We identified senior leaders (i.e., director, head, lead, or vice-president titles) in the United States through purposive and snowball sampling for semi-structured interviews. The sample was limited to U.S.-based companies due to constraints in time and access to participants, allowing for a manageable and focused research process with context-specific findings. Leveraging the Building H Index, which evaluates products based on five health-related behaviors and their consequences (34), we listed companies most influential on the same five lifestyle behaviors: how people eat, move, sleep, socialize, and spend time outside. Our sample included streaming platforms, rideshare apps, social media platforms, and food delivery companies. These companies were selected for their impact, respectively, on sleep habits, physical activity and daily movement, social interaction, and eating habits. We cross-referenced the list with exchange-traded funds focused on innovative technologies to identify gaps (35, 36). We used company “people” pages on LinkedIn to identify relevant prospects using the search terms “social impact,” “corporate social responsibility OR CSR,” “ESG,” “policy,” and “responsible innovation.” We used RocketReach for cold outreach, searching by LinkedIn URL for corporate emails. Where emails were unavailable, we sent direct messages on LinkedIn.

We identified impact-driven investors using an analogous methodology. We drafted an initial list of potential investment firms by consulting The Banker’s Investment Banking Awards for sustainable investing categories, and the LinkedIn search terms “impact investing,” “ESG,” and “socially responsible investing.” We recruited investors with a social impact focus, and if possible, a technology-centric investment thesis, or ones that worked at large banks, venture capital firms, and private equity firms.

Where there was a dearth of respondents, or, a particular company of interest, we sourced interviewees through first and second-degree networking.

After conducting outreach to 83 individuals, 37 had no response after three attempts, eight declined, four offered referrals to colleagues in their place, and four deferred participation. We made outreach attempts at approximately 2 week intervals. Those who declined explained their decision, citing either lack of time or expertise. A single interviewer conducted interviews with 19 stakeholders, nine investors, nine company employees, and one individual currently in an investor role who was previously a company employee. Those that did not respond were either very senior, or poorly targeted, with both resulting in a lack of interest or time to participate. Not all recruitment occurred on the same timeline as after 10 interviews, responses were skewed toward the investor stakeholder group. As a result, additional interviews were determined to be required with company employees to achieve thematic saturation. Ten prospective interviewees were not interviewed after having achieved thematic saturation: these were individuals who responded to initial outreach, or who were referred through past interviewees, but had not yet consented to participate. Recruitment efforts ceased as interviews were no longer yielding new insights, indicating readiness for analysis. Examples of titles of those interviewed include:

The technology employees interviewed maintain accountability for considering the impact of their companies’ products on their consumers, typically under the umbrella of social issues. The investors all have impact-based theses: that is, they allocate the capital under their jurisdiction based not only on commercial returns but impact as well. These interviewees have a responsibility to consider the impact of their products and investments, and as such, are not your average employees or investors—they are intentionally leaders in the impact space.

This research project underwent review by the Johns Hopkins University Bloomberg School of Public Health Institutional Review Board (IRB), and was deemed exempt as it does not involve human subjects or poses minimal risk to participants.

Data collection occurred between October 2021 and January 2022. We intended the interview guide to elicit participants’ in-depth perspectives on the following domains: current social impact strategy, its measurement, whether and how health might influence the latter, the future of impact for tech and health, and motivators and barriers to implementing a health-promoting strategy (full interview guide in Appendix 1). Figure 2 visualizes the seven categories pursued and used for analysis.

Interviews averaged 45 min and were audio-recorded and transcribed directly through the Zoom video conferencing software used to conduct the sessions. We conducted interviews until we achieved thematic saturation, determined based on ongoing data review up to the point at which no new themes, patterns, or insights emerged from the data being collected.

Supported by NVivo (version 12.7.0), we used a grounded theory approach based in content analysis to interpret the interview transcripts. Grounded theory is most appropriate for research that seeks to discover something new, grounded in the data collected from those who experience the process—here, the intention is to develop a theory regarding the motivators and path to implementation for stakeholders integrating health into their impact strategy (37, 38). Content analysis entailed creating deductive codes based on the questions in the interview guide, yielding the overarching coding categories (blue in the codebook, see Appendix 2). This was followed by inductive coding under those categories by reading and re-reading the transcripts: allowing for the quantification and analysis of the presence and relationship of repeated words, themes, and concepts among interviewees to determine emergent themes and patterns (39, 40).

After coding was complete, a second coder performed a validity check for 25% of transcripts (41). The second coder and first author compared codes and crosswalked the transcripts to confirm face validity.

Social impact strategy guided investment, product development, or partnership decisions. Across stakeholders, strategy needed to be integrated into the business mission: allocating capital toward maximizing the opportunity for double returns, both commercial and impact. For investors, this is true regardless of sector: impact-driven investors want to find where they can best foster good with their capital. If a company chooses to tackle social issues without ties to an existing product and in-house expertise, the effort is unlikely to be successful—whether due to lack of cross-organization buy-in, sustained funds, or available capacity as this initiative would be apart from business-as-usual expectations. For example, it makes sense that a meal kit-delivery company would take on the issue of food insecurity, or for an e-commerce company to explore how they might impact financial inclusion. All companies have an opportunity to identify the social issues that most resonate with their consumers, and them as a company:

Still, stakeholders are experiencing growing pains in the implementation of their mostly nascent approaches to achieving social impact. But, with lofty goals that can be expected:

All stakeholders want to ensure the factors they perceive to be most important are being measured. But, many interviewed perceived existing frameworks to be focused on risk, as opposed to impact, and were not sufficiently nuanced for their needs and entailed overly burdensome implementation. For investors, it is especially important to be able to tie that impact to financial benefit—as a result, several reluctantly had to create their own. Today, companies do measure impact and investors do conduct diligence and monitor investments accordingly, but for the most part, this does not touch on health outside of healthcare.

Impact reporting needs to be a distinct effort from business operations reporting—even though both contribute to financial ROI. This separation is necessary to avoid impact initiatives from being superseded by short-term cost-cutting efforts, and to drive acceptance of short-term trade-offs to accrue long-term non-financial material gains.

The onus is on the company to conduct such reporting, for investors to be able to respond to any data. Quantitative data is seen as more objective here, and a perceived lack of rigor when it comes to measuring impact efforts broadly precludes growth in the impact space—especially for health.

Ultimately, metrics are an indicator of what efforts and resources are being prioritized: if you do not measure, you do not know, and you cannot compete. “Even if the number is not what it should be, […] the second you start reporting on something, the second you start tracking it, you start to improve it” (Investor #6). This matches established thought, as laid out by Nelson et al. (42), that the choice of metrics influences, organizes, and shapes behaviors early in the development of a new field or trend.

When it comes to frameworks in the future, multiple interviewees expressed that common metrics should be used as an organizing principle for determining health impact, allowing for comparison both across companies and industry verticals (e.g., education, food, commerce). This would require, and speaks to the demand for, data standardization, including success benchmarks for impact work. Improved measurement is seen as an opportunity to scale impact initiatives, and increase credibility. Many stakeholders expressed that if trustworthy health measures were readily available, there would be no obvious reason to exclude them from their impact initiatives:

Additional aspirations for future frameworks include driving equitable outcomes through product use, a requirement to report publicly to increase the accessibility of data, and a desire to capture “total returns”—that is, positive externalities that result from impact investments should be captured in the calculation of financial ROI. Indeed, it is the positive framing of externalities that could motivate companies to take action as health-conscious corporate citizens. Investors are interested in seeing their capital tied to social impact:

Interviewees expressed the power of collective action, that garnering more widespread employee awareness and buy-in for impact initiatives would be a facilitator of both pace and progress. Many pointed to the need to integrate equity into product strategy to yield an equitable product development process and build product trust. Centering equity also requires the acknowledgment of both positive and negative externalities, to allow for balancing of both, and ideally being proactive to avoid the negative and to enhance the positive. Some expressed the opportunity for health impact initiatives to bridge communities on and off a product, requiring collaborative product and product policy development (among teams with agency) with external experts. There is a nervousness around first-mover disadvantage, though, where the first organization to do something might be the one that is critiqued and others can benefit from that precedent.

Still, many believed that by making health a part of their brand position, it could become a selling point:

Companies that take action to consider health impact have the opportunity for health-positive influence on market dynamics. Interviewees flagged several factors as influential toward adopting a health-promoting strategy. First, interviews suggested that externally increased regulation via government or compliance requirements would yield immediate changes. Health-promoting actions by peer companies could also create new table stakes (this was viewed as net positive, in turn acknowledging that consideration of social impact is not a zero-sum game). Investor demand could drive company differentiation or new competitive advantage. Consumers, who provide a different stakeholder perspective, are taking health more seriously, resulting in pressure on companies to adopt socially responsible practices and the need for public buy-in around their authenticity: “One thing that’s so powerful about consumers right now is that they are demanding this from the brands they consume from.” -Company #5. Internally, employees are increasingly catalyzing change around companies’ social impact decisions, both due to need for their buy-in, and their demand. Finally, modern media cycles and social media have created greater visibility and comprehension of social issues today. Of note, the latter three points were perceived to be especially resonant for Gen Z employees and consumers [consistent with Nielsen (25) and IBM (26)].

The comprehensiveness of these motivators for change indicates this is not a niche trend:

Additional motivators for health metrics were non-stakeholder specific. Executive sponsorship could lead to company-wide accountability (indeed, CEOs account for 30% of variance around whether companies focus on corporate social responsibility) (43). The ability to influence tech policy was seen as attractive. Improved data quality, including clear attribution and digestible metrics, could convince skeptics and better capture positive product externalities. Proven cost–benefit could trigger investor or C-suite demand, and that benefit might be tied to evidence of de-risking a business or the marketability of positive impact (or of avoiding reputational risk). The rise of stakeholder capitalism could change tides. The most timely influencer, though, and which might quicken that rise, is COVID-19 (44). Companies and investors outside the healthcare sector were previously not convinced there could be “Health in All Companies,” and that health outcomes were of material value to private sector businesses. Increasingly, these entities are realizing that health is a prerequisite, both for financial participation and regular functioning. Indeed, this is an indicator that COVID-19 could change corporate priorities if the opportunity is appropriately leveraged: focusing on health and health equity in products could become an earning platform.

Despite the many motivators for organizations and investors, companies and investors identified several barriers to incorporating health impact into their corporate strategies. As opposed to motivators, the barriers to adoption are primarily internal to organizations. As described by one investor, lack of alignment with existing strategy can create roadblocks: “The farther upstream you get the more competing priorities there probably are, but I think you can make the case for … many … different kinds of verticals [vis-a-vis their health impact] at the top of the funnel” (Investor #7). Indeed, the financial margin to pivot priorities can be substantial as it is costly to stand up programs, both due to resources (financial and talent) and a question of who bears the cost (the company or consumer). The false stigma of concessionary returns does not help this belief (45). Without executive buy-in and internal collaboration, this margin is unlikely to be overcome. Part of this cost is the burden, both financial and labor, for additional reporting, which is heightened by ongoing tension debating the industry- vs. company-specific metrics, the appropriate atomic unit of measurement (e.g., company vs. product vs. algorithm), and the degree of appropriate reporting. For example, not all consumers’, or investors’, priorities are the same. Adoption by the majority would be necessary to maximize utility. Further, perceived inability to audit data according to off-product behavior, disparate data standards, and lack of direct attribution and rigor for health data creates further barriers around reporting:

Further, buy-in among employees and leadership is difficult with tension around individual decisions (both of those doing the work, and those using a product) and company-level accountability for social impact decisions. The sole external barrier consistently noted was the worry around regulatory issues and possible market pushback (e.g., why is a company/investor not already doing this, and if peers have better results).

The process for developing a health impact strategy should be seen as the organizing principle: this is the roadmap to determine a measurement system, as is outlined in the logic model in Figure 3. Organizations must adopt a theory of change approach, where they break down the inputs, outputs, and outcomes to understand the relationship between them and how to get from one to the next. This should entail (1) defining one’s values and identifying strengths, available resources (financial, labor, and talent), and possible levers of influence, (2) establishing a matrix of both potential risks and positive contributions, alongside their magnitude, then prioritizing which are most important to address and which can be tolerated, (3) distilling these priorities into how they can be measured. For example, move from “we make games,” to “games require movement,” to “movement is good for health,” “let us determine how to track movement through our product.”

Organizations need to consider both process measures, to see ROI more quickly, and second-order effects (i.e., how does how users engage on a product influence how they behave off of it, like how options presented through a meal kit service might influence cooking choices otherwise). In determining which social outcomes they can most influence, user variation must be considered to ensure equitable distribution of outcomes. After process and policy implementation, testing must occur within the product to ensure no unintended experiences are created for any user.

While building this process, organizations must remember that they should only measure what they can control. Ultimately, there needs to be a clear line from the measures selected, to their value, the reason for their implementation, and what they will accomplish, to optimize for adoption and utility.

It will be easier, and more effective, to motivate investment in health strategies such as those proposed here when they are aligned with business priorities. If these strategies require significant investment without immediate (or negative) financial returns, companies will need to confront difficult trade-offs reconciling short-term profit goals with long-term mission. This tension is inevitable given the conflicting horizons of financial vs. social returns.

Companies that aspire to integrate health impact into their social impact strategy can adopt design principles to drive health-positive product development. Investors should evaluate these same traits during diligence.

Design for empathy: From the outset, product teams could consider users of all backgrounds and how they might experience their product. Ideally, this might include participatory design processes (46). This can prevent unforeseen consequences for particular subsets of users. Companies may consider the implications of financial accessibility here, with discounts for the healthier choice.

Institute accountability: As part of any existing checks that might need to be considered before the launch of a new feature, e.g., approval from legal or compliance teams, there could be a check around the health of the user experience. By adding accountability as a company-wide process, any new feature would be subject to this consideration.

Design proactively: By implementing the above principles, teams can avoid post-hoc bandaids that are reactive to poor health or unanticipated behavior experienced through their products. Proactive decision making, including, for example, opportunities for education around healthier choice within a product, can negate the need for reactive, less integrated solutions (this is similar to the philosophy around medical errors) (47, 48). This may include design prominence of health-promoting activities (e.g., healthy foods, transit options), and prevention of harming behaviors (e.g., design decisions that limit sleep, going outside, physical activity).

Feature health as reward: If designed to foster health-positive behavior, by virtue of using the product correctly, users can inherently experience positive health outcomes (e.g., a rideshare app that defaults to pick-up/drop-off a 5-min walk from the designated location point), or teams can choose to explicitly offer in-product rewards for doing so (e.g., points in a game based around physical activity).

Consider holistic user journey: Teams can build a user journey that encourages healthy behavior, even if it occurs outside the product (i.e., education may occur through a product, but the actual behavior can be outside of it). Based on user behavior, teams can continuously iterate on the journey so that the most intuitive experience is the healthiest experience.

The interviews surfaced several areas that should be considered for measurement of health impact, and a starting point to address one of the most repeated perceived barriers. Adopting these guidelines for measures can create accountability, and can act as a signal to the market that they are prioritizing health. Indeed, while interviewees expressed a tension between product-, company-, and industry-specific measures, all acknowledged some level of consistency in measurement is needed to determine which companies’ and investors’ approaches are working, should be rewarded, and should be a model for others.

Reach and impact, including access, affordability, ease, and equity. This includes user participation, but also how (not just if) users are using a product. For example, does a company promote product uses that might positively influence health?

User awareness and education around the social impact initiatives implemented and the healthier choice being presented.

Healthy growth, which would require defining product health and any dose–response relationship that might exist as a threshold. This may also include the health of discourse, if applicable to the product in question. Growth may also be reflected in revenue: what proportion of sales reflect healthy options.

Product safety, privacy: this would entail understanding the potential for harm, including negative externalities.

Equitable distribution of outcomes and experience, and overall fairness: this would include measuring variation based on demographics and accessibility, and self-efficacy for healthy behaviors being fostered.

Overall proxy for general health: a single metric for measuring health impact was sorely wanted by many, if not most, of interviewees, as well as interest in one that might be mental health-specific. A few do exist, for example, the Mental and Physical Health Domain from Harvard’s Flourishing Index (49), however, they require survey implementation and would be self-reported, as per these sample questions:

The strong agreement between investors and tech employees interviewed can be expected due to intentional recruitment for their impact focus. By participating, interviewees aimed to advance their field and practice, introducing bias. Recommendations, being grounded in individual perceptions, hinder discerning importance and extent of generalizability. Further, the relatively small sample size, though intentionally limited due to thematic saturation, introduces the possibility that the results presented may not capture the full diversity of views within the broader population of technology executives and impact-focused investors, particularly across different geographic regions.

Public health has historically flagged negative commercial determinants of health (13–16), and implemented policies accordingly (e.g., limiting sugar-sweetened beverages, restricting public smoking). There is an opportunity for the private sector to help stem the tide of chronic disease, especially in this post-COVID moment. We need to normalize assuming accountability for the potential positive health impacts of companies (32), and technology specifically—perhaps by taking a page out of the HiAP playbook (33). This research can act as a foundation on which policy can be built to guide technology development that promotes positive health behaviors at the population level. We have tried the stick, what about the carrot? More research is required to cement the financial value of considering health impact. We need to move from Congressional hearings on negative health impacts of tech companies to recommendations on what they can do differently and policies to develop products with positive externalities.