UBC Undergraduate Research

HBI Hydration Stations Chung, Queena; Kwong, Jamie Lee; Marchand, Shara; Tseng, John; Wong, Joy 2018-04-09

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UBC Social Ecological Economic Development Studies (SEEDS) Sustainability Program  Student Research Report         HBI Hydration Stations Queena Chung, Jamie Lee Kwong, Shara Marchand, John Tseng, Joy Wong University of British Columbia FNH 473 Themes: Health, Community, Wellbeing April 9, 2018        Disclaimer: “UBC SEEDS Sustainability Program provides students with the opportunity to share the findings of their studies, as well as their opinions, conclusions and recommendations with the UBC community. The reader should bear in mind that this is a student research project/report and is not an official document of UBC. Furthermore, readers should bear in mind that these reports may not reflect the current status of activities at UBC. We urge you to contact the research persons mentioned in a report or the SEEDS Sustainability Program representative about the current status of the subject matter of a project/report”. 1 Table of Contents EXECUTIVE SUMMARY ....................................................................................................................................... 2 INTRODUCTION ..................................................................................................................................................... 3 SITUATIONAL ASSESSMENT AND PLANNING FRAMEWORK ............................................................. 4 i. Problems ................................................................................................................................................................ .......... 4 ii. Behaviours ..................................................................................................................................................................... 5 iii. Mediating Factors ...................................................................................................................................................... 6 iv. Health Behaviour Theories ..................................................................................................................................... 8 PROJECT GOALS AND OBJECTIVES ..............................................................................................................10 OUTPUTS ................................................................................................................................................................11 EVALUATION PLAN.............................................................................................................................................15 CONCLUSION ........................................................................................................................................................17 AUTHORS CONTRIBUTIONS ...........................................................................................................................18 REFERENCES ........................................................................................................................................................20 APPENDICES .........................................................................................................................................................23                      2 Executive Summary  Obesity is a common and current health issue in the world today, as it poses multiple risks to a person’s physical and mental health. The high intake of sugar sweetened beverages (SSBs) has contributed to the increasing rate of obesity both in Canada and internationally. Factors such as taste, cost, and food environments are among the many considerations that influence beverage choice. In an effort to address this problem, UBC Wellbeing has launched a hydration station pilot project in collaboration with FNH 473 students, which is being implemented as part of the Healthy Beverage Initiative.  The Hydration Station Pilot Project aimed to improve the diet quality and lifestyle habits of the UBC community by encouraging tap water consumption over SSBs. Using the Community Organization Theory and Health Belief Model for guidance, this initiative involved the establishment and evaluation of two tap water stations for UBC staff and students to use as an alternative to SSBs. We also developed and distributed two post-intervention surveys as another output and as a means of evaluating the project. We used these online questionnaires to qualitatively and quantitatively assess behavioural changes and level of satisfaction resulting from the hydration stations. It was found that 84% of users increased their water consumption and 50% of users reported a decrease in their SSB intake, indicating that the project had a positive impact on the health of UBC staff and students who used the stations. In addition, the hydration stations were found to be feasible and easy to maintain by caretakers and suggested an interest in expanding the project to implement more stations around campus.    3 Introduction The University of British Columbia (UBC) has been actively involved in creating a “nutritionally sound campus” through the creation of a framework to guide food and nutrition strategies (UBC Wellbeing, 2017). Our project is part of a Healthy Beverage Initiative (HBI) developed by the framework to promote the use of tap water and inform consumers on healthy beverage options. The target population of the HBI and our project are students and staff of UBC’s Vancouver campus. The high sugar content of sugar-sweetened beverages (SSBs) provides little satiety and excess calories, therefore it may contribute to weight gain (Malik et al., 2006). The increased likelihood of weight gain from SSBs increases the risk for further health complications such as diabetes, high blood pressure, and heart disease (Dietitians of Canada, 2017). The increasing prevalence of this issue calls for public health strategies to discourage consumption of SSBs to promote a healthy lifestyle. Our contribution is based on the community organization theory, which acknowledges common issues and priorities within UBC and identifies approaches to reach collective wellbeing in the community (USDHHS, 2005). In this case, the HBI has identified the need for healthier and more sustainable beverage options on campus. Additionally, our project uses the Health Belief Model to encourage community members to change their beliefs on the use of tap water and consequently change their actions on SSB consumption. With consideration of these theories, our project’s intervention of implementing hydration stations provides a possible strategy to support community members in actively participating in both personal and community health.    4 The Problem Obesity is defined by the World Health Organization as having “an abnormal or excess fat accumulation that presents a risk to health” (WHO, 2018). Numerous studies have been conducted around the world on the regional prevalence of excess fat accumulation. As a result of these studies, the common method to assess an individual’s nutritional status is through their Body Mass Index (BMI) (Shields et al., 2008). A person with a BMI higher than 30 is considered obese (WHO, 2018).  Over the recent years, reports have indicated that the rate of obesity in Canada has consistently risen (Shields and Tjepkema, 2006). In 1986, 13% of Canadian men and 16% of women were obese. By 2004, the percentage of both obese men and women had significantly risen to 23%. A similar significant increase has also been observed in the rest of the world (Tjepkema, 2006). A summary gathered by Statistics Canada (2014) indicated that 20.2% of Canadians aged 18 years or older reported a BMI which classified them as obese. The adverse health consequences that result from this excess weight status are well known. Obesity is a risk factor for type 2 diabetes, cardiovascular diseases, high blood pressure, osteoarthritis, and other conditions (Tjepkema, 2006). On top of the physiological detriments, Cheng et al. (2016) also reported that psychosocial and mental health issues are commonly seen in obese persons due to overall public stigma and discrimination. Contributing factors to the increased onset of obesity include an increase in fast food availability, growing portion sizes, and a sedentary lifestyle (Le Petit and Berthelot, 2006). Hu (2013) found that sugar-sweetened beverages (SSBs) have a large role to play 5 in excess energy intake and that reduction in SSB intake may reduce the prevalence of obesity and its related diseases. Behaviours According to a systematic review conducted by Malik et al. (2006), the consumption of SSBs is positively associated with weight gain and/or obesity. It is proposed that the low satiety of SSBs causes users to consume more food in their subsequent meals. Dietitians of Canada (2017) recommend that added sugars should be limited to 13 teaspoons or less per day. Consuming SSBs alone may contribute more sugar than this recommended amount (Dietitians of Canada, 2017). For example, a 355 mL can of pop contains 10 teaspoons of added sugar, 473 mL of specialty coffee contains 17 teaspoons of added sugar, and a 1000 mL slushie contains 24 teaspoons of added sugar (Dietitians of Canada, 2017). 78% of British Columbians were found to have at least one SSB a week, with their top choices being fruit juice, specialty coffee or tea, and regular soda, pop, or slushies (Rasali et al., 2014). Data from Brisbois et al. (2014) estimates that “added sugars average about 11%-13% of total energy intake” among Canadians. In terms of SSB intake among students, 65% of undergraduate students surveyed at the University of Arkansas indicated that they consume SSBs everyday (West et al., 2006). Researchers predicted that students had an average of 543 ± 671 kcal per day from SSBs alone (West et al., 2006). Another survey conducted in Bangladesh found that 54% of university students consumed SSBs more than two times a week (Bipasha et al., 2017). Both studies reported that male students were more likely to consume SSBs than female students (Bipasha et al., 2017; West et al., 2006). 6 Park et al. (2011) found that various unhealthy behaviours were also associated with high SSB consumption. The odds for drinking SSBs were higher for adults who smoked, were physically inactive, watched television for prolonged periods of time, or frequently visited fast-food restaurants (Park et al., 2011). Mediating Factors Factors on the individual level for behaviours around sugar-sweetened beverage consumption include income, convenience and personal preference. According to the Centre for Disease Control (2017), SSB consumption is higher amongst lower income adults and families. Additionally, SSB and fast-food purchases can be influenced by taste and cost-effectiveness (Bipasha, Raisa & Goon, 2017). Taste in particular, can serve as a barrier to reduce SSB consumption, as humans have a natural liking for sweet foods. Additional barriers include peer and family influences on beverage choice, which tie into the interpersonal level. Institutional factors that influence the consumption of SSBs among university students include the drink options provided in their school environment. In the survey conducted in Bangladesh, 95% of students reported that they would pick healthier drinks such as lemon water if given the choice in their food environment (Bipasha et al., 2017). Previously, the IWK Health Centre in Nova Scotia implemented hydration stations in their institution. As a result of the removal of SSBs from the facility, 66% of people felt that their water consumption had increased and 52% felt their juice/pop consumption had decreased since the implementation of the hydration stations (Connell and Macdonald, 2017). Therefore, policies, which can determine what drink options are available in vending machines, cafeterias, and so forth, also play a large role in an individual’s 7 decision to drink SSBs. As mentioned above, Dietitians of Canada have made recommendations in regards to SSB consumption, but it is evident that most people do not follow these guidelines. If policies could be implemented at the institutional and/or national level, there may be higher adherence to these recommendations. Many community-based approaches center around the ever-growing forms of media available to citizens (Falbe et al. 2016). In one study, messages emphasizing the health risks of SSBs were distributed through television, digital channels, and local organizations. 53% of survey respondents gained new beliefs about the risks associated with SSBs (Farley et. al 2017). Following this shift, SSB sales decreased 3.4% and soda sales dropped 4.1% during the same time frame, 15 weeks.             Public health policy is considered to have the highest level of impact, as it regulates the entire population. There are currently no known policies regarding the purchase and consumption of any amount of sugar sweetened beverages in Canada. In 2015, an excise tax was implemented in the community of Berkeley, California (Falbe et al. 2016). The excise tax was expected to play a prominent role in the purchasing patterns of consumers as they would see higher shelf prices before making a firm decision (Falbe et al. 2016; Dietitians of Canada 2016). The researchers in California found that, over a one-year period from when the excise tax was introduced, SSB consumption decreased 21% overall. A meta-analysis of SSB taxation indicated that higher SSB prices led to a reduction in SSB consumption. This reduction in consumption resulted in decreased BMI and ultimately, a low prevalence of obesity (Escobar et al. 2013). Limitations: 8          Our first limitation is a lack of data regarding current SSB consumption among UBC students. If time permitted, it would have been ideal to have conducted a pre-study survey to assess the current use of SSBs and the knowledge on their link to obesity. We also used information from universities around the world and based our project off of the hydration stations implemented at the IWK Health Centre. Therefore, another limitation would be the lack of a comparable project conducted specifically in a university setting. Health Behaviour Theories Community Organization Theory (Community level): The first theory that has contributed to our project planning is the Community Organization theory. As discussed in Theory at a Glance, this theory involves identifying common problems within a community, mobilizing resources and implementing strategies to reach collective goals (USDHHS, 2005). Problems are initially voiced by community members, to which health professionals respond by launching programs that help deal with issues of concern (USDHHS, 2005). We chose this model to use for overarching guidance as we were able to identify these criteria within our project. As advocates for health and wellness at UBC, our community partners identified the issue of SSB consumption on campus, thus initiating the launch of the hydration station pilot project. We hope that through these stations, we will provide students and staff on UBC campus with a physical resource to access healthy beverage options, as well as the knowledge to make healthy beverage choices on a day-to-day basis.   Health Belief Model (Intrapersonal level): 9 The Health Belief Model was also chosen to consider change in behaviour around SSBs at the individual level. The Health Belief Model aims to determine why people may or may not partake in a behaviour (USDHHS, 2005). It involves determining an individual’s perceived threat to a health problem, the benefits of avoiding the threat, and revealing what factors influence one’s decision to act (USDHHS, 2005). Therefore, this model fit well with the scope of this project, as it aims to discourage consumption of sugar-sweetened beverages and raise awareness about the development of chronic diseases such as obesity and diabetes. We considered the 6 main constructs of the Health Belief Model and will address certain constructs in our intervention. The 6 main constructs outlined in the Health Belief Model are as follows: 1. Perceived susceptibility: Do students and staff on UBC campus believe they are susceptible to developing obesity or diabetes later in life based on SSB consumption? 2. Perceived severity: Do students and staff on UBC campus understand the implications of obesity or diabetes on quality of life? 3. Perceived benefits: Do students and staff on UBC campus believe that choosing healthier beverage options can reduce their risk of obesity or diabetes later in life? 4.  Perceived barriers: Do students and staff on UBC campus believe that the costs of decreasing SSB consumption are outweighed by the benefits? 5.  Cues to action: Will the posters providing information on the benefits of reducing SSB consumption prompt UBC students and staff to consume more tap water? 6.  Self-efficacy: Following the hydration station interventions, will students and staff on UBC campus feel confident to make healthy beverage choices more often in the future? 10 Project Goals and Objectives Overall Goal: To improve the diet quality and lifestyle habits of the UBC community to minimize risk of chronic diseases.   Short-term Objectives (2 months to 1 year):   ● By Feb 26th, 2018 implement 2 hydration stations for UBC students and staff to use as an alternative to consuming sugar sweetened beverages.  ● By March 2018 increase by 2 the number of UBC staff members who feel confident and capable of maintaining the use of the hydration stations  ● By March 2018, the majority of UBC students and staff members who used the hydration station will show positive attitudes towards the use of the hydration stations Medium-term Objectives (1-5 years):        ● Increase by 2, the number of hydration stations on UBC campus that promote the use of tap water within the next 12 months.  ● Increase by 10% the percentage of UBC community members who are aware of the impact of SSBs on health  ● Increase by 10% the awareness of UBC community members about the benefits of drinking tap water on personal and environmental health  ● Increase by 2, the number of collaborations between organizations within UBC to support the healthy beverage initiative within 5 years Long-term Objectives (over 5 years):   ● UBC will continue to promote the use of tap water and reduction of sugar sweetened beverage intake through the implementation of more hydration stations and/or other similar initiatives. Note: An outline of our logic model can be found in Appendix A.  11 Outputs Hydration Stations Structure: Our main intervention is the piloting of 2 hydration stations around campus to assess the use and potential changes in beverage consumption habits. Based on the community organizational theory, identifying common issues and implementing possible strategies using resources within the community is effective in reaching collective goals (USDHHS, 2005). Similarly, UBC has identified a need for healthier and more sustainable beverage options on campus and our intervention aims to promote UBC’s collective goal of being a “nutritionally sound campus”. Having an appealing hydration station with fruit and herb infused water will provide an alternative to SSBs. We predicted that it would encourage the UBC community to drink more tap water; thus, reducing sugar intake and promoting hydration in our target population. The location of these stations were determined to be the UBC Recreation Center student office and the UBC War Memorial Gym office space. These locations were chosen based on the perspective of the stewards (staff members in-charge of maintenance of the station) and how easy it would be to refill the stations and popularity of the location. Thus, these locations were chosen because of their proximity to kitchen areas and high traffic of staff and students. Content: The hydration station comes with an infusion beverage dispenser (3- or 5-gallon), a cutting board and knife, tent cards indicating water flavours, an instruction and maintenance sheet, checklist sheet, and an infographic (Appendix B (i-v)). The infographic contained information such as a project summary, benefits of drinking water, 12 and reasons for reducing consumption of SSBs. This educational material was intended to inform participants of the constructs of the Health Belief Model and will serve as a “cue to action” by prompting UBC community members to consume more tap water in replacement of SSBs. Particularly, the infographic outlines the perceived benefits of drinking tap water over SSBs and contributes to the perceived severity of SSBs increasing risk for developing obesity, diabetes, and heart disease. The maintenance sheet is a user-friendly guide to maintaining the operation of the hydration station. It includes information on set-up, suggested water flavours, clean-up, and how to use the provided checklist. The checklist is a record of the usage and maintenance of the station. The facilities were instructed to record the number of times the beverage dispenser was refilled, the water flavour(s) used, and to provide other comments about the station. This information was used for data collection purposes in our evaluation to determine the popularity of the station.  Delivery: Our community partners, Melissa Baker and Heather Quigley, connected us with the facilities to inform them about the nature of our project and to ask for permission to implement a hydration station in their facility. Before the intervention began, our group members met with stakeholders of these facilities to go over set-up (i.e. using the checklist). The facilities were responsible for acquiring the ingredients for the hydration stations but were reimbursed by UBC Wellbeing. The duration of the intervention took place over a 3-week period.  During the intervention, our group members had a check-in meeting to observe the progress of our intervention. Post-intervention Surveys 13 Structure: We developed 2 questionnaires to be distributed at the end of our intervention. Survey A was for the staff and students who shared the space in which our hydration stations were placed. Survey B was for the caretakers who were in charge of the hydration stations and completing tasks such as cleaning and refilling the water. The purpose of our questionnaires was to determine the feasibility of implementing hydration stations in terms of maintenance, and to also collect data on student and staff support of the stations. We decided to do a survey as we wanted to reach a large group of people. It was a convenient and efficient way to receive their feedback. Content: Survey A consisted of questions that asked participants about their usage, any behavioural changes after implementation and their opinions on the hydration stations. For example, in order to address the perceived benefits and barriers using the Health Belief Model, we asked users to select what made them decide on the hydration station over another option, providing choices such as “convenience”, “cost-effective”, “taste”, and so on. We also wanted to measure the effect of the hydration station on the participants’ behaviour, so we included the question “Do you feel your water consumption has increased since the implementation of the hydration station?”. As previously mentioned, the hydration stations also came with an infographic highlighting the benefits of drinking water. We wanted to determine if the infographic was an effective “cue to action” and therefore, we asked users if the infographic increased their motivation to drink more tap water. Additional sample questions included in survey A can be found in Appendix C(i). 14 Survey B targeted staff members who were involved in maintaining the hydration stations, otherwise known as the “caretakers”. We wanted to collect general feedback about the station as well as obtain any recommendations and improvements for future implementation of hydration stations to make it easier and simpler to maintain.  Specifically, we were interested in how easy or difficult the caretakers felt it was to upkeep the hydration station and any challenges they faced. Again, specific questions included on survey B can be found in Appendix C(ii). Delivery: We developed our surveys through the UBC Qualtrics software and distributed our surveys online. Our community partner, Melissa Baker, emailed the questionnaires to Heather and Mike Tan—the lead person in charge of the hydration stations at the War Memorial Gym and UBC Rec Center—respectively. These two lead contacts then distributed the email to their staff and students using the spaces. Surveys were available to complete for approximately one week following the last day of the intervention. After data was collected we were able to analyze and summarize the results regarding the feasibility and the likeability of the hydration stations.     15 Evaluation Evaluation is an important component of project planning as it helps ensure goals are being met and that funds are being used effectively (Rideout, 2015). Evaluation methods administered for the Hydration Stations were used primarily to ensure the short-term goals were achieved, and to work towards goals in the long-term. Both formative and impact evaluation were used for our project. Formative evaluation is used to ensure that the intervention is being delivered as planned, as well as for improving ongoing activity (Hammond, 2018). During the intervention, we checked in with our partners to assess the implementation of the hydration stations. We ensured the equipment, cleaning procedures and intervention documentation instructions were clear and being followed. It also allowed our community partners to ask questions and provide feedback on what was going well, and/or how we could better support them. For each hydration station, we provided a checklist including a section to record the number of refills needed each day, and any comments about the popularity of the flavours or the station in general. This allowed us to assess the amount of work needed to upkeep each station as well as the popularity of the stations. Monitoring provided qualitative data during the intervention. It also ensured that the stations were being managed and implemented properly, as to increase the likelihood of achieving our objectives. Impact evaluation was used in order to assess achievement of our outcome objectives. This was done through the development and distribution of two surveys, which included questions evaluating popularity of the station with station users and the ease of upkeep with station caretakers. We used these surveys as an indicator of our project’s 16 success. Responses provided both quantitative and qualitative data. Refer to Appendix C for sample survey questions. As the implementation of the hydration stations was a small-scale pilot study, we hoped that through our evaluation we would gain an idea of the feasibility of the project for the future. The user survey results were fairly positive overall. 84% of users indicated an increase in their water consumption and 50% noted a decrease in their SSB intake over the two weeks. 95% of users believed that more hydration stations on campus would positively impact their (or other’s) water consumption. For a complete summary of the user survey results please refer to Appendix D(i). For the caretaker survey, both respondents ranked the experience as extremely easy or somewhat easy and noted they would do the project again. One challenge that was noted was keeping up with the refilling process during the busier periods. For a summary of the caretaker survey results please refer to Appendix D(ii). Overall this project was well received by station users and quite feasible from the point of view of the caretakers. Because our intervention was only two weeks, it was difficult to measure the feasibility of a long-term project. Caretakers were eager to participate in this project again, but permanently integrating the upkeep of the hydration stations into their daily tasks may pose challenges. More thought into possible funding strategies for a long-term program is needed, as UBC Wellbeing would currently be only able to cover half of maintenance costs. We recommend that future projects look into ways of evaluating the extent to which the distribution of hydrations throughout campus are able to decrease consumption of SSBs. This may require collaboration with UBC Food Services and other stakeholders on campus to measure this. 17 Conclusion In conclusion, the pilot Hydration Station project conducted this semester provided great insight into the feasibility of implementing future hydration stations on the UBC campus. Key contributions by our team included an educational infographic, data evaluation through completion of two surveys, as well as a final newsletter report that will be provided to stakeholders who oversaw the HBI projects. For future experimental designs, we recommend that recurrent communication between the FNH 473 students and project invigilators be established and maintained throughout the semester, as it is not uncommon for new questions and concerns to arise. This communication would also be beneficial towards achieving one of our medium-term objectives: to collaborate with other organizations on the UBC campus to promote more hydration stations. As well, proper deadlines should be confirmed early on in the project, as the ambiguity of our deadlines proved to be difficult as the semester drew to an end. Due to the timeline of our project, it was difficult to assess whether the hydration station users and caretakers would still be as eager for a permanent hydration station as they were with our pilot project. This proves to oppose a long-term objective that we set: for UBC to continue to promote the usage of tap water and reduction of SSB intake through the implementation of more hydration stations and/or similar initiatives. The next steps required to reach our objectives should be to elucidate the long-term impacts that a permanent hydration station entails. Such impacts include caretaker compliance, departmental costs of maintenance, as well as the association between increased water intake and decreased SSB consumption.   18 Author’s Contributions The research and literature review was split equally between all members of the group. Joy and Shara researched existing interventions that were similar to the idea of the hydration stations and Queena, John and Jamie researched current SSB intake levels in BC as well as their link to chronic diseases. Joy, Shara, Jamie and Queena attended all group meetings on Mondays and all 5 students attended multiple meetings with community partners. Shara conducted all email contact with our community partner, Melissa Baker. During our group meetings everyone contributed to making our checklist and instructions for the hydration stations as well as our survey questions. Queena made the finalized survey on Qualtrics and tent cards on Canva to label the flavours of each water station, and Shara made the informational poster to go with each station. When writing our situational assessment, Joy worked on the introduction, project goals and objectives, Queena worked on the mediating factors and behaviours sections, John worked on the mediating factors section, Jamie worked on the mediating factors and the health behaviour models sections, and Shara reviewed and edited the paper. Everyone contributed to the logic model presentation over reading week. When writing the final report, Joy and Queena wrote the Outputs section, while Jamie and Shara wrote the Evaluation section. Shara also summarized all author’s contributions and John wrote the conclusion. Queena wrote the executive summary and Shara created the table of contents and title page. Joy compiled everything needed for our Appendices and John organized our Reference page. Joy also created our Newsletter (Appendix E) to send to our community partners and John and Queena created the slides for our presentation. 19 Finally, Jamie and Shara completed all Teamwork Session Evaluation forms and edited our final report.   20 References  Bipasha, M. S., Raisa, T. S., & Goon, S. (2017). Sugar Sweetened Beverages Consumption among University Students of Bangladesh. International Journal of Public Health Science (IJPHS), 6(2), 157-163. http://dx.doi.org/10.11591/ijphs.v6i2.6635  Brisbois, T. D., Marsden, S. L., Anderson, G. H., & Sievenpiper, J. L. (2014). Estimated intakes and sources of total and added sugars in the canadian diet. Nutrients, 6(5), 1899-1912. 10.3390/nu6051899  Centers for Disease Control and Prevention. (2017). Get the Facts: Sugar-Sweetened Beverages and Consumption. Retrieved from https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-intake.html  Cheng, H. L., Medlow, S., & Steinbeck, K. (2016). The Health Consequences of Obesity in Young Adulthood. Current Obesity Reports, 5(1), 30-37. doi:10.1007/s13679-016-0190-2  Connell, A., Macdonald, B., (2017) Sugar-Sweetened Beverages Out, Hydration Stations In [Powerpoint Slides]    Dietitians of Canada (2016). Taxation and Sugar-Sweetened Beverages. Retrieved February 24, 2018, from https://www.dietitians.ca/Downloads/Public/DC-Position-SSBs-and-taxation.aspx  Dietitians of Canada. (2016). Taxation and Sugar-Sweetened Beverages. Retrieved February 24, 2018, from https://www.dietitians.ca/Downloads/Public/DC-Position-SSBs-and-taxation.aspx  Dietitians of Canada. (2017). Sugary Drink Sense Factsheets. [online] Available at: https://www.dietitians.ca/Your-Health/Nutrition-A-Z/Sugary-Drinks/Sugary-Drink-Sense-Factsheets.aspx [Accessed 20 Feb. 2018].  Escobar, M. A., Veerman, J. L., Tollman, S. M., Bertram, M. Y., & Hofman, K. J. (2013). Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis. 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Vancouver, B.C.: Provincial Health Services Authority.  Rideout, C. [Candice Rideout]. (2015, February 19th). FNH 473 Video 3: Evaluation   [Video File]. Retrieved from https://www.youtube.com/watch?v=4pMMpoPSf9c  Shields, M., Gorber, S. C., & Tremblay, M. S. (2008, June). Retrieved February 24, 2018, from http://www.statcan.gc.ca/pub/82-003-x/2008002/article/10564-eng.pdf  Shields, M., & Tjepkema, M. (2006, August). Trends in Adult Obesity. Retrieved February 24, 2018, from http://www.statcan.gc.ca/pub/82-003-x/2005003/article/9279-eng.pdf  Statistics Canada (2015, November 27). Overweight and obese adults (self-reported), 2014. Retrieved February 24, 2018, from http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14185-eng.htm  22 Tjepkema, M. (2006, August). Adult Obesity. Retrieved February 24, 2018, from http://www.statcan.gc.ca/pub/82-003-x/2005003/article/9276-eng.pdf  UBC Action Framework for a Nutritionally Sound Campus . (2017). Retrieved February 11, 2018, from https://wellbeing.ubc.ca/food-nutrition  US Department of Health and Human Services, National Institutes of Health. (2005). Theory at a Glance: A Guide for Health Promotion Practice. National Cancer Institute, 12-23. Retrieved from https://cancercontrol.cancer.gov/brp/research/theories_project/theory.pdf  West, D. S., Bursac, Z., Quimby, D., Prewitt, T. E., Spatz, T., Nash, C., . . . Eddings, K. (2006). Self-reported sugar-sweetened beverage intake among college students. Obesity, 14(10), 1825-1831. 10.1038/oby.2006.210  WHO. (n.d.) Obesity. Retrieved February 24, 2018, from http://www.who.int/topics/obesity/en/                      23 Appendix  A) Logic Model   B) Hydration Station and Resources  i) Hydration Stations  (Left - UBC REC Centre Athletics Staff Room, Right - War Memorial Gym Staff Room)    24 ii) Tent cards   iii) Instructions and Maintenance Sheet    25 iv) Checklist Sheet     26 v) Infographic      27 C) Survey Questions i) Survey A  ii) Survey B      28  D) Survey Results:  i) General User (Staff/Students) Survey Results 29 30 31 32 33 34 35 36 37          38 ii) Caretaker Survey Results 39                      40 E) Newsletter Article    UBC Social Ecological Economic Development Studies (SEEDS) Sustainability Program  Student Research Report         HBI Hydration Stations Queena Chung, Jamie Lee Kwong, Shara Marchand, John Tseng, Joy Wong University of British Columbia FNH 473 Themes: Health, Community, Wellbeing April 9, 2018        Disclaimer: “UBC SEEDS Sustainability Program provides students with the opportunity to share the findings of their studies, as well as their opinions, conclusions and recommendations with the UBC community. The reader should bear in mind that this is a student research project/report and is not an official document of UBC. Furthermore, readers should bear in mind that these reports may not reflect the current status of activities at UBC. We urge you to contact the research persons mentioned in a report or the SEEDS Sustainability Program representative about the current status of the subject matter of a project/report”. 1 Table of Contents EXECUTIVE SUMMARY ....................................................................................................................................... 2 INTRODUCTION ..................................................................................................................................................... 3 SITUATIONAL ASSESSMENT AND PLANNING FRAMEWORK ............................................................. 4 i. Problems ................................................................................................................................................................ .......... 4 ii. Behaviours ..................................................................................................................................................................... 5 iii. Mediating Factors ...................................................................................................................................................... 6 iv. Health Behaviour Theories ..................................................................................................................................... 8 PROJECT GOALS AND OBJECTIVES ..............................................................................................................10 OUTPUTS ................................................................................................................................................................11 EVALUATION PLAN.............................................................................................................................................15 CONCLUSION ........................................................................................................................................................17 AUTHORS CONTRIBUTIONS ...........................................................................................................................18 REFERENCES ........................................................................................................................................................20 APPENDICES .........................................................................................................................................................23                      2 Executive Summary  Obesity is a common and current health issue in the world today, as it poses multiple risks to a person’s physical and mental health. The high intake of sugar sweetened beverages (SSBs) has contributed to the increasing rate of obesity both in Canada and internationally. Factors such as taste, cost, and food environments are among the many considerations that influence beverage choice. In an effort to address this problem, UBC Wellbeing has launched a hydration station pilot project in collaboration with FNH 473 students, which is being implemented as part of the Healthy Beverage Initiative.  The Hydration Station Pilot Project aimed to improve the diet quality and lifestyle habits of the UBC community by encouraging tap water consumption over SSBs. Using the Community Organization Theory and Health Belief Model for guidance, this initiative involved the establishment and evaluation of two tap water stations for UBC staff and students to use as an alternative to SSBs. We also developed and distributed two post-intervention surveys as another output and as a means of evaluating the project. We used these online questionnaires to qualitatively and quantitatively assess behavioural changes and level of satisfaction resulting from the hydration stations. It was found that 84% of users increased their water consumption and 50% of users reported a decrease in their SSB intake, indicating that the project had a positive impact on the health of UBC staff and students who used the stations. In addition, the hydration stations were found to be feasible and easy to maintain by caretakers and suggested an interest in expanding the project to implement more stations around campus.    3 Introduction The University of British Columbia (UBC) has been actively involved in creating a “nutritionally sound campus” through the creation of a framework to guide food and nutrition strategies (UBC Wellbeing, 2017). Our project is part of a Healthy Beverage Initiative (HBI) developed by the framework to promote the use of tap water and inform consumers on healthy beverage options. The target population of the HBI and our project are students and staff of UBC’s Vancouver campus. The high sugar content of sugar-sweetened beverages (SSBs) provides little satiety and excess calories, therefore it may contribute to weight gain (Malik et al., 2006). The increased likelihood of weight gain from SSBs increases the risk for further health complications such as diabetes, high blood pressure, and heart disease (Dietitians of Canada, 2017). The increasing prevalence of this issue calls for public health strategies to discourage consumption of SSBs to promote a healthy lifestyle. Our contribution is based on the community organization theory, which acknowledges common issues and priorities within UBC and identifies approaches to reach collective wellbeing in the community (USDHHS, 2005). In this case, the HBI has identified the need for healthier and more sustainable beverage options on campus. Additionally, our project uses the Health Belief Model to encourage community members to change their beliefs on the use of tap water and consequently change their actions on SSB consumption. With consideration of these theories, our project’s intervention of implementing hydration stations provides a possible strategy to support community members in actively participating in both personal and community health.    4 The Problem Obesity is defined by the World Health Organization as having “an abnormal or excess fat accumulation that presents a risk to health” (WHO, 2018). Numerous studies have been conducted around the world on the regional prevalence of excess fat accumulation. As a result of these studies, the common method to assess an individual’s nutritional status is through their Body Mass Index (BMI) (Shields et al., 2008). A person with a BMI higher than 30 is considered obese (WHO, 2018).  Over the recent years, reports have indicated that the rate of obesity in Canada has consistently risen (Shields and Tjepkema, 2006). In 1986, 13% of Canadian men and 16% of women were obese. By 2004, the percentage of both obese men and women had significantly risen to 23%. A similar significant increase has also been observed in the rest of the world (Tjepkema, 2006). A summary gathered by Statistics Canada (2014) indicated that 20.2% of Canadians aged 18 years or older reported a BMI which classified them as obese. The adverse health consequences that result from this excess weight status are well known. Obesity is a risk factor for type 2 diabetes, cardiovascular diseases, high blood pressure, osteoarthritis, and other conditions (Tjepkema, 2006). On top of the physiological detriments, Cheng et al. (2016) also reported that psychosocial and mental health issues are commonly seen in obese persons due to overall public stigma and discrimination. Contributing factors to the increased onset of obesity include an increase in fast food availability, growing portion sizes, and a sedentary lifestyle (Le Petit and Berthelot, 2006). Hu (2013) found that sugar-sweetened beverages (SSBs) have a large role to play 5 in excess energy intake and that reduction in SSB intake may reduce the prevalence of obesity and its related diseases. Behaviours According to a systematic review conducted by Malik et al. (2006), the consumption of SSBs is positively associated with weight gain and/or obesity. It is proposed that the low satiety of SSBs causes users to consume more food in their subsequent meals. Dietitians of Canada (2017) recommend that added sugars should be limited to 13 teaspoons or less per day. Consuming SSBs alone may contribute more sugar than this recommended amount (Dietitians of Canada, 2017). For example, a 355 mL can of pop contains 10 teaspoons of added sugar, 473 mL of specialty coffee contains 17 teaspoons of added sugar, and a 1000 mL slushie contains 24 teaspoons of added sugar (Dietitians of Canada, 2017). 78% of British Columbians were found to have at least one SSB a week, with their top choices being fruit juice, specialty coffee or tea, and regular soda, pop, or slushies (Rasali et al., 2014). Data from Brisbois et al. (2014) estimates that “added sugars average about 11%-13% of total energy intake” among Canadians. In terms of SSB intake among students, 65% of undergraduate students surveyed at the University of Arkansas indicated that they consume SSBs everyday (West et al., 2006). Researchers predicted that students had an average of 543 ± 671 kcal per day from SSBs alone (West et al., 2006). Another survey conducted in Bangladesh found that 54% of university students consumed SSBs more than two times a week (Bipasha et al., 2017). Both studies reported that male students were more likely to consume SSBs than female students (Bipasha et al., 2017; West et al., 2006). 6 Park et al. (2011) found that various unhealthy behaviours were also associated with high SSB consumption. The odds for drinking SSBs were higher for adults who smoked, were physically inactive, watched television for prolonged periods of time, or frequently visited fast-food restaurants (Park et al., 2011). Mediating Factors Factors on the individual level for behaviours around sugar-sweetened beverage consumption include income, convenience and personal preference. According to the Centre for Disease Control (2017), SSB consumption is higher amongst lower income adults and families. Additionally, SSB and fast-food purchases can be influenced by taste and cost-effectiveness (Bipasha, Raisa & Goon, 2017). Taste in particular, can serve as a barrier to reduce SSB consumption, as humans have a natural liking for sweet foods. Additional barriers include peer and family influences on beverage choice, which tie into the interpersonal level. Institutional factors that influence the consumption of SSBs among university students include the drink options provided in their school environment. In the survey conducted in Bangladesh, 95% of students reported that they would pick healthier drinks such as lemon water if given the choice in their food environment (Bipasha et al., 2017). Previously, the IWK Health Centre in Nova Scotia implemented hydration stations in their institution. As a result of the removal of SSBs from the facility, 66% of people felt that their water consumption had increased and 52% felt their juice/pop consumption had decreased since the implementation of the hydration stations (Connell and Macdonald, 2017). Therefore, policies, which can determine what drink options are available in vending machines, cafeterias, and so forth, also play a large role in an individual’s 7 decision to drink SSBs. As mentioned above, Dietitians of Canada have made recommendations in regards to SSB consumption, but it is evident that most people do not follow these guidelines. If policies could be implemented at the institutional and/or national level, there may be higher adherence to these recommendations. Many community-based approaches center around the ever-growing forms of media available to citizens (Falbe et al. 2016). In one study, messages emphasizing the health risks of SSBs were distributed through television, digital channels, and local organizations. 53% of survey respondents gained new beliefs about the risks associated with SSBs (Farley et. al 2017). Following this shift, SSB sales decreased 3.4% and soda sales dropped 4.1% during the same time frame, 15 weeks.             Public health policy is considered to have the highest level of impact, as it regulates the entire population. There are currently no known policies regarding the purchase and consumption of any amount of sugar sweetened beverages in Canada. In 2015, an excise tax was implemented in the community of Berkeley, California (Falbe et al. 2016). The excise tax was expected to play a prominent role in the purchasing patterns of consumers as they would see higher shelf prices before making a firm decision (Falbe et al. 2016; Dietitians of Canada 2016). The researchers in California found that, over a one-year period from when the excise tax was introduced, SSB consumption decreased 21% overall. A meta-analysis of SSB taxation indicated that higher SSB prices led to a reduction in SSB consumption. This reduction in consumption resulted in decreased BMI and ultimately, a low prevalence of obesity (Escobar et al. 2013). Limitations: 8          Our first limitation is a lack of data regarding current SSB consumption among UBC students. If time permitted, it would have been ideal to have conducted a pre-study survey to assess the current use of SSBs and the knowledge on their link to obesity. We also used information from universities around the world and based our project off of the hydration stations implemented at the IWK Health Centre. Therefore, another limitation would be the lack of a comparable project conducted specifically in a university setting. Health Behaviour Theories Community Organization Theory (Community level): The first theory that has contributed to our project planning is the Community Organization theory. As discussed in Theory at a Glance, this theory involves identifying common problems within a community, mobilizing resources and implementing strategies to reach collective goals (USDHHS, 2005). Problems are initially voiced by community members, to which health professionals respond by launching programs that help deal with issues of concern (USDHHS, 2005). We chose this model to use for overarching guidance as we were able to identify these criteria within our project. As advocates for health and wellness at UBC, our community partners identified the issue of SSB consumption on campus, thus initiating the launch of the hydration station pilot project. We hope that through these stations, we will provide students and staff on UBC campus with a physical resource to access healthy beverage options, as well as the knowledge to make healthy beverage choices on a day-to-day basis.   Health Belief Model (Intrapersonal level): 9 The Health Belief Model was also chosen to consider change in behaviour around SSBs at the individual level. The Health Belief Model aims to determine why people may or may not partake in a behaviour (USDHHS, 2005). It involves determining an individual’s perceived threat to a health problem, the benefits of avoiding the threat, and revealing what factors influence one’s decision to act (USDHHS, 2005). Therefore, this model fit well with the scope of this project, as it aims to discourage consumption of sugar-sweetened beverages and raise awareness about the development of chronic diseases such as obesity and diabetes. We considered the 6 main constructs of the Health Belief Model and will address certain constructs in our intervention. The 6 main constructs outlined in the Health Belief Model are as follows: 1. Perceived susceptibility: Do students and staff on UBC campus believe they are susceptible to developing obesity or diabetes later in life based on SSB consumption? 2. Perceived severity: Do students and staff on UBC campus understand the implications of obesity or diabetes on quality of life? 3. Perceived benefits: Do students and staff on UBC campus believe that choosing healthier beverage options can reduce their risk of obesity or diabetes later in life? 4.  Perceived barriers: Do students and staff on UBC campus believe that the costs of decreasing SSB consumption are outweighed by the benefits? 5.  Cues to action: Will the posters providing information on the benefits of reducing SSB consumption prompt UBC students and staff to consume more tap water? 6.  Self-efficacy: Following the hydration station interventions, will students and staff on UBC campus feel confident to make healthy beverage choices more often in the future? 10 Project Goals and Objectives Overall Goal: To improve the diet quality and lifestyle habits of the UBC community to minimize risk of chronic diseases.   Short-term Objectives (2 months to 1 year):   ● By Feb 26th, 2018 implement 2 hydration stations for UBC students and staff to use as an alternative to consuming sugar sweetened beverages.  ● By March 2018 increase by 2 the number of UBC staff members who feel confident and capable of maintaining the use of the hydration stations  ● By March 2018, the majority of UBC students and staff members who used the hydration station will show positive attitudes towards the use of the hydration stations Medium-term Objectives (1-5 years):        ● Increase by 2, the number of hydration stations on UBC campus that promote the use of tap water within the next 12 months.  ● Increase by 10% the percentage of UBC community members who are aware of the impact of SSBs on health  ● Increase by 10% the awareness of UBC community members about the benefits of drinking tap water on personal and environmental health  ● Increase by 2, the number of collaborations between organizations within UBC to support the healthy beverage initiative within 5 years Long-term Objectives (over 5 years):   ● UBC will continue to promote the use of tap water and reduction of sugar sweetened beverage intake through the implementation of more hydration stations and/or other similar initiatives. Note: An outline of our logic model can be found in Appendix A.  11 Outputs Hydration Stations Structure: Our main intervention is the piloting of 2 hydration stations around campus to assess the use and potential changes in beverage consumption habits. Based on the community organizational theory, identifying common issues and implementing possible strategies using resources within the community is effective in reaching collective goals (USDHHS, 2005). Similarly, UBC has identified a need for healthier and more sustainable beverage options on campus and our intervention aims to promote UBC’s collective goal of being a “nutritionally sound campus”. Having an appealing hydration station with fruit and herb infused water will provide an alternative to SSBs. We predicted that it would encourage the UBC community to drink more tap water; thus, reducing sugar intake and promoting hydration in our target population. The location of these stations were determined to be the UBC Recreation Center student office and the UBC War Memorial Gym office space. These locations were chosen based on the perspective of the stewards (staff members in-charge of maintenance of the station) and how easy it would be to refill the stations and popularity of the location. Thus, these locations were chosen because of their proximity to kitchen areas and high traffic of staff and students. Content: The hydration station comes with an infusion beverage dispenser (3- or 5-gallon), a cutting board and knife, tent cards indicating water flavours, an instruction and maintenance sheet, checklist sheet, and an infographic (Appendix B (i-v)). The infographic contained information such as a project summary, benefits of drinking water, 12 and reasons for reducing consumption of SSBs. This educational material was intended to inform participants of the constructs of the Health Belief Model and will serve as a “cue to action” by prompting UBC community members to consume more tap water in replacement of SSBs. Particularly, the infographic outlines the perceived benefits of drinking tap water over SSBs and contributes to the perceived severity of SSBs increasing risk for developing obesity, diabetes, and heart disease. The maintenance sheet is a user-friendly guide to maintaining the operation of the hydration station. It includes information on set-up, suggested water flavours, clean-up, and how to use the provided checklist. The checklist is a record of the usage and maintenance of the station. The facilities were instructed to record the number of times the beverage dispenser was refilled, the water flavour(s) used, and to provide other comments about the station. This information was used for data collection purposes in our evaluation to determine the popularity of the station.  Delivery: Our community partners, Melissa Baker and Heather Quigley, connected us with the facilities to inform them about the nature of our project and to ask for permission to implement a hydration station in their facility. Before the intervention began, our group members met with stakeholders of these facilities to go over set-up (i.e. using the checklist). The facilities were responsible for acquiring the ingredients for the hydration stations but were reimbursed by UBC Wellbeing. The duration of the intervention took place over a 3-week period.  During the intervention, our group members had a check-in meeting to observe the progress of our intervention. Post-intervention Surveys 13 Structure: We developed 2 questionnaires to be distributed at the end of our intervention. Survey A was for the staff and students who shared the space in which our hydration stations were placed. Survey B was for the caretakers who were in charge of the hydration stations and completing tasks such as cleaning and refilling the water. The purpose of our questionnaires was to determine the feasibility of implementing hydration stations in terms of maintenance, and to also collect data on student and staff support of the stations. We decided to do a survey as we wanted to reach a large group of people. It was a convenient and efficient way to receive their feedback. Content: Survey A consisted of questions that asked participants about their usage, any behavioural changes after implementation and their opinions on the hydration stations. For example, in order to address the perceived benefits and barriers using the Health Belief Model, we asked users to select what made them decide on the hydration station over another option, providing choices such as “convenience”, “cost-effective”, “taste”, and so on. We also wanted to measure the effect of the hydration station on the participants’ behaviour, so we included the question “Do you feel your water consumption has increased since the implementation of the hydration station?”. As previously mentioned, the hydration stations also came with an infographic highlighting the benefits of drinking water. We wanted to determine if the infographic was an effective “cue to action” and therefore, we asked users if the infographic increased their motivation to drink more tap water. Additional sample questions included in survey A can be found in Appendix C(i). 14 Survey B targeted staff members who were involved in maintaining the hydration stations, otherwise known as the “caretakers”. We wanted to collect general feedback about the station as well as obtain any recommendations and improvements for future implementation of hydration stations to make it easier and simpler to maintain.  Specifically, we were interested in how easy or difficult the caretakers felt it was to upkeep the hydration station and any challenges they faced. Again, specific questions included on survey B can be found in Appendix C(ii). Delivery: We developed our surveys through the UBC Qualtrics software and distributed our surveys online. Our community partner, Melissa Baker, emailed the questionnaires to Heather and Mike Tan—the lead person in charge of the hydration stations at the War Memorial Gym and UBC Rec Center—respectively. These two lead contacts then distributed the email to their staff and students using the spaces. Surveys were available to complete for approximately one week following the last day of the intervention. After data was collected we were able to analyze and summarize the results regarding the feasibility and the likeability of the hydration stations.     15 Evaluation Evaluation is an important component of project planning as it helps ensure goals are being met and that funds are being used effectively (Rideout, 2015). Evaluation methods administered for the Hydration Stations were used primarily to ensure the short-term goals were achieved, and to work towards goals in the long-term. Both formative and impact evaluation were used for our project. Formative evaluation is used to ensure that the intervention is being delivered as planned, as well as for improving ongoing activity (Hammond, 2018). During the intervention, we checked in with our partners to assess the implementation of the hydration stations. We ensured the equipment, cleaning procedures and intervention documentation instructions were clear and being followed. It also allowed our community partners to ask questions and provide feedback on what was going well, and/or how we could better support them. For each hydration station, we provided a checklist including a section to record the number of refills needed each day, and any comments about the popularity of the flavours or the station in general. This allowed us to assess the amount of work needed to upkeep each station as well as the popularity of the stations. Monitoring provided qualitative data during the intervention. It also ensured that the stations were being managed and implemented properly, as to increase the likelihood of achieving our objectives. Impact evaluation was used in order to assess achievement of our outcome objectives. This was done through the development and distribution of two surveys, which included questions evaluating popularity of the station with station users and the ease of upkeep with station caretakers. We used these surveys as an indicator of our project’s 16 success. Responses provided both quantitative and qualitative data. Refer to Appendix C for sample survey questions. As the implementation of the hydration stations was a small-scale pilot study, we hoped that through our evaluation we would gain an idea of the feasibility of the project for the future. The user survey results were fairly positive overall. 84% of users indicated an increase in their water consumption and 50% noted a decrease in their SSB intake over the two weeks. 95% of users believed that more hydration stations on campus would positively impact their (or other’s) water consumption. For a complete summary of the user survey results please refer to Appendix D(i). For the caretaker survey, both respondents ranked the experience as extremely easy or somewhat easy and noted they would do the project again. One challenge that was noted was keeping up with the refilling process during the busier periods. For a summary of the caretaker survey results please refer to Appendix D(ii). Overall this project was well received by station users and quite feasible from the point of view of the caretakers. Because our intervention was only two weeks, it was difficult to measure the feasibility of a long-term project. Caretakers were eager to participate in this project again, but permanently integrating the upkeep of the hydration stations into their daily tasks may pose challenges. More thought into possible funding strategies for a long-term program is needed, as UBC Wellbeing would currently be only able to cover half of maintenance costs. We recommend that future projects look into ways of evaluating the extent to which the distribution of hydrations throughout campus are able to decrease consumption of SSBs. This may require collaboration with UBC Food Services and other stakeholders on campus to measure this. 17 Conclusion In conclusion, the pilot Hydration Station project conducted this semester provided great insight into the feasibility of implementing future hydration stations on the UBC campus. Key contributions by our team included an educational infographic, data evaluation through completion of two surveys, as well as a final newsletter report that will be provided to stakeholders who oversaw the HBI projects. For future experimental designs, we recommend that recurrent communication between the FNH 473 students and project invigilators be established and maintained throughout the semester, as it is not uncommon for new questions and concerns to arise. This communication would also be beneficial towards achieving one of our medium-term objectives: to collaborate with other organizations on the UBC campus to promote more hydration stations. As well, proper deadlines should be confirmed early on in the project, as the ambiguity of our deadlines proved to be difficult as the semester drew to an end. Due to the timeline of our project, it was difficult to assess whether the hydration station users and caretakers would still be as eager for a permanent hydration station as they were with our pilot project. This proves to oppose a long-term objective that we set: for UBC to continue to promote the usage of tap water and reduction of SSB intake through the implementation of more hydration stations and/or similar initiatives. The next steps required to reach our objectives should be to elucidate the long-term impacts that a permanent hydration station entails. Such impacts include caretaker compliance, departmental costs of maintenance, as well as the association between increased water intake and decreased SSB consumption.   18 Author’s Contributions The research and literature review was split equally between all members of the group. Joy and Shara researched existing interventions that were similar to the idea of the hydration stations and Queena, John and Jamie researched current SSB intake levels in BC as well as their link to chronic diseases. Joy, Shara, Jamie and Queena attended all group meetings on Mondays and all 5 students attended multiple meetings with community partners. Shara conducted all email contact with our community partner, Melissa Baker. During our group meetings everyone contributed to making our checklist and instructions for the hydration stations as well as our survey questions. Queena made the finalized survey on Qualtrics and tent cards on Canva to label the flavours of each water station, and Shara made the informational poster to go with each station. When writing our situational assessment, Joy worked on the introduction, project goals and objectives, Queena worked on the mediating factors and behaviours sections, John worked on the mediating factors section, Jamie worked on the mediating factors and the health behaviour models sections, and Shara reviewed and edited the paper. Everyone contributed to the logic model presentation over reading week. When writing the final report, Joy and Queena wrote the Outputs section, while Jamie and Shara wrote the Evaluation section. Shara also summarized all author’s contributions and John wrote the conclusion. Queena wrote the executive summary and Shara created the table of contents and title page. Joy compiled everything needed for our Appendices and John organized our Reference page. Joy also created our Newsletter (Appendix E) to send to our community partners and John and Queena created the slides for our presentation. 19 Finally, Jamie and Shara completed all Teamwork Session Evaluation forms and edited our final report.   20 References  Bipasha, M. S., Raisa, T. S., & Goon, S. (2017). Sugar Sweetened Beverages Consumption among University Students of Bangladesh. International Journal of Public Health Science (IJPHS), 6(2), 157-163. http://dx.doi.org/10.11591/ijphs.v6i2.6635  Brisbois, T. D., Marsden, S. L., Anderson, G. H., & Sievenpiper, J. L. (2014). Estimated intakes and sources of total and added sugars in the canadian diet. Nutrients, 6(5), 1899-1912. 10.3390/nu6051899  Centers for Disease Control and Prevention. (2017). Get the Facts: Sugar-Sweetened Beverages and Consumption. Retrieved from https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-intake.html  Cheng, H. L., Medlow, S., & Steinbeck, K. (2016). 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BMC Public Health, 13(1). doi:10.1186/1471-2458-13-1072  Falbe, J., Thompson, H. R., Becker, C. M., Rojas, N., Mcculloch, C. E., & Madsen, K. A. (2016). Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption. American Journal of Public Health, 106(10), 1865-1871. doi:10.2105/ajph.2016.303362 Farley, T. A., Halper, H. S., Carlin, A. M., Emmerson, K. M., Foster, K. N., & Fertig, A. R. (2017). Mass Media Campaign to Reduce Consumption of Sugar-Sweetened Beverages in a Rural Area of the United States. American Journal of Public Health, 107(6), 989-995. doi:10.2105/ajph.2017.303750 21  Hammond, G. (2018). Health Promotion Programs: Evaluation [Powerpoint Slides].  Retrieved from           https://canvas.ubc.ca/courses/1874/pages/week-6-program-evaluation?module_item_id=279880  Hu, F. B. (2013). Resolved: there is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. 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Retrieved February 24, 2018, from http://www.who.int/topics/obesity/en/                      23 Appendix  A) Logic Model   B) Hydration Station and Resources  i) Hydration Stations  (Left - UBC REC Centre Athletics Staff Room, Right - War Memorial Gym Staff Room)    24 ii) Tent cards   iii) Instructions and Maintenance Sheet    25 iv) Checklist Sheet     26 v) Infographic      27 C) Survey Questions i) Survey A  ii) Survey B      28  D) Survey Results:  i) General User (Staff/Students) Survey Results 29 30 31 32 33 34 35 36 37          38 ii) Caretaker Survey Results 39                      40 E) Newsletter Article    HBI:HYDRATION STATIONSObesity & SSBs ▸ 1 in 5 Canadian adults are obese▹ Similar increases observed worldwide▸ Associated with adverse health consequences▸ Positively linked with intake of sugar-sweetened beverages ▸ 78% of British Columbians consume SSBs everyday▸ Target intervention population: UBC staff and studentsProgram Goals & ObjectivesShort-term Objective: Implement 2 hydration stations for UBC staff and students to use as an alternative to consuming SSB’sGoal: To improve the diet quality and lifestyle habits of the UBC community Long-term Objective: For UBC to continue to promote the use of tap water & reduction of SSB intake through the implementation of more hydration stations and/or other similar initiativesMedium-term Objective:Within the next 18 months, increase by 2 the number of hydration stations on the UBC campus that promote the use of tap waterTheoretical Framework▸ Community Organization Theory▸ Health Belief ModelProgram Outputs▸ Hydration stations▸ Infographic ▸ SurveysWhat is included with the Hydration Station? War Memorial Gym Staff RoomHydration StationsUBC Rec Center Athletics Staff RoomInfographicPerceived benefitsPerceived severity Cue to actionPerceive  S verityPerceived Benefits2 Post-Intervention Surveys▸ Purpose: to determine the feasibility of implementing hydration stations around the campus by way of:▹ Gathering student and staff opinions▹ Physical implementation of the actual stations▸ Survey A▹ People who shared the space in which our hydration stations were implemented▸ Survey B▹ People who were in charge of maintaining the stationSurvey A▸ Barriers and benefits▹ What made you decide on the hydration station over another option? Informational poster, convenience, cost-effective, taste, etc▸ Cues to Action▹ Did the poster increase your motivation to drink more tap water?Survey B▸ General feedback from caretakers▹ How easy or difficult it was▹ Any challenges faced that were not considered?▹ Would you support future hydration stations?▸ Recommendations for future hydration stations?Evaluation/Results User Survey: ▸ 39 respondents all indicating they used the stations  ▸ 84% indicated an    in their water consumption▸ ~50% noted a    in their SSB intake ▸ 95% indicated an    in water stations would positively impact water consumption▸ 100% want to see more on campus Evaluation/Results Caretaker Survey:  ▸ Both respondents ranked as extremely easy or somewhat easy ▸ Challenges included refilling process and dealing with busier times ▸ People liked different flavours, would prefer colder water ▸ Both noted they would do this project again Lessons LearnedWhat we learned: ▸ Benefits and challenges with working together with the community ▸ Evaluation should be considered at all stages ▸ Provide clear and concise instructions What we would do differently: ▸ Better communication▸ Clarify timeline ▸ Allocate more time for meetingsQuestions?

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