications for policy initiatives relating to domestic heating and fuel poverty.