Development and Evaluation of the Sugar-Sweetened Beverages Media Literacy (SSB-ML) Scale and Its Relationship With SSB Consumption

Testing the effectiveness of narrative messages using critical health communication

BACKGROUND

Latinos suffer from health disparities associated with excessive consumption of sugar-sweetened beverages. This study aimed to test the effectiveness of messaging using critical health communication approaches and delivered by two narrative modalities (video and comic book) with similar content that aims to empower Latinos to advocate for social change and to make individual behavior change related to sugary beverage consumption.

METHODS

Participants (N = 129 Mexican American women between 18 and 29 years) completed an online survey before and after exposure to an embedded stimulus. Participants were randomly assigned to a stimulus, a narrative message in video or comic book format, both developed using critical health communication approaches that focused on individual harms and social causes of sugary beverage consumption.

RESULTS

Paired sample t-test results showed that both narrative messages increased intentions to reduce sugary beverage consumption (Video: P < 0.01; d = 0.43; Comic: P = 0.03; d = 0.28). Both groups also demonstrated significant improvements in sugary beverage-related media literacy (Video: P = 0.01, d = 0.34; Comic: P = 0.05, d = 0.25), public health literacy (Video: P = 0.05, d = 0.24; Comic: P = 0.01, d = 0.32), and empowerment to engage in sugary beverage-related community movements (Video: P = 0.003, d = 0.38; Comic: P = 0.034, d = 0.27).

CONCLUSIONS

This study provides initial evidence indicating the effectiveness of narrative messages in two modalities using critical health communication for promoting individual behavioral intention and social activation in reducing sugary beverage consumption.

Do Descriptive Norm Appeals in Public Service Ads Reduce Freedom Threats? Examining the Effects of Normative Messages and Media Literacy Skills on Decreasing Reactance

While health communication campaigns seek to encourage and promote healthy behaviors, they are not always successful. Health communication efforts may fail for several reasons, such as viewers experiencing excessive freedom threats and reactance. This study (n = 201) proposes and demonstrates that descriptive norm appeals in health PSAs can indirectly lead to enhanced behavioral intentions toward the message advocacy via reducing perceived freedom threats, inhibiting psychological reactance, and improving message credibility. However, this serial mediation was only found for message viewers with relatively low media literacy skills - precisely, who did not show considerable critical thinking toward media content. For participants who reported a high level of critical thinking toward media content, the use of descriptive norm appeals did not decrease freedom threats, nor did it indirectly affect behavioral intentions. The findings of this study contribute to the theory of psychological reactance and norms-based research. Both theoretical and practical implications are provided for health communication scholars and practitioners.

Perceptions of Sports and Energy Drinks: Factors Associated with Adolescent Beliefs

PURPOSE

To understand what factors are associated with adolescents' perceived healthfulness of sports drinks (SD) and of energy drinks (ED), with a focus on health risk, athletics, and media-related variables.

DESIGN

Cross-sectional survey.

SETTING

Online.

SUBJECTS

U.S. adolescents ages 14-18 years (n = 501) recruited from a combination of non-probability and probability-based panels.

MEASURES

Outcome variables were perceived healthfulness of SDs and of EDs. Independent variables included adolescents' health background (oral health, diabetes risk, self-reported weight); behaviors (SD and ED consumption, athletic identity, sports participation, physical activity), and media items (media literacy, exposure to advertisements on TV, YouTube, social media).

RESULTS

Regression results indicated that adolescents' increased perception that SDs are healthy was significantly associated (P<.05 level) with casual sports participation (b=.56, se=.27), athletic identification (b=.28, se= .11), exposure to SD advertisements on social media (b=.55, s =.25), and higher consumption (b=.28, se= .13). For adolescents' perceptions of EDs, significantly related correlates included athletic identification (b=.26, se=10), having an increased risk of diabetes (b= -.79, s =.26), poorer oral health (b=.33, se=.16), and consumption (b=.76, s =.16); increased media literacy was associated with more accurate perceptions (b=-.35, se=.14).

CONCLUSIONS

Adolescents' hold different perceptions about the healthfulness of sports and energy drink, and their beliefs about each drink are related to different types of factors that may have implications for public health interventions. Cross-sectional survey design and adolescent self-reports are limitations.

Psychometric properties of the Chinese version of the sugar-sweetened beverages media literacy scale for undergraduates

Specific domains of the Sugar-Sweetened Media Literacy Scale (SSM-ML) have been shown to significantly assess sugar-sweetened beverage (SSB) calorie intake in the US population. This study aimed to describe the psychometric properties of the revised Chinese version of the SSB-ML (C-SSB-ML) and evaluate its validity and reliability. Results from 975 undergraduates at two of the largest universities in a province in southwest China showed that Cronbach's alphas for the overall scale, the three dimensions, and two-halves analysis were satisfactory (0.71-0.92). The criterion-related validity of the C-SSB-ML was positively associated with the e Health literacy scale (eHEALS). Confirmatory factor analysis showed that the three-factor model of the C-SSB-ML had adequate fit indices χ² (153) = 4349.93, p < 0.001; Comparative fit index (CFI), Tucker-Lewis index (TLI), Incremental fit index (IFI) >0.90; Standardized Root Mean Square Residual (SRMR) <0.07; and Root Mean Square Error of Approximation (RMSEA) <0.08. Our findings provide evidence for a valid and reliable tool that can be used to assess sugar-sweetened media literacy in Chinese undergraduates and will help organizations leverage media literacy in strategy formulation to ensure SSB intake is controlled as much as possible through effective efforts on all fronts.

Superlatives, clickbaits, appeals to authority, poor grammar, or boldface: Is editorial style related to the credibility of online health messages?

Adolescents, as active online searchers, have easy access to health information. Much health information they encounter online is of poor quality and even contains potentially harmful health information. The ability to identify the quality of health messages disseminated via online technologies is needed in terms of health attitudes and behaviors. This study aims to understand how different ways of editing health-related messages affect their credibility among adolescents and what impact this may have on the content or format of health information. The sample consisted of 300 secondary school students (M_age = 17.26; SD_age = 1.04; 66.3% female). To examine the effects of manipulating editorial elements, we used seven short messages about the health-promoting effects of different fruits and vegetables. Participants were then asked to rate the message’s trustworthiness with a single question. We calculated second-order variable sensitivity as the derivative of the trustworthiness of a fake message from the trustworthiness of a true neutral message. We also controlled for participants’ scientific reasoning, cognitive reflection, and media literacy. Adolescents were able to distinguish overtly fake health messages from true health messages. True messages with and without editorial elements were perceived as equally trustworthy, except for news with clickbait headlines, which were less trustworthy than other true messages. The results were also the same when scientific reasoning, analytical reasoning, and media literacy were considered. Adolescents should be well trained to recognize online health messages with editorial elements characteristic of low-quality content. They should also be trained on how to evaluate these messages.

Excessive Gaming and Online Energy-Drink Marketing Exposure Associated with Energy-Drink Consumption among Adolescents

In this study, we examined excessive online gaming by adolescents and the resultant effects of their exposure to the online marketing of energy drinks and alcohol, and whether marketing literacy could serve as a mitigating factor. This cross-sectional study was conducted in 2020. Data were obtained from a sample of 2613 seventh-grade students from 30 middle schools in Taiwan. A self-administered questionnaire was conducted. The results showed that nearly 18% of the adolescent respondents had used energy drinks, while 75% reported seeing energy-drink advertisements on the internet in the past year. Multiple regression results indicated that factors such as being male, reporting excessive gaming, being exposed to higher levels of online energy-drink marketing, and reporting alcohol use were positively associated with energy-drink consumption. A higher level of online energy-drink marketing-affective literacy, however, was negatively associated with energy-drink consumption. In conclusion, factors that predicted energy-drink consumption among adolescents included excessive gaming and exposure to online energy-drink marketing, but marketing-affective literacy tended to lessen the impact of such advertising.

Protocol: Effectiveness of message content and format on individual and collective efficacy in reducing the intention to consume sugar-sweetened beverages

The strategic use of media is a common approach to promote health. A large body of evidence identifies specific features that increase message efficacy, including tailoring messages to the target audience and using a storytelling format. Yet most message testing research has focused on individual-level outcomes, ignoring the social and environmental determinants of health behaviors, which require collective action and political will to change. Grounded in an ecological approach to communication, we will carry out two double-blinded randomized experiments to test the relative effectiveness of message tailoring (culturally-tailored vs. standard) and format (narrative vs. didactic) to increase the intention to reduce individual sugar-sweetened beverage consumption, the understanding of social and commercial determinants of health, and the sense of empowerment among young adult Latinas. Based on power analyses (80% power at alpha = 0.05), we will randomize 438 participants to two groups (traditional standard infographic and culturally-tailored infographic) in the first study, and 662 participants to two groups (culturally-tailored infographic and culturally-tailored comic book) in the second study. All participants will be measured by a pre-treatment test and an immediate post-treatment test. We hypothesize that culturally-tailored comic book will be most effective, and traditional standard infographic will be least effective, on all levels of outcomes. This study will provide empirical evidence in communication strategies to help young Latinos or other racial/ethnic minority young people to pursue positive dietary behaviors that both benefit themselves and contribute to change of social norms.

Factors Influencing the Sugar-Sweetened Beverage Intake of Caregivers of Adolescents in Appalachia

OBJECTIVE

To identify factors that influence the sugar-sweetened beverage (SSB) intake of caregivers of middle school-aged adolescents.

DESIGN

Cross-sectional.

SETTING

Southwestern Virginia, US, part of Central Appalachia.

PARTICIPANTS

Caregivers (n = 362) of adolescents enrolled in the Kids SIPsmartER trial. Participants were mostly female (91%) and non-Hispanic White (96%), and 21% received Supplemental Nutrition Assistance Program (SNAP) benefits.

MAIN OUTCOME MEASURES

Caregiver daily SSB intake and demographics, personal-level, interpersonal-level, and environmental-level determinants.

ANALYSIS

Descriptive statistics, 1-way ANOVA, and stepwise regression.

RESULTS

On average, caregivers consumed 25.7 (SD, 33.2) fluid ounces of SSB per day. In the final model, which included all variables, age (β = -0.41; P < 0.05), receiving SNAP benefits (β = 14.19; P ≤ 0.01), behavioral intentions (β = -5.48; P ≤ 0.001), affective attitudes (β = -2.15, P < 0.05), perceptions of whether their adolescent frequently consumes high amounts of SSB (β = 1.92; P ≤ 0.001), and home availability (β = 7.43; P ≤ 0.01) were significantly associated with SSB intake.

CONCLUSIONS AND IMPLICATIONS

Caregivers of Appalachian middle school students are high SSB consumers. Findings highlight the importance of implementing behavioral interventions for caregivers of adolescents that target multiple levels of influence, including demographic, personal-level, interpersonal-level, and environmental-level factors. Interventions may be particularly important for communities and groups with higher SSB intakes, such as those in Appalachia and who receive SNAP benefits.

Applying the socio-ecological model to understand factors associated with sugar-sweetened beverage behaviours among rural Appalachian adolescents

Objective:

The objective of the current study was to identify factors across the socio-ecological model (SEM) associated with adolescents’ sugar-sweetened beverage (SSB) intake.

Design:

This cross-sectional study surveyed adolescents using previously validated instruments. Analyses included descriptive statistics, ANOVA tests and stepwise nonlinear regression models (i.e., two-part models) adjusted to be cluster robust. Guided by SEM, a four-step model was used to identify factors associated with adolescent SSB intake – step 1: demographics (i.e., age, gender), step 2: intrapersonal (i.e., theory of planned behaviour (attitudes, subjective norms, perceived behavioural control, behavioural intentions), health literacy, media literacy, public health literacy), step 3: interpersonal (i.e., caregiver’s SSB behaviours, caregiver’s SSB rules) and step 4: environmental (i.e., home SSB availability) level variables.

Setting:

Eight middle schools across four rural southwest Virginia counties in Appalachia.

Participants:

Seven hundred ninety seventh grade students (55·4 % female, 44·6 % males, mean age 12 (sd 0·5) years).

Results:

Mean SSB intake was 36·3 (sd 42·5) fluid ounces or 433·4 (sd 493·6) calories per day. In the final step of the regression model, seven variables significantly explained adolescent’s SSB consumption: behavioural intention (P < 0·05), affective attitude (P < 0·05), perceived behavioural control (P < 0·05), health literacy (P < 0·001), caregiver behaviours (P < 0·05), caregiver rules (P < 0·05) and home availability (P < 0·001).

Conclusions:

SSB intake among adolescents in rural Appalachia was nearly three times above national mean. Home environment was the strongest predictor of adolescent SSB intake, followed by caregiver rules, caregiver behaviours and health literacy. Future interventions targeting these factors may provide the greatest opportunity to improve adolescent SSB intake.

The reach and effectiveness of SIPsmartER when implemented by rural public health departments: a pilot dissemination and implementation trial to reduce sugar-sweetened beverages

SIPsmartER is a theory-based, 6-month, multi-component health literacy intervention shown to improve sugar-sweetened beverages (SSB) behaviors among adults in rural, southwest Virginia. The objective of this pilot trial was to understand the reach and effectiveness of SIPsmartER when delivered by existing staff in public health practice settings. This pre-post research design was conducted in partnership with four medically underserved southwest Virginia Department of Health (VDH) districts. Validated measures and standardized data collection techniques were used. Analyses included descriptive statistics and multilevel mixed-effects linear regressions models. Of 928 individuals screened, 586 (63%) were eligible and 117 (20% of eligible) enrolled in SIPsmartER (79% retained). The sample was majority female (71%) and white (94%) and had ≤high school education (59%) and an annual income of approximately $12,500. Relative to the county population, the enrolled study sample was representative for age and race, yet underrepresented for men and overrepresented for low income and low educational attainment. Significant improvements from baseline to 6 months were observed for the primary SSB outcome (-403 [confidence interval [CI] = -528, -278] SSB kcals/day) (p < .001). SSB-related attitudes, perceived behavioral control, behavioral intentions, and media literacy also significantly improved (all p < .05). SIPsmartER appears to be promising for VDH and potentially other health departments in medically underserved areas. When compared to the previous effectiveness trial, existing VDH staff achieved similar reach and effectiveness for some, but not all, outcomes. Future work is needed on methods to support health departments in developing strategies to reach new participants and to integrate SIPsmartER into sustained practice.

Reducing Television Influences on US Adolescents Who are High Reactance

Watching a lot of television (TV), where alcohol consumption is depicted frequently and mostly positively, can enhance teens' drinking intentions. This influence is particularly problematic among high-reactance teens (that is, those with a predisposition to resist adult control). This study documents one strategy parents can use to counteract TV influences: parental presence during the TV viewing experience (co-viewing). Survey data were collected from a nationally representative sample of parents and their children aged 13-17 (N = 396). Parents reported how they monitored their children's TV consumption, and adolescents completed a survey in which they reported the amount of TV they watch, completed a trait reactance scale and indicated their views and intentions regarding drinking. Results revealed that the influence of TV viewing on adolescents' drinking intentions was lower for teens high in trait reactance who grew up with parents who co-view television with them. This did not occur when parents adopted instructive or restrictive communication strategies. The parental monitoring strategy of co-viewing thus emerges as a promising protective approach for a population that has traditionally been considered vulnerable (i.e., high reactance teens).

Kids SIPsmartER, a cluster randomized controlled trial and multi-level intervention to improve sugar-sweetened beverages behaviors among Appalachian middle-school students: Rationale, design & methods

The intake of sugar-sweetened beverages (SSB) is disproportionately high in Appalachia, including among adolescents whose intake is more than double the national average and more than four times the recommended daily amount. Unfortunately, there is insufficient evidence for effective strategies targeting SSB behaviors among Appalachian youth in real-world settings, including rural schools. Kids SIPsmartER is a 6-month, school-based, behavior and health literacy program aimed at improving SSB behaviors among middle school students. The program also integrates a two-way short message service (SMS) strategy to engage caregivers in SSB role modeling and supporting home SSB environment changes. Kids SIPsmartER is grounded by the Theory of Planned Behavior and health literacy, media literacy, numeracy, and public health literacy concepts. Guided by the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance), this type 1 hybrid design and cluster randomized controlled trial targets 12 Appalachian middle schools in southwest Virginia. The primary aim evaluates changes in SSB behaviors at 7-months among 7th grade students at schools receiving Kids SIPsmartER, as compared to control schools. Secondary outcomes include other changes in students (e.g., BMI, quality of life, theory-related variables) and caregivers (e.g., SSB behaviors, home SSB environment), and 19-month maintenance of these outcomes. Reach is assessed, along with mixed-methods strategies (e.g., interviews, surveys, observation) to determine how teachers implement Kids SIPsmartER and the potential for institutionalization within schools. This paper discusses the rationale for implementing and evaluating a type 1 hybrid design and multi-level intervention addressing pervasive SSB behaviors in Appalachia. Clincialtrials.gov: NCT03740113.

A Participatory Process to Engage Appalachian Youth in Reducing Sugar-Sweetened Beverage Consumption

Children and adolescents consume excessive amounts of sugar-sweetened beverages (SSBs), which are associated with adverse health outcomes. We describe a yearlong participatory research study to reduce SSBs in Central Appalachia, where excessive consumption is particularly prevalent. This study was conducted in partnership with a community advisory board in Southwest Virginia. Nine "youth ambassadors," aged 10 to 13 years helped to systematically adapt SIPsmartER, an effective theory-based program for Appalachian adults, to be age and culturally appropriate and meet desired theoretical objectives. They then assisted with delivering the curriculum during a school-based feasibility study and led an advocacy event in their community. Satisfaction surveys and feedback sessions indicate that ambassadors found the program acceptable and important for other students. Validated surveys and focus groups suggested that theoretical objectives were met. Findings from these mixed methods sources informed curricular changes to further enhance acceptability and refine theoretical objectives. Participation in follow-up advocacy activities was tracked and described. Following the yearlong study, ambassadors reported having advocacy skills and motivation to continue reducing SSB intake in their community. Results, challenges, and lessons learned are presented to inform larger efforts to enhance acceptability of programs and inspire youth to take action to reduce health disparities in Appalachian communities.

Kids SIP smartER: A Feasibility Study to Reduce Sugar-Sweetened Beverage Consumption Among Middle School Youth in Central Appalachia

PURPOSE

To test the feasibility of Kids SIP smartER, a school-based intervention to reduce consumption of sugar-sweetened beverages (SSBs).

DESIGN

Matched-contact randomized crossover study with mixed-methods analysis.

SETTING

One middle school in rural, Appalachian Virginia.

PARTICIPANTS

Seventy-four sixth and seventh graders (5 classrooms) received Kids SIP smartER in random order over 2 intervention periods. Feasibility outcomes were assessed among 2 teachers.

INTERVENTION

Kids SIP smartER consisted of 6 lessons grounded in the Theory of Planned Behavior, media literacy, and public health literacy and aimed to improve individual SSB behaviors and understanding of media literacy and prevalent regional disparities. The matched-contact intervention promoted physical activity.

MEASURES

Beverage Intake Questionnaire-15 (SSB consumption), validated theory questionnaires, feasibility questionnaires (student and teacher), student focus groups, teacher interviews, and process data (eg, attendance).

ANALYSIS

Repeated measures analysis of variances across 3 time points, descriptive statistics, and deductive analysis of qualitative data.

RESULTS

During the first intervention period, students receiving Kids SIP smartER (n = 43) significantly reduced SSBs by 11 ounces/day ( P = .01) and improved media ( P < .001) and public health literacy ( P < .01) understanding; however, only media literacy showed between-group differences ( P < .01). Students and teachers found Kids SIP smartER acceptable, in-demand, practical, and implementable within existing resources.

CONCLUSION

Kids SIP smartER is feasible in an underresourced, rural school setting. Results will inform further development and large-scale testing of Kids SIP smartER to reduce SSBs among rural adolescents.