Abstract
Background: The consumption of unhealthy commodities, namely tobacco, alcohol, and ultra-processed foods, is a major risk factors for developing noncommunicable diseases, which account for approximately 71% (41 million) of global deaths per year. Effective public health policies are needed to prevent such deaths and the preceding ill health. However, it is widely recognised that unhealthy commodity industries (UCIs) use their influence to oppose the development and implementation of these public health policies. Interventions are thus needed to prevent and mitigate UCI influence. Although literature on such interventions is emerging, current conceptualisations remain incomplete as they lack considerations of the wider systemic complexities surrounding UCI influence such as UCI ability to adapt to or circumvent interventions and underlying structures that enable UCI influence. This thesis explores how system thinking can enhance stakeholders understanding and conceptualisation of the complexities surrounding the problem of, and possible interventions to prevent and mitigate, UCI influence on public health policy.Methods: This thesis used online participatory systems mapping workshops conducted between November 2021 and February 2022. Twenty-three online workshops were conducted, involving 52 geographically diverse stakeholders representing academics, civil society, public officials, and global governance organisations. As a starting point for the workshops, a preliminary systems map of UCI influence on public health policy was developed based on recent research. In Paper I, the preliminary systems map guided discussions and was refined to produce a final systems map of UCI influence on public health policy. For Paper II, the preliminary systems map facilitated discussions with participants to identify and explore potential interventions, challenges, and actions to support interventions. Paper III used the same workshop data (i.e., workshop notes, whiteboard comments, and transcripts) to develop a heuristic to help guide stakeholders use systems thinking to critically assess and reflect on interventions. NVivo was employed for the analysis of workshop data in Papers I – III. In addition, Paper I used Kumu systems mapping software to analyse the data by consistently comparing system elements and interconnections, while Paper II utilised codebook thematic analysis, and Paper III employed thematic analysis.
Findings: The final systems map consisted of 64 elements across five interdependent themes, representing key pathways through which UCIs impact public health policy. Participants also identified 27 diverse, interconnected and interdependent interventions corresponding to each of the systems map’s pathways: 1) UCIs directly accessing public sector decisionmakers; 2) UCIs creating confusion and doubt about policy decisions; 3) UCIs prioritising commercial growth and profits; 4) UCIs leveraging legal and dispute settlement processes; and 5) UCIs leveraging policymaking norms, rules, and laws in their favour. The heuristic proposed three interrelated dimensions for stakeholders to pragmatically integrate systems thinking and critically engage and reflect upon interventions to address UCI influence on public health policy: 1) Who or what is involved in advancing an intervention? 2) Who or what does an intervention target? 3) What is an interventions’ relationship to the broader system of UCI influence?
Conclusions: Systems thinking is a useful lens through which to study UCI influence on public health policy and how it can be addressed. The systems map revealed that UCI influence is systemic, characterised by high complexity, interlinked practices, and emerging from complex interactions among disparate national and global social, political, and economic structures. Although interventions identified by stakeholders are disparate and heterogeneous, they are theoretically interdependent, applying to diverse parts of the system. The work, therefore, suggests that for maximal impact interventions should align, work collectively, and be applied synchronously. Additionally, interventions need to be supported by intermediary actions for successful implementation. The findings suggest that, to enhance intervention development and implementation, guidance should be created to encourage stakeholders to critically consider intervention complexity. The heuristic developed herein serves as an initial step towards such guidance.
| Date of Award | 11 Sept 2024 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Michael Bloomfield (Supervisor), Mateusz Zatonski (Supervisor), Krista Bondy (Supervisor) & Anna Gilmore (Supervisor) |