The extent and nature of children’s real-time exposure to alcohol marketing using wearable cameras and GPS devices By Timothy J. Chambers A thesis submitted for the degree of Doctor of Philosophy at the University of Otago New Zealand May 2018 ii Abstract Alcohol places substantial financial, physical, social and psychological burdens on society. There is mounting evidence that childhood exposure to alcohol marketing increases the likelihood children will begin drinking, and current drinkers will increase consumption. However, children’s exposure to alcohol marketing is typically measured using self-report data, television viewing data or street marketing audits, which are subject to bias and often do not provide quantifiable rates of daily exposure. This study uses an innovative methodology to quantify the extent and nature of children’s real-time exposure to alcohol marketing using wearable cameras and GPS devices. Children aged 11-13 years (n=167) were randomly selected from 16 schools in Wellington, New Zealand. The children wore wearable cameras that automatically captured images approximately every seven seconds and GPS devices that captured latitude and longitude coordinates every five seconds for a four-day period between June 2014 and July 2015. Content analysis of images (n = 700,000) was manually undertaken to assess children’s exposure to alcohol marketing. Image data were linked to GPS data to examine the spatial patterning of children’s exposure to alcohol marketing. On average, children were exposed to alcohol marketing 12.4 (95% CI 9.1, 17.1) times per 10 hours, excluding within supermarkets. Children were exposed at home (73%), on- licence alcohol outlets (9%), off-licence shop fronts (5%) and sporting venues (5%). Children were exposed via product packaging (62%), sports sponsorship (11%) and shop front signage (11%). There were stark differences in exposure by sociodemographic characteristics with exposure rates for Māori 5.4 times higher than New Zealand European children and boys 2.0 times higher than girls. In addition, children were exposed to alcohol marketing within supermarkets 3.3 times per week. Children were exposed to alcohol marketing on 85% of their visits to supermarkets for an average of 46 seconds per exposure. In New Zealand, the findings provide strong evidence to support the Law Commission and Ministerial Forum on Alcohol Advertising and Sponsorship recommendations for legislative restrictions on alcohol marketing, in particular, a ban on alcohol sponsorship of sport. These findings highlight the urgent need for strict legislative restrictions on all iii forms of alcohol marketing as called for in the World Health Organization’s Global Alcohol Strategy. Given the global nature of alcohol marketing, these findings may be applicable in other jurisdictions. iv Acknowledgements This thesis is the result of a collective effort of supervisors, colleagues, funders, study participants, friends and family. It has been one of the greatest challenges of my professional career. One that has simultaneously provided a source of frustration, validation and enjoyment. To my supervisors Professor Louise Signal, Dr Moira Smith and Assistant Professor Amber Pearson I extend a huge thank you! Throughout my PhD, you have provided valuable advice and challenged me to fulfil my potential. Your support has extended far beyond this thesis, including support for my other academic pursuits, scholarship applications and sporting goals. In addition, I would like to thank Professor Ichiro Kawachi and Assistant Professor Amber Pearson for hosting me for one year as part of this thesis at Harvard University and Michigan State University. My Fulbright experience at Harvard and Michigan State was a once in a lifetime experience and something that has assisted my transition into a career in academia. This thesis would simply not be possible without the vision and dedication of the Kids’Cam team, specifically Professor Louise Signal, Professor Cliona Ni Mhurchu, Dr Moira Smith, Dr James Stanley and soon to be Dr Michelle Barr. The ever-expanding research team, projects and overall interest in all Kids’Cam research has rewarded your foresight and belief in the potential of the Kids’Cam method. I also thank all the funders that supported Kids’Cam and my PhD project. Thank you to the Health Research Council of New Zealand for funding Kids’Cam. Also to the University of Otago for funding my PhD programme through the Special Health Research Scholarship and Fulbright New Zealand for funding my tenure at Harvard University and Michigan State University as a Visiting Scientist. I would also like to thank the Division of Health Sciences and the University of Otago, Wellington for proving funding for my attendance at conferences in Brazil and France. I would like to thank all the staff and students at the University of Otago, Wellington for your support over the past three years; in particular, the staff and students within the Department of Public Health. v The Kids’Cam team and I extend our gratitude to the parents, children and schools that let us into their lives to find ways we can improve the health of our children. And finally, I would like to thank my partner Lydia for all her support throughout my PhD. This included pausing your promising career in secondary education and leaving home to live with me in the United States for an entire year. I could not have done this without your support and positivity. THANK YOU vi Statement of participation This thesis was conducted as part of Kids’Cam, a study funded by a Health Research Council of New Zealand (programme grant #13/724). Kids’Cam was funded to quantify the nature and extent of children’s exposure to food and non-alcoholic beverage marketing using wearable cameras. Kids’Cam included 168 randomly selected Year 8 children from 16 randomly selected schools across the Wellington region. Kids’Cam was one of five studies that formed the Dietary Interventions: Evidence and Translation (DIET) programme, a five-year programme of research focused on informing national and international policies on the most effective and cost-efficient ways to improve population diets and health. DIET was a collaborative research programme led by Professor Cliona Ni Mhurchu (CNM) at the National Institute for Health Innovation (NIHI) at the University of Auckland with collaborators at the University of Otago, Wellington, and The George Institute for Global Health and Oxford University. Further information about DIET can be found at https://diet.auckland.ac.nz/. The Kids’Cam research team Kids’Cam was led by Professor Louise Signal (LS), at the University of Otago, Wellington. The Kids’Cam research team consisted of Dr Moira Smith (MS), Dr James Stanley (JS), Dr Gabrielle Jenkin (GJ), Miss Tolotea Lanumata (TL), Miss Michelle Barr (MB), Mr Tim Chambers (TC), Miss Christina McKerchar (CM). Assistant Professor Amber Pearson (AP), Professor Janet Hoek (JH), Dr Cathal Gurrin (CG), Professor Alan Smeaton (AS), Dr Zhengwei Qiu (ZQ), Dr Jiang Zhou (JZ), Aaron Duane (AD). Māori oversight for Kids’Cam was provided by Toi Tangata, as part of the DIET Advisory Group and by Christina McKerchar (Ngāti Kahungunu, Tūhoe and Ngāti Porou descent). In addition to the collaboration with NIHI, Kids’Cam was also a collaboration with researchers at the Insight Centre for Data Analytics at Dublin City University (DCU). The team from DCU included AS, CG, ZQ, JZ and AD. These researchers developed software to review the wearable camera images and upload the images to the Kids’Cam server. The team at DCU also developed coding software that enabled us to attach codes directly to the images. Further, they worked with JS (Kids’Cam biostatistician) to vii develop the back end of the software to translate the image codes into numerical data for statistical analysis This thesis was also assisted by two researchers from Michigan State University; Chris Lowrie (CL) and Zachery Rzotkiewicz (ZR). (CL) wrote the Python script for the automated imputation method, and (ZR) integrated the ST-DBSCAN algorithm into the software application used for the destination analysis. My role in Kids’Cam Data collection Between February 2015 and June 2015, I was involved in 15 of the 25 data collection cycles at 11 different schools. I led data collection in 13 of 15 of the data collection cycles and assisted MB on the other two. In total, I collected data for 86 participants (51% of all Kids’Cam participants). Image coding I assisted MB in the development of the Kids’Cam coding framework and had a substantial role in testing and refining it. I contributed to the development of the coding rules and coding protocol document. Along with MB, I was a gold standard image coder for Kids’Cam, responsible for training other coders. My role in Kids’Cam Alcohol Kids’Cam Alcohol is the name for the study that was conducted as part of this thesis and is used to differentiate between the main Kids’Cam project outlined above. Image data I developed the coding schedule for Kids’Cam Alcohol, using concepts from Kids’Cam, which I also helped develop. I coded all images, outside school time, for 167 of the participants with valid image data (approximately 700,000 images). viii GPS data As mentioned above, in total, I collected data for 86 participants (51% of all Kids’Cam participants), including their GPS data. I converted all 150 participants’ GPS data (150 of the 168 had valid GPS data) from GPX files into Shapefiles using ArcGIS (ESRI, Redlands, CA). I led the development of the GPS data cleaning protocol and conducted the data cleaning for all participants’ GPS data. I led the development of an imputation method for missing GPS data (working with CL) and then conducted the automated and manual imputation for all 150 participants with GPS data.