Meeting the challenges of the 21st century: the fundamental importance of trust for transformation.

BACKGROUND: This paper is one of a collection on challenges facing health systems in the future. One obvious challenge is how to transform to meet changing health needs and take advantage of emerging treatment opportunities. However, we argue that effective transformations are only possible if there is trust in the health system. MAIN BODY: We focus on three of the many relationships that require trust in health systems, trust by patients and the public, by health workers, and by politicians. Unfortunately, we are seeing a concerning loss of trust in these relationships and, for too long, the importance of trust to health policymaking and health system functioning has been overlooked and under-valued. We contend that trust must be given the attention, time, and resources it warrants as an indispensable element of any health system and, in this paper, we review why trust is so important in health systems, how trust has been thought about by scholars from different disciplines, what we know about its place in health systems, and how we can give it greater prominence in research and policy. CONCLUSION: Trust is essential if health systems are to meet the challenges of the 21st century but it is too often overlooked or, in some cases, undermined.

The WHO Foundation in global health governance: Depoliticizing corporate philanthropy.

The creation of the WHO Foundation during the COVID-19 pandemic represents a significant institutional development in the politics of financing the World Health Organization (WHO). In the context of longstanding acute financial pressures, the objective of the WHO Foundation is to widen WHO's resource base by attracting philanthropic donations from the commercial sector. In placing funding decisions 'at one remove' from WHO, the stated expectation is that the WHO Foundation will act as an intermediary, insulating the WHO from potential conflicts of interest and reputational risk through a combination of strategic distance from WHO and proximity with its norms and rules of engagement with non-state actors. Yet, whether this model has translated into practice remains understudied. In this article, we focus on emerging institutional practices within the WHO Foundation, highlighting a drift from its stated governance model. Based on analysis of WHO Foundation documents, we demonstrate how due diligence and transparency practices within the Foundation have been redesigned in ways that contradict or subvert its claims to applying alignment with WHO's governance norms, notably relating to its engagement with health harming industries such as alcohol and petrochemical companies. While this situation may seem paradoxical, we argue that, in placing funding decisions 'at one remove' from the formal institutions and structures of WHO, the creation of the Foundation has served to displace this issue to a more secluded arena where drifts in practice are less exposed to political oversight and scrutiny. Focusing on the discursive aspects of this process of depoliticisation, we contend that the Foundation has strategically managed 'fictional expectations' of accountable and transparent governance in order to mitigate concerns about its mandate and functions. This assessment provides new and important insights into the depoliticizing functions of the WHO Foundation and the significant implications this may have for global health governance.

Agnogenic practices and corporate political strategy: the legitimation of UK gambling industry-funded youth education programmes.

Agnogenic practices-designed to create ignorance or doubt-are well-established strategies employed by health-harming industries (HHI). However, little is known about their use by industry-funded organizations delivering youth education programmes. We applied a previously published framework of corporate agnogenic practices to analyse how these organizations used them in three UK gambling industry-funded youth education programmes. Evidential strategies adopted previously by other HHI are prominent in the programmes' practitioner-facing materials, evaluation design and reporting and in public statements about the programmes. We show how agnogenic practices are employed to portray these youth education programmes as 'evidence-based' and 'evaluation-led'. These practices distort the already limited evidence on these educational initiatives while legitimizing industry-favourable policies, which prioritize commercial interests over public health. Given the similarities in political strategies adopted by different industries, these findings are relevant to research and policy on other HHI.

Under the influence: system-level effects of alcohol industry-funded health information organizations.

There is now an established body of evidence that the alcohol industry seeks to obstruct public health policies that could affect the availability, affordability or marketing of alcohol. In parallel, the alcohol industry is active in funding corporate social responsibility initiatives, with a particular focus on 'responsible drinking' campaigns, often facilitated by national-level charities established and/or funded by the alcohol industry and associated organizations. While evidence continues to grow regarding biases in the content produced by such health information organizations, they remain active in partnerships with government health departments on national health promotion campaigns and provide a range of health-related information to the public, community organizations and schools. To understand the implications of such access for policymakers, researchers and the public, there is a need to consider the wider, system-level influences of such organizations and their place in wider alcohol industry strategies. In this article, we describe evolving evidence of the direct and indirect strategic effects of such organizations and demonstrate how they serve key roles in the alcohol industry through their existence, content, partnerships and public profiles. We end by considering the implications for how we conceptualize charities established or funded (entirely or partly) by harmful commodity industries, and to what extent current conflicts of interest guidelines are sufficiently effective.

The Commercial Determinants of Health and Evidence Synthesis (CODES): methodological guidance for systematic reviews and other evidence syntheses.

BACKGROUND: The field of the commercial determinants of health (CDOH) refers to the commercial products, pathways and practices that may affect health. The field is growing rapidly, as evidenced by the WHO programme on the economic and commercial determinants of health and a rise in researcher and funder interest. Systematic reviews (SRs) and evidence synthesis more generally will be crucial tools in the evolution of CDOH as a field. Such reviews can draw on existing methodological guidance, though there are areas where existing methods are likely to differ, and there is no overarching guidance on the conduct of CDOH-focussed systematic reviews, or guidance on the specific methodological and conceptual challenges. METHODS/RESULTS: CODES provides guidance on the conduct of systematic reviews focussed on CDOH, from shaping the review question with input from stakeholders, to disseminating the review. Existing guidance was used to identify key stages and to provide a structure for the guidance. The writing group included experience in systematic reviews and other forms of evidence synthesis, and in equity and CDOH research (both primary research and systematic reviews). CONCLUSIONS: This guidance highlights the special methodological and other considerations for CDOH reviews, including equity considerations, and pointers to areas for future methodological and guideline development. It should contribute to the reliability and utility of CDOH reviews and help stimulate the production of reviews in this growing field.

Brexit, trade and the governance of non-communicable diseases: a research agenda.

BACKGROUND: The UK's post-Brexit trade strategy has potentially important implications for population health and equity. In particular, it will impact on the structural risk factors for non-communicable diseases (NCDs), including the consumption of health-harming commodities such as tobacco, alcohol and ultra-processed food and beverages. This article catalogues recent developments in UK trade policy. It then presents a narrative review of the existing research literature on trade and health and previous, prospective studies on the health impacts of Brexit. In so doing it identifies key questions and foci for a future research agenda on the implications of UK's emerging trade regime for NCD prevention. MAIN TEXT: We identify five key areas for future research. (1) Additional scholarship to document the health effects of key trade agreements negotiated by the UK government; (2) The implications of these agreements for policy-making to address health impacts, including the potential for legal challenges under dispute settlement mechanisms; (3) The strategic objectives being pursued by the UK government and the extent to which they support or undermine public health; (4) The process of trade policy-making, its openness to public health interests and actors and the impact of the political and ideological legacy of Brexit on outcomes; (5) The impact of the UK's post-Brexit trade policy on partner countries and blocs and their cumulative impact on the global trade regime. CONCLUSIONS: Further research is urgently need to understand the ways in which the UK's post-Brexit trade strategy will impact on NCDs and policy responses to address these, including the openness of the trade policy architecture to health issues. The outcomes of this process will have wider systemic effects on the global trade regime with implications for health. Researchers must be cognizant of the ideological components of the policy debate which have been absent from previous analysis of Brexit, trade and health.

Understanding the US Health Care Industry as a Commercial Determinant of Health.

This JAMA Forum discusses 4 commercial determinants of health, including political practices, preference shaping, the legal and extralegal environment, and product generation and promotion, that can undermine public health goals.

Advertising Alternative Cancer Treatments and Approaches on Meta Social Media Platforms: Content Analysis.

BACKGROUND: Alternative cancer treatment is associated with a greater risk of death than cancer patients undergoing conventional treatments. Anecdotal evidence suggests cancer patients view paid advertisements promoting alternative cancer treatment on social media, but the extent and nature of this advertising remain unknown. This context suggests an urgent need to investigate alternative cancer treatment advertising on social media. OBJECTIVE: This study aimed to systematically analyze the advertising activities of prominent alternative cancer treatment practitioners on Meta platforms, including Facebook, Instagram, Messenger, and Audience Network. We specifically sought to determine (1) whether paid advertising for alternative cancer treatment occurs on Meta social media platforms, (2) the strategies and messages of alternative cancer providers to reach and appeal to prospective patients, and (3) how the efficacy of alternative treatments is portrayed. METHODS: Between December 6, 2021, and December 12, 2021, we collected active advertisements from alternative cancer clinics using the Meta Ad Library. The information collected included identification number, URL, active/inactive status, dates launched/ran, advertiser page name, and a screenshot (image) or recording (video) of the advertisement. We then conducted a content analysis to determine how alternative cancer providers communicate the claimed benefits of their services and evaluated how they portrayed alternative cancer treatment efficacy. RESULTS: We identified 310 paid advertisements from 11 alternative cancer clinics on Meta (Facebook, Instagram, or Messenger) marketing alternative treatment approaches, care, and interventions. Alternative cancer providers appealed to prospective patients through eight strategies: (1) advertiser representation as a legitimate medical provider (n=289, 93.2%); (2) appealing to persons with limited treatments options (n=203, 65.5%); (3) client testimonials (n=168, 54.2%); (4) promoting holistic approaches (n=121, 39%); (5) promoting messages of care (n=81, 26.1%); (6) rhetoric related to science and research (n=72, 23.2%); (7) rhetoric pertaining to the latest technology (n=63, 20.3%); and (8) focusing treatment on cancer origins and cause (n=43, 13.9%). Overall, 25.8% (n=80) of advertisements included a direct statement claiming provider treatment can cure cancer or prolong life. CONCLUSIONS: Our results provide evidence alternative cancer providers are using Meta advertising products to market scientifically unsupported cancer treatments. Advertisements regularly referenced "alternative" and "natural" treatment approaches to cancer. Imagery and text content that emulated evidence-based medical providers created the impression that the offered treatments were effective medical options for cancer. Advertisements exploited the hope of patients with terminal and poor prognoses by sharing testimonials of past patients who allegedly were cured or had their lives prolonged. We recommend that Meta introduce a mandatory, human-led authorization process that is not reliant upon artificial intelligence for medical-related advertisers before giving advertising permissions. Further research should focus on the conflict of interest between social media platforms advertising products and public health.

Conceptualising the commercial determinants of suicide: broadening the lens on suicide and self-harm prevention.

Suicide is preventable, yet, in many settings, robust suicide prevention strategies have not been implemented. Although a commercial determinants of health lens is increasingly being applied to industries important to the field of suicide prevention, the interplay between the vested interests of commercial actors and suicide has received little attention. There is a need to shift attention to the causes of the causes, directing more focus to the ways that commercial determinants influence suicide and shape suicide prevention strategies. Such a shift in perspective, with an evidence base and precedents to draw upon, has transformative potential for research and policy agendas dedicated to understanding and addressing upstream modifiable determinants of suicide and self-harm. We propose a framework intended to help guide efforts to conceptualise, research, and address the commercial determinants of suicide and their inequitable distribution. We hope these ideas and lines of inquiry help to catalyse connections between disciplines and open further debate and discussion as to how to take such an agenda forward.

Protecting children and young people from contemporary marketing for gambling.

Around the world, children are being exposed to intensive marketing for gambling products. This normalizes perceptions that gambling is essentially a harmless form of entertainment, despite mounting evidence of the harms it causes. Young people and their parents are supportive of strategies to protect children from being exposed to gambling marketing. Yet existing regulatory efforts are inconsistent and inadequate, and have not protected children from exposure to the many forms of marketing now being developed and exploited by the gambling industry. We outline existing knowledge about strategies used by the gambling industry to market its products, with a specific focus on the potential impact of gambling marketing on young people. We provide a definition of gambling marketing and outline the different forms of promotion that are currently used to market gambling, current regulatory responses, and the impact of marketing on children and young people. We then argue that a comprehensive public health approach to gambling is urgently required, which must include effective action to limit the influence of marketing for gambling products, while recognizing that it is never possible to insulate children entirely from their reach.

• Gambling marketing has become particularly pervasive and aligned with major cultural activities such as sport. • Evidence clearly shows the normalizing impact of marketing on children and young people's gambling attitudes and consumption intentions. • Current regulatory efforts are inadequate and have not protected children and young people from exposure to a range of different forms of marketing. • Young people and their parents support the implementation of significant restrictions on gambling marketing. • The array of marketing mechanisms used by the gambling industry should be addressed as part of a comprehensive public health policy approach to protect children from gambling harms.

How Do Industry-Funded Alcohol and Gambling Conferences Frame the Issues? An Analysis of Conference Agendas.

OBJECTIVE: There is a growing evidence base that unhealthy commodity industries (including alcohol and gambling) promote industry-favorable framings of product harms and solutions. These framings adopt a focus on the individual while overlooking broader influences and solutions. One potential method to influence the framing of harms and solutions is funding and organizing conferences. This study aims to examine how industry-funded alcohol and gambling conferences present themselves and frame product harms and solutions. METHOD: We conducted a descriptive examination and framing analysis of industry-funded alcohol and gambling conference descriptions and agendas or programs to examine how conferences were presented. We also examined how the included topics framed the issues of product harm and solutions. A hybrid approach (using both deductive and inductive coding) was used for framing analysis, informed by previous research. RESULTS: All the included conferences were targeted at professionals outside of the respective industry, many specifically mentioning researchers or policy makers. Several of the conferences offered professional credits for attendance. We identified four key frames that are consistent with the existing evidence base: a complex link between product consumption and harm, focus on the individual, deflection from population-level approaches, and medicalization/specialization of solutions. CONCLUSIONS: We found industry-favorable framings of harms and solutions within the alcohol and gambling conferences included in our sample. These conferences are aimed at professionals outside of the industry, including researchers and policy makers, with several offering professional credits for attendance. Greater awareness of the potential for industry-favorable framings at conference settings is required.

A qualitative framing analysis of how firearm manufacturers and related bodies communicate to the public on gun-related harms and solutions.

There is a growing understanding that the producers and sellers of harmful products directly and indirectly affect population health and policy, including through seeking to influence public understanding about the nature of harms and their solutions. However, the firearm industry and related organisations have not to date been the subject of this type of enquiry. This study sought to address this evidential gap through examining the ways in which the firearm industry and industry-associated organisations frame firearms, firearm-related harms and possible solutions to gun violence. This was a thematic qualitative documentary analysis of materials from 7 of the largest firearm manufacturers and associated organisations. Two authors independently extracted textual material from web articles, press releases, annual reports and shareholder communications between 1st April 2019 to 1st April 2020 (302 documents). A hybrid approach combining both deductive and inductive coding was adopted, guided by the literature on the commercial determinants of health and using NVivo version 12. The firearm industry and firearm industry-funded organisations use framings about the safety and role of guns, evidence on associated harms and solutions that align with the industry's business interests, consistent with evidence on other harmful product manufacturers. This study identified framing strategies employed by the firearm industry and related organisations. These included attempts to undermine evidence, linking regulation to a dystopian future, minimising some of the most common harms, placing the responsibility for harms on individuals, and attempting to foster a heightened sense of risk to personal safety.