Using the Theory of Planned Behavior to Understand Drink Choices in Southwest Virginians

Background: Between 1977 and 2002, the per capita intake of caloric beverages doubled in the United States, with most recent data from 2005–2006 showing that children and adults consume about 172 and 175 kcal daily, respectively, from sugar-sweetened beverages (SSB) (Brownell et al., 2009). Also, a high intake of SSB has been related to many adverse health outcomes including type 2 diabetes, obesity, dental carries and heart disease (Malik, Schulze, & Hu, 2006; Vartanian, Schwartz, & Brownell, 2007; Schulze et al., 2004; Ismail, Sohn, Lim, & Willem, 2009; Fung et al., 2009); however, few studies have explored factors that influence SSB consumption. In addition, no theory-based interventions have been implemented targeting this public health problem.

Objective: The primary objective of this study was to apply the Theory of Planned Behavior (TPB) (Ajzen, 1991) to investigate culturally specific attitudes, subjective norms and behavioral capabilities related to SSB, water, and artificially sweetened drink consumption among adults residing in rural Southwest Virginia. In addition, programmatic issues related to implementation of SSB interventions, including small group sessions and interactive voice response (IVR) technology was explored.

Methods: A total of 8 focus groups were completed with 54 participants. Each focus group took place with residents from one of the 11 identified rural Southwest Virginia counties. Four focus groups included individuals on city water and four contained residents on well water to investigate any discrepancies in attitudes, norms and perceived behavioral control related to the intake of various drinks. Participants needed to be at least 18 years of age, English speaking, and consume >1 cup of SSB per day. A semi-structured script guided by the TPB constructs was used to facilitate the focus group discussions. All focus groups were transcribed verbatim. Two researchers independently reviewed the transcripts and met to identify major themes and develop a coding system. Three researchers independently coded meaning units (MU) to the major themes and subsequently met to review codes and reconcile disagreements.

Results: The most notable themes that emerged included taste (n= 161 MU), availability/convenience (n= 95 MU), cost (n= 28 MU), and habit/addiction (n= 57 MU). Participants also continuously emphasized the importance of their doctor's advice and health concerns on their beverage choices. The majority of the participants (n=27 MU) indicated they would be willing to participate in a program with three small group sessions and phone calls, yet when asked specifically about receiving multiple interactive voice technology telephone messages, most participants said that they would not be receptive to an automated message (n=21 MU).

Conclusions: Collectively, these findings provide unique cultural insight to better understand the salient beliefs associated with beverage behaviors and helps inform intervention development and delivery in the targeted vulnerable region of Southwest Virginia.