TYPE Original Research PUBLISHED 23 September 2022 DOI 10.3389/fpubh.2022.917456 Advertising of unhealthy foods OPEN ACCESS and beverages around primary EDITED BY Ghada A. Soliman, and junior high schools in City University of New York, United States Ghana’s most urbanized and REVIEWED BY Joaquin Barnoya, Unidad de Cirugía Cardiovascular de populous region Guatemala, Guatemala Vasanti Malik, University of Toronto, Canada Gideon Senyo Amevinya1, Stefanie Vandevijvere2, *CORRESPONDENCE Amos Laar Bridget Kelly3, Seth Kwaku Afagbedzi4, Richmond Aryeetey1, alaar@ug.edu.gh Akosua Pokua Adjei1, Wilhemina Quarpong5, Akua Tandoh1, SPECIALTY SECTION Silver Nanema1 6This article was submitted to , Charles Agyemang , Francis Zotor 7, Public Health and Nutrition, Matilda E. Laar8, Kobby Mensah9, Dennis Laryea10, a section of the journal Frontiers in Public Health Gershim Asiki11, Michelle Holdsworth12 and Amos Laar1* RECEIVED 11 April 2022 1Department of Population, Family and Reproductive Health, School of Public Health, University of ACCEPTED 22 August 2022 Ghana, Accra, Ghana, 2Sciensano, Service of Lifestyle and Chronic Diseases, Brussels, Belgium, PUBLISHED 23 September 2022 3Early Start, School of Health and Society, University of Wollongong, Wollongong, NSW, Australia, 4 CITATION Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana, 5Nutrition Amevinya GS, Vandevijvere S, Kelly B, and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States, Afagbedzi SK, Aryeetey R, Adjei AP, 6Department of Public and Occupational Health, Amsterdam University Medical Center (UMC), Quarpong W, Tandoh A, Nanema S, University of Amsterdam, Amsterdam, Netherlands, 7Department of Family and Community Health, Agyemang C, Zotor F, Laar ME, University of Health and Allied Sciences, Ho, Ghana, 8Department Family and Consumer Sciences, Mensah K, Laryea D, Asiki G, School of Agriculture, University of Ghana, Accra, Ghana, 9Department of Marketing and Holdsworth M and Laar A (2022) Entrepreneurship, University of Ghana Business School, University of Ghana, Accra, Ghana, Advertising of unhealthy foods and 10Non-communicable Disease Programme, Ghana Health Service, Accra, Ghana, 11African beverages around primary and junior Population and Health Research Center, Nairobi, Kenya, 12UMR MoISA (Montpellier Interdisciplinary high schools in Ghana’s most Centre on Sustainable Agri-Food Systems), (Univ Montpellier, CIRAD, CIHEAM-IAMM, INRAE, Institut urbanized and populous region. Agro, IRD), Montpellier, France Front. Public Health 10:917456. doi: 10.3389/fpubh.2022.917456 COPYRIGHT Introduction: The advertising of energy-dense, nutrient-poor foods and © 2022 Amevinya, Vandevijvere, Kelly, beverages is a common feature in obesogenic food environments. Such Afagbedzi, Aryeetey, Adjei, Quarpong, Tandoh, Nanema, Agyemang, Zotor, advertising, within and around settings where children live, learn, and play, Laar, Mensah, Laryea, Asiki, negatively aects their food acquisition and consumption. We examined the Holdsworth and Laar. This is an extent and nature of food and beverage advertising around primary and junior open-access article distributed under the terms of the Creative Commons high schools in Ghana’s most populous and urbanized region, Greater Accra. Attribution License (CC BY). The use, distribution or reproduction in other Materials and methods: Outdoor advertisements for foods and beverages forums is permitted, provided the within a 250m road network distance of 200 randomly sampled schools original author(s) and the copyright were geocoded. For each food and beverage advertisement, information was owner(s) are credited and that the original publication in this journal is collected on the setting, type, size, and number of product types featured cited, in accordance with accepted in the advertisement. Promotional techniques (promotional characters and academic practice. No use, distribution or reproduction is permitted which premium oers) used in advertisements were documented. Advertised does not comply with these terms. foods and beverages were classified using the INFORMAS and NOVA food classification systems. Results: A total of 5,887 advertisements were identified around the schools surveyed, 42% of which were for foods and beverages. Advertisements were most prevalent at food outlets (78% of all food advertisements), but also along roads and on non-food structures. Overall, 70% of food advertisements featured non-core/unhealthy products, while 12 and 14% had core/healthy Frontiers in PublicHealth 01 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 and miscellaneous (including soup cubes, seasonings, and tea) products. About 4% of food advertisements had only a product/brand name or logo displayed. One out of two of the foods and beverages advertised were ultra- processed foods, 30% processed, 3% processed culinary ingredients, and 17% unprocessed or minimally processed foods. Sugar-sweetened beverages were the most advertised food product type (32%). Promotional characters were found on 14% of all food advertisements (most–69% were cartoons or manufacturer’s characters), while 8% of all food advertisements had premium oers (including price discounts and gift/collectables). Conclusions: There is an abundance of unhealthy food advertisements around primary and junior high schools in the Greater Accra Region. Policy actions such as restricting the promotion of unhealthy foods in children’s settings are needed to protect pupils from such advertising practices. KEYWORDS food environments, food advertising, unhealthy foods, schools, children, Ghana Introduction digital spaces, magazines, etc.) where they frequently utilize (16). They are particularly vulnerable because of their susceptibility Preventing overweight and obesity among children is to advertising techniques; they lack the cognitive ability to a global public health priority. Since the 1980s, childhood recognize the persuasive intent of advertising (17). overweight and obesity have risen worldwide (1, 2). An increase Currently, the literature on food marketing highlights from 4% in 1975 to over 18% in 2016 was reported among the extensive advertising of less healthy options such as school children aged between 5 and 19 years globally (3). Diverse energy-dense foods and beverages, particularly sugar-sweetened studies have identified exposure to unhealthy food environments beverages (12). Television food advertising remains the most as a major determinant of overweight and obesity, especially researched advertising platform, although research on other among countries undergoing what is termed the nutrition media and settings is increasingly gaining attention. Reports transition (4–6). Ghana is at an advanced stage of the nutrition from studies on outdoor food advertisements conducted in New transition; there is a rapid shift toward consumption of energy, Zealand (18), Australia (19, 20), and the USA (20) consistently fat, sugary, and salty foods and low levels of physical activity show that most outdoor food advertisements are for unhealthy (7, 8). food or beverages, and they vary according to neighborhood A known factor driving the preference, acquisition, and characteristics. While data on outdoor food advertising in consumption of unhealthy foods is food and beverage marketing low-and middle-income countries is limited, accumulating (9, 10). The World Health Organization (WHO) defines evidence suggests a significant predominance of unhealthy food marketing as “any form of commercial communication or marketing in these countries. For instance, Chacon et al. found message that is designed to, or has the effect of, increasing most the advertised food products around public schools in the recognition, appeal, and/or consumption of particular Guatemala were for sweetened beverages and soft drinks (21). products and services” (11). Existing marketing platforms, such In Mongolia and the Philippines, Kelly et al. reported over as television, radio, and outdoor advertisement channels (e.g., 85% prevalence of unhealthy food and drinks in the vicinity billboards, merchandise, and posters), are used to communicate of schools (22). Furthermore, a recent study of outdoor food messages and promote products and services to consumers advertising around schools in Africa-Uganda recorded that (12). Promotional messages featured on these platforms are over 80% of the food advertisements featured unhealthy food often packaged using persuasive marketing techniques deployed products (23). Our assessment of outdoor food advertising in the toward specific target individuals with common needs or urban cities of Ghana also identified sugar-sweetened beverages characteristics (13). Such marketing techniques include the use as the most widespread food or beverage sold or advertised of celebrity or sports endorsements, promotional characters, (24, 25). product claims, gifts/incentives, competitions, and games which Recognizing this evidence, the 63rdWorld Health Assembly are likely to appeal to children (14, 15). For children and endorsed a set of recommendations on the marketing of adolescents, they are mostly exposed to such marketing food and beverages to children (11). Member states were techniques staged in media/settings (e.g., on television, schools, encouraged to use these recommendations to develop new Frontiers in PublicHealth 02 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 and/or strengthen existing policies on food and non-alcoholic primary schools and 812 public junior high schools, with a total beverage marketing to children. However, in 2020, the enrolment of 431,782 (30). WHO Global NCD Progress Monitor report indicated that A representative sample of six study districts was selected Morocco is the only country within the African region to from the Greater Accra Region using a multistage sampling have fully implemented the WHO recommendation on the approach.We first grouped the 16 administrative districts within marketing of foods and non-alcoholic beverages to children (26). the Greater Accra region using the decentralized system of Currently, countries such as Chile and Spain are safeguarding administration under the local government system of Ghana children from unhealthy food environments through the into three strata: Metropolitan, Municipal, and District. A promulgation of zoning laws prohibiting the promotion of metropolitan covers urban areas with populations of over unhealthy foods to children (27). In Ghana, food advertising 250,000. Amunicipal has a population of 95,000 ormore, while a is regulated by the Food and Drug Authority of the Ministry district covers a wider geographical area, combining rural areas of Health. However, anecdotal evidence suggests that there is and small towns, with a minimum population of 75,000 people. indiscriminate advertising of unhealthy foods and beverages These administrative divisions are by themselves indications within Ghanaian children’s settings, including the immediate of the population density and urbanization status and give school environment. Empirical data is required to substantiate an idea of district-level “poverty incidence” (PI). The Ghana this assertion and guide public health initiatives and/or Statistical Service calculates and defines poverty incidence as strategies aiming to improve children’s food environment, the proportion of the population living below the national including through policy development and implementation. poverty line (6.6%). From each stratum, a random selection of This descriptive study aimed to examine the extent and nature Accra Metropolitan (PI: 2.6%) out of two metropolitans; Ningo of outdoor foods, and beverages advertising around selected Prampram District (PI: 31.2%) and Kpone Katamanso District schools in the Greater Accra region of Ghana. (PI: 3.5%) from the five district assemblies; and La Nkwantanang Madina Municipal (PI: 2.8%), Ashaiman Municipal (PI: 4.4%), and Ga South Municipal (P1: 15.2%) from nine municipalities was performed. Materials and methods Study design Schools sampling This descriptive cross-sectional survey is part of the MEALS4NCDs Project (28) which aims to measure and Schools were the primary sampling unit (PSU) in this study. support public sector actions that create healthy food A sample of 200 schools representing about 25% of the schools marketing, retail, and provisioning environments for within the region was selected from the six study districts. For children and adolescents in Ghana. The project adopted each district, schools were stratified by levels (primary only, standardized frameworks, indicators, and tools to assess JHS only, and those having both JHS and primary levels). The food promotion, food provision, and the Ghanaian required number of schools for each stratum from each district community’s readiness to support policy actions toward was calculated and sampled using proportionate sampling on healthier food environments. The design of this current the basis of the number of available schools for each level. study draws substantially from the outdoor advertising This information was obtained from the EducationManagement protocol developed by the International Network for Food Information System (EMIS) of the Ghana Education Service. and Obesity/NCDs Research Monitoring and Action Support Subsequently, a systematic random sampling technique was used (INFORMAS) (29). to select the participating schools from each stratum after sorting using roll size data, defined as the number of pupils in the school. Full details on the sampling methodology have been published elsewhere (28). Study location Figure 1 displays the geographical location of the 16 Data collection administrative districts in the Greater Accra Region. The Greater Accra region was purposively selected out of Ghana’s For each selected school, zones earmarked for assessment ten geographical regions (at the time the study was being were road networks within a distance of 250m from the main conducted). It is the most populous and urbanized region entrance of each school. The 250m distance is in accordance in Ghana and hosts the capital city, Accra. The region has with the INFORMAS protocol (29) and has been used by a cosmopolitan mix of cultures from all the other regions previous studies investigating outdoor food advertising (19). of Ghana. In 2018, the region had a total of 862 public The 250m is considered a walkable distance that students Frontiers in PublicHealth 03 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 FIGURE 1 Map of the Greater Accra region of Ghana showing the various districts and poverty incidence. can travel to make purchases during breaktime. Identification visits and directly auditing all road networks in the dedicated of the main entrance of each school was manually done by zones at the selected schools for advertisements of food or field supervisors with assistance from the head teachers after non-food products. Assessment for each school zone was providing informed consent. All selected schools consented to completed at a visit. Field workers used an observational participate in the study. checklist, designed using the Open Data Kit (ODK) application Data collection was carried out between July and August on an Android-based mobile phone with a built-in camera 2020 during weekdays (Monday–Friday, 9:00 a.m. to 5:00 p.m.) and geo-positioning functions, to objectively record descriptive while schools were in session. This period ensured survey information about each food advertisement. This format allowed activities were conducted while full academic session was simultaneous coding of advertisement characteristics (size of ongoing, allowing other components of the MEALS4NCDs advertisement, setting of advertisement, type of advertisement, project that required engagement with school authorities to be number of product types in the advertisement, product’s carried out. Prior to data collection, field research assistants with name and brand, and the use of promotional characters a minimum of a bachelor’s degree were trained on using the and premium offers), photograph, and recording of the geo- data collection tool and study protocol. Emphasis was placed location coordinates of the advertisements found. Effort was on the definition of an advertisement and what qualifies as a made to record the names of all products depicted in food (including alcoholic and non-alcoholic beverages) or non- the advertisement in the event the advertisement promoted food advertisement. Inter-coder reliability examination among multiple products. field personnel was performed to check coding reliability after a pretesting exercise as part of the training. A total of 55 advertisements identified at a test site were independently coded Food classification by 12 research assistants. Data collected by the first author (GSA) was used as a reference, and percentage agreement was Classification of food products in advertisements was calculated for all field research assistants individually. Inter- performed after the completion of field data collection. code reliability calculated ranged from 85 to 90%. In this study, A separate training session was organized for three advertisements were defined in accordance with the INFORMAS personnel (including GSA and AL) on how to correctly Outdoor Advertising Protocol (29). classify advertised food products. Inter-coder reliability Six field teams (two-person teams) were each assigned to testing was performed before commencing with the one of the six districts and tasked with conducting on-site actual classification of the food advertisement. Each Frontiers in PublicHealth 04 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 coder got a minimum of 80% inter-coder reliability on a Ethics test dataset. Two different food classification systems, the NOVA Permission to conduct this study was obtained in 2019 classification system and the INFORMAS food classification from the Greater Accra regional office as well as the system, were used to classify the foods and beverages advertised. participating district offices of the Ghana Education Service. With limited application in the Ghanaian setting, the two Ethics approval was granted by the Ghana Health Service classification systems were adopted to ascertain how each Ethics Review Committee (Approval # GHS-ERC 005-06-19) evaluates the local food and beverage advertisements. The and the University of Ghana Ethics Committee for Humanities INFORMAS food classification system classifies food into (Approval # ECH 152-18-19). “core/healthy”, “non-core/unhealthy” and “miscellaneous” foods. This classification system is based on defined cut-off points of fat and sugar (per 100 g of food). The cut-off points are Results different for each food group, taking into account differences in nutrient density. This food-based system encompasses Assessment was conducted at all 200 sampled schools. Most 11 sub-food groups under core/healthy foods, 15 sub-food of the schools were from the Accra metropolitan area (n = groups under non-core/unhealthy and 11 subgroups under 54) with Ashaiman municipality recording the lowest number miscellaneous. Core/healthy foods include fruits, vegetables, of sampled schools (n = 13). The “poverty incidence” across and water, while foods such as sweetened beverages, ice cream, the selected districts ranged from 2.6% (lowest) for Accra and sweet biscuits are categorized as non-core/unhealthy foods. Metropolitan to 31.2% (highest) for Ningo Prampram District. Miscellaneous foods include soup cubes, seasonings, and tea. Those advertisements with only a product/brand name or logo were classified separately. In this study, an advertisement Extent of food advertisement in the areas was considered non-core/unhealthy if at least one food item around schools in the advertisement was coded as non-core/unhealthy. This classification system has been used by previous studies, In total, 5,887 advertisements were identified, of which 2,469 including some in Sub-Saharan Africa on outdoor food (42%) were food-related. The number of food advertisements advertising (23, 24). The NOVA food classification, which is per school varied widely (range= 1–125) with a median number based on the nature, extent, and purposes of the industrial of 14 food advertisements. As shown in Figure 2, the proportion processes’ foods are subjected, classifies foods into four groups: of food advertisements recorded in areas (districts) with a low Unprocessed and minimally processed foods; processed poverty incidence was higher compared to those with a high culinary ingredients; processed foods; and ultra-processed poverty incidence. Food advertisements were more prevalent in foods and drinks products (31). Unprocessed and minimally the vicinity around of “JHS only” schools (median = 22) than processed foods include fresh and frozen vegetables, fruits, in the vicinity of “Primary only” schools and Basic (having both cereals, meats, poultry, and fish. Processed culinary ingredients primary and JHS units) schools (median= 11)—see Table 1. include plant oils, animal fats, sugar and salt. Examples of processed foods include canned vegetables in brine, fruits in syrup, fish preserved in oil, while ultra-processed foods include ice cream, chocolates, candies, cookies, noodles, and Characteristics of foods and beverages carbonated drinks. Alcoholic drinks are not considered in advertisements this classification. Overall, the majority (78%) of food advertisements were either within the premises of food shops (mostly Statistical analysis convenience/provision shops) or attached to them. About 15% of adverts were by the roadside, and the remaining Statistical software, IBM SPSS Statistics for were posted on non-food buildings (6%) or in other settings Windows version 21, was used for data cleaning (2%)—mobile stalls and bus shelters. Most food advertisements and statistical analysis. All recorded outdoor food (71%) promoted a single food product, although 19% had two advertisement data was used in the analysis. Descriptive or more different products. About 10% of food advertisements analyses (frequencies, median, and Interquartile display only the product/brand name or logo. Most food range) were used to summarize the number and advertisements were in the form of posters or banners (71%). characteristics of food advertisements, including those About half (49%) of the food advertisements were small in size, for promotional techniques (promotional characters and while over one-third (34%) were of medium size and 10% were premium offers). large (Table 2). Frontiers in PublicHealth 05 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 FIGURE 2 Hotspot map of advertisements recorded by district. TABLE 1 Median number of food and beverage advertisements along Types of advertised foods and beverages a 250m road network around schools by school type and location characteristics. Two-thirds (70%) of the food advertisements featured non- Median food (25-, 75- core/unhealthy foods. Core/healthy foods and miscellaneous adverts percentiles) foods contributed to 12 and 14% of food advertisements, respectively. About 4% of food and beverage advertisements School type had only a product/brand name or logo. The most frequently Primary school only (6–11 y) 11 (7, 22) advertised food product subcategory was sugar-sweetened Junior high school only (12–15 y) 22 (12, 41) beverages (32%), followed by alcoholic beverages (12%) Basic school (6–15 y) 11 (4, 22) and high-fat and/or sugar-flavored dairy products and their School location alternatives (11%)—see Table 3. Four out of the top five most Accra metropolitan 19 (12, 41) frequently advertised product subcategories belonged to the Ashaiman municipal 13 (8, 35) non-core/unhealthy food category. Bottled water (8%) was Ga South municipal 4 (2, 7) the most advertised product within the core food category. La Nkwantanang Madina municipal 23 (11, 47) Advertisements for fruits and fruit products, and vegetables and Kpone Katamanso district 16 (9, 33) vegetable products were rarely found (1 and 2%, respectively). Ningo Prampram district 12 (5, 24) About 69% of the foods and beverages advertised were ultra- Location poverty incidence processed foods; 29% were processed; 5% were processed High poverty incidence schools 6 (3, 14) culinary ingredients; and 19% were unprocessed or minimally Low poverty incidence schools 20 (10, 39) processed foods according to the NOVA classification system (see Figure 3). The number of unhealthy food ads was higher Frontiers in PublicHealth 06 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 TABLE 2 Characteristics of food advertisements in/around schools in understanding environmental cues like advertising activities Greater Accra. that promote the consumption of unhealthy foods. Findings Frequency (n) Percent (%) from this study demonstrate that outdoor food advertisements (42%) are pervasive around schools in the Greater Accra Setting of advertisement region. Previous studies have reported varying densities of food Food shop 1,924 78 advertisements at schools, citing neighborhood characteristics Road 364 15 such as socioeconomic status and geographical (rural/urban) Non-food building 140 6 locations as contributing factors (32–34). Our study reveals s Mobile stall 38 2 lower density of food advertisements in schools located in areas Bus Shelter 3 0 with high poverty incidence areas compared to those in low Format of advertisement poverty incidence areas, which are more urbanized and have Poster/banner 1,744 71 high population density neighborhoods. Food marketers gain Merchandise (e.g., branded umbrella, branded 308 13 more value (brand exposure) when food products are advertised fridge) in a high-density neighborhood due to the number of people Free-standing sign 243 10 that could be exposed to the advertisements as compared to the Painted building/wall 152 6 same activity in low-population areas. Billboard 21 1 Several studies have indicated the predominance of Number of product type in advertisement marketing of energy-dense, nutrient-poor foods and beverages around schools (18, 23, 24). The presence of unhealthy Only product/brand name 244 10 food advertising in and around schools can influence school Single food product type 1,746 71 children’s food choices, considering the repeated exposure to Two or more food product types 479 19 these advertisements (35, 36). Such exposure can also contribute Size of advertisement to what is referred to as the “normalization” of junk food >A4 paper 177 7 (37, 38), as well as act as a cue for unhealthy food purchase and Small (>A4 but <1.3× 1.9m) 1,203 449 consumption (9). Medium (>1.3× 1.9m but <2.0× 2.5m) 845 34 The vast majority of food advertisements observed in our Large (>2× 2.5m) 244 10 study promoted unhealthy food products, and most commonly sugar-sweetened beverages. This aligns with earlier research around schools in the high poverty incidence area compared to by Green et al. (25), which found that almost half of food the low poverty incidence urban area, with a median of 12 and and beverage advertisements in deprived urban neighborhoods 3, respectively (Table 4). in Ghana and Kenya were for sugar-sweetened beverages. In Uganda, a study that assessed food and beverage advertising surrounding schools in urban and peri-urban areas using Description of promotional techniques the same methodology as the current study reported that 86% of food advertisements featured unhealthy products, Approximately 14% (n = 334) of food advertisements of which sugar-sweetened beverages were again the most featured a promotional character. Cartoons/company owned advertised product (23). The ubiquitous promotion of sugar- characters (69%) and “for kids” images (23.4%) were the sweetened beverages around schools means school children are most predominantly used promotional characters compared to exposed to a large number of unhealthy food and beverage others, such as famous sports people, non-sport celebrities, and advertisements that can influence their intake. The dominance amateur sports people. Premium offers were present in 8% (n of sugar-sweetened beverage advertising as referenced in the = 184) of all food advertisements. They include price discounts aforementioned studies is consistent with reports of deliberate, (28.8%), price promotions (60.9%) and “gifts and collectables” relentless, and pronouncedmarketing activities of such products (7.6%). As shown in Figure 4, of the advertisements that featured in this and other LMICs (39). Efforts aimed at improving a promotional technique, non-core foods advertised had the population food environments and thus NCDs recommend the highest number of promotional characters and premium offers establishment of local or national policies that will limit the used (74 vs. 96%, respectively). marketing of high-fat, salt, and sugar (HFSS) foods, especially to children (40, 41). It is important that these policies encompass tighter restrictions on sugar-sweetened beverages as they appear Discussion to be the most advertised food products. Health researchers and practitioners have consistently raised Tackling obesity and diet-related NCDs demands a concerns about the proliferation of unhealthy food marketing multi-sectoral and multidisciplinary approach, including in settings frequented by children, including the school Frontiers in PublicHealth 07 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 TABLE 3 Food categories and distribution by proportion of food desired outcomes. In some countries, like South Korea, areas advertisements in/around schools in Greater Accra. around schools are prohibited from food advertising practices N % to prevent school children exposure to unhealthy marketing practices (44). In the literature, it is evident that food-related FOOD CATEGORY activities within the environment where people live or spend Core foods most of their hours can influence their dietary patterns (45, Bottled water 189 8 46). Basic schools in Ghana are typically situated within the Meat and meat alternatives—include meat, poultry, 177 7.2 community and are exposed to commercial activities, including fish, legumes and eggs the sale and advertisement of food products by food vendors Rice/rice products without added fat, sugar or salt 143 5.8 operating in and around the school. Zoning initiatives that Vegetables/vegetable products without added fats, 47 1.9 restrict unhealthy food promotion and availability and also sugars or salt promote the availability of healthy foods like fruits, and whole Low fat milks/yogurts and their alternatives 32 1.3 grain products could be useful to ensure a healthy school food Fruits/fruit products without added sugar 31 1.3 environment in Ghana. Baby foods (exclude milk formulae) 28 1.1 In our study, more than one in ten food advertisements Low fat/salt meals—include frozen or packaged 24 1.0 surrounding schools were for alcoholic beverages. Elsewhere, meals exposure to outdoor alcohol advertising has been found to Low sugar and high fiber breakfast cereals 17 0.7 be positively associated with intentions to consume alcohol Oils high in mono- or polyunsaturated fats 15 0.6 among school children (47). Further, higher exposure to outdoor Non-core foods alcoholic beverage advertising was found to be associated with Sugar sweetened beverages 799 32.4 higher intakes (48). The harmful use of alcohol is recognized by the WHO as a causal factor in more than 200 diseases, Alcohol 302 12.2 including NCDs and injury conditions (49). Like with other High fat and/or sugar flavored dairy products and 278 11.3 unhealthy foods and beverages, exposing children to marketing their alternatives activities for alcohol could be detrimental to their wellbeing. In Meat and meat alternatives processed or preserved 206 8.3 recent years, Ghana’s Food and Drug Authority has developed in salt guidelines for advertisements on foods and beverages, which Ice cream, iced confection and desserts 130 5.3 include specific requirements for the advertisements of alcoholic Flavored/fried instant rice and noodle products 127 5.1 beverages (50). The guidelines restrict the airing of alcohol Sweet breads, biscuits, cakes, muffins, and high fat 90 3.6 advertising on radio and television between 08:00 a.m. and savory biscuits, pies and pastries 08:00 p.m. It also prohibits the placement of alcohol advertising Fruit juice/drinks (<98% fruit) 64 2.6 materials within 200 meters of schools. However, observations Other high fat/salt products 57 2.3 from this study show that outdoor advertisements, including Fast food (not only healthier options advertised), 56 2.3 posters and billboards, are used to promote alcohol within e.g., burgers, fries, soft drinks the school neighborhood, some of which were within the 200 Sweet/Savory snack foods 37 1.5 meter prohibited zone. It is therefore important that future High sugar and/or low fiber breakfast cereals 17 0.7 amendments to the guidelines should encompass restrictions for Chocolate and candy 11 0.4 all outdoor advertising platforms in settings such as the school Miscellaneous food environment. At the time this study was undertaken, there were Local restaurant mixed dishes 446 18.1 no specific national regulations to restrict the marketing of Recipe additions (including soup cubes, oils, dried 214 8.7 sugar-sweetened beverages to children, even though Ghana is herbs and seasonings) a signatory to World Health Assembly Resolution 63.14, which Tea and coffee (excluding sweetened powder-based 31 1.3 sought to encourage efforts that would restrict the marketing of teas or coffees) unhealthy food and non-alcoholic beverages to children (11). Some advertisements depicted more than one food or beverage product. Clearly, results from this study show that efforts by regulatory bodies in Ghana need to be intensified. Our study also found that posters and banners were the environment (42). This concern is precipitated by the increasing most used outdoor advertising type, accounting for over 70% rates of overweight and obesity among children of school- of all advertisements recorded, although other channels like going age (43). Considering that school nutrition interventions billboards, merchandise, and free-standing signs were also are implemented to positively promote healthy food choice recorded. The usage of stationary materials like posters and and intake among school-going aged children, the presence of banners as a means of advertising food has been reported to unhealthy food advertising may be a barrier to achieving the be heavily placed in close proximity to settings like schools Frontiers in PublicHealth 08 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 FIGURE 3 The proportion (%) of promoted foods and beverages by food categories. FIGURE 4 Promotional technique used on food advertisements by food categories. Frontiers in PublicHealth 09 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 TABLE 4 Median (25-, 75-percentiles) number of food and beverage the advertisements (58, 59). Fernandes et al. reported that category advertised by school characteristics. unhealthy foods are being sold to Ghanaian children in schools Food category by private or independent vendors (59). Given that not all food outlets provide healthy food, the Ghana Education Service can Core Non-core Miscellaneous put in place regulations to restrict the sale and promotion of foods foods having high sugar and fat content within the premises of the school compound. There is a need to extend this School type regulation out of the school premises to include the immediate Primary school only (6–11 y) 4 (2, 4) 10 (5, 30) 3 (2, 6) surroundings accessible to school children since there is a chance Junior high school only (12–15 y) 3 (1, 5) 12 (7, 35) 4 (2, 6) for students to visit food outlets close to the school premises. Basic school (6–15 y) 2 (1, 4) 9 (3, 19) 2 (1, 4) Regarding the link between promotion of unhealthy foods School location and health outcomes, most evidence relates to the effect Accra metropolitan 3 (1, 4) 12 (9, 23) 3 (2, 6) of promotion on preferences and choices rather than on Ashaiman municipal 4 (2, 9) 4 (2, 9) 2 (1, 10) the ultimate adverse outcome, such as obesity. Some have, Ga south municipal 2 (1, 3) 2 (1, 5) 1 (1, 3) nevertheless, argued that, independent of other factors, exposure La Nkwantanang Madina municipal 4 (2, 6) 20 (9, 33) 4 (1, 7) to unhealthy food marketing is a modifiable risk factor for Kpone Katamanso district 4 (1, 5) 10 (5, 22) 2 (1, 5) obesity (60, 61). Kessler describes how sugar, fat, and salt activate Ningo Prampram district 2 (1, 3) 9 (4, 19) 2 (1, 4) neurons involved in taste perception, reward, and conscious Location poverty incidence control of eating. He theorizes that “chronic exposure to highly High poverty incidence schools 4 (1, 5) 12 (8, 28) 4 (1, 6) palatable foods changes our brains, conditioning us to seek Low poverty incidence schools 2 (1, 3) 3 (2, 9) 1 (1, 4) continued stimulation. Over time, a powerful drive for sugar, fat, and salt competes with our conscious capacity to say no”. He identifies dopamine as one of the key neurotransmitters and other places where they can be repeatedly seen by large mediating the rewiring of brain circuits in this way. numbers of people (4, 51, 52). For posters in particular, its attributes make them easily placeable onto any surfaces at Contribution to knowledge multiple locations. Marketing researchers see this channel of advertisement as particularly impactful since it is embedded Globally, poor diet is a major contributor to overweight and into the physical environment and people cannot avoid being obesity among children and adolescents. Environmental factors exposed to it easily as compared to advertisements broadcast influence availability of poor diets, and dietary habits. One such on platforms like television or radio (53). Therefore, efforts to factors is food and beverage marketing. In the literature, food regulate unhealthy food advertisements must be comprehensive advertising, a form of food and beverage marketing, has been in scope and should cover all advertising channels, including shown to primarily promote products high in fat, sugar, sodium, stationary outdoor advertisements. or salt content. Public health experts and international health The present study also showed that over three-quarters of organizations have advised governments and policymakers to food advertisements were placed at food outlets. This finding restrict the marketing of unhealthy foods, particularly to children. is suggestive that marketers exploit food outlets as marketing However, research and monitoring reports show that unhealthy platforms. Available literature shows that promotional activities, food marketing persists. Most of the data are from studies especially in-store advertising at retail outlets, have the ability conducted in high-income countries. Such evidence is limited in to influence consumer purchase by providing cues toward the lower and middle income countries. Context-relevant data certain brands or products (54). Our assessment of in-store are required to inform regional and local guidelines, policies or advertising is reported elsewhere (55). In their investigation of regulations. The current study investigated the food and beverage the retail food store exterior advertisements and the products advertising landscape in a lower middle-income country, Ghana, sold in retail outlets, Barquera et al. found that about 60% of focusing on the school environment. The pervasive advertising the advertised products were available at the food shops (4). of sugar-sweetened and alcoholic beverages as recorded in this For school children, food outlets within the school vicinity study demands policy action to limit the exposure to children of are places frequented during school hours, especially during unhealthy food advertisements. break periods to purchase foods for consumption (56, 57). The presence of food advertisements at food outlets in the school environment can influence the purchasing behavior and Limitations consumption patterns as a result of repeated exposure (10). Children, in particular, are seen as vulnerable to marketing Having been purposively delimited to the Greater Accra activities since they are not able to recognize the intent behind Region, the results from this study may not be generalizable Frontiers in PublicHealth 10 frontiersin.org Amevinya et al. 10.3389/fpubh.2022.917456 to other regions of Ghana. Any attempt to extrapolate the FZ, MEL, KM, DL, GA, and SV secured funding and findings should recognize this limitation. Cross-sectional in contributed to research design. GSA, APA, WQ, SKA, design, this study could not detect seasonal variations in and SN collected and analyzed the data. GSA drafted the marketing practices. manuscript. All authors reviewed and approved the final manuscript. Conclusion Funding Overall, the data shows that school children in public sector basic schools in the Greater Accra Region of Ghana are This study was supported by funding from the International exposed to unhealthy food advertisements, particularly sugar- Development Research Centre (IDRC) Food, Environment, and sweetened beverages. There is a clear need for a national policy Health Program—IDRC, Canada - Grant Number: 108983-001 that restricts the advertisement of these protects, especially in (PI—AL). The funder, however, played no role in the study children’s settings. design, data collection, analysis or interpretation, or in writing the manuscript. Data availability statement The raw data supporting the conclusions of this article will Conflict of interest be made available by the authors, without undue reservation. The authors declare that the research was conducted in the absence of any commercial or financial relationships Ethics statement that could be construed as a potential conflict of interest. The studies involving human participants were reviewed and approved by the Ghana Health Service Ethics review committee (Approval # GHS-ERC 005-06-19) and the University of Ghana Ethics Committee for Humanities (Approval # ECH 152-18- Publisher’s note 19). All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated Author contributions organizations, or those of the publisher, the editors and the reviewers. 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