TYPE Original Research

PUBLISHED 29 September 2022

DOI 10.3389/fpubh.2022.943295

Perceptions of sugar-sweetened
OPEN ACCESS beverages among adolescents in
North Carolina
EDITED BY
Lisa Bailey-Davis,
Geisinger Health System, United States

REVIEWED BY
Neha Rathi, Lindsey Haynes-Maslow1*, Sarah Ray2 and Kristen Giombi3
Banaras Hindu University, India
Jessica Goehringer, 1
Department of Agricultural and Human Sciences, North Carolina State University, Raleigh, NC,
Geisinger Health System, United States United States, 2 Center for Communication Science, RTI International, Atlanta, GA, United States,
3
*CORRESPONDENCE
Health Economics Program, RTI International, Research Triangle Park, NC, United States
Lindsey Haynes-Maslow
[email protected]

SPECIALTY SECTION Introduction: Sugar-sweetened beverage (SSB) consumption among

This article was submitted to adolescents contributes to diet-related chronic disease including obesity, type
Public Health and Nutrition,
a section of the journal
2 diabetes, and poor oral health.
Frontiers in Public Health Objective: To better understand adolescents’ perceptions, attitudes, and
RECEIVED 13 May 2022 consumption behaviors around SSBs by conducting virtual workshop
ACCEPTED 05 September 2022
discussions with adolescents in NC.
PUBLISHED 29 September 2022

CITATION Materials and methods: Adolescents ages 11–17 in communities with

Haynes-Maslow L, Ray S and Giombi K a high proportion of Supplemental Nutrition Assistance Program (SNAP)
(2022) Perceptions of
sugar-sweetened beverages among
eligible households were selected to participate in a series of virtual group
adolescents in North Carolina. workshops during summer 2021. A semi-structured discussion guide was
Front. Public Health 10:943295. used by a workshop facilitator. Workshop discussions centered around general
doi: 10.3389/fpubh.2022.943295
health perceptions, SSB perceptions, and consumption behaviors. A thematic
COPYRIGHT
© 2022 Haynes-Maslow, Ray and
analysis was used to summarize knowledge, beliefs, attitudes, and perceptions
Giombi. This is an open-access article around SSBs.
distributed under the terms of the
Creative Commons Attribution License Results: Approximately 36 adolescents participated across four group
(CC BY). The use, distribution or workshops. Parents and caregivers influenced adolescents most when it came
reproduction in other forums is
to making beverage choices. Positive SSB perceptions included liking the taste
permitted, provided the original
author(s) and the copyright owner(s) and the association with special times and social events. Negative opinions
are credited and that the original focused on associated health risks (diet-related chronic disease and poor oral
publication in this journal is cited, in
accordance with accepted academic
health). Some adolescents acknowledged SSBs were not healthy but suggested
practice. No use, distribution or they could be consumed occasionally. Very few participants mentioned any
reproduction is permitted which does benefits from SSBs; those that mentioned benefits stated they provided energy,
not comply with these terms.
replaced electrolytes, and tasted good.
Conclusion: Findings provide several key insights that can contribute to
the development of messages aimed at curbing SSB consumption among
adolescents. For example, messages that focus on catching adolescents’
attention and sharing short- and long-term health consequences of high SSB
consumption resonated with adolescents, but because occasional SSB intake
was not seen as consequential, messages that suggest abstinence from SSBs
may not be helpful in reducing consumption.

KEYWORDS

adolescents, sugar-sweetened beverage, marketing, low-income, perceptions

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Introduction old) adolescents (17). The survey also found that there was a
strong association between the perceived value of SSBs and
Approximately one in seven adolescents ages 10–17 in higher levels of consumption (17).
the United States suffers from obesity. In North Carolina, the The purpose of this study was to better understand
childhood obesity rate is higher than the national average, adolescents’ attitudes and behaviors related to access,
16.1% compared to 15.5%, respectively (1). Not only do availability, and consumption of SSBs. A series of virtual
these adolescents have health risks and complications during workshops with low-income adolescents in North Carolina
that developmental period, but they also have a higher were conducted during the summer of 2021. In addition to
likelihood of being obese adults and developing diet-related general attitudes and behaviors related to SSBs, the workshops
chronic disease such as type 2 diabetes, hypertension, explored trusted sources of information about health and other
and cardiovascular disease (2–6). They are also more topics, and opinions on specific types of SSB products (to gauge
likely to experience anxiety, depression, and low self- understanding, as well as motivators and barriers). This paper
esteem, compounding the physical effects of diet-related focuses specifically on the youth perceptions of SSBs.
disease (7, 8).
Sugar-sweetened beverage (SSB) intake among children
is a leading contributor to obesity (9, 10) and strongly Materials and methods
discouraged by leading child health organizations, including the
Robert Wood Johnson Foundation’s Healthy Eating Research The study authors conducted a series of virtual group
Program (11). SSBs are the primary source of added sugar for workshops to explore adolescents’ perceptions, attitudes, and
adolescents and are the top contributor of empty calories in behaviors around SSBs and SSB messaging. These workshops
their diets (12). The National Health and Nutrition Examination were designed as modifications to traditional focus groups by
Survey (NHANES) data analyses from 2003-2004 to 2013- adjusting the location (virtual), and gathering of participants
2014 show that SSB consumption has declined in children, (i.e., some groups took place with each participant in a different
but these declines have been predominantly for higher-income, location and on an individual screen; some participants were
white children (13). SSB consumption among children is still able to gather into a single room) to accommodate restricted
disproportionate by racial and socioeconomic status with SSB protocols due to the COVID-19 pandemic.
intake higher among non-Hispanic blacks and low-income This type of group discussion is useful to obtain detailed
children (13, 14). information about personal and group perceptions because
Poor dietary habits continue to be a public health problem they can provide a broad range of information and offer the
in the United States, and parents and caregivers are the primary opportunity to seek clarification on potentially complex or
gatekeepers to adolescents’ beverage consumption (15). Low- nuanced questions (18). RTI International’s Institutional Review
income adolescents who are most at risk for poor diets are often Board (IRB) designated the research and materials as “Not
eligible for the Supplemental Nutrition Assistance Program Human Subjects Research” and therefore exempt from review.
Education (SNAP-Ed), the nutrition education component of
the Supplemental Nutrition Assistance Program (SNAP) (16).
The goal of SNAP-Ed is to improve the likelihood that persons
Data collection
eligible for the Supplemental Nutrition Assistance Program
The research team’s plans for the four workshop discussions
(SNAP) will make healthy food and lifestyle choices that prevent
were informed by research suggesting the appropriate number
obesity (16).
to suggest theme saturation in similar traditional focus groups
North Carolina State University’s (NCSU) SNAP-Ed
(specifically, two to three moderated groups have been found
program, Steps to Health, works to improve the diet and health
to include at least 80% of themes; three to six groups will
of low-income North Carolinians (www.ncstepstohealth.org).
include 90% of themes) (19). NCSU worked with Family and
Steps to Health sought to understand how North Carolina
Consumer Science (FCS) cooperative extension agents who
adolescents perceive and consume SSBs, and to gather data
deliver nutrition education for Steps to Health to recruit
that could be used to develop a social marketing campaign
that would appeal to adolescents and reduce SSB consumption. participants and assemble the virtual workshops. Middle and
In 2020, an online survey of SNAP-eligible North Carolina high school adolescents ages 11–17 in communities with a
adolescents ages 11–17 found that more than three-quarters high proportion of SNAP eligible households were selected to
of respondents (87%) reported drinking at least one SSB per participate. To ensure geographic diversity across the state, FCS
day. Sodas (40%) and fruit flavored drinks (36%) were the most agents recruited participants located in the three main regions of
commonly consumed SSBs, and consumption patterns did not the state (western, central, and eastern North Carolina). Eligible
vary between younger (11–14 years old) and older (15–17 years adolescents were those who reported they were: (1) between

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the ages of 11 and 17; (2) lived in a SNAP-eligible household; before using it during the formal workshop discussions. This
(3) spoke English; and (4) had access (either individually or paper focuses on questions in the guide that centered around:
in a group) to a computer with the Zoom web conferencing (1) general health perceptions, and (2) SSB perceptions and
program (20). behaviors. These sections are listed in further detail below:
Before participating in the workshop discussion, parents
gave their permission to have their child participate. Prior to
the adolescents beginning the workshop, they provided their General healthy behaviors—perceptions and
assent. Each workshop was conducted remotely on Zoom and behaviors
was audio (but not video) recorded. To ensure privacy, a group- Participants were asked a series of questions to orient them
specific Zoom link was sent to participants or the FCS agent to the general topic of healthy behaviors. These questions also
and a “waiting room” was enabled so that only those who the helped ground the workshop discussion by asking what comes
moderator admitted into the meeting were allowed to enter and to mind when adolescents hear certain key phrases, including
participate in the workshop. To protect confidentiality, only first “healthy eating” or a “healthy diet.” Participants were then asked
names were used in the discussion. Workshop discussions lasted about how important “healthy eating” was (including avoiding
approximately 60 min and were led by a trained moderator unhealthy foods), and about who influences them when they
familiar with the research topic and a notetaker who observed make choices about what to eat or drink.
and recorded detailed comments and non-verbal reactions.
To facilitate recruitment and maximize participation while
considering limitations around in-person data collection and Sugar sweetened beverages—perceptions and
considering COVID-19 protocols, workshops were conducted behaviors
using a flexible approach. This included relying on guidance Participants were shown a series of six sets of images that
from the FCS agent that recruited and assembled the groups, and depicted different categories, or types, of SSBs. Each stimuli set
the needs of adolescent participants. As a result, the workshops featured a group of images representing individual products
were conducted under two types of configurations. The first (images were generically labeled to avoid brand associations
involved adolescents gathering in a single location watching the outside of the product type). Stimuli sets included: (1) soda,
workshop facilitator and viewing stimuli on a single screen. (2) water, (3) energy drinks, (4) 100% fruit juice and milk,
For this configuration, the room of adolescents were not on (5) sports drinks, and (6) fruit flavored beverages, sweetened
video (the moderator could not see the youth). The FCS agent teas, and lemonade (see Figure 1). After seeing each set of
present with the adolescent participants in the room aided images, participants were asked to describe their first reactions,
in facilitating the discussion. The second configuration had thoughts, feelings, and opinions for each of the image sets
adolescent participants join via their own device (e.g., laptop verbally or via the “chat” feature in Zoom. Participants were
or phone) with one participant per device. For this setup, then asked to describe their overall reaction to the phrases “sugar
adolescent participants joined from home or another location. sweetened beverages” and “sugary drinks” and the products
Due to the funding source, adolescents were not compensated that the phrases represented. Adolescent participants provided
for participating in the group discussions. details regarding situations when they chose to drink SSBs, and
about parental and peer influences in those decisions. They also
described health risks associated with drinking SSBs.

Workshop discussion guide development

and procedures Analysis

A semi-structured discussion guide was developed Workshop discussions were audio recorded and transcribed.
containing questions related to attitudes, behaviors, norms, and Detailed notes (participant comments and non-verbal reactions,
consumption of SSBs, as well as items related to information including nodding or raising hands to indicate agreement with
sources and perceptions of SSB advertising (Appendix A). a point), audio transcriptions, and the Zoom chat transcript
Questions were modified and expanded based on results from a were organized into a meta-matrix by moderator question.
2020 online survey of SNAP-eligible North Carolina adolescents The study authors employed an inductive approach to develop
ages 11–17. The phrasing of questions had already tested a coding scheme that allowed for thematically summarizing
with youth regarding the perceived value of SSBs and general participants’ responses. Coding used the comprehensive data
attitudes toward them (17). This discussion guide was pilot (notes, audio transcripts, chat records) in the matrix and were
tested with one group of adolescents to ensure that questions organized around knowledge, beliefs, attitudes, and perceptions
could be easily understood and interpreted by potential around SSBs and advertising perceptions and preferences and
participants. No changes to the discussion guide were made allowed for focusing on the interpretation and meaning of the

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themes (21–23). The moderators (SR and KG) independently

reviewed the transcripts and discussed participants’ responses to
questions. The two moderators (SR and KG) compared themes
and reconciled any discrepancies through discussions. After
discussing the participant responses, they (SR and KG) identified
themes based on similar and related topics (23). Key findings
are summarized below, and illustrative quotes are included to
highlight participant comments to give context.

Results
A total of four virtual workshop discussions were conducted
with adolescents during the summer of 2021 (see Table 1). Two
of the workshops were held in a classroom with adolescent
participants viewing a large screen showing the facilitator. The
other two used the format of adolescents participating from
home on their individual device via Zoom. Approximately 36
adolescents ages 11–17 participated across the four discussions.
Due to the nature of the virtual setup, during one of the
workshops, facilitators were unable to see all participants
who gathered in a single location through the video. The
onsite FCS agent who helped facilitate reported the number of
participants; however, some left early and therefore the number
of participants who participated in that discussion may not be
exact. Virtual workshops were held in Yadkin, Richmond, Wake,
and Northampton counties in North Carolina.

Perceptions and behaviors around

healthy eating or a healthy diet

When participants were asked What do you think of when

you think about “healthy eating” or a “healthy diet” there was a
general consensus across the adolescents that healthy eating or a
healthy diet included consuming fruit, vegetables, grains, dairy,
and protein. One participant mentioned healthy (lean) meat and
another mentioned following MyPlate guidance based off the
2020 Dietary Guidelines for Americans (24). One participant
commented, “From a high school point of view, [healthy eating]
is a big thing. . . like body image, us being healthy—a lot of girls
are focusing on it.” [Female, Group 1]. Only three participants
independently mentioned beverages when asked about a healthy
diet: one participant noted that a healthy diet includes drinking
more water while the two other participants mentioned avoiding
soda. Adolescent participants also mentioned avoiding pizza,
candy, fast food, processed/pre-made food, chips, cereal, and ice-
cream.
In response to the question, “Who or what influences you
FIGURE 1
when it comes to making choices about what you eat or drink?”
Sample sugar sweetened beverage stimuli. most adolescent participants stated that their parents/caregivers
influenced them: “My parents influence me the most. Friends

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TABLE 1 Workshop participants, locations, and dates.

Group Number Number of Participants Location Group Type Date

1 10 Yadkin county Home with individual devices 9/07/2021

2 15* Richmond county Classroom with large screen 9/08/2021
3 3 Wake county Classroom with large screen 9/14/2021
4 8 Northampton county Home with individual devices 9/14/2021

* Because moderators were not able to see participants who were gathered in a single location, the number of participants who completed the Group 2 discussion may not be exact.

don’t have a big influence.” [Male, Group 4]. A couple of or energized, or feeling that they fill you up so you do not each
participants mentioned friends as influential: “[My friends] as much. One participant commented, “[Soda] makes me think
influence me because I know a lot of my drinks drink a lot of of being hyper and caffeinated because my parents always tell me
water, so I just started drinking more water sometimes.” [Male, if I drink too much soda that I will get hyper.” [Male, Group
Group 4]. One participant noted that she sometimes ate food 1]. In addition, several participants mentioned health risks
or beverages at her friends’ houses that she would not usually associated with drinking soda (e.g., causing pimples, diabetes,
consume at home: “Some things I eat at my friends’ houses are being unhealthy): “[Soda] tastes good, but it’s not always good for
different than what I eat at home.” [Female, Group 1]. you to drink all the time.” [Female, Group 4].
When asked whether they had a positive, negative, or neutral
opinion of sodas, among those participants who responded
Perceptions and behaviors around sugar to this question, 10 participants had only positive opinions
of sodas, 10 participants had only negative opinions, and 12
sweetened beverages
participants had both positive and negative opinions. Positive
opinions were centered on liking the taste and thinking
The workshop facilitator shared a series of six sets of images
of special times when they drink them. Negative opinions
that depicted different categories, or types, of SSBs. Stimuli sets
were focused on associated health risks of consuming too
included: (1) soda, (2) water, (3) energy drinks, (4) 100% fruit
much sugar. Some participants acknowledged that sodas were
juice and milk, (5) sports drinks, and (6) fruit flavored beverages,
not good for them, but suggested they were okay to drink
sweetened teas, and lemonade (see Figure 1). After seeing each
in moderation.
set of images, participants were asked how they would “label”
the type of beverage using a word or phrase (i.e., identify the
category to which they belonged). There was general consensus
across all workshops around the categorization of each of the Water image sets
SSB image sets, with participants recognizing the connection After showing adolescents the water image set (which
between the individual products in each set and offering similar included water, mineral water, and water with fresh fruit),
language to label them. This was followed up by the moderator participants associated the images with words and phrases
asking the participants to consider their experiences with these including “cold, ice, refreshing, crisp, summer refresher, no
beverages (positive or negative opinions), situations when they sugar, healthy, beneficial”.
might drink them, and any other opinions regarding the SSB When adolescent participants were asked to share their
type. We describe adolescent participant response to each of the initial thoughts about the water image set, they said that
six SSB categories below. the images made them think about health. More specifically
participants discussed how water helps keep them alive and
hydrated, is beneficial for their skin (relating water consumption
Soda image sets to acne prevention), and is necessary for the human to function:
When adolescents were shown the soda image set (which One participant made this connection by noting a perception
included soft drinks and other sugar-sweetened carbonated that the body already consists mostly of water: “You can drink
drinks), participants associated the images with words and [water] all the time. . . it doesn’t hurt your body. . . your body
phrases including “fizzy, bubbly, artificial flavors, sugar, very is mostly water anyway so just adding water helps it.” [Male,
sweet, sticky, cold, tasty.” Adolescents shared that the soda image Group 4]. Participants also mentioned that the water image
made them think about situations when they would drink them, set made them think about “taste”, such as “tasty with ice” or
such as church potlucks and cook-outs. Other participants said having no sugar in it and not having any taste. When asked
that the images prompted thoughts related to the immediate about situations when they would drink water, most adolescent
effects of drinking them, including feeling hyper (due to caffeine) participants mentioned water was best after playing or exercising

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outside when the weather is hot. Additionally, some adolescents these “breakfast drinks” made them think about the taste
pointed out that they could drink water all the time, as and health related topics. When discussing taste, participants
opposed to SSBs. were specific: one participant commented that orange juice
Among participants who responded when asked about was too sour, and another said they didn’t like the pulp in
their positive or negative opinions of water, nearly all 100% orange juice. Regarding health-related topics, several
had positive opinions of water and only two adolescents participants mentioned that some people are lactose intolerant,
expressed some negative opinions. Positive reactions were while others stated that milk is good for their bones: “[Fruit
focused on the health benefits of drinking water, water’s juice and milk] are healthy drinks and milk is good for the
refreshing qualities and its taste. The two participants who bones.” [Female, Group 4]. When asked about when they would
included negative comments suggested that some water consume “breakfast drinks” participants said that they would
sources (such as free tap water) may not be clean or safe have milk with cereal and drink the other juices mostly in
to drink. the morning. As one male participant commented, “I think
[orange juice] is really good breakfast thing; you wake up and get
some OJ. I eat a lot of cereal, so I like milk.” [Male, Group 3].
Energy drinks image sets Several participants simply noted that 100% fruit juice and milk
After being presented with the energy drink image set, were “healthy”.
participants associated the images with words and phrases Among those who responded when asked about positive
including, “unhealthy, chemicals, espresso shots, sugary, bad and negative opinions of the image set, seven adolescents had
for you, [brand name] energy drink, hyper, and energetic.” Of only positive opinions, and two had both positive and negative
these associations, the most frequent response among adolescent opinions. Positive reactions included the health benefits and
participants was “hyper.” Some participants said that the images taste, while the negative reactions were centered on disliking the
of energy drinks made them think about their wide availability. taste (mentioned above).
As one participant said, “Everyone at school drinks [energy
drinks] because they are in the vending machines.” [Female,
Group 1]). Additionally, a few participants mentioned examples Sports drinks image sets
of advertising that suggests the type of person who drinks them After showing adolescents the sports drink image set
(specifically race car drivers). Others discussed the negative (which included sports drinks, bottles that mimicked a brand-
health effects from consuming too much of them: “I heard one name product, electrolyte drinks, and other energizing drinks),
time that someone drank too many energy drinks and they died participants said that words and phrases associated with those
from that.” [Female, Group 4]. beverages included, “thirst quenching, healthy, sports recovery,
Among participants who responded when asked about their drinks for athletes or during physical activity, sweat, salt,
positive or negative opinions of energy drinks, no participants and summer party drink.” When asked what they thought
had only positive opinions of energy drinks, nine participants about sports drinks after seeing the image set, adolescent
had only negative opinions, and four participants had both participants said they thought about specific sports or activities
positive and negative opinions. Negative attitudes focused on the when they drink them (such as soccer, softball, basketball,
associated health risks, particularly related to the impact of high volleyball, and football; as well “field days” at school).
levels of caffeine in the body. Those who had both positive and Some participants remembered drinking a brand name sports
negative reactions acknowledged that they believed they were drink when they were sick or during the summer. Several
unhealthy, but that they liked the “boost” that the caffeine gave participants noted that it could be used to replenish electrolytes
them, as it helped them get energy for staying engaged in school and salt in the body. Lastly, specific sport drink flavors
or other afterschool activities. As one participant stated, “I know were mentioned.
[energy drinks] are bad for you but sometimes I like to drink them Among adolescents who responded to questions about
when I’m tired.” [Female, Group 1]. negative and positive opinions about sports drinks, four
adolescents had only positive opinions and three adolescents had
positive and negative opinions. Some of those who had only
100% fruit juice and milk image sets positive reactions cited the potential health benefits: “[Sports
When adolescents were presented with the 100% fruit drinks] helps replenish electrolytes and salt.” [Female, Group
juice and milk image set (which included orange juice, apple 1]. Other participants suggested that they felt the drinks were
juice, and milk), adolescent participants said that words and refreshing. Those who had both positive and negative reactions
phrases associated with this image set (participants called liked the hydration benefits for some physical activities [as one
them “breakfast drinks”) included: “breakfast, fruit, healthy, participant noted: “We have (sports drinks) during/after sports so
and strong.” Adolescent participants said that the image of you can get hydrated after your game because you might not have

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had as much to drink during the game.” (Female Group 1)], but relationship between the two (27). However, since adolescents
did not like the tasted or also acknowledged that they contained in this study were recruited from SNAP-Ed classes, this may
added sugar. have increased their health literacy as the curriculum focuses on
promoting the consumption of beverages low in added sugar,
and the negative health impacts of consuming large amounts
Fruit drinks, teas, and lemonade image sets of SSBs.
When adolescents were presented the fruit drinks image Additionally, adolescent responses revealed that they viewed
set (which included fruit drinks, sweetened tea, and lemonade), their parents/caregivers as role models in terms of what
adolescents said they associated fruit drinks with words and beverages to drink. Other research supports that children and
phrases such as, “sweet, sugary, artificial, summer camp, adolescents look to their parents/caregivers for guidance and
unhealthy, drinks for kids, tasty, hyper, and loaded with often mirror or mimic their health behaviors (28). This is
sugar.” Adolescent participants said that the images made consistent with a 2012 study that showed parent support for
them think about the about taste, situations where they might healthy beverage consumption was associated with reduced
consume them, health risks, and specific ingredients or brand SSB consumption among 541 children between the ages of
names of fruit juices. In terms of taste, some participants felt 5 and 8 years old (28). Additionally, since parents/caregivers
the fruit drinks tasted “artificial” but were still “tasty” or a are more likely to be responsible for stocking foods and
desirable beverage option. Places or situations where adolescent beverages at home, if they purchase SSBs, children are more
drink fruit drinks included celebrations (especially with young likely to consume them (29). Therefore, raising parents’
children) or cookouts. One participant mentioned a perceived and caregivers’ awareness of the impacts that their own
health risk that fruit drinks can negatively impact kidney health behaviors have on their children continues to be a
functioning. Finally, adolescent participants generally noted promising public health strategy to curb SSB consumption
mentioned that sugar was a main ingredient in fruit drinks and among adolescents.
other participants mentioned specific brands neither negatively Strategies for raising awareness among parents and
or positively. caregivers can take many forms, including through social
Among adolescent participants who responded to the marketing—the use of consumer marketing techniques (e.g.,
question about positive and negative opinions about fruit drinks, audience segmentation, advertising campaigns) to promote
a few had both positive and negative opinions. Those who voluntary behavior change to achieve positive population-
had negative opinions cited the health risks associated with level effects (30). Findings from this study will be useful in
consuming too much sugar: “They are not very healthy and informing the development of a social marketing campaign
loaded with lots of sugar.” [Female, Group 4]. Those with positive aimed at reducing SSB consumption among adolescents.
reactions noted, “[Fruit drinks] are nostalgic but unhealthy” For example, messages that focus on catching adolescents’
[Female, Group 1] when talking about them in relation to past attention and sharing both short- and long-term health
celebrations or other social gatherings. consequences of high SSB consumption may resonate with
adolescents. However, because occasional SSB intake was
not seen as consequential among workshop participants (e.g.,
Conclusions consuming soda or sweet tea during special occasions), messages
that suggest abstinence from SSBs may not be helpful in
This study provides several key insights regarding reducing consumption.
adolescents’ perceptions, attitudes, and consumption behaviors Previous research on social marketing campaigns and
around SSBs in NC. First, research on the correlation between interventions implemented in the United States and Europe
low-income adolescents and health literacy is mixed. This have targeted adolescent SSB consumption with positive effects
study shows that low-income adolescents participating in (31–33). For example, the evaluation of a campaign in the
our workshop discussions had fairly high health literacy Netherlands that promoted the consumption of water over
regarding the harms of consuming SSBs. For the purposes SSBs directly to adolescents found that the intervention was
of this discussion, health literacy “is the extent to which related to an overall reduction in SSB consumption (31).
individuals attain, manage, and understand health information Communication campaigns targeting the influence of parents
and apply that information in health decision-making” (25). have had similar results (32, 33). For example, exposure to
In a 2018 systematic review of adolescent health literacy and a city-wide media campaign in Philadelphia that targeted
health behaviors (26), among five studies that examined the parents with a child between the ages of 3–16 years to
relationship between income and health literacy, four studies reduce SSB consumption was significantly associated with
found that having lower incomes was associated with lower the parents’ intent to substitute non–sugary drinks for SSBs
health literacy, while only one found no statistically significant for their children (33). However, there are still gaps in our

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understanding of how adolescents understand and receive SSB- drinks, (4) 100% fruit juice and milk, (5) sports drinks, and
specific social marketing campaign messages and materials, (6) fruit flavored beverages, sweetened teas, and lemonade.
particularly when media messages are intended to reach The information we have learned about adolescent perceptions
them directly. of these drinks could help contribute to the development of
Like all research, this study had several limitations. Due messages aimed at reducing SSB consumption. Future research
to protocols for research during the COVID-19 pandemic, the should continue to examine adolescent perceptions, attitudes,
workshops were virtual, which required a hybrid set-up of all and consumption behaviors around SSBs. Additionally, raising
adolescents watching one large screen or adolescents being awareness among parents/caregivers regarding the level of
on their individual screens. Some adolescents did not have influence on their children is an important factor to consider.
their cameras enabled, so it was difficult to gauge some non- SSB intake among adolescents is a leading contributor to obesity
verbal responses or cues to the moderator’s questions. Because and other diet-related chronic diseases. Researchers and public
of this adaptation, the workshops were not traditional focus health practitioners should continue to examine strategies and
groups; however, the consistent application of a single discussion interventions aimed at decreasing SSB consumption.
guide, stimuli presentation, and coding scheme allowed us to
summarize findings across all group discussions. The virtual
environment may have also had some advantages over in person Data availability statement
group research, including facilitating more participant diversity
by reducing some barriers (e.g., transportation, time) and The raw data supporting the conclusions of this article will
encouraging contributions to the discussion, and has been used be made available by the authors, without undue reservation.
successfully to collect information with variety of audiences,
including adolescents (34).
Ethics statement
Additionally, due to the small sample size and restrictive
geographic location (adolescents had to live in NC), results
The studies involving human participants were reviewed
may not be generalizable to adolescent populations in
and approved by RTI International’s Institutional Review
other states. Lastly, since adolescents were already enrolled
Board. Written informed consent to participate in this
in SNAP-Education classes, they may have had higher
study was provided by the participants’ legal guardian/next
health literacy regarding the harms of SSBs, which could
of kin.
have influenced their responses in the discussion. In
addition, as a qualitative study with a self-selected group
of participants, there are limitations in the generalizability Author contributions
of findings.
Each group included a facilitator who led the discussion and LH-M, SR, and KG: conceptualization and methodology,
a dedicated notetaker, who captured detailed notes including writing—review and editing, and writing—original draft
verbal comments and other observations about the group. preparation. SR and KG: analysis and investigation. LH-M:
Group discussions were also audio recorded and transcribed. funding acquisition. All authors have read and agreed to the
The combination of these data allowed for a comprehensive published version of the manuscript.
review of participants’ responses and reactions. The use
of thematic analysis based off the combination of detailed
notes that captured non-verbal responses (e.g., raised hands, Funding
nodding, and other indicators of agreement where possible),
audio transcriptions and chat transcripts from each of the The study was funded by the United States Department
workshops is a strength in that it focuses on the interpretation of Agriculture’s Supplemental Nutrition Assistance Program-
and meaning of themes (22). Lastly, both of the workshop Education (SNAP-Ed) (Grant #00041221).
facilitators independently reviewed the data and coded
responses. Discrepancies around interpretation of themes were Acknowledgments
discussed until agreement was reached. During this process, they
identified themes based on similar and related topics to reach The authors would like to thank North Carolina State
a consensus. University’s Family and Consumer Science Agents that
This study reveals several important themes, including that helped recruit youth and organize the workshop discussions.
adolescents have both positive and negative opinions regarding Additionally, we thank our study participants for their time and
six different types of beverages: (1) soda, (2) water, (3) energy sharing their thoughts with the workshop facilitators.

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Haynes-Maslow et al. 10.3389/fpubh.2022.943295

Conflict of interest organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
The authors declare that the research was conducted in the claim that may be made by its manufacturer, is not guaranteed
absence of any commercial or financial relationships that could or endorsed by the publisher.
be construed as a potential conflict of interest.

Supplementary material
Publisher’s note
The Supplementary Material for this article can be found
All claims expressed in this article are solely those of the online at: https://www.frontiersin.org/articles/10.3389/fpubh.
authors and do not necessarily represent those of their affiliated 2022.943295/full#supplementary-material

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