University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH AND SCIENCE UNIVERSITY OF GHANA HEALTHINESS OF FOODS AND BEVERAGES ADVERTISED ON GHANAIAN TELEVISION PROGRAMMES TARGETING CHILDREN BY IRENE AMPONSAH KUMI (10294532) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE DECEMBER, 2018. University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Irene Amponsah Kumi hereby declare that this dissertation is the result of my own independent research conducted apart from works of others which have been duly acknowledged. This work was done under the supervision of Dr Amos Laar. I affirm that this work has never been publish in whole or in part in any institution for any academic award. ……………………………… ……………………………… IRENE AMPONSAH KUMI DATE (STUDENT) ……………………………… ………………………………… DR AMOS LAAR DATE (SUPERVISOR) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to God for His love throughout my entire program, to my parents Mr & Mrs Kumi and to my sister Freda Kumi for their immense support. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I would like to extend my profound gratitude to my supervisor, Dr Amos Laar for his time, patience and effort into shaping me academically and also making this work a reality. I appreciate your input in my academics, thank you very much Dr I would also like to express my most profound gratitude to my foster parents, Rev & Mrs Ayeh Otu for their constant encouragement throughout the difficult times in my academics, Rev Abbey for constantly ensuring that I lacked nothing and my friend Sampson Kafui Djonor for his immense support. Dr Louis Agyemang Siriboe, words cannot express how much I appreciate your support. I am sincerely thankful, you were just amazing, thank you very much. To all the staff of school of public health, staff of department of Population, Family and Reproductive Health, and to my colleagues, I say a special thank you to all for playing vital roles in my academic life. Last but not least, I would love to appreciate my parents, Mr & Mrs Kumi and my sister for supporting me in various ways. I am indeed very grateful. I just can’t stop thanking you. Finally, God has been excellent throughout my schooling. Thank you, Lord. iii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION .................................................................................................................. i DEDICATION ..................................................................................................................... ii ACKNOWLEDGEMENT .................................................................................................iii TABLE OF CONTENTS ................................................................................................... iv LIST OF TABLES ............................................................................................................ vii LIST OF ABBREVIATIONS ........................................................................................... ix ABSTRACT ......................................................................................................................... x CHAPTER ONE ................................................................................................................. 1 INTRODUCTION ............................................................................................................... 1 1.1 Background ................................................................................................................. 1 1.2. Problem statement ...................................................................................................... 3 1.2.1. Conceptual Framework ........................................................................................ 6 1.2.2 Description of components of conceptual framework .......................................... 8 1.3. Objectives ................................................................................................................... 9 1.3.1. General objective ................................................................................................. 9 1.3.2. Specific objectives ............................................................................................... 9 1.4. Research questions ..................................................................................................... 9 1.5. Study justification ....................................................................................................... 9 1.6. Operational Definitions ............................................................................................ 11 CHAPTER TWO .............................................................................................................. 13 LITERATURE REVIEW ................................................................................................. 13 2.1. Introduction .............................................................................................................. 13 2.2 Strategies adapted by advertisers to market products to children ............................. 14 2.3. Healthiness of foods and beverages advertised and its measurement ...................... 17 2.3.1 Core/Non-Core Food Classification ................................................................... 17 2.3.2 EU Nutrient Profiling System ............................................................................. 17 2.3.3. PAHO Nutrient Profiling System ...................................................................... 18 2.4. Types of foods and beverages advertisements targeting children ............................ 19 2.5 Usage of claims in child directed advertisements ..................................................... 20 2.6 Relationship between unhealthy food, obesity and NCDs ........................................ 21 iv University of Ghana http://ugspace.ug.edu.gh 2.7 Measures to limit television food advertisement directed at children ....................... 22 2.8 Summary .................................................................................................................. 23 CHAPTER THREE .......................................................................................................... 24 METHODS ........................................................................................................................ 24 3.1 Introduction ............................................................................................................... 24 3.2. Study Type ............................................................................................................... 24 3.3. Study setting ............................................................................................................. 24 3.4 Study design .............................................................................................................. 25 3.5 Study population ........................................................................................................ 25 3.6 Sampling procedure ................................................................................................... 25 3.7 Study variables .......................................................................................................... 27 3.8 Data coding ................................................................................................................ 28 3.9 Quality control ........................................................................................................... 29 3.10 Data analysis ............................................................................................................ 29 3.11 Ethical considerations .............................................................................................. 30 CHAPTER FOUR ............................................................................................................. 31 RESULTS .......................................................................................................................... 31 4.1. General information on advertisements shown on the various TV channels ........... 31 4.2. Categories of foods and beverages advertised on selected Ghanaian TV channels . 33 4.3 Healthiness of foods and beverages on selected Ghanaian TV programs ................. 38 4.4 Persuasive Techniques of Food Advertisements ....................................................... 39 CHAPTER FIVE ............................................................................................................... 42 DISCUSSION .................................................................................................................... 42 5.1 Introduction ............................................................................................................... 42 5.2 Children’s prime time on TV .................................................................................... 42 5.3 Categories of foods and beverages advertised .......................................................... 44 5.4 Proportion of healthy foods and beverage advertisement ......................................... 45 5.5 Persuasive technique used in foods and beverages advertising................................. 47 5.6 Impact of results on public health ............................................................................. 48 v University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX ................................................................................................................. 50 CONCLUSIONS AND RECOMMENDATIONS .......................................................... 50 6.1 Conclusion ................................................................................................................. 50 6.2 Recommendation ....................................................................................................... 51 6.2.1 Policy Makers ..................................................................................................... 51 6.2.2 Future Research Direction .................................................................................. 51 REFERENCES .................................................................................................................. 52 APPENDICES ................................................................................................................... 60 vi University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Advertisements shown per channel and days (n=1926) ....................................... 32 Table 2: Periods Advertisements were shown on the various TV stations ......................... 33 Table 3: Category of advertisements shown on the various TV channels .......................... 34 Table 4: Rate of adverts per channel ................................................................................... 34 Table 5: Categories of various foods and beverages advertisements .................................. 35 Table 6: Time of foods and beverages advertisements per hour and Day of the Week ...... 36 Table 7: Food Advertisements per Day of the Week .......................................................... 37 Table 8: Association between health status of foods adverts and TV Stations (N=590) .... 38 Table 9: Rate of healthy and non-healthy adverts per TV station....................................... 38 Table 10: Persuasive techniques of foods and beverages advertisements .......................... 39 Table 11: Category of food advert whiles children were on at vacation. (N=98)............... 41 vii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual framework .......................................................................................... 7 Figure 2: Composite week sampling showing various days of data collection .................. 27 Figure 3: Health Claims Made by Food Advertisements .................................................... 40 viii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS Ads Adverts DHS Demographic and Health Survey EU European Union HFSS High in fat, sugar or salt INFORMAS International Network for Food and Obesity/non- communicable diseases Research, Monitoring and Action Support LMICs Low- and Middle-Income Countries NCA National Communication Authority NCDs Non-communicable diseases PAHO NP Pan American Health Organization Nutrition Profile PTs Persuasive techniques SSB Sugar-sweetened Beverage TV Television UKNPM United Kingdom nutrition profile model US United States WHO World Health Organisation ix University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background –The frequency of television adverts on energy-dense nutrient-poor foods and non-alcoholic beverages are directed at children is of great public health concern. There is an established link between food adverts and children’s food consumption and purchases. Childhood obesity and diet-related non-communicable diseases is likely to persist if recommendations on food and non-alcoholic beverages marketing targeted at children by World Health Organisation are not adhered to. Little is known about what pertains in Ghana with regards to food advertisements on television directed at children. Objective: To assess the healthiness of foods and non-alcoholic beverages advertised on Ghanaian television programs targeting children. Methods: A cross-sectional study involving three television channels in Ghana were recorded over a four month period. Composite week sampling technique was used to sample the days for recording, totalling 43 days: weekdays and weekend inclusive. Content analysis of food and beverage product advertised was categorized into major food groups through coding. Broadcast recording commenced each day from 0600hrs to 1800hrs and was coded using a Microsoft excel spreadsheet, then imported into Stata version 15 for data analysis. Mean, percentages, standard deviations and frequencies were used to describe the data. Chi square test was carried out to determine the significance between channels per healthiness of food and time of food advertisements per day of the week. Results: Of the 1,926 adverts recorded, 590 were of foods and beverages. Categories of advertised foods were: sugar sweeten beverages 25.8%, the most advertised, followed by snacks 12.8%, milks and yogurt 12.4%, instant noodles 7.1%, candy/chocolate and ice creams 6.4%, breakfast cereals, and beverages 5.3%, fruits 2%, water and vegetables were x University of Ghana http://ugspace.ug.edu.gh less than 1.5%. Energy-dense nutrient-poor food adverts dominated across all three TV channels. The most used persuasive technique were those utilizing sensory based characteristics (Taste, texture, appearance and aroma) 44%, followed by adverts which suggested use for children 30%, and 29% of the adverts used animation, children and cartoon characters, health claims 18%, 14% portrayed happiness, fun and pleasure, 13% indicated that product was convenient to use, 6% had price tag, 5% were new brands and 2% had suggested use (e.g. great for lunch box). None of the products advertised had a disclaimer, however they had health claims, nutrient content claims etc. Conclusion: Unhealthy food adverts persist and are accompanied by at least one persuasive technique which has significant influence on children’s purchases and consumption of appreciable amount of foods and beverages high in fats, sugar and salt, then subsequently increasing the rate of obesity and NCDs in Ghana. xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background Television (TV) advertisement (ads) is an influential tool which fosters in children an autonomous decision to purchase independently of their parents. Children are vulnerable, hardly understand the intent of advertisers thus they are easily influenced and buy the advertised products at all cost (Boyland & Whalen, 2015). They also become preoccupied with the products advertised persistently and insist on parents to purchase the product for them (Cairns et al, 2008). Children’s exposure to nutrient poor-energy dense foods and beverages advertisement is common and this have been demonstrated in various regions and countries of the world (Kelly et al., 2014, Rovirosa et al., 2017, Uribe Bravo, 2012, Karupaiah et al., 2008). Television advertisement on foods and beverages is shown to greatly influence children to make particular brand choice, buy these products and consume (Norman et al., 2016, Cairns et al., 2009). Such unhealthy eating habits formed during childhood continues into adult life (Perry et al., 2004). Excessive accumulation of these unhealthy foods and beverages leads to childhood obesity and its associated diet related non-communicable diseases (NCDs), for example, diabetes mellitus, high cholesterol, cardiovascular diseases and cancers leading to premature death (Ng et al., 2013, Dehghan et al., 2013). Unhealthy products include those that are high in saturated fats, trans-fat, free sugars or salt (United Nations, 2011). In 2017, global estimates report on childhood obesity and overweight showed an increased burden globally as at 2016 (Global estimates report, 2017). The obesity pattern in Africa has also increased, recording 8.5% in 2010 and is estimated to be 12.7% if unhealthy dietary practises do not change (De Onis et al., 2010). 1 University of Ghana http://ugspace.ug.edu.gh The National Health and Nutrition Survey of Mexico (2012), showed that there was substantial increase in overweight and obesity among children under 5 years from 26.6 % to 33.6 % between the period of 1988 and 2012 and from 28.2 % to 36.9 % for children 5- 11 years between 1999 and 2012. Gupta et al (2012) indicates that rapid dietary transitions to junk foods with minimal physical activities among other causes are the leading cause of obesity in recent times in the developing countries possibly due to globalization and the proliferation of unhealthy foods and beverages advertisements. In recent times, Ghana has also experienced increase in obesity and non-Communicable Diseases (NCDs). This can be attributed to “nutrition transition”, thus shifting from our local complex carbohydrates and fibre rich foods to “modern” junk foods due to exposure (Ofori-Asenso et al., 2016). Despite several recommendation and restrictions on foods and beverages advertisements geared towards children, such as the Sydney Principles and the WHO non-communicable disease (NCD) action plan and monitoring framework, for which reduction of junk food marketing to children is one of the indicators, energy-dense nutrient poor foods still dominate on TV. Systems for classifying healthiness of promoted foods and beverages include nutrient profiling models that assign numerical values to nutrients as part of a scoring system, including for negative nutrients (e.g. saturated fat, sugar and sodium) and positive components (e.g. fruit, vegetables, nuts, fibre and protein). One of such profiling system was developed by the UK Food Standards Agency to underpin regulations restricting food and non-alcoholic beverage advertising on television (Food Standards Agency, 2006). Nutrient information for also classifying foods and beverages into either healthy or unhealthy could be determined through data collection as part of the International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS) module for monitoring the composition of foods and beverages 2 University of Ghana http://ugspace.ug.edu.gh (Neal, Sacks, Swinburn et al., 2013). These are models used in monitoring healthiness of foods and beverages on television (Adams, et al., 2012). Foods and beverages are usually grouped according to nutrition guidelines, and foods are often categorised according to major food categories of healthy/core and unhealthy/non-core items and miscellaneous/subgroups: fast food, sweets, dairy, cereals, chips/crackers, beverages, fruits/vegetables and others (Kelly, et al., 2010, Guran, et. al., 2010). Data on foods and beverages advertisements on Ghanaian TV to children appears limited, thus this current study would enlighten us about the kinds of foods and beverages advertised on television targeting children, its healthiness or otherwise and the accompany persuasive techniques. 1.2. Problem statement World Health Organization (WHO) is alarmed at the current proliferation of obesogenic food environment especially food advertised on TV targeting children, obesity prevalence, especially childhood obesity and its associated NCDs. These are grave worldwide public health problems of this recent times for which we ought to deal with before the problem of obesity and NCDs further escalates (WHO Fact sheet, 2017). WHO in 2016, found that more than 41 million children under the age of five were reported to be overweight/obese globally. Of these, nearly half live in Asia and about a quarter in Africa. Although most countries like Ghana are still struggling with under- nutrition, poverty and infectious disease issues, globalization has made societies richer. Richness, weight gain and NCDs co-exist (Ofori-Aseno et al., 2016). Ghana over the years had been battling with childhood malnutrition largely due to inadequate nutrition. We are in a cultural shift where children consume more of energy 3 University of Ghana http://ugspace.ug.edu.gh dense nutrient poor food. A transformation of what children are fed with motivated by foods and beverages advertisements targeting children (Boyland, et. al., 2016). In Ghana, being obese sadly connote being healthy but like any other developing country, Ghana faces the risk associated with obesity and overweight, if current unhealthy dietary trends do not change (De Onis et al., 2010). According to the Ghana Demographic and Health Survey (GDHS) in 2014, Ghana had choked some successes, in that the proportion of stunted children has reduced steadily from 35% in 2003 to 19% in 2014 while children who are wasted have reduced from 8% in 2003 and 9% in 2008 and to 5% in 2014. Underweight children have reduced from 18% in 2003 to 11% in 2014. Overweight is said to have fluctuated between 4-5% between 2003 and 2008, and at 3% as at 2014. But while we have made these important progresses, it is worth noting that children who are obese and overweight are still at risk of contracting non-communicable diseases such as cardiovascular, diabetes etc. and are also at increased risk of suffering psychological ill health (e.g., related to bullying and social isolation resulting in low self-esteem and poor quality of life) Reilly & Wilson, 2006. Consequences of overweight and obesity during childhood are substantial. Children who are obese are more likely to be obese in adulthood, which in turn puts them at risk of NCDs. Further, as explained by Lobstein, (2010), children may exhibit early signs of NCDs without knowledge of the problem for which the outcome can be very fatal. Most of these diseases cause premature deaths in addition to long term morbidities. In Ghana overall overweight/obesity among women has increased by about one-third in a decade i.e. from 25% in 2003 to 40% in 2014 (GDHS, 2014). This is a worrying trend that could increase preventable diet related NCDs which are a significant cause of death in Ghana (MOH, 2012), thus early intervention is crucial. Many of these obesities and its associated complications impose substantial burden on the health care system in developing countries with weak health systems, and if allowed 4 University of Ghana http://ugspace.ug.edu.gh unmitigated the implications are that the cost of its care may overwhelm not only the health budget but also affect the provisions of basic social amenities. Jempson states that, “worldwide it is estimated that there are 1.8 billion TV viewers under the age of 15 years. Of these, 190 million live in the richest regions and 1.6 billion the developing world” (Jempson, 2008). Thus, significant number of children in Africa have access to TV. According to Osei-Hwere, “an audience research figure from 1997 shows that there were 1.9 million television sets in Ghana reaching about half of the population of Ghana (Osei-Hwere, 2008). Furthermore, the 2010 population census for Ghana, points out that, children below the age of 15 constituted 38.3% of the population (Ghana Statistical Service, 2012). Cultivation theory developed by Gerbner states that, “the more a person is exposed to a message provided by the media, the more likely that person is to believe the message is real” (Gerbner et al., 2008.) The cultivation theory assumes that over time, particular symbols, images, messages, meanings from television messages become dominant and are absorbed as the truth (Miller, 2005). “Television has long term effects which are small, gradual, indirect but cumulative and significant” (Chandler, 1995). Evra (1990) argues that “by virtue of inexperience, young viewers may depend on television for information. Extensive studies have been carried out in several countries on food and beverages advertised on TV targeting children but in Ghana, after extensive literature search there was no information on this topic, thereby making this study the first to be conducted in this country. This study seeks to explore the healthiness of foods and beverages advertised on Ghanaian TV targeting children. 5 University of Ghana http://ugspace.ug.edu.gh 1.2.1. Conceptual Framework In recent times, there are multiple medium through which advertisers channel their messages to their targets. (Story and French, 2004). Despite the fact that policies on foods and beverages advertisement directed at children exist, children are still being exposed to these adverts on TV. Children, once exposed to these foods and beverages advertisements, they become convinced about the food products. They either purchase these products with their “pocket monies” or persistently request parents to get it for them. This exposure is capable of shaping children’s dietary habits, leading to frequent intake of energy-dense nutrient poor foods and subsequently resulting in child ill health (obesity and NCDs). Reason for which the WHO have set of recommendations to restrict adverts of foods high in fats, salt and sugar (HFSS) but rather promote healthy foods. 6 University of Ghana http://ugspace.ug.edu.gh Influences children’s food preferences Children Positive beliefs Influences Consumption e xposure to about children’s of foods and foods and advertised food beverages beverages foods and purchase high in fat, advertisements beverages salt and on TV sugar Influences children’s Policies on food request adv ertisement of foo ds high in fat, sal t and sugar to children Less energy Energy expenditure intake Child health / Obesity / NCDs Figure 1: Conceptual framework 7 University of Ghana http://ugspace.ug.edu.gh 1.2.2 Description of components of conceptual framework 1. Restrictions and policies to prevent the promotion of foods and beverages high in fats, sugar and salt to children has explicitly been documented by WHO to guide Member States in developing their policies on food and non-alcoholic beverage promotion to children (WHO, 2010). This is necessary to create healthy food environments to reduce obesity and NCDs and their related inequalities. Thus, systems such as the International Network for Food and Obesity/non- communicable diseases Research Support (INFORMAS), are established to monitor and evaluate the implementation of the recommendations to ensure policy objectives are being achieved. 2. Despite restriction, children are being exposed to unhealthy food and beverage advertisement on TV. These unhealthy products include those that are high in fats, sugar and salt (HFSS). 3. Systematic reviews have shown that persistent exposure to foods and beverages advertisement generates positive beliefs about the advertised product and further influences children’s food preferences, purchase and request (Cairns et al,2008). 4. Dietary pattern or behaviour is formed after child’s exposure, leading to consumption of the advertised foods. Persistent consumption of these unhealthy food products accumulates calorie in the individual. 5. If accumulated calorie/energy is not expended, results in obesity and associated diet related NCDs 8 University of Ghana http://ugspace.ug.edu.gh 1.3. Objectives 1.3.1. General objective To evaluate the healthiness of foods and beverages advertised on selected Ghanaian TV programs targeting children. 1.3.2. Specific objectives 1. To identify the category of foods and beverages advertised on selected Ghanaian TV programs targeting children 2. To assess the healthiness of foods and beverages on selected Ghanaian TV programs. 3. To identify the persuasive techniques that accompany food and beverage advertisements. 1.4. Research questions 1. What are the types of foods and beverages advertised on Ghanaian TV programmes? 2. What food and beverage type advertised the most? 3. Are the adverts accompanied by persuasive techniques? 4. Are there policies restricting the promotion of foods and beverages to children enforced? 5. What proportion of the foods and beverages are healthy? 1.5. Study justification Prevalence of childhood obesity, according to the Healthy People report (2010), is caused by unhealthy diet consumption worldwide (Healthy people, 2010). In the same manner Henderson et al (2004), linked the increasing prevalence of childhood obesity sadly to the eruption of modernization, for which television advertising of non-core foods and beverages is the key factor. Television offers one of the first mediums through which 9 University of Ghana http://ugspace.ug.edu.gh children encounter advertisements on foods, and so in their quest to watch TV they are exposed to volumes of advertisements comprising foods and beverages high in fats, sugar and or salt (Boyland & Halford, 2013). Harris et al. (2009) demonstrated that food advertising was able to prime automatic eating behaviours and increase children’s consumption by 45%. Amidu et al. (2013) showed in their study that childhood obesity has now become a global epidemic. WHO reports that childhood obesity is the greatest public health challenge in these recent times, it further estimated that in 2016, the number of overweight children under the age of five may exceed 41 million globally (WHO, 2016). And of great concern is the fact that approximately half of all overweight children under 5 lived in Asia and one quarter lived in Africa (de Onis et al., 2010). A review done by Prathapan et al. (2014) on foods and beverages advertisements on TV aimed at children indicated that there are five main categories of foods and beverages being promoted to children. According to Hastings et al. (2003) these products are; “sugar- coated breakfast cereals, soft-drinks, confectionary, savoury snacks and fast food outlets”. Neville et al. (2005), pointed out that 50% of all foods and beverages advertised while children watch TV were unhealthy. Furthermore, confectionaries and fast food restaurants were advertised more with very little advertisements on fruits and vegetables. Similarly, Powell et al. (2007) also found greater proportion 98% of foods and beverages advertised were unhealthy. Additional search made by Prathapan et al. (2014) revealed that Kelly et al. (2010) in their study compared channels in Australia and concluded that energy-dense nutrient poor foods during popular children’s programmes, contributed up to 65.9% despite the regulations on advertisements targeting children. 10 University of Ghana http://ugspace.ug.edu.gh Prathapan et al. (2014), looked at time spent on food and beverages advertisements on television and found out that a study in Singapore revealed the time spent on a food and beverage products per hour being higher during children’s prime time of watching TV. These evidences support that TV is the primary medium for which advertisers persistently reach out to children (Powell, 2013). The marketing industry in Ghana is self-censored in advertising of unhealthy foods directed at children, this unfortunately is not enforced (Global report, 2016). The significance of promoting healthy lifestyle including healthy foods in children and adults, restricts unhealthy food promotion through advertisement. However, due to the paucity of information on food advertisements on television and the steady rise in death from NCDs accounting for 39% of all death in Ghana due to behavioural and metabolic risk factors (WHO, 2011), there is a pressing need to evaluate the healthiness of foods and beverages advertised on TV. Should the study be disregarded, tendencies that obesity and NCDs will escalate leaving extremely grave consequences on the health, productivity and future of the Ghanaian population and add to health care cost. Additionally, this study will fill gap on the absence of data on the healthiness of foods and beverages advertised on Ghanaian TV programs. 1.6. Operational Definitions CHILDREN – Individuals below age 18 below HEALTHY/CORE FOODS AND BEVERAGES – Healthy foods and beverages according to WHO (Fact sheet 2015) consist of protein, fibre, fresh fruits and vegetables, and nuts. PESTER POWER – Ability to convince parents to buy an advertised product FOOD – Products for ingesting in other that it offers nutritional support. 11 University of Ghana http://ugspace.ug.edu.gh UNHEALTHY/NON-CORE FOOD - Energy dense, nutrient poor foods. These are processed foods containing trans-fats; and high amounts of saturated fats (e.g. cheese, ice cream, fatty meat), salt from processed foods (e.g. ready meals; processed meats like bacon, ham and salami; cheese and salty snacks) or from food consumed frequently in large amounts (e.g. bread) WHO, (2015) SUGAR-SWEETENED BEVERAGE – Free sugars are all sugars added to foods or drinks by the manufacturer, cook or consumer, as well as sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates (WHO, 2015). According to CDC (2017), Sugar sweetened beverages are any liquids that are sweetened with various forms of added sugars, corn syrup, dextrose, fructose, glucose, high-fructose corn syrup, honey, lactose, malt syrup, maltose, molasses, raw sugar and sucrose. Examples are fruit drinks, sports drinks, energy drinks, coffee and tea beverages with added sugars. SNACKS – Foods made from flour or dough-based, example cakes, cookies, pastries, chips, and biscuits. TELEVISION ADVERTISEMENT – Spot advertisement broadcast during or in- between programs. ADVERTISEMENT/MARKETING – Commercial activities designed to increase brand recognition, appeal to its target group for purchase CHILDREN’S PEAK / PRIME VIEWING TIMES – Significantly greater number of children watching television at a particular time of the day. 12 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1. Introduction According to Story et al. (2007), children are exposed to media saturated environment such as television, radio, newspapers, magazines, poster, internet, phones etc. Although all this medium persists, TV still remain the potent medium through which advertisers communicate their products to children (Kelly et al., 2010). Advertisers have the potential to offer unique features that makes TV more appealing to children. It is reported by the American Academy of child and adolescent psychiatry (2001) that children spend more time watching television each year than they spend in school and findings from a survey by the UK broadcast regulator shows that television is the media device that would be most missed by children and adolescents (Ofcom, 2013). Sigman, (2012) further explains that children spend time watching screen media more than it was in the past. In spite of the availability of other options, television is still the media activity 5–15yr olds would prefer to do when given the choice and as such more time is spent watching television every week (an average of 14.6h) than undertaking any other media activity (Ofcom, 2013). This tends to suggest that children watch a great deal more television programmes meant specifically for them and that created for adults as well. Thus, viewing TV programmes seems common among these young consumers and exposes them to a lifestyle of high consumption of energy-dense nutrient poor foods and beverages leading to overweight/obesity and NCDs. A study conducted by Harris et al. (2009) and reported by Huang et al. (2011), demonstrated that the number one risk factor for disease and death are foods advertised during children’s viewing times. These foods marketed are mostly concentrated on low 13 University of Ghana http://ugspace.ug.edu.gh nutrient and energy dense quality products which is capable of initiating impulsive eating habits which in effect increases children’s consumption by 45%. Boyland et al. (2016), in a systematic review and a meta-analysis affirms that there is an increase in children acute exposure of food and non-alcoholic beverages to children. According to (WHO, 2017), over 41 million children under the age of five were reported to be obese globally in 2016. Out of these figures over two thirds that is more than 30 million reside in the developing countries whiles the remaining which is only a few are from the developed world. Kearney (2010), in a study indicated that alarming trend of prevalence of overweight and obesity is due to the rapid urbanisation and recent dietary behaviour In view of the 2014-2020 action plan in response to halt the growing prevalence of obesity and associated non-communicable diseases by the European Union (EU), it’s extremely worrying because the problem of obesity and NCDs persist. Globally, substantial amount of money will be spent on NCDs given the prevalence of overweight and obesity across broad (EU action plan, 2014). A study conducted by Gbadamosi et al. (2012) reported on a study carried out by Morgan (2007) that most households in Ghana who owns a TV set out numbers those who own a refrigerator. A study shows that “children watch television whenever they want in the morning, after school, during dinner, while doing their homework, at weekends and that most homes have a television set in virtually every room” (Karet, 2004, pp.51-59). 2.2 Strategies adapted by advertisers to market products to children Powell et al. (2013) have demonstrated that the main aim of advertisers is to entice children to gain their attention by using multi-faceted and techniques such as licenced and trending cartoon characters, celebrities’ children love (footballers, actors and actresses etc.), giveaways, animations, use of humour and fun appeals. These strategies are 14 University of Ghana http://ugspace.ug.edu.gh extremely engaging and attractive to children (Cairns et al. 2013) thereby improves product recognition and create positive brand attitudes from early ages (Hebden et al. 2011). The persistent showing of these adverts via numerous channels (TV, internet, billboards, radio) is geared towards convincing children to purchase the food product. A review by Hastings et al. (2003) points out those free giveaways with a purchase is used to promote the products on television to children thereby increasing requests among children resulting in high sales for marketers. In Singapore, a study conducted by Huang et al. (2011) was also observed to use the technique of giving free gifts to purchases made. Example, soft drinks were offered free of charge with purchase of raw rice and free toys with the purchase of food products. “The strategies used by advertisers in the South African TV media are similar to those seen in other countries in that they include persuasive appeals that target more than one sensory mode, namely vision and auditory modes. In the current study the advertisers used a mixture of personalities, such as celebrities, ordinary people, professionals and cartoon characters, to advertise food-related products. The majority of advertisements that used celebrities, such as popular and attractive TV presenters, soap opera actors and sportsmen, were shown during the children and family viewing times” Mchiza et al. (2013). These strategies of advertisements are widely used by most food and beverage companies to catch the attention of children for their gain. According to Huang et al. (2011) these marketing strategies are mostly focused on products that are energy dense nutrient poor. These does not only expose children to unhealthy eating behaviour but also confuses them on what a healthy meal should be. Prathapan et al. (2016) in their study on content analysis of food and beverages advertisements targeting children and adults on television in Sri Lanka, further confirms that free giveaways were marketing strategies aimed at children since their study found a strong association between free offers and child -focused ads. Prathapan et al. (2016) 15 University of Ghana http://ugspace.ug.edu.gh reported that in the year 2012 a study conducted by Samaraweera and Samanthi indicated that 38% of the children pestered for foods that featured celebrities and popular characters on television, while another 49% believed that providing offers on the advertised product would increase demand. Increase in these demands were said to have increase food expenditure by 59 rupees. Clearly children are vulnerable to marketing strategies because of their undeveloped cognitive ability to perceive the persuasive techniques marketers use in reaching out to them (Graff et al. 2012). Furthermore, TV advertisements stays on the minds of children more easily than other types of media, as they are more likely to develop a receptive memory with visual simulation generated by TV (Nassar & Al-Zien, 2012). These results in increase purchase and consumption of foods and beverages that are of energy dense and nutrient poor (Boyland & Whalen, 2015), and then subsequently result in diet related non- communicable diseases (Cairns et al, 2008). Ayantunji et al. (2012) carried out a study about “children’s attitudinal reaction on television advertisement: the African experience” admits “that children enjoyed watching television advertisements in addition to its entertainment features, especially the cartoons, dancing, animations, celebrities, humour and those that promote food. This was obvious at the ease with which they were able to recall advertising messages and especially those that are food related believing that once they consume such foods, they are a step becoming the hero they have admired all this while”. Thus, children least have an idea about marketer’s intent or they are simply immature cognitively to understand their intent (Graff et al. 2012). 16 University of Ghana http://ugspace.ug.edu.gh 2.3. Healthiness of foods and beverages advertised and its measurement Understanding the epidemiologic distribution of NCDs, overweight and obesity in children and the influx of unhealthy foods and beverages ads to children on TV, the WHO has done tremendous work by setting recommendations on dietary intake and encouraging healthy eating patterns all through the cause of life to prevent malnutrition and NCDs (WHO,2018). There are several ways by which the nutritional content of foods and beverages can be assessed, thereby classifying or ranking the foods as healthy or not; i. Core/Non-Core food classification ii. WHO EU Nutrient Profiling System iii. PAHO Nutrient Profiling System 2.3.1 Core/Non-Core Food Classification For easy comparability of healthy and unhealthy foods and beverages advertised across board, the International Network for food and Obesity/ non-communicable diseases Research, Monitoring and Action Support (INFORMAS) developed a classification system as core or healthy/non-core or unhealthy food classification (Swinburn et. al., 2013). This is an evidence-based food system module used to monitor food environment among countries and studies (Ni Mhurchu et. al., 2013). It is use by categorising food into three major groups namely; core or healthy, non-core or unhealthy and miscellaneous. Unlike other food-based systems e.g. UK nutrition profile model, all foods after categorisation ought to be coded. 2.3.2 EU Nutrient Profiling System The EU nutrient profiling system is an acceptable tool by WHO for assessing nutritional content based on its category-specific system model. The nutrients covered by this model 17 University of Ghana http://ugspace.ug.edu.gh are, total fat, saturated fat, total sugars, added sugars and salt. The model is designed for use by government and food companied to determine whether the food item ought to be marketed to children or not. To use this model, first the food category under which the item fall is identified. Example sugar sweetened beverages, fruit, breakfast cereals. Once the category is identified, the nutritional content of the food must be checked against relevant set thresholds for that food product category if it fits to be marketed or not. Should the ad be for a restaurant meal, all the food item must meet the criteria. 2.3.3. PAHO Nutrient Profiling System Americas, realising the alarming rate at which overweigh/obesity and non-communicable diseases developed the Pan American Health Organisation Nutrition Profile Model (PAHO NP Model) to be used by its member states in other to regulate marketing and consumption of energy-dense nutrient poor food and non-alcoholic beverages. This model seeks to address the amount of free sugars, salt, saturated fat, total fat and trans-fatty acids in food item. The PAHO NP Model is applicable to processed and ultra-processed foods and beverages and not natural unprocessed foods like fruits, flour, roots and tubers, fruit juice without added sugar etc. (Swinburn et. al., 2013). Healthy foods and beverages could be defined as “foods recommended in a national food- based dietary guidelines, dietary guidelines or food-based standards whereas unhealthy foods are defined as processed foods or non-alcoholic beverages high in saturated fats, trans fats, added sugar and or salt” (Ghana Food EPI, 2018). This current study adopted the standardised taxonomy developed by INFORMAS and based on the codex standards, foods were classified into healthy, unhealthy or miscellaneous. Using the INFORMAS classification suggests that a food has a particular nutritional property. Nutrition data, if available is also used to establish nutrient (Fats, sugar and salt) cut-off points for easy classification into major food groups. Most studies exploring and monitoring the extent of 18 University of Ghana http://ugspace.ug.edu.gh food and beverage ads on TV, adopted any of these measures (Kelly et al., 2014; Kelly et al., 2010). 2.4. Types of foods and beverages advertisements targeting children The kinds of foods and beverages advertised during children’s viewing times have been shown to be overwhelmingly high in fats, sugar and or salt. Several studies conducted, showing the most common foods advertised were in agreement with what Hastings et al. (2003) termed as the “BIG FOUR” namely: pre-sugared breakfast cereals, soft-drinks, confectionary, savoury snacks. Fruits and vegetables which are healthy product are almost always seen to be the least advertised products (Neville, et al., 2005). A study by Kelly et al. (2014) on children’s exposure to advertised foods and beverages in the Asia -Pacific indicates that sugar sweetened beverages were the most advertised, followed by low fat dairy, high fat dairy, baby and toddler formula and ice-cream. Similar study done in China, using content analysis method found the most advertised food and beverage products to be, sugar sweetened beverages, followed by deserts and sweets (Li et al., 2016). A review conducted for by Bacardí-Gascón and Jiménez-Cruz on TV food advertising geared to children in Latin-American countries and among the Hispanics in the USA, found twenty-three studies published since 1986 to 2014 (Bacardí-Gascón & Jiménez-Cruz, 2015). The food type mostly advertised in majority of the studies were mainly unhealthy foods such as sugary drinks, snacks, sweet, sweetened cereals, chocolate, chips, sweetened juice and fast foods. In Argentina Rovirosa et al. (2017), indicated that the most frequently advertised food and beverages was dairy dessert, followed by fast food meals, yogurt, modified milk for 1 to 3year olds, candies, biscuits, 19 University of Ghana http://ugspace.ug.edu.gh powder juice, seasonings with sweet snacks and soft drinks coming much later on the list. This differ though but most of the foods are HFSS. Clearly, these findings on the food type advertised to children are in line with those termed by Hastings et al., as the “BIG FIVE” and almost all of these foods and beverages are energy-dense nutrient poor. It may not follow the same order depending on the setting and the preference of the people. Example in China, there was no advert on fast food and breakfast cereals because they are not fan of cereals, more so the Chinese believe in the family system where three meals is prepared out of fresh ingredients per day, thus making fast foods irrelevant (Li et al., 2016). Advertisers spend huge sums of money on TV adverts (Li et al., 2016) thus to possibly influence their targets and to impact sales. Therefore, the likelihood that advertisers research on cultural values and preference of the people is key. These findings support the need for monitoring and enforcement of recommendations to restrict the marketing of energy-dense nutrient poor foods to children. 2.5 Usage of claims in child directed advertisements Food advertisement high in fats, sugar and salt directed at children have been map with restrictions all over the world. To counter this, marketers had adopted to provide some nutritional information about their products to parents and caregivers instead, whilst with children the focus is making the brand more fun, humorous and desirous (Lobstein et al. 2008). Emond et al., (2005), demonstrated that 42% of advertisement were apportioned to grasp the attention of parents and caregivers with the nutrient content of the food products. These are absolutely geared towards convincing parents to purchase their products. These new techniques adopted by marketers diverts attention from the nutritional poor products 20 University of Ghana http://ugspace.ug.edu.gh to increasing the patronage of their products leading to the already existing burden of NCDs (WHO, 2015). 2.6 Relationship between unhealthy food, obesity and NCDs Given that children preferred targets when it comes to food marketing, ultimately because their impact on sales is positive (Story & French, 2004), the impact of unhealthy foods in the development of childhood obesity and NCDs is of great public health concern (Linn, 2004). Strong evidence exists that there is a link between exposure to unhealthy food and beverage advertisements to children, creating unhealthy choices, purchases and the consumption of energy dense nutrient poor foods (Hasting et al., 2003; Powell et al., 2013; Kelly et al., 2015). Boyland and Whalen (2015) in a study, focused on the effect of children’s exposure on consumption as it’s the most pertinent outcome measure for obesity and NCDs, presented that food intake was greater in children following their exposure. These unhealthy food environments and over consumption of energy dense foods according to Swinburn et al. (2011), are the existing current drivers for population weight gain and related NCDs. The WHO data from the period of 1980 to 2008 showed that every region in the world’s obesity rate had almost doubled, with one in every three adults having a high blood pressure and one in ten adults suffering a diabetes (WHO, 2012). Among other factors that cause NCDs, current estimates from the Global Burden of Disease studies indicates that between 1990 and 2010 global burden of disease continue to rise and it was attributed to diet. Foods and beverages advertisements directed at children have come under serious monitoring and scrutiny because unhealthy foods dominate (high fat, sugar and or salt), these ads are created such that it increases their demand for the advertised product (Botha 21 University of Ghana http://ugspace.ug.edu.gh et al., 2012; Powell et al., 2013) couple with the fact that children have less control over what they see compared to adults. A systematic review conducted Sadeghirad et al. (2016) affirms that exposure of unhealthy food ads influences children dietary behaviour. In other to control the increasing rate of obesity and NCDs, one of the two indicators proposed by WHO is to reduce junk food advertisements to children. INFORMAS also seeks to monitor activities of food environment, to contribute and strengthen government policies on food environment, obesity and NCDs (Kelly et al., 2014). 2.7 Measures to limit television food advertisement directed at children The growing menace of childhood obesity and its concomitant complications has been directly linked to unrestricted advertisement of unhealthy food and beverage directed at children on our TV. Almost all studies on the impart of food and beverage advertisements directed at children shows that, the exposure is linked to children’s unhealthy dietary intake and unhealthy preferences leading to obesity and NCDs. Globally, several measures have been put in place to restrict advertisements of highly processed HFSS foods and beverages directed at children (WHO, 2010). In 2009, the WHO Global Strategy on Diet, Physical Activity and Health was enacted in response to the alarming rate at which obesity and diet related NCDs were increasing. World Health Organization (WHO, 2010) and the Pan American Health Organization (PAHO, 2011) realised the need to halt advertisement of unhealthy foods to children, thus recommendations for restrictions formulated to enable member states adopt. The Ghana healthy food environment policy index (food EPI) promulgated in September 2018, states in relevant policy documents the intent to regulate the advertisement of unhealthy foods and non-alcoholic beverages particularly to children however there is inadequate action on the part of government to enforce these policies. There is a need 22 University of Ghana http://ugspace.ug.edu.gh therefore for local organizations, NGOs, civil society organisation to enforce and make government own policy a priority. 2.8 Summary The advertisement of unhealthy foods on our television directed at children leads to choices of unhealthy foods as their preference. Relevant literature on unhealthy food products advertised have been explored in relation to the burden of childhood obesity and related NCDs. Many of these studies have been conducted in the Western world with very little in LIMCs and more importantly no evidence on the food and beverage ads on Ghanaian TV directed at children 23 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.1 Introduction This chapter describes the methods of the study. It includes; type of study, study design, population, sampling techniques and sample size, data collection technique and method, data analysis and interpretation, quality control and ethical considerations. 3.2. Study Type A cross-sectional study design making use of a Content Analysis method of TV channels was deployed to assess the healthiness of foods and beverages being advertised to children in Ghana. Previous studies (international and local) have made use of this method which proficiently evaluates communication in a systematic, objective and quantitative manner for the purpose of measuring variables and explains the content of mass medium communication (Berelson, 1952; Kerlinger, 2000; Laar, 2010). Many studies involved in media - print (newspapers, magazines), television, video, movies, and the Internet uphold content analysis as the optimal method. Thus, the informed choice to adopt this method. 3.3. Study setting In Ghana there are three categories of TV channels; the analog TV with free to air channels, digital TV which consist of all the analog TV channels plus some non- Ghanaian channels (also free- to- air) and satellite or decoder channels which are paid for TV channels. Ghana is gradually transitioning from the analog TV type (thus old box TV) to digital TV. 24 University of Ghana http://ugspace.ug.edu.gh According to National Communication Authority (NCA), 51 TV channels were on air at the end of 31st June 2017. All these channels have some time allocated for children’s programme except TV C on the digital television which shows children programme all day long. This study was conducted from three selected TV channels in Ghana denoted by A, B and C. Selection was based on nationwide coverage, children’s channel, channel with lots of children’s program and free-to-air. This is so because data are limited on what children’s audience density is at a particular time and the channel, they watch the most. 3.4 Study design Commercials for foods and beverages during a four months period, i.e. December 2017, January, March and May 2018 were recorded from live TV broadcasts onto a hard disk using the composite week sampling method to maximize the potential of capturing all days of the week, programming and adverts as well. All programming from 8:00a.m. through to 6:00p.m. were recorded on all days; vacations, holidays, weekdays and weekends inclusive. 3.5 Study population Target population refers to the entire group of objects to which researchers are interested in generalizing the conclusions. The target population for this study are the foods and beverages advertised on TV targeting children in Ghana. 3.6 Sampling procedure In Ghana there are three categories of TV channels; the analog, digital and satellite or decoder channels. According to the GeoPoll, the top 10 most watched TV channels in Ghana from December to July 2017 are in this order; 25 University of Ghana http://ugspace.ug.edu.gh 1. UTV 2. TV3 3. VIASAT ONE 4. GH ONE 5. JOY PRIME 6. GTV (STATE OWNED) 7. ADOM TV 8. METRO TV 9. JOY NEWS 10. CRYSTAL TV However, it was not stated whether the audiences were adults, children or both. Of these top 10 channels a purposive sampling technique was used to select three channels that is GTV which is state owned and has nationwide coverage and TV3 which shows more children’s programs, plus Smile TV which is designated for children. A random sampling technique was used to select four months, from September 2017 to May 2018 for data collection. Composite week sampling technique was used in the selection of the day for which data will be collected or recorded, whereby a day is drawn every week for all three TV channels every month throughout the sampling period. According to Laar (2010), the work of Riffe et al. (1997) affirms work of previous studies which reveals that composite week sampling is superior to both random and consecutive day sampling. In this study data recording started in December 2017 on a Monday with TV A, then followed by TV B on a Wednesday and TV C on a Friday of the first week. In the second week TV A was recorded on Tuesday, TV B on Thursday, then TV C on Saturday. This trend followed for the rest of the sampling period, a total of 43days recorded. Every TV channel had all days of the week covered and there were no overlaps 26 University of Ghana http://ugspace.ug.edu.gh Figure 2: Composite week sampling showing various days of data collection 3.7 Study variables • Date of advertisement • Days of recording - Day on which adverts were recorded • Time of adverts - Period when the advertisement was broadcast • Type of products - The advertised product type 27 University of Ghana http://ugspace.ug.edu.gh • Total number of advertisements targeting children • Food type - Advertised foods and beverages • Use of health claims - Advertisements of foods and beverages conferring health benefits • Use of disclaimer - Advertisements with disclaimer or not • Use of animations, cartoons or celebrities - Advertisements featuring celebrities, cartoons or animations. Advertisements on foods and beverages on TV targeting children • Healthy foods and beverages advertisements - Nutrient dense and low in discretionary energy • Unhealthy foods and beverages advertisements – Energy dense nutrient poor foods or foods containing high undesirable nutrient including fats, salts and sugar. 3.8 Data coding All recorded television program was reviewed on a computer with the hard disk in situ, all broadcast advertisements identified and grouped into foods and non-food. All the foods advertisements were coded according to predefined variables, date of advertisements, channel, days of recording, time of ads, type of products, total number of ads targeting children, food type, use of health claims, giveaways, use of disclaimer, use of animations, cartoons or celebrities with the aid of a coding sheet. This was entered into a Microsoft Excel spread sheet and all the necessary categorisation of the advertisements data made. Classification of foods and beverages were further coded into three major food groups, i.e. core/healthy for items that were nutrient dense and low in discretionary energy, non- core/unhealthy for products that were relatively high in undesirable nutrient including fats, 28 University of Ghana http://ugspace.ug.edu.gh salts and sugar or miscellaneous (adverts on recipe additions, supermarkets, local restaurants, tea and coffee, baby and toddler milk formulae etc) based on food, contextual and advertisements information categorization adopted from INFORMAS module for monitoring the composition of foods and beverages Neal et al. (2013) (appendix 1). 3.9 Quality control For advertisements on foods and beverages coding ambiguities, a standard coding procedure was developed in accordance with the guidelines outlined by the International Network for Food and Obesity/non-communicable diseases, Research, Monitoring and Action Support (INFORMAS). All variables relevant to the study were coded onto an excel spread sheet. A pre-recording training was carried out to prepare research assistant to avoid errors in the data entry as per coding demands. Care was taken to adhere to coding protocols; Twelve hours of content was selected at random and coded independently by my supervisor, a trained research assistant and myself to ensure consistency and reliability of the data. Thus more than one person performed data coding, where doubts or lack of agreement about a food or beverage arise, we decided by consensus and based on the guidelines. Items were coded into three groups: healthy foods, non-healthy foods and miscellaneous. 3.10 Data analysis Cleaning and entering of data onto excel spread sheet started on 1st of June then analysis began on the 30th of July 2018. Stata version 15 statistical software was used to analyse data. Univariate analysis of means, percentages, frequencies and standard deviations were used to describe dataset. A Chi square test was used to carry out test of significance within 29 University of Ghana http://ugspace.ug.edu.gh TV channels and advertisements shown between weekdays and weekends. Level of significance for all data analysis was set at p<0.05. 3.11 Ethical considerations This study sought for clearance though it did not directly deal with human beings or animals from Ghana health service ethics review committee. GHS-ERC number – GHS- ERC: 167/12/17. TV channels were coded using alphabets in other to maintain anonymity. Data collected were not lined or cannot be traced to a particular TV channel. Data collected were preserved and only used for the purpose for which it was intended for. 30 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS This section of the research work outlines the findings obtained from the study. It describes the different advertisements shown on 3 TV channels (TV A, TV B and TV C for children), the days these adverts were shown, rate of adverts, the category of adverts (non-food or food/beverage advertisements, healthy or non-health food advertisements), various associations and persuasive techniques utilized in the adverts. 4.1. General information on advertisements shown on the various TV channels The study recorded 1,926 adverts shown on the 3 TV channels within a period of four months (December, 2017, January, March and May, 2018). A composite week sampling technique was used in selecting the days for advertisement transmission among the various TV channels (Figure 1). In all, there were 43 days of transmission resulting in the recorded number of advertisements. TV A recorded the highest number of adverts (67.1%) followed by TV B recording 17.8% of all adverts recorded and then TV C (15.2%) as shown in Table 1. The rate of advertisement shown was 8.6 adverts/hr. on TV A and 2.1 adverts/hr. on TV B. With the exception of TV C that was viewed for 15 days, all the other channels were viewed for 14 days. Three hundred and twenty-nine (329) advertisements (17.1%) were recorded on Mondays accounting for the day with highest number of ads per week at a rate of 5.5 adverts/hr. However, the number of adverts per day did not differ significantly from each other. Wednesdays recorded the least number of advertisements (n=174, 9%, 2.9 adverts/hr.). With the exception of Fridays where data collection was done for 7 days, 6 days of adverts transmission was employed for all the days of the week. 31 University of Ghana http://ugspace.ug.edu.gh Table 1: Advertisements shown per channel and days (n=1926) Frequency (N) Percent (%) Rate of Advert (Ads/hr) General Ads Per TV Channel TV A 1,292 67.1 8.61 TV B 342 17.8 2.44 TV C 292 15.2 2.09 General Ads per Days Monday 329 17.1 5.48 Tuesday 324 16.8 5.40 Wednesday 174 9.0 2.90 Thursday 316 16.4 5.27 Friday 196 10.2 2.80 Saturday 301 15.6 5.02 Sunday 286 14.8 4.77 It is noteworthy that the average duration for each advertisement was found to be 40.8 ± 24.0 seconds with the maximum adverts time being two and a half minutes (150 seconds) and the minimum being 3 seconds. The time of the day in which adverts were shown did not differ from each other as shown in Table 2. From the table, most of the adverts (n=270; 14%) were shown within the hours of 1 and 2pm while the least number of adverts (n=135; 7%) was shown between the hours of 5 and 6pm. Adverts were shown within different programmes (sports, movie, news, etc.) and in between programmes on the TV stations. 33.4% of the adverts (n=643) were shown in- between programmes. One hundred and eighty-two (182) advertisements (9.5%) were shown during breakfast shows while 169 (8.8%) were shown during cartoon and children programmes. 32 University of Ghana http://ugspace.ug.edu.gh Table 2: Periods Advertisements were shown on the various TV stations Frequency Percentage Period Ad was aired News 130 6.8 Sport 36 1.9 Soap Operas 109 5.7 Series 295 15.3 Movie 188 9.8 Talk Show 65 3.4 Miscellaneous Entertainment 13 .7 Children, Cartoon 169 8.8 Music or Music video 66 3.4 Religious 13 .7 Health related 5 .3 Breakfast show 182 9.5 In-between programmes 643 33.4 Others 12 .6 Time of ad in hour intervals 8:00- 8:59Hrs 204 10.6 9:00- 9:59Hrs 175 9.1 10:00- 10:59Hrs 153 7.9 11:00- 11:59Hrs 235 12.2 12:00- 12:59Hrs 169 8.8 13:00- 13:59Hrs 270 14.0 14:00- 14:59Hrs 220 11.4 15:00- 15:59Hrs 186 9.7 16:00- 16:59Hrs 179 9.3 17:00- 17:59Hrs 135 7.0 4.2. Categories of foods and beverages advertised on selected Ghanaian TV channels The adverts shown were first grouped into 2 categories, namely: food and non-food adverts as shown in Table 3. The non-food adverts constituted majority of advertisements shown (n=1,336, 69.4%). Of all the 590 food adverts recorded, 37.1% were on sugar sweetened snacks and drinks. Eighty (n=80, 13.6%) were on fast foods and restaurants, and 2.4% were on alcoholic beverages. With the exception of 115 adverts (19.5%), all the food/beverage advertisements shown were non-healthy. 33 University of Ghana http://ugspace.ug.edu.gh Table 3: Category of advertisements shown on the various TV channels Frequency Percentage (%) Type of Ad Food Ad 590 30.6 Non-food ad 1336 69.4 Type of Beverage or Food Product Cereals / breakfast foods 29 4.9 Sugar snacks / drinks 219 37.1 Food items with added salt and fat 25 4.2 Fast food / restaurants 80 13.6 Healthy foods / drinks 115 19.5 Alcohol / alcoholic beverages 14 2.4 Recipe additions 31 5.3 Tea and coffee 1 .2 Others 76 12.9 The frequency of food and non-food advertisements shown per TV channel is as shown in Table 4. TV B showed 70.2% of non-food adverts at a rate of 6.1 adverts/hr. Sixty-eight (20%) adverts shown by TV C were on foods/beverages at a rate of 0.5 adverts/hr. Of all the adverts recorded for TV A, 137 (47%) were food/beverage adverts at a rate of 1 advert/hr. Table 4: Rate of adverts per channel Frequency % Rate of Ad (Ads/hr) Non-Food Ads Per Channel (n=1336) TV A 907 70.2 6.05 TV B 274 80.1 1.96 TV C 155 53.1 1.11 Food Ads Per Channel (n=590) TV A 385 29.8 2.57 TV B 68 19.9 0.49 TV C 137 46.9 0.98 34 University of Ghana http://ugspace.ug.edu.gh Further grouping of the various foods/beverages advertisements showed that 23.6% (n =139) were adverts on sugar sweetened beverages. Thirty-one (n=31, 5.3%) were on ice creams and deserts, 66 adverts (11.2%) were on milks and yoghurts while 41 advertisements (6.9%) were on fried instant rice and noodle products (Table 5). Table 5: Categories of various foods and beverages advertisements Food category (n=590) Frequency % Low sugar and high fibre breakfast cereals (<20g sugar / 100g 29 4.9 and >5g dietary fibre / 100g) Meat and its alternatives processed or preserved in salt tinned, all 27 4.6 preserved ready to eat meats, poultry, fish Sugar sweetened beverages 139 23.6 Ice cream and dessert 31 5.3 Chocolate and candies 6 1.0 Alcohol 14 2.4 Full cream milk and yoghurt (>3g fat / 100g) 24 4.1 Savoury snack foods (added salt and fat) 25 4.2 Plain starch product, rice without added fat, sugar or salt, plain 36 6.1 biscuits and crackers Meat and meat alternatives, include poultry, meat, fish, egg 3 .5 Fruits and fruit products without added fats, sugars or salt 11 1.9 Vegetables and vegetable products without added fats, sugars or 3 .5 salt Milks and yoghurts (<3g fat / 100g) 66 11.2 Water 8 1.4 Flavoured / fried instant rice and noodle products 41 6.9 Flour or dough-based snacks e.g. cakes, sweet buns, biscuits 53 9.0 Others 74 12.5 35 University of Ghana http://ugspace.ug.edu.gh Table 6 shows time of foods and beverages advertisements by day of the week irrespective of the category. Tuesday between 1400hrs to 1459hrs had the highest recording of 39% and Wednesday between 1500hrs to 1559hrs had the least ad 1.8%. From the table adverts were observed to be shown at any time of the day, thus advertisements shown did not differ from the days of the week. Table 6: Time of foods and beverages advertisements per hour and Day of the Week Day of The Week Time of Day Mon Tues Wed Thurs Fri Sat Sun [n (%)] [n (%)] [n (%)] [n (%)] [n (%)] [n (%)] [n (%)] 08:00 – 08:59 14(27.5) 7(13.7) 0(0.0) 16(31.4) 9(17.7) 4(7.8) 1(2.0) 09:00 – 09:59 7(12.1) 4(6.9) 3(5.2) 15(25.9) 14(24.1) 8(13.8) 7(12.1) 10:00 – 10:59 3(8.8) 0(0.0) 0(0.0) 9(26.5) 4(11.8) 3(8.8) 15(44.1) 11:0 – 11:59 15(20.6) 9(12.3) 9(12.3) 17(23.3) 7(9.6) 7(9.6) 9(12.3) 12:00 – 12:59 3(7.7) 6(15.4) 3(7.7) 8(20.5) 1(2.5) 14(36.0) 4(10.3) 13:00 – 13:59 9(11.4) 23(29.1) 5(6.3) 8(10.1) 2(2.5) 14(17.7) 18(22.8) 14:00 – 14:59 11(13.4) 32(39.0) 6(7.3) 4(4.9) 0(0.0) 6(7.3) 23(28.1) 15:00 – 15:59 6(10.5) 19(33.3) 1(1.8) 5(8.8) 8(14.0) 6(11.0) 12(21.1) 16:00 – 16:59 13(20.0) 18(27.7) 2(3.1) 6(9.2) 7(10.8) 6(9.2) 13(20.0) 17:00 – 18:00 4(7.7) 3(5.8) 3(5.8) 7(13.5) 7(13.5) 18(34.6) 10(19.2) 36 University of Ghana http://ugspace.ug.edu.gh Table 7 below is the summary of Table 6, showing the sum of adverts each day of the week for the entire recording period. The number and types of foods and beverages advertisements shown within the various days of the week was found to have more non- healthy foods and beverages than healthy ones. Table 7: Food Advertisements per Day of the Week Non- Undetermined/ Healthy Healthy Miscellaneous N (%) N (%) N (%) Day of the Week Monday 30 (35.7) 46 (54.8). 8 (9.5) Tuesday 29 (24.0) 81 (66.9) 11 (9.1) Wednesday 13 (40.6) 14 (43.8) 5 (15.6) Thursday 33 (34.7) 51 (53.7) 11 (11.6) Friday 19 (32.2) 31 (52.5) 9 (15.3) Saturday 24 (27.9) 54 (62.8) 8 (9.3) Sunday 18 (16.2) 77 (69.4) 16 (14.4) Total 166 (28.2) 354 (60.2) 68 (11.6) 37 University of Ghana http://ugspace.ug.edu.gh 4.3 Healthiness of foods and beverages on selected Ghanaian TV programs Tables 8 and 9 show the association between the healthy status of foods and beverages advertisements and the various TV channels. All the channels show greater proportion of their foods and beverages advertisements being unhealthy. TV A showed 63.9% of unhealthy foods and beverages advertisements, followed by TV B 54.4% and TV C 53%. Unhealthy foods and beverages advertisements are about twice as high compared to healthy food advertisements on the channels except for TV C which is almost equal. The rate of show of unhealthy foods and beverages advertisements on all the TV channels compared to the show of healthy foods advertisements was found to be statistically significant at Chi square = 26.55; p < 0.001. Table 8: Association between health status of foods adverts and TV Stations (N=590) TV A TV B TV C X2 P-value N % N % N % Food Type 26.55 <0.001 Healthy Food Ads 91 23.6 17 25.0 58 42.6 245 63.9 37 54.4 73 53.0 Non-Healthy Food Ads 48 12.5 14 20.6 6 4.4 Miscellaneous Total 385 68 137 Table 9: Rate of healthy and non-healthy adverts per TV station Healthy Rate of Ad Non-Healthy Rate of Ad Miscellaneous Rate of Ad Food Ad (Ads/hr) Food Ad (Ads/hr) Food Ad (Ads/hr) [n (%)] [n (%)] [n (%)] TV A 91 (23.6) 0.61 245 (63.9) 1.63 48 (12.5) 0.32 TV B 17 (25.0) 0.12 37 (54.4) 0.26 14 (20.6) 0.10 TV C 58 (42.6) 0.41 73 (53.0) 0.52 6 (4.4) 0.04 38 University of Ghana http://ugspace.ug.edu.gh 4.4 Persuasive Techniques of Food Advertisements Various persuasive techniques were used to attract the admiration of children. Of all the foods and beverages advertisements shown, 260 (44.1%) utilized sensory based characteristics such as portraying sweet taste, having nice texture and appearance and appealing aroma. One hundred and seventy-eight (30.2%) of the foods and beverages advertisements were suggested for children utilization and 168 (28.5%) employed the use of animation, children, cartoons and celebrities. These are shown in Table 10 below. Table 10: Persuasive techniques of foods and beverages advertisements Techniques Used (n= 590) Frequency Percentage Health Claims 103 17.5 Adverts utilized sensory based characteristics 260 44.1 (Taste, texture, appearance, aroma) New brand development 27 4.6 Suggested use (e.g. great for lunch box) 9 1.5 Was suggested for use for/by children 178 30.2 Indicated convenient use 79 13.4 Had a price tag 38 6.4 Sponsored Ads 332 56.3 Use of animation, children and cartoon 168 28.5 Portraying happiness, fun and pleasure 263 13.7 Ad shown whiles children were on vacation 98 16.6 Each advertisement was assessed independently and measured based on these persuasive characteristics to avoid overlaps. None of the advertisements or products advertised had a disclaimer or puffery (claiming to be better than other products) attached to them. 39 University of Ghana http://ugspace.ug.edu.gh Various types of health claims were made by 103 (5.3%) food advertisements. This is as shown in Figure 3. These include nutrient and other function claim, general health claims and nutrient content claims. Figure 3: Health Claims Made by Food Advertisements Three hundred and seven (307) advertisements were shown while children were on school vacation. Out of that, 209 (68.1%) were non-food advertisements. The categories of the food ads shown during the vacation period are as shown in Table 11. Advertisements on sugar sweetened beverages was 14%, 10.2% were on alcohol and 12.2% were on flavoured or fried instant noodles while 13.3% were on flour or dough-based snacks such as cakes, sweet buns and biscuits. 40 University of Ghana http://ugspace.ug.edu.gh Table 10: Category of food ads whiles children were on vacation. (N=98) Table 11: Category of food advert whiles children were on at vacation. (N=98) Food category Frequency % Meat and its alternatives processed or preserved in salt tinned, all 3 3.1 preserved ready to eat meats, poultry, fish Sugar sweetened beverages 14 14.3 Ice cream and dessert 7 7.1 Alcohol 10 10.2 Savoury snack foods (added salt and fat) 7 7.1 Plain starch product, rice without added fat, sugar or salt, plain 6 6.1 biscuits and crackers Meat and meat alternatives, include poultry, meat, fish, egg 1 1.0 Fruits and fruit products without added fats, sugars or salt 5 5.1 Vegetables and vegetable products without added fats, sugars or salt 2 2.0 Milks and yoghurts (<3g fat / 100g) 2 2.0 Water 2 2.0 Flavoured / fried instant rice and noodle products 12 12.2 Flour or dough-based snacks e.g. cakes, sweet buns, biscuits 13 13.3 Others 14 14.3 41 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Introduction This chapter discusses into details the results from the previous chapter in order of the study objectives. • Categories of foods and beverages advertised • Proportion of healthy foods and beverage advertisement • Types and frequency of persuasive techniques accompanying food ads 5.2 Children’s prime time on TV Despite several regulatory measures, such as the WHO Global Action Plan for which all member states were encouraged to participate in promoting healthy diet to children to help curb the obesity and NCDs menance by 2013-2020 (WHO, 2013) and the Ghanaian policies recommended to restrict and regulate (MOH, 2012) TV foods and beverages advertising to children. Results from this study shows that Ghanaian children are being exposed to unhealthy foods and beverages through exposure to advertisements. Implying that these policies have not been adequately enforced by the government of Ghana meanwhile countries like Chile, Spain, Uruguay and Hungary have effectively implemented these policies that promote unhealthy foods ad to children (Ghana food EPI,2018). In Ghana, this is the first study to identify the healthiness and extent of foods and beverages advertised on TV. Therefore, there is limited documentation on children’s exposure to unhealthy foods and beverages advertisements and whether these adverts are been regulated. However, a study by Steiner-Asiedu et al. (2012) in the Ga-East district of 42 University of Ghana http://ugspace.ug.edu.gh Ghana stated that obese and overweight school children spent more time watching television. Aryeetey et al. (2017) also reported from their study that, more than half of the children participating in the study spent at least two hours/day watching TV in the week prior to the survey. This survey was however limited by its use of self-reported data among the children under study. In Ghana since the analog TV is widely used and there is no designated channel for children coupled with parents working away from home, children are said to watch TV at any time they want in the morning, after school, during dinner, while doing their homework, and at weekends (Karet 2004). Thus, in Ghana children watch TV and even watch programs that are not specifically meant for them. Findings from an Australian study showed that prime time was between 6 to 9pm on weekdays and early mornings on Saturday was loaded with ads of unhealthy foods (Chapman et al.,2006). In the United States, prime time was observed from 7am to 10pm each day (Harrison and Marske, 2005), Seoul in South Korea had a prime time of 5 to 10pm on a weekday and on weekend 9 to 11am and 6 to 8pm (Kelly et al., 2014). Thus, prime time varies depending on the setting and possibly times children are not in school. It may also differ based on the differences in classification and the method used to define the period (Kelly et al., 2014). Table 6 shows how food and beverages advertisements stretches all over the days per the time of the day. Frequency of food and beverages advertisement totalled 30.6% of the total recorded period. It was determined from this study that the total mean time for foods and beverages advertisement was approximately 40.8 sec with about 2 adverts per hour for channel A, accounting for most of the adverts among the three TV channels recorded. This is similar to a related study done in Argentina where foods/beverages advert time was less than a minute and about 2 adverts shown per hour (Rovirosa et al., 2016). Implying that in Ghana, adverts on foods and beverages are 43 University of Ghana http://ugspace.ug.edu.gh lower compared to non-food adverts, similar to a study conducted in Mexico (Pérez- Salgado et al.,2010) and Chile (Uribe Bravo,2012). Though the foods and beverages advertisements are low, majority of these foods are unhealthy. 5.3 Categories of foods and beverages advertised Categories of foods and beverages identified from this study, were grouped according to nutrition guidelines and major food categories of healthy and nonhealthy items and subgroups: fast food, sweets, dairy, cereals, chips/crackers, beverages, fruits/vegetables and other (Kelly et al. 2010). The trend of classification of foods and beverages advertised to children in other studies ( Boyland et al, 2011, Guran et al, 2010, Bell et al. 2009) are similar to those found in this study with sweetened beverages being the most advertised (25.8%) food group. That is belona, cowbell tea, ideal coffee, tea and choco, miski choco (an instant all-in-one drink), coke, energy drink, kasapreko royal drink, Kaeser apple drink, moringa drink, origin 0 drink, richoco and malt drink. The result of this study is similar to the results of previous studies which indicate that majority of advertisement broadcast during times children are watching TV are sugar-sweetened drinks (Amini et al., 2014, PAcrez-Salgado et al., 2010). In a study conducted by Kelly et al. (2014) across six sites in the Asia-Pacific indicated that sugar sweetened drinks topped the rate of advertised non-core foods and beverages. Alangea (2014) in her work on determinants of obesity among basic school pupils in the Ga-East municipality, reported that sugar-sweetened beverages including soft drink consumption has been linked to child and adolescent obesity (Vartanian et al., 2007), she further explained that the likely reason for consumption of SSB on weight gain is that sugary foods induce less satiety which results in incomplete energy compensation that 44 University of Ghana http://ugspace.ug.edu.gh leads to increased caloric intake (Olsen & Heitmann, 2009). The next most frequently advertised foods were snacks or foods that are mostly taken in-between meals (12.8%), that is cake, pie, cornelly (salted corn snack), muffin, pizza, popcorn, potato chips, burger and biscuits. These are ready to use snacks for which children are likely to identify with and has the potential to influence their preference, purchases and consumption (Cairns et al, 2013) contributing to the increasing rate of global burden of obesity and NCDs (Ng et al.,2013). Milks and yogurt (12.4%), instant noodles (7.1%), candy/chocolate and ice creams (6.4%), breakfast cereals and beverages (5.3%), fruits (2%), water and vegetables were less than 1.5%. Foods and beverages advertisements on TV targeting children from previous research in various developed countries indicates that foods and beverages high in fats, sugar and salt (HFSS) dominates whereas fruits and vegetables have constantly been on the low rate and more so the repeated presentation of unhealthy foods and beverages to children makes them more convinced about the product because they are seen more often whether they like to see the adverts or not. This is no different from the findings from this study. 5.4 Proportion of healthy foods and beverage advertisement Of the 590 of foods and beverages advertisements, the rate of non-healthy foods advertisements dominated across all three TV channels as shown in table 7, and a Chi square analysis done was found to be statistically significant at p<0.001. This is similar to previous studies that have indicated that unhealthy foods targeting children dominates healthy foods advertisements (Kelly et al., 2014; Ng et al., 2013; Li et al., 2010). TV B which is a private owned channel and free to air had the highest unhealthy foods and beverages advertisements as shown in table 8 and had a rate of 1.6adverts/hr which is three time more than a healthy food adverts shown. TV C owned by the state and free to 45 University of Ghana http://ugspace.ug.edu.gh air also showed unhealthy foods at a rate of 0.3adverts/hr. though lower also showed unhealthy foods adverts three times more than healthy food advertisements. TV A which is children designated channel had the least unhealthy foods and beverages advertisements shown at a rate of 0.5adverts/hr as against 0.4adverts/hr for healthy foods and beverages advertisements. This is not consistent with previous studies on rate of food advertisements on children’s TV channels. Of all the 307 advertisements shown while children were on vacation, 209 (68.1%) were non-food adverts. The categories of the foods and beverages advertisements shown during the vacation period revealed that sugar sweetened beverages (14.3%), snacks (13.3%), instant noodles (12.2%), ice cream and desert (7.1%) and as usual fruits and vegetables were least to be advertised as shown Table 11. One striking advertisement shown was alcoholic beverages, though always stated that not for children below 18years was 10% and aired before 6pm. Clearly this shows that laws on restricting alcohol advertisement to children and after 7pm are not being enforced. However, another interesting observation was that no baby milk or infant formulae was advertised indicating that the regulatory instrument to restrict marketing baby and toddler milk formulae is in place and so same can be instituted for unhealthy foods and beverages advertisements. Although TV advertisements have not been reviewed in the Ghanaian setting, there is a compelling evidence from previous studies that children are exposed more to unhealthy foods and beverages advertisements (Vilaro et al. 2016) and findings from this study affirms to that. WHO estimated that more than 40 million children under the age of 5 years were overweight and obese in 2012 and this figure may reach 70 million by 2025 if this existing exposure to unhealthy foods and beverages does not change (WHO, 2014). 46 University of Ghana http://ugspace.ug.edu.gh Therefore, the persistent high exposure of unhealthy foods and beverages advertisements targeting children and the global statistics of NCDs are worrying, these have led the WHO to spear head the global action plan for which the reduction of unhealthy foods and non- alcoholic beverages marketing is one key core component to help curb the overweight and NCDs menace (WHO, 2013). Dovey et al. (2011) indicated in their study that exposure of healthy foods and beverages advertisements to children would decrease their preference and consumption of sweetened snacks. Thus, can create positive attitudes in children similar to their attitude toward junk foods (Dixon et al., 2007). 5.5 Persuasive technique used in foods and beverages advertising Foods and beverages advertisements to children are mostly accompanied with varied persuasive techniques (Kelly et al. 2010), such as the use of emotional apples; fun, happiness, pleasure (Harris et al. 2010), licenced characters example micky mouse (DeMarius, 2012), giveaways, children and celebrities. The objective was to find out what persuasive techniques accompany foods and beverages advertisements in the Ghanaian setting because it appears these techniques are used mostly to advertise unhealthy food (Kelly et al. 2010). Findings from this current study revealed that the most used technique were advertisements utilizing sensory based characteristics (Taste, texture, appearance, aroma) 44%, followed by advertisements which suggested use for/by children (30%), and (29%) of the adverts used animation, children, celebrities and cartoon characters. These persuasive marketing techniques are used to attract children’s attention, particularly when children see these models, celebrities and their peers in adverts they become convinced and approve of the product. There is convincing evidence that children are vulnerable and are not able to understand the persuasive intent of marketers until around age 12 or later in 47 University of Ghana http://ugspace.ug.edu.gh life (Carter et al. 2011). Danovitch and Mills (2014) also found in their study that children preferred licensed character (e.g. ben 10) over unfamiliar characters. Health Claims (18%), (14%) portrayed happiness, fun and pleasure, (13%) indicated that product was convenient to use, (6%) had price tag, (5%) were new brands and (2%) suggested use of the food (e.g. great for lunch box) as shown in table 9. None of the adverts or products advertised had a disclaimer or claimed to be better than other products. Taste and/or fun (64%) were used as primary persuasive appeals in a study directed at children in Spain while a similar figure was found by Boyland et al. (66.5%), as appeal to fun. These two appeals (taste and fun) are present in this study 44% and 13% respectively, indicating how common it is used in advertisements directed at children. According to Cairns et al. (2013), marketing techniques directed at children are becoming more sophisticated and able to distort the facts about the product in favour of the advertiser, negatively influencing children food preferences and consumption patterns. These findings concur with other previous studies which identify that child targeted advertisements use more and varied persuasive techniques. This outcome is worth knowing to address the current public health concerns regarding policy changes on the use of persuasive techniques in foods and beverages advertisements directed at children, and the fact that they are vulnerable and do not understand the marketing intent despite recommendations on the use of excessive persuasive marketing techniques (Graff et al., 2012). 5.6 Impact of results on public health Ghana, in a systematic review and meta-analysis on obesity epidemic conducted by Ofori- Asenso et al. (2016) showed a significant rise in prevalence of overweight and obesity and NCDs. Nutrition transition from diets rich in complex carbohydrates and fibre to energy- 48 University of Ghana http://ugspace.ug.edu.gh dense nutrient poor foods (high in fats, sugar and salt) have been the key drivers of these obesity and NCDs menace among other causes (Kearney J., 2010). This current study revealed that the rate of unhealthy foods (high in fats, sugar and or salt) dominated the foods and beverages advertised to children for which soft drinks or sugar sweetened beverages were the most advertised and the least being fruits and vegetables. If regulatory measures are not enforced, children will grow up to accept these foods and replace it for healthy foods. Ofori-Asenso et al. (2016), findings show that Ghanaians have seen increase availability of soft drinks and processed foods. A study conducted by Day and Pearce, (2011) indicated that fast foods joint, vending machines selling sugar sweetened beverages and other energy dense foods were found around schools. A similar study conducted by Alangea (2014) found that consumption of snacks among school pupils was high, about 91% of pupils consuming non-carbonated sweetened drinks within a week and 55% of them consuming carbonated drink as well. She further concluded that one behavioural factor significantly associated with raised BMI in school pupils were the consumption of sugar sweetened beverages. Thus, the persistent increase in the rate at which unhealthy foods are advertised to children and in a manner to convince them into buying and consuming the products will have possible “implication on current and future population health, burden of chronic diseases, health care spending while we still managing infectious and parasitic diseases as a country. Public health preventive measures appropriate are needed urgently to curb this epidemic.” (Ofori-Asenso et al., 2016) 49 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSIONS AND RECOMMENDATIONS This chapter presents the conclusion based on the findings of this study with exact recommendations. 6.1 Conclusion To the best of my knowledge, this current study is the first to assess the healthiness of foods and beverages advertised to children in the Ghanaian setting. The food environment continues to expose children to appreciable amount of unhealthy foods via numerous medium such as the internet, schools, billboards, super markets and on TV. These unhealthy food exposures are contributing factor to the surging global burden of obesity and diet-related non-communicable diseases. Despite several measures put in place to control foods and beverages advertised on TV to children, the rate of unhealthy (high in fat, sugar and or salt) foods and beverages advertisements dominates on both analog and digital TV channels. Advertised foods were categorised into three major groups namely; core/healthy, non-core/unhealthy and miscellaneous. Sugar sweetened beverages were the most advertised category and fruits and vegetables were least advertised. There was no advert on baby milk or infant formulae, this shows the extent to which regulations to restrict marketing of these products have been enforced. Findings from this work also indicated that persuasive techniques are greatly used in this setting as well, although children below 12 years age not cognitively matured to understand marketer’s intent. 50 University of Ghana http://ugspace.ug.edu.gh 6.2 Recommendation The findings of this study have vital suggestions for foods and beverages advertised on Ghanaian television programs. 6.2.1 Policy Makers 1. Laws on restricting the marketing of foods to children should be enforced to minimize the children’s exposure to unhealthy foods and beverages 2. Surveillance and monitoring systems should be put in place to constantly check the activities of advertisers and to serve as a guide to generate suitable guidelines for the needs of individual and the country as a whole. 3. Public health advocates should educate the entire population on the surging rise of NCDs and its debilitating effects in relation to unhealthy dietary habit. 6.2.2 Future Research Direction 1. This study did not examine data from early mornings and late evenings, advertisements directed at children may be shown at the time. Future studied should capture those periods to ascertain the kind of advertisements shown. 2. Given the duration for which this study took place, data was collected in some atypical month such as December. Future studies should replicate the same for other months excluding seasonality’s and public holidays, to determine if results are compared to this study. 51 University of Ghana http://ugspace.ug.edu.gh REFERENCES Adams, J., Tyrrell, R., Adamson, A.J., & White, M. (2012). Effect of restrictions on television food advertising to children on exposure to advertisements for ‘less healthy’ foods: repeat cross-sectional study. PLoS ONE; 7, e31578. doi:10.1371/journal .pone.0031578. Alangea, O. D. (2014). Determinants of obesity among basic school pupils in the Ga-East municipality. ugspace.ug.edu.gh American Academy of Paediatrics (2001). Children adolescents and television. Paediatrics, 107, 423-426. Amidu, N., Owiredu, W.K.B.A., Saaka, M., Quaye, L., Wanwan, M., Kumibea, P. D., Zingina, F.M., & Mogre, V. (2013). Determinants of childhood obesity among basic school children aged 6 – 12 years in Tamale Metropolis. Amini, M., Djazayery, A., Majdzadeh, R., Taghdisi, M.H., & Jazayeri, S. (2015). Effect of school-based interventions to control childhood obesity: A review of reviews. Aryeetey, R., Lartey, A., Marquis, G.S., Nti, H., Colecraft, E., & Brown, P. (2017). Prevalence and predictors of overweight and obesity among school-aged children in urban Ghana. https://doi.org/10.1186/s40608-017-0174-0 Ayantunji, G., Hinson, E.R., Tukamushaba, E.K., & Ingunjiri, I. (2012). Children’s attitudinal reactions to TV advertisements The African experience. DOI: 10.2501/IJMR-54-4-543-566. Bacardí-Gascón, M., & Jiménez-Cruz, A. (2015). TV Food advertising geared to children in Latin-American countries and Hispanics in the USA: A review Nutr Hosp. 31(5),1928-1935 ISSN 0212-1611 • CODEN NUHOEQ S.V.R. 318 Bell, R.A., Cassady, D., Culp, J., Alcalay, R. (2009). Frequency and types of foods advertised on Saturday morning and weekday afternoon English- and Spanish- language American television programs. J Nutr Educ Behav; 41: 406–413. Boyland, E.J., & Halford, J.C. (2013). Television advertising and branding. Effects on eating behaviour and food preferences in children. Appetite: 62, 236–241. Boyland, E., Nolan, S., Kelly, B., Tudur-Smith, C., Jones, A., Halford, J.C.G., & Robinson, E. (2016). Advertising as a cue to consume: A systemic review and meta-analysis of the effect of acute exposure to unhealthy food and non-alcoholic beverage advertising on intake in children and adults. AJCN. Doi; 10. 3945/ajcn. 115. 120022. Boyland, E.J., & Whalen, R. (2015). Food advertising to children and its effects on diet: A review of recent prevalence and impact data. Pediatric Diabetes, 16(5), 331-337. 52 University of Ghana http://ugspace.ug.edu.gh Cairns, G., Angus, K., & Hastings, G. (2009). The extent, nature and effects of food promotion to children: A review of the evidence to December 2008. World Health Organisation: Geneva 2009. http://www.who.int/dietphysicalactivity/Evidence_Update_2009.pdf Cairns, G., Angus, K., Hastings, G., & Caraher, M. (2013). Systemic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite, 62, 209-215. Carter, M. A., & Swinburn, B. (2004). Measuring the ‘obesogenic’ food envinronment in New Zealand primary schools. Health Promotion International, 19, 15. Chaman, K., Nicholas, P., & Suramaniam, R. (2006). How much food advertising is there on Australian television? Health Promot Int. 21, 172-80 https://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf. Chandler, D. (1995). Theories of Mass Media. https://www.coursehero.com (accessed on 13 December, 2017) Danovitch J. H., & Mills C. M. (2014). How familiar characters influence children’s judgments about information and products. Journal of experimental child psychology. 128, 1-20. Day, P.L., & Pearce, J. (2011). Obesity-promoting food environments and the spatial clustering of food outlets around schools. American journal of preventive medicine, 40, 113-121. Dehghan, M., Mente, A., Zhang, X., Swaminathan, S., Li, W., Mohan, V., et al. (2017). Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study Demarius, D. (2016). "A Content Analysis of Advertising on Children’s Television Networks" Theses and Dissertations. 1801. http://scholarworks.uark.edu/etd/1801 De Onis, M., Blössner, M., & Borghi, E. (2010). Global prevalence and trends of overweight and obesity among preschool children. The American Journal of Clinical Nutrition, 92, 1257-1264. Dovey, T.M., Taylor, L., Stow, R., Boyland, E.J., Halford J.C.G. (2011). Responsiveness to healthy food advertisement / commercials is only evident in children under the age of seven with low food neophobia. Appetite 2011; 56:440-446 Dixon, H.G., Scully, M.L., Wakefield, M. A., White, V. M. & Crawford, D. A. 2007. The effects of television advertisements for junk food verses nutritious food on children’s food attitudes and preferences. Soc Sci Med, 65, 1311-23. Emond, A. J., Bernhardt, M. A., Gilbert-Diamond, D., Li, Z., & Sargent, J. D. (2015). Commercial Television Exposure, Fast Food Toy Collecting, and Family Visits to Fast Food Restaurants among Families Living in Rural Communities. DOI: 10.1016/j.jpeds.2015.09.063 53 University of Ghana http://ugspace.ug.edu.gh Osei-Hwere, E.M. (2008). Children's Television in Ghana: History, Policy, Diversity, and Prospects in a Changing Media Environment (accessed 30 March, 2018) European Food and Nutrition Action Plan 2015–2020. Copenhagen: WHO Regional Office for Europe; 2014. http://www.euro.who.int/__data/assets/pdf . Evra, J.V. (1990). Television and child development. https://www.questia.com Food Standards Agency. The nutrient profiling model, 2006. [WWW document]. URL http://collections.europarchive.org/tna/20100927130941/ http://food.gov.uk/healthiereating/advertisingtochildren/nutlab/nutprofmod (accessed 21 June, 2018). Gbadamosi, A. (2012). Acculturation: an exploratory study of clothing consumption among black African women in London (UK). Journal of Fashion Marketing and Management, 16, 1, 5–10. Gerbner, G., Gross, L., Morgan, M., & Signorielli, N. (1994). Growing up with television: the cultivation perspective. In J. Bryant &D. Zillman (Eds.), Media effects: Advances in Theory and Research (pp. 17-41). Hillsdale NJ: Lawrence Erlbaum Associates. Ghana Demographic and Health Survey (2014). Global report. (2016). Advertising and marketing to children. c2e31879-87c6-4182-81d3- 4865217d91c1 Graff, S., Kunkel, D., & Mermin, S.E. (2012). Government can regulate food advertising to children because cognitive research shows that it is inherently misleading. Health Aff., 31(2), 392–398. Gupta, N., Goel, K., Shah, P., & Misra, A. (2012). Childhood obesity in developing countries: epidemiology, determinants and prevention. Endocr Rev., 33, 48-70. Guran, T., Turan, S., Akcay, T., et al. (2010). Content analysis of food advertising in Turkish television. J. Paediatr Child Health, 46, 427–430. Harris, J.L., Bargh, J.A., & Brownell K.D. (2009). Priming effects of television food advertising on eating behaviour. Health Psychol., 28, 404-13. Hastings, G., Stead M., McDermott L., Forsyth A., MacKintosh, A.M., & Rayner, M. (2003). Review of research on the effects of food promotion to children. Glasgow (United Kingdom): Centre for Social Marketing, The University of Strathclyde; 2003. Hebden, L., King, L., & Kelly, B. (2011). Art of persuasion: an analysis of techniques used to market foods to children. J Paediatr Child Health, 47(11), 776–782. Henderson, V.R., & Kelly, B. (2005). Food advertising in the age of obesity: content analysis of food advertising on general market and African American television. J Nutr Educ Behav., 37, 191-6. 54 University of Ghana http://ugspace.ug.edu.gh Huang, L., Mehta K., & Wong, M.L. (2011). Television food advertising in Singapore: the nature and extent of children's exposure. Health Promot Int. Jun., 27(2), 187-96. Jempson, M., & Searle, D. (1999). The Media and Children's Rights: A handbook for media professionals. UNICEF: Press Wise. https://www.mikejempson.eu Karet, N. (2004). Understanding children’s response to TV. Advertising & Marketing to Children, January–March, pp. 51–59. Karupaiah, T., Chinna, K., Loi, H.M., Lim, S.M., & Noor, M.I. (2008). What’s on Malaysian television? —a survey on food advertising targeting children. Asia Pacific Journal of Clinical Nutrition, 17, 483–491. Kelly, B., Halford, J.C., Boyland, E.J., et al. (2010). Television food advertising to children: a global perspective. Am J Public Health., 100, 1730–1736. Nassar, M.A., & Al-Zien, A. (2012). Effects of television advertising on children in the Middle East. Educ Bus Soc Contemp Middle E Issues 5(4), 267–280. Norman, G. J., Nutter, S. K., Ryan, S., Sallis, J.F., Calfas, K.J., & Patrick, K. (2006). Community design and access to recreational facilities as correlates of adolescent physical activity and body-mass index. Journal of physical activity & health, 3, S118. Obesity Update 2017: http://www.oecd.org/health/obesity-update.htm Ofcom. Children and Parents: media use and attitudes report. 2014 (available from http://stakeholders.ofcom.org.uk/binaries/research/media-literacy/october-2013/ research07Oct2013.pdf). Olsen, N., & Heitmann, B. (2009). Intake of calorically sweetened beverages and obesity. Obesity reviews, 10, 68-75. Vartanian, L., Schwartz, M. B., & Brownell, K. D. 2007. Effects of soft drink consumption on nutrition and health. A systematic review and meta-analysis. American Journal of Public Health, 97, 667-675. Kelly, B., Smith, B., King, L., Flood, V., & Bauman, A. (2008). Television food advertising to children: the extent and nature of exposure. Public Health Nutrition: 10(11), 1234–1240. Kelly, B., Halford, J.C.G., Boyland, E.J., Chapman, K., Bautista-Castano, I., & Berg, C. (2010). Television food advertising to children a global perspective. Am J Public Health; 100: 1730e6. Kelly, B., King, M.L., Chapman M.N.D.K., Boyland, E., Bauman A.E., & Baur, L.A. (2015). Ahierarchy of unhealthy food promotion effects: identifying methodological approaches and knowledge gaps. Am J Public Health, 105, e86-95. Kelly, B., Hebden, L., King, L., Xiao, Y., Yu, Y., He, G., Li, L., Zeng, L., Hadi, H., Karupaiah, T., Hoe, S.N., Noor, I.M., Yoon, J., & Kim H. (2014). Children’s 55 University of Ghana http://ugspace.ug.edu.gh exposure to food advertising on free-to-air television; an Asian-Pacific perspective. Health promotion international. Doi: 10.1093 Kearney J. (2010). Food consumption trends and drivers. Philos Trans R Soc Lond Ser B Biol Sci., 365(1554), 2793–80. Kristen, H., Amy, L., & Marske, M.A. (2005). Nutritional Content of Foods Advertised During the Television Programs Children Watch Most. doi: 10.2105/AJPH.2004.048058 Laar, A., Barnes. A., Tandoh, A., Bash,T., Aryeetey. R., et al. (2018). Ghana food environment policy index. Lobstein, T., Jackson-Leach, R., Moodie, M.L., Hall, K.D., Gortmaker, S.L., & Swinburn, B.A. (2015). Child and adolescent obesity: part of a bigger picture. Lancet Lond Engl., 385(9986), 251020 Li, S., Ye, J., Blades, M., et al. (2016). Foods shown on television in China. Chinese Sociological Dialogue, 1 (2), 120-139. ISSN 2397-2009. https://doi.org/10.1177/297200916686761 Mexican National Health and Nutrition Survey – Research Gate https://www.researchgate.net/publication/268687527 Mchiza, Z.J., Temple,N.J, Steyn, N.P., et al. (2013). Content analysis of television food advertisements aimed at adults and children in South Africa. DOI: https://doi.org/10.1017/S136898001300205X Miller, J. G. (2005). Essential role of culture in developmental psychology https://doi.org/10.1002/cd.135 M.O.H. (2012). National policy for the prevention and control of chronic non- communicable diseases in Ghana. Accra: Ministry of Health, Republic of Ghana. Morgan, M. (2007). How we spend our disposable income. The Statesman, 9 May: http://www.thestatesmanonline .com Neal, B., Sacks, G., Swinburn, B., et al. (2013). Monitoring the levels of important nutrients in the food supply. Obes Rev 14 (Suppl. 1), 49–58. Neville, L., Thomas, M., & Bauman, A. (2005). Food advertising on Australian television: the extent of children's exposure. Health Promote Int., 20(2),105-12. Ng, M., Fleming, T., Robinson, M., Thomson, B., Graetz, N., Margono, C., et al. (2014). Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet., 384(9945), 766-81. Ni Mhurchu, C., Vandevijvere, S., Waterlander, W.E., et al. (2013). Monitoring the availability of healthy and unhealthy foods and nonalcoholic beverages in 56 University of Ghana http://ugspace.ug.edu.gh community and consumer retail food environments globally. Obes Rev., 14 (Suppl. 1): 108– 119. Ofori-Asenso, R. (2016). Overweight and obesity epidemic in Ghana-a systematic review and meta-analysis, BMC Public Health, 16(1), 1239. Ofori-Asenso, R., Agyeman A.A., & Laar, A. (2017). Metabolic Syndrome in Apparently “Healthy” Ghanaian Adults: A Systematic Review and Meta-Analysis. International journal of chronic diseases. Pan American Health Organization. Recommendations from a Pan American Health Organization Expert Consultation on the Marketing of Food and Non-alcoholic Beverages to Children in the Americas. PAHO: Washington DC, 2011 Sigman, A. (2012). Time for a view on screen time. https//adc.bmj.com Pérez-Salgado, D., Rivera-Márquez, J.A., Ortiz-Hernández, L. (2010). Publicidad de alimentos en la programación de la televisión mexicana: ¿los niños están más expuestos? Salud Pública Méx 2010; 52(2):119-26. Powell, L.M., Schermbeck, R.M., Chaloupka, F.J. (2013). Nutritional content of food and beverage products in television advertisements seen on children’s programming. Child Obes 2013; 9:524–31. Powell, L.M., Szczpka, G., Chaloupka, F.J., et al. (2007). Nutritional content of television food advertisements seen by children and adolescents in the United States. Pediatrics, 120, 576-83 Prathapan, S., Wijewardena, K., & Prathapan, R. (2014). A Review on Food and Beverages Advertisements on Television aimed at Children. International Journal of Scientific. Reilly, J.J., & Wilson, D. (2006). Childhood obesity. Br Med J., 333, 1207–1210 Riffe, D., & Freitag, A. (1997). A Content Analysis of Content Analyses: Twenty-Five Years of Journalism Quarterly Research Publications. https://doi.org/10.1177/107769909707400306 ISSN 2250-3153 Rovirosa, A., Zapata, E.M.B., Gómez, P., Gotthelf, S., & Ferrante, D. (2017). Food and beverage advertising on children’s TV channels in Argentina: Frequency, duration, and nutritional quality Arch Argent Pediatr., 115(1), 28-34/28. Sadeghirad, B., Duhaney, T., Motaghipiheh, S., Campbell, NRC., & Johnston, B.C. (2016). Influence of unhealthy food and beverage marketing on children’s dietary intake and preference: a systematic review and meta-analysis of randomized trials. Obes Rev Off J Int Assoc Study. Samaraweera, S. (2012). Television Advertising and Food Demand of Children in Sri Lanka: A Case Study from Galle District. Kelaniya, Sri Lanka: University of Kelaniya. 57 University of Ghana http://ugspace.ug.edu.gh Steiner-Asiedu, M., Addo P., Bediako-Amoa, B., Fiadjoe, F.Y.M., & Anderson, A.K. (2012). Asian Journal of Medical Sciences; 99 – 104. Story, M., & French, S. (2004). Food Advertising and Marketing Directed at Children and Adolescents in the US. Int J Behav Nutr Phys Act., 1, 3-19. Story, M., Kaphingst, K.M., Robinson-O'Brien, R., & Glanz, K. (2007). Creating Healthy Food and Eating Environments: Policy and Environmental Approaches https://doi.org/10.1146/annurev.publhealth.29.020907.090926 Swinburn, B., Sacks, G., Lobstein, T., Rigby, N., Baur, L.A., & Brownell, K.D. (2008). The “Sydney Principles” for reducing the commercial promotion of foods and beverages to children. Public Health Nutr.,11(9), 881–6. Swinburn, B.A., Sacks, G., Hall, K.D., McPherson, K., Finegood, D.T., Moodie, M.L., et al. (2011). The global obesity pandemic: shaped by global drivers and local environments. The Lancet, 378(9793), 80414. Swinburn, B., Sacks, G., & Vandevijvere, S. (2013). INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview key principles. Obesity review, 14, 1-12. Surgeon General of the United States. Healthy People 2010. Available at: http://wwv.',healthypeople. gov/data/data2010.htm, Uribe, B.R. (2012). Un momento y ya volvemos: un análisis de contenido de la publicidad infantil en la televisión chilena. Com Soc (Guadalaj) 2012; 18:79-106 Vilaro, M., Riggsbee, K., Zhou, W., Colby, S., Byrd-Bredbenner, C., Olfert, M., Barnett, T., Kidd, T., & Mathews, A. (2016). Development and Testing of the Food Choice Priorities Survey for College Students. DOI: https://doi.org/10.1016/j.jand.2016.06.159 United Nations. Political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases, 2011. [WWW document]. URL http:// www.ncdalliance.org/hlm (accessed 4 December 2018). World Health Organization. Set of recommendations on the marketing of foods and non- alcoholic beverages to children. Geneva, 2010. World Health Organization, (2011). Pan-American Health Organization. Recommendations from a Pan-American Health Organization Expert Consultation on the Marketing of Food and Non-Alcoholic Beverages to Children in the Americas. Washington: PHAO. WHO (2012). A framework for implementing the set of recommendations on the marketing of foods and non-alcoholic beverages to children (2012) Geneva: WHO. http://www.who.int/dietphy sicalactivity/MarketingFramework2012.pdf. Accessed 10 Sept 2018 58 University of Ghana http://ugspace.ug.edu.gh WHO, (2013). Regional Office for Europe, Vienna: Declaration on Nutrition and Non- Communicable Diseases in the Context of Health 2020 World Health Organization. (2010). Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: WHO Press; 2010. World Health Organization. Global action plan for the prevention and control of non- communicable diseases 2013-2020. Geneva, Switzerland: World Health Organization; 2013. World Health Organization. Set of recommendations on the marketing of foods and non- alcoholic beverages to children. Geneva: World Health Organization; 2010. World Health Organization. A framework for implementing the set of recommendations on the marketing of foods and non-alcoholic beverages to children (in preparation). Geneva: World Health Organization; 2011. World Health Organisation. Guidance note on the integration of non-communicable diseases into the United Nations development assistance framework, 2015. https://www.who.int/nmh/ncd-task-force/guidance-note.pdf World Health Organization. Report of the commission on ending childhood obesity. Geneva: WHO, 2016. 59 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix I: Study Code Sheet VARIABLE INDICATORS DESCRIPTION RESPONSE Date of ad: Recorded as day / month / year Day of the week • Monday • Tuesday • Wednesday • Thursday • Friday • Saturday • Sunday Time of ad • Morning (0800HRS. to 1200HRS) • Afternoon (1201 noon to 1600HRS.) • Evening (1601HRS to 1800HRS) TV channels • TV3 (CODED AS 1) • GTV (CODED AS 2) • SMILE TV (CODED AS 3) Program name in which advert was shown Program category 1 = News, commentary, political programs 2 = Sport (a specific program or a sport event) 3 = Soap opera 4 = Series (not specifically for children) 5 = Movie (not specifically for children) 6 = Documentary 7 = Reality show 8 = Talk show 9= Miscellaneous entertainment: e.g. variety, spectacles, contests 10 = Children: cartoon, movies, series or other show for children 11 = Music or music video 12 = Religious 13 = Health related 14= Other Type of product • Cereals/Breakfast Foods (CODED AS 1; e.g. Yamvita, cerelac,) • Sugared Snacks/Drinks (CODED AS 2) 60 University of Ghana http://ugspace.ug.edu.gh • Any food items with added sugar listed in its ingredients (e.g. Coca-Cola, Candies, Energy drink, Kalypo) • Fast Food/Restaurants (CODED AS 3; e.g. KFC, Eddy’s pizza) • Healthy Foods/Drinks (CODED AS 4; Fruits and Vegetables, 100% Fruits and Vegetables Juices) • Alcohol/all alcoholic beverages (CODED AS 5; e.g alomo bitters) • Recipe additions (including soup and stew cubes, oils, dried herbs and seasonings) • Tea and coffee • Baby and toddler milk formulae Ads targeting children • FUN: Associates positive affect with product use by having joy and cheer. (YES / NO) • HAPPINESS: Associates positive affect with the product’s use by smiling, dancing, etc. (YES / NO) • PLEASURE: Emphasizes the satisfaction or joy one gains through use of purchase of the product (YES / NO) • NEUTRAL: The product does not appear to provide an emotional message in the ad (YES / NO) Total number of food • Per episode ads targeting children • Per day • On weekday • On weekends Food type Healthy • Low sugar and high fibre breakfast cereals (<20g sugar/100g and >5g dietary fiber /100g) Code as 1 • Fruits and fruit products without added sugars, fats or salt (e.g. 100% Fruit juice) Code as 2 • Vegetables and vegetable products without added fats, sugars or salt, Code as 3 • Milks and yoghurts (<3g fat/100g) e.g. Soy and alternative probiotic drinks, Coded as 4 • Water, Code as 5 • Oils high in mono or polyunsaturated fats and plant-based margarines and spreads, Code as 6 61 University of Ghana http://ugspace.ug.edu.gh Unhealthy • High sugar and /or low fiber breakfast cereals (>20g sugars/100g or <5g dietary fiber /100g) Code as 7 • Spicy instant noodle products, Code as 8 • Flour or dough-based snacks e.g. breads, cakes, muffins, pies and pastries, biscuits, chips, Code as 9 • Tinned products processed or preserved in salt, Code as 10 • Sugar sweetened beverages e.g. non-diet soft drinks, flavoured juice drink, sweetened tea, sport drink, Code as 11 • Full cream milks and yoghurts, ice cream and desserts, (> 3g fat/100g), Code as 12 • Chocolate and candy, Code as 13 • Alcohol, Code as 14 • Others, Code 15 Health or nutritional YES / NO claims associated with the advertised food product Claims description (1-7) 1= Health related ingredients claims 2= Nutrient content claims (e.g. low fat) 3= Nutrient comparative claims (e.g. reduced fat) 4= General health claims (e.g. healthy diet) 5= Nutrient & other function claim (e.g. calcium good for bone) 6= Reduction of disease risk claims (e.g. HF tick) 7= Other claims (e.g. organic) Disclaimers relating to YES / NO advice or warning about consumption of the product Use of animations, YES / NO cartoons, celebrities or children Giveaways YES / NO 62 University of Ghana http://ugspace.ug.edu.gh Appendix II Number of Advertisement by Type of Foods and Beverages Food category (n=590) Frequency % Non-Healthy Origin O (Sugar sweetened drink) 14 2.3 Alomo bitters (alcoholic beverage) 10 1.7 Belona (Sugar sweetened beverage 24 4.1 Burger 3 0.5 Biscuit 25 4.2 Cake and Pie 14 2.3 Candy/Chocolate 6 1.1 Club bear 4 0.7 Coke 17 2.9 Cornelly (Salted corn snack) 16 2.7 Cowbell tea 4 0.7 Dano milk 2 0.3 Tin fish 26 4.4 Energy drink 11 1.9 Fanmilk 4 0.7 Sandra ice cream 27 4.6 Ideal tea, coffee and choco 16 2.7 Indomie 42 7.1 Kaeser apple drink 4 0.7 Kasapreko royal drink 29 4.9 Malt drink 10 1.7 Miski choco 12 2.0 Moringa drink 4 0.7 Muffin 2 0.3 Papa’s pizza and Eddy’s Pizza 7 1.2 Popcorn 8 1.4 Richoco 7 1.2 Potato chips 1 0.2 63 University of Ghana http://ugspace.ug.edu.gh Number of advertisements by type of Food and beverage (Cont’d) Food category (n=590) Frequency % Healthy Apple 6 1.0 Awake purified water 8 1.4 Banana 4 0.7 Cabbage 1 0.2 Cerelac 20 3.4 Cowbell milk 33 5.6 Egg 2 0.3 Fanmaxx 25 4.2 Milo 7 1.2 Nido 10 1.7 Vegetables 2 0.3 Water melon 2 0.3 Yumvita 4 0.7 Gogurt 5 0.9 Miscellaneous Cake tekniks 5 0.9 Food show 12 2.0 Edziban 12 2.0 Frytol 13 2.2 House of food, cakes and pastries 5 0.9 Lipton 1 0.2 Gino tomato paste 8 1.4 Onga 19 3.2 Mr chef seasoning cube 2 0.3 Pork 1 0.2 Rice 36 6.1 64 University of Ghana http://ugspace.ug.edu.gh Appendix III: Letter of Ethical Clearance 65