Building a qualitative systems map: applying systems thinking to the commercial determinants of health and industry influence on health policy

Abstract Background Unhealthy commodities are major drivers of the global burden of noncommunicable diseases. Commercial actors attempt to influence policy to undermine regulation and existing literature draws attention to the underlying macro-level factors that enable this influence. Public health literature also suggests that industry adapts to regulation and such influence may thus be considered a complex adaptive system. Therefore, this study aimed to build a qualitative systems map to help communicate the complexity of industry influence and develop a tool to facilitate the identification of interventions in follow up research. Methods In-person group model grouping workshops were adapted for the online environment. A preliminary qualitative systems map was developed by synthesising two recent studies to facilitate workshop discussions and expedite the mapping process. Twenty-three small group system mapping workshops were conducted with a total of 52 stakeholders, representing researchers, civil society, and public officials from various geographical regions. Results The qualitative systems map identifies five pathways through which industry influences policy: a) direct access to public sector decisionmakers; b) creation of confusion and doubt about policy decisions; c) prioritisation of commercial growth; d) industry leveraging the legal and dispute settlement processes; and e) industry leveraging policymaking rules and processes. The pathways contribute to perpetuating macro-level factors that enable industry to deploy practices to influence policy. Conclusions A system thinking approach can be applied to industry influence on health policy to depict a complex adaptive system. Interventions need to take into consideration the system's complexity and adaptivity. Further research is needed to test, and improve the systems map and identify interventions to achieve systems change.

Growing research around the globe shows that for-profit corporations incur increasingly adverse impacts on health and well-being of people, the planet and the global economy. Their health damaging products and practices fuel non-communicable disease epidemics, damage the earth's natural environment and interfere in health policy making. Such corporate interference in social and public health policy, research and practice is well documented for the pharmaceutical, tobacco, food and beverage, alcohol and arms industries. A commercial determinant lens allows a better understanding of heath inequalities by drawing attention to corporate actors and their tactics as drivers of ill-health rather than people's behaviors. This framework also makes it possible to present interventions to counter these influences. This workshop panel of 5 scholars and activists from around the world who are members of the Governance, Ethics and Conflict of Interest in Public Health Network serves to confirm the detrimental reach of industry practices and the global responses to this interference in public health. It aims to add to the emerging body of knowledge on commercial determinants of health using innovative research approaches and findings. The format is a series of 5 short sequential presentations, followed by an interactive discussion with the audience, moderated by the panel organizer. The presentations will showcase the research methods used including multi-stakeholder interviews, policy analyses, systems mapping and analyses of policy debates. The presentations will also document examples and cases of corporate capture of food industry in Europe, a global mapping of corporate systems, industry interference in health-protecting laws in Columbia, exploitation of humanitarian emergencies in Lebanon, and suggestions of ways forward to protect adults and children from industry vested interests with a Public Health Playbook.

Key messages:
Corporate interference in public health is a growing concern globally for its health harming influence on health systems and future generations.
Continued concerted research revealing overt and covert health harming industry practices is needed to counter their impact on PH in a world fraught with global challenges and uncertainty.
Background: Unhealthy commodities are major drivers of the global burden of noncommunicable diseases. Commercial actors attempt to influence policy to undermine regulation and existing literature draws attention to the underlying macro-level factors that enable this influence. Public health literature also suggests that industry adapts to regulation and such influence may thus be considered a complex adaptive system. Therefore, this study aimed to build a qualitative systems map to help communicate the complexity of industry influence and develop a tool to facilitate the identification of interventions in follow up research.

Methods:
In-person group model grouping workshops were adapted for the online environment. A preliminary qualitative systems map was developed by synthesising two recent studies to facilitate workshop discussions and expedite the mapping process.
Twenty-three small group system mapping workshops were conducted with a total of 52 stakeholders, representing researchers, civil society, and public officials from various geographical regions.

Results:
The qualitative systems map identifies five pathways through which industry influences policy: a) direct access to public sector decisionmakers; b) creation of confusion and doubt about policy decisions; c) prioritisation of commercial growth; d) industry leveraging the legal and dispute settlement processes; and e) industry leveraging policymaking rules and processes. The pathways contribute to perpetuating macrolevel factors that enable industry to deploy practices to influence policy.

Conclusions:
A system thinking approach can be applied to industry influence on health policy to depict a complex adaptive system. Interventions need to take into consideration the system's complexity and adaptivity. Further research is needed to test, and improve the systems map and identify interventions to achieve systems change.
Abstract citation ID: ckac129.089 ''We will take money from anywhere to support our work'': industry funding of humanitarian assistance in crises

Methods:
This research presents the experiences of humanitarian agencies in Lebanon on their funding from corporations, and the perceived influences on the populations served over a twoyear period coinciding with a long-lasting refugee crisis, the COVID-19 pandemic, an epic economic collapse and the devastation of a large part of Beirut from a cataclysmic explosion in its port. The study used qualitative in-depth interviews with representatives of non-governmental organizations working in Lebanon with Lebanese and refugees.

Results:
Funding from corporations starts with a two-way communication process between the organizations and the corporations, which recently started to be initiated by the corporations themselves after the Beirut blast. Funding from the tobacco, food and beverage industries is reported to come with conditions described to enhance their visibility, yet described as necessary, helps disadvantaged communities and sustains the organizations' operations. Other results relating to the availability of guidelines for detecting and managing COI from corporate funding are discussed. The law popularly known by the title 'Junk Food', was approved in Colombia in 2021 after years of advocacy from the Civil Society. Many authors as M. Mialon (2019Mialon ( , 2020Mialon ( , 2021 have documented the level of actions to intervene in the legislative space of the Parliament in Colombia created by the food industries to change the terms of the content of this law. Nowadays and after the approval of the text interpreted as a victory for Civil Society, Colombia is confronted with the reregulation of the law, leading to a new form of capture: the capture of the spaces of decision-making actors in public health policy in the country. We present an analysis of the case from a follow-up study designed by our organization FIAN Colombia (human rights organization that advocates for the right to adequate food and nutrition). The data used in this process of monitoring and action research comes from the observational data of the advocacy scenario made during the debates of the law in the Colombian parliament, based on the proceedings of the work meetings with congressmen, academia and civil society. This research-action process makes it clear that the collective action of advocacy from civil society manages to mobilize conditions to denounce the corporate capture of decision-making spaces and the execution of public health policies, and generates pressures based on research free of conflict of interest to reduce this capture. Similarly, there is a capacity to demand accountability that was generated from this process in Colombia, and that turns out to be a pilot experience for other regions. Corporate capture is the deliberately planned process whereby political decisions respond to a particular interest of a private nature, in detriment to the public interest. The result is an unjust regulation or the absence of regulation where this is necessary for the protection of the common good. Corporate capture of public health has to do with commercial determinants of health, such as alcohol, tobacco, sugarsweetened beverages and ultra-processed foods. Capturerelated actions are targeted at civil society, experts, public-health officials, civil servants and politicians. These actions range from material (corruption, revolving doors and donations to political parties) to intellectual (distortion of science and professional training), social (control of information and communication) and/or cultural (group identity, status and relationship of the regulator with the representatives of private corporations). The most common capture strategies are aimed at biasing scientific results, creating consumers from an early age, promoting a good image of corporations, questioning the legitimacy and appropriateness of governmental intervention aimed at regulating their activity, controlling professional education; and exerting pressure on governments and international bodies. To illustrate this phenomenon, we present findings from several examples of corporate capture of food policies in Europe. Preliminary results from publicly available information suggest that most of the mentioned tactics were used in Europe in order to block nutritional profiles, health warnings on food and effective food advertising regulations. We suggest implications for how European legislation can better protect European citizens, especially children, from vested interests aimed at promoting the consumption of unhealthy food and beverages.