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HBI Institutional Responsibility : Sugar-Sweetened Beverages : Factors that Influence Motivation and… Lee, Ashley; Yu, David; Whang, Josh; Yu, Qian (Lynn); Yang, Zhi (Zee) 2018-04-30

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UBC Social Ecological Economic Development Studies (SEEDS) Sustainability Program  Student Research Report         HBI Institutional Responsibility: Sugar-Sweetened Beverages: Factors that Influence Motivation and Consumption, Correlates, and Interventions among University Students Ashley Lee, David Yu, Josh Whang, Qian (Lynn) Yu, Zhi (Zee) Yang University of British Columbia PSYC 321 Food, Wellbeing April 30, 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”. DETERMINANTS OF SSB CONSUMPTION 2 ABSTRACT          The consumption of sugar-sweetened beverages (SSBs) has been linked to negative consequences such as obesity, type II diabetes, elevated blood pressure, and coronary heart disease (5). Moreover, young adults consume the most SSBs compared to any other age group (3). These negative consequences and the high rates of SSB consumption among young adults show the need for interventions targeted at reducing SSB consumption. In order to facilitate these interventions, this study sought to examine what factors influence university students’ motivation and consumption of SSB. We distributed an online survey to 105 undergraduate students from the University of British Columbia (UBC) through social media platforms and in-person administration. Results demonstrate that seventy-eight students indicated taste as their primary motivator for SSB consumption while fourteen students indicated convenience/ease of access. Few students chose caffeine (n=4), nutritional content (n=2), and price (n=2) as their primary motivator. Moreover, students who consumed SSBs primarily for the taste had the highest levels of SSB consumption compared to any other condition. Correlates were also observed and there was a significant positive relationship between stress level and SSB consumption, a significant negative relationship between sleep duration and SSB consumption, and a nonsignificant relationship between perceived ill effects of SSB consumption and SSB consumption.                             DETERMINANTS OF SSB CONSUMPTION 3 INTRODUCTION          Excess weight and obesity in all age groups continue to be at high levels in Canada with 62% of Canadians having excess weight or obesity (15). The transition to college appears to be a challenging period and reducing additional weight gain during these years can be an important tool for fighting against the increasing obesity rates in Canada (8, 18). One major determinant of weight gain among young adults is the consumption of sugar sweetened beverages (3). Young adults consume the most calories from sugar sweetened beverages (SBBs) of any age (330 calories a day on average) and approximately 15% of totally daily calorie intake of Canadian adults comes from sugar (3). This exceeds the 2015 WHO recommendation to limit free sugar consumption to 10% of total energy intake to reduce the risk of overweight, obesity, and tooth decay (20). Based on a 2000 calorie diet, 10% of total energy intake equates to 50 grams of free sugar and a single can (250 mL) of sugar sweetened soda can contain up to 40 grams (20). With the consumption of foods like fruits and honey, people can easily exceed this 10% limitation.  SSB consumption is an issue that requires a lot of attention; evidence that supports the relationship between SSB consumption and negative health outcomes is growing. A meta-analysis of 88 studies reported there was a clear and consistent correlation between SSB consumption and increased caloric intake (17). Many studies have found evidence supporting the relationship between body weight and intake of SSBs in both children and adults (9, 10, 11 17). Besides its association with excess weight, SSB consumption has been associated with decreased dietary nutrients, elevated blood pressure, increased coronary heart disease, and increased risk of type 2 diabetes (5). The prevalence of SSB consumption among young adults and the relationship between SSB consumption and negative health outcomes show the need for successful interventions to reduce SSB consumption among college students.   RESEARCH QUESTION AND HYPOTHESIS          This current study seeks to investigate this question: what factors influence university students’ motivation and consumption of sugar sweetened beverages? Our study defines SSB as pre-packaged beverages that include any form of sugar added during the manufacturing process. We hypothesize: (1) the highest level of SSB consumption will occur in the group that chooses taste as primary motivator for SSB consumption; (2) taste will be the primary motivator for SSB consumption followed by price, caffeine, convenience, and nutritional content; (3) a positive correlation between stress level and SSB consumption; and (4) a negative correlation between sleep duration, perceived ill effects of SSB and SSB consumption. Our first and third hypotheses are motivated by the finding from a study that demonstrated that sugar consumption may activate a metabolic negative feedback pathway, which may shut off stress responses and reinforce habitual sugar overconsumption (16).This means that one craves sugar to reduce stress responses in the brain.  The order of the second hypothesis is influenced by several studies. First, two studies found that among college students, taste and price were the most important factors in choosing beverages but price was secondary to taste (1, 2). Therefore, we place taste before price. Next, research has found that through its dependency effects, the addition of low concentration of caffeine can significantly increase consumption of SSB (7). However, a report demonstrated that in young adults, most caffeine is consume through coffee so we hypothesize that caffeine would come in third(13). Convenience is placed fourth because a study conducted on students from a private university in Bangladesh found that only 8% of students chose convenience as the primary motivator for SSB consumption(1). We anticipate that nutritional content will be the DETERMINANTS OF SSB CONSUMPTION 4 least popular motivator because a study conducted on 250 students at the University of Cambridge found that the perceptions of risk of SSB was not correlated to consumption (19). Our fourth hypothesis is motivated by a study by which found that short sleep duration is associated with greater intake of SSBs (12).    METHODS Participants:  Our study engaged 105 participants, all of whom are undergraduate students at UBC. Of these, 6 students indicated that they do not drink SSBs. There were 39 third year students, 34 fourth year students, 16 second year students, 9 students who are fifth year and above, and 7 first year students. We had 48 female participants, 53 males participants, 3 participants who prefer not to reveal their gender, and 1 participant who stated that their gender was not listed.   Conditions In order to test our second hypothesis about the main motivators for SSB consumption, we asked, “Why do you drink SSBs?” and listed 5 options (taste, nutritional content, price, convenience, and caffeine; independent variables). Other questions about sleep duration (“How many hours of sleep do you get?”), stress level (“Rate you stress level of a scale of 1-5”), and perceived ill effects of SSB consumption (“In your opinion, how often do you think people need to drink SSB for it to cause ill health?”) were asked in an effort to find correlations of variables to SSB consumption. Demographic questions about gender and year level were asked in the form of multiple choice. The survey also included a asking students to indicate their level of support for specific interventions targeted at reducing SSB consumption (see figure 1 in results section for interventions). Participants indicated their support using a 1-5 Likert Scale that ranged from “extremely supportive” to “extremely unsupportive.”   Measures In the form of multiple choice question, the survey asked about “how often” SSB was consumed (ranging from never to 2 times per day) and “how much” was consumed (ranging from 250 mL to 1L). They were asked to determine the SSB consumption level (dependent variable). SSB consumption (mL/day) was calculated by converting “how often” into units per day and then multiplying it by “how much” in mL. See Appendix B for specific conversions.     Procedure We posted the survey link on Facebook groups (Class of 2021, 2020, 2019), sent survey links to our friends, and encouraged our friends to share with their UBC schoolmates. Our link was also posted on the announcements page of our course (PSYC 321). Data was also collected in-person (via online survey) by members of our team who reached out to students in the Nest, Irving Barber Library, and the Kenny Building. Researchers stood away from participants in order to reduce the impact of Hawthorne Effect. Participants read a consent form before completing survey, which consisted of 14 questions. At the start of the survey, SSB was defined and common SSBs were listed. Data collection took place from March 1st –March 15th 2018.   RESULTS There was a statistically significant difference (p<0.05) in mean SSB consumption between the groups as determined by one-way ANOVA (F(4,94)=2.66, p=0.0375). Therefore, DETERMINANTS OF SSB CONSUMPTION 5 the null hypothesis (μ taste= μ nutritional content= μ convenience= μ price= μ caffeine) was rejected. See figure 1E in Appendix E for the mean SSB consumption and standard deviation in each condition. Since, nutritional content (n=4), price (n=2), and caffeine (n=2) conditions had small sample sizes, this study focused only on the taste(n=78) and convenience (n=13) conditions to perform the post hoc tukey test. This test revealed that SSB consumption is statistically significantly lower in the convenience condition compared to the taste condition (p<0.05). There was also a statistically significant negative relationship between SSB consumption and sleep duration (r= -0.477; p<0.05), a significant positive relationship between SSB consumption and stress level (r=0.566; p<0.05), and a significant negative relationship between sleep duration and stress level (r=-0.507; p<0.05), and a non-significant negative relationship between perceived ill effects of SSB consumption and SSB consumption (r=-0.013; p>0.05).  Our result demonstrate that our first hypothesis that the highest level of consumption will occur in the group that chooses taste as primary motivator was supported. The post hoc tukey test revealed that SSB consumption is significantly lower in the convenience condition compared to the taste condition (p<0.05). Our second hypothesis that taste will be the primary motivator for SSB consumption followed by price, caffeine, convenience/ease of access, and then nutritional content was partly supported. As seen in the ANOVA table (see figure 1E), the primary motivator was taste (n=78), followed by convenience/ease of access (n=13), nutritional content (n=4), and tie between price (n=2) and caffeine (n=2). Our third hypothesis was supported as there was a significant positive correlation between SSB consumption and stress. And our fourth hypothesis that there was a negative correlation between sleep duration and perceived ill effects of SSB and SSB consumption was partly supported. Although there was a significant negative correlation between sleep duration and SSB consumption, there was a non-significant correlation between knowledge about health impacts of SSB and SSB consumption. Although not in the hypothesis, we examined the support students had for different interventions (see figure 1 for interventions). There was a statistically significant difference (p<0.05) in mean support between these six interventions as determined by one-way ANOVA (F(5,623)=2.23, p=0). The post hoc tukey test revealed for mean support of interventions was in decreasing order: μ intervention 3> μ intervention 5 >μ intervention 4>μ intervention 1>μ intervention 2= μ intervention 6. The test revealed a significant difference between interventions 1, 3, 4, and 5 (p<0.05) and a non-significant difference between intervention 2 and 6 (p=0.99). Please see figure 4E in Appendix E for mean support and standard deviation for each intervention.  Figure 1: Student support for the six interventions. Green text represents the top 4 interventions that were supported. The red text represents the 2 interventions that were the least supported.  DISCUSSION The prevalence of SSB consumption among UBC students is apparent as only 6 out of 105 students indicated that they did not drink SSB. This is not surprising given that sugar DETERMINANTS OF SSB CONSUMPTION 6 consumption is the greatest in young adults than any other age group (3). The results indicate that the primary motivators for these 99 students were taste and convenience but convenience was secondary to taste. Moreover, the group of students that drank SSB primarily for the taste had the highest consumption levels. Stress could be the underlying mechanism as to why students drink SSBs as sugar activates pleasure centers of the brain, reduces the stress hormone cortisol (16), and increases habitual overconsumption (16). Future studies should look at whether students are willing to switch over to drinks that are sweetened by 0 calories sweeteners (ex. stevia, swerve, aspartame) and if these drinks also reduce stress responses in the same way sugar does. Other studies can also examine what is it about the taste that drives students to consume SSBs (ex. fizziness, sugary taste, refreshing…etc.).  Convenience/ease of access was the second most popular factor in choosing SSB and this can be due to a variety of reasons. One explanation is that although water can be accessed for free at drinking fountains, students need to carry around a water bottle in order  to sip water throughout the day. SSBs come in cans or plastic bottles, which makes it more convenient as they can be easily thrown away after consumed. Second, convenience could also refer to the close proximity of sugary drink vendors on campus. SSBs is easily accessible in residence cafeterias, vendors in the Nest, and vending machines scattered throughout the campus. Another convenience could be that many restaurants on the UBC campus such as the Nest (ex. Emporium Noodle, Iwana Taco, Pie R2 Pizza) and the Village (ex. My Home Cuisine, Black Pearl) all offer set deals where students can get a pop or bubble tea with a meal. The reduced price and convenience can demotivate students from combining their meals with alternative healthier drinks like milk or tea. Further studies can examine what makes SSBs so convenient to students (ex. Is it the set deals, the prevalence of vending machines, hassle of carrying a bottle…etc.?) Nutritional content, price, and caffeine were not popular reasons. As mentioned in the introduction, we hypothesized that nutritional content and caffeine would not be popular reasons due to past research. However, it was unexpected that price would be one of the least chosen motivators. Price may have been a non-popular factor in choosing SSB because bottled waters cost similar to a 375mL can of SSB (2). In fact, college students reported that given the similar price of water and SSB, they would choose SSB because they would want more flavor (2).   The significant positive correlation between stress and SSB consumption supports the possibility that stress can motivate students to choose SSB over non-sweet drinks. To have better insight to the direction of this relationship, future studies can include questions that ask students about their mood and/or stress level after SSB consumption (How do you feel after drinking SSBs?) or questions that directly ask if they believe that sugar helps them feel less stressed. Moreover, the significant positive correlation of stress and sleep indicates that sleep, stress, and SSB consumption may be interrelated. In fact, one study showed that inadequate sleep increases cortisol levels (stress) and makes people inclined to crave sugar  (6). The third correlation we looked at was between SSB consumption and perceived ill effects of its consumption. There was a nonsignificant correlation which demonstrates that knowledge about health impacts has limited influence of consumption. One study that interviewed students reported that most students “cited their youth as a factor in their disregard for potential health dangers of sugar-sweetened beverage consumption” (2). Future studies can examine whether students have accurate perceptions of the ill effects of SSB consumption. Our study also examined 6 interventions for reducing SSB consumption and specific recommendations will be outlined in the next section. As with all studies, our study is not without limitations. One limitation was the small sample size in the taste, nutritional content, and caffeine conditions so we could not compare all DETERMINANTS OF SSB CONSUMPTION 7 groups on SSB consumption level. Another limitation is that we provided students with only 5 motivators to choose from when asking why they consumed SSB. There may have been other motivators that we failed to examine. Also, to measure SSB consumption levels, we used retrospective questions regarding “how often” and “how much” they consumed. It cannot be guaranteed that their reported SSB consumption levels are accurate. Moreover, we cannot determine a causal relationship between SSB consumption and sleep duration as well as stress level; future studies can create an experimental design to examine these effects. Other limitations include that it was conducted only on undergraduate students in UBC and they were conveniently sampled so it may not be representative of the UBC community at large.  Nevertheless, our study provides important insight on what drives SSB consumption in young adults and correlates of SSB consumption such as stress and sleep level, which can facilitate success of interventions designed to decrease college students’ consumption of SSB.    RECOMMENDATIONS           Our results demonstrate that many students support UBC regulating unhealthy products (see figure 1 and figure 4E). Our study found that the intervention that was most supported was placing healthier beverage options at eye levels in stores and vending machines. We recommend that our clients work with cafeterias on campus to design the layout of drinks displayed so that more healthier drinks (naturally sweetened smoothies, milk, sparkling water…etc.) are placed at eye level. And if feasible, UBC should monitor the number of SSBs in vending machines and include healthier drinks such as naturally sweetened drinks and place these at eye level. In fact, one study found a significant positive association between availability of SSBs in vending machines and its consumption (14). The second most popular intervention was running a social marketing campaign to educate students about health impacts. Our results showed that perceived ill effects of SSB consumption and SSB consumption did not correlate. A possible explanation for this is that student believe that they are not vulnerable or immune to these ill effects because they are still young (2). We recommend that our clients work with UBC Communications to create campaigns that inform college students that all age groups are vulnerable to the negative consequences of SSB consumption. One study found that to reduce high SSB intake, students felt that intervention using shocking visual images would be most effective (2). The third most supported intervention was the limiting serving size of SSB to less than 250 mL. We recommend that cafeterias and vendors on campus get rid of SSBs larger than 375mL (a regular can size) so that portion sizes are reduced. Majority of students were not supportive of removing SSBs from view or increasing the price (see figure 1 and figure 4E);  therefore, these interventions are not recommended. Also, many students reported that price was not a primary motivator and this could be possibly be due to bottled water and SSBs (375 mL) having similar prices. Reducing the cost of bottled water may incentivize students to choose water as SSBs will be comparatively more expensive.  Our results also show the interrelatedness of sleep, stress, and SSB consumption. We recommend interventions that aim to increase sleep and reduce stress in students. For example, educational campaigns can include tips on how to get a good sleep or how to cope with stress. Since taste was the primary factor for SSB consumption in 74% of our sample, we recommend introduction of drinks sweetened with 0 calorie sweeteners. Convenience was also a common motivator for SSB consumption and we recommend that there should be a reduction in the number of SSBs sold on campus. For example, SSBs can be eliminated from cafeterias and cafes/restaurants where students can use their UBC flex dollars or meal plans.  REFERENCES DETERMINANTS OF SSB CONSUMPTION 8  (1) Bipasha, M., Raisa, T. and Goon, S. (2017). Sugar Sweetened Beverages Consumption  among University Students of Bangladesh. International Journal of Public Health Science, 6(2), pp.157-163.  (2) Block, J. P., Gillman, M. W., Linakis, S. K., & Goldman, R. E. (2013). “If It Tastes Good, Im  Drinking It”: Qualitative Study of Beverage Consumption Among College Students. Journal of Adolescent Health,52(6), 702-706. doi:10.1016/j.jadohealth.2012.11.017  (3) Brisbois, T., Marsden, S., Anderson, G., & Sievenpiper, J. (2014). Estimated Intakes and  Sources of Total and Added Sugars in the Canadian Diet. Nutrients,6(5), 1899-1912. doi:10.3390/nu6051899  (4) Canadian Health INdex 2016(Rep.). (2016). Retrieved https://cdn.sunlife.com/static/ca/Learn  and Plan/Market insights/Canadian Health index/Canadian_Health_Index_2016_en.pdf  (5) Delpier, T., Giordana, S., & Wedin, B. M. (2013). Decreasing Sugar-Sweetened Beverage  Consumption in the Rural Adolescent Population. Journal of Pediatric Health  Care,27(6), 470-478. doi:10.1016/j.pedhc.2012.07.002  (6) Greer, S. M., Goldstein, A. N., & Walker, M. P. (2013). The impact of sleep deprivation on  food desire in the human brain. Nature Communications, 4, 2259. http://doi.org/10.1038/ncomms3259  (7) Keast, R. S., Swinburn, B. A., Sayompark, D., Whitelock, S., & Riddell, L. J. (2015).  Caffeine increases sugar-sweetened beverage consumption in a free-living population: A  randomised controlled trial. British Journal of Nutrition,113(02), 366-371. doi:10.1017/s000711451400378x  (8) Lloyd-Richardson, E. E., Bailey, S., Fava, J. L., & Wing, R. (2009). A Prospective Study of  Weight Gain During the College Freshman and Sophomore Years. Preventive Medicine, 48(3), 256–261. http://doi.org/10.1016/j.ypmed.2008.12.009  (9) Malik, V. S., Pan, A., Willett, W. C., & Hu, F. B. (2013). Sugar-sweetened beverages and  weight gain in children and adults: A systematic review and meta-analysis. The American  Journal of Clinical Nutrition,98(4), 1084-1102. doi:10.3945/ajcn.113.058362  (10) Malik, V. S., Schulze, M. B., & Hu, F. B. (2006). Intake of sugar-sweetened beverages and  weight gain: A systematic review1–3. The American Journal of Clinical Nutrition,84(2),  274-288. doi:10.1093/ajcn/84.1.274  DETERMINANTS OF SSB CONSUMPTION 9 (11) Pan, L., Li, R., Park, S., Galuska, D. A., Sherry, B., & Freedman, D. S. (2014). A  Longitudinal Analysis of Sugar-Sweetened Beverage Intake in Infancy and Obesity at 6  Years. Pediatrics,134(Supplement). doi:10.1542/peds.2014-0646f  (12) Prather, A. A., Leung, C. W., Adler, N. E., Ritchie, L., Laraia, B., & Epel, E. S. (2016).  Short and sweet: Associations between self-reported sleep duration and sugar-sweetened  beverage consumption among adults in the United States. Sleep Health,2(4), 272-276.  doi:10.1016/j.sleh.2016.09.007  (13) Reid, J. L., Mccrory, C., White, C. M., Martineau, C., Vanderkooy, P., Fenton, N., &  Hammond,  D. (2017). Consumption of Caffeinated Energy Drinks Among Youth and Young Adults in Canada. Preventive Medicine Reports,5, 65-70. doi:10.1016/j.pmedr.2016.11.012  (14) Shi, L. (2010). The Association between the Availability of Sugar-Sweetened Beverage in  School Vending Machines and Its Consumption among Adolescents in California: A Propensity Score Matching Approach. Journal of Environmental and Public Health, 2010, 735613. http://doi.org/10.1155/2010/735613  (15) Statistics Canada. Body Composition of Adults, 2012 to 2013. Retrieved from:  http://www.statcan.gc.ca/pub/82-625- x/2014001/article/14104-eng.htm  (16) Tryon, M. S., Stanhope, K. L., Epel, E. S., Mason, A. E., Brown, R., Medici, V., . . .  Laugero, K. D. (2015). Excessive Sugar Consumption May Be a Difficult Habit to Break: A View From the Brain and Body. The Journal of Clinical Endocrinology & Metabolism,100(6), 2239-2247. doi:10.1210/jc.2014-4353  (17) Vartanian, L. R., Schwartz, M. B., & Brownell, K. D. (2007). Effects of Soft Drink  Consumption on Nutrition and Health: A Systematic Review and Meta-Analysis. American Journal of Public Health, 97(4), 667–675. http://doi.org/10.2105/AJPH.2005.083782  (18) Vella-Zarb, R. A., & Elgar, F. J. (2009). The ‘Freshman 5’: A Meta-Analysis of Weight  Gain in the Freshman Year of College. Journal of American College Health,58(2), 161-166. doi:10.1080/07448480903221392  (19) Warner, Rich  and Marie-Ann Ha. “University Students’ Knowledge, Consumption Patterns  and Health Perceptions of Sugar Sweetened Beverages (SSB)”. EC Nutrition 11.6 (2017): 223-232.  DETERMINANTS OF SSB CONSUMPTION 10 (20) World Health Organization. WHO Guideline : Sugars intake for adults and children. World  Health Organization. 2015:1-49. Available from http://www.who.int/nutrition/publications/guidelines /sugars_intake/en/                                     APPENDIX A: CONDITIONS DETERMINANTS OF SSB CONSUMPTION 11  Condition 1: Motivators (conditions) for SSB Consumption. Mean SSB consumption levels and number of students in each condition were examined.      Condition 2: Question asked to examine perceived ill effects of SSB Consumption. SSB consumption and perceived ill effects of SSB consumption were correlated. The perceived ill effects answer choices were converted to per day. Therefore, 1-2/month was coded as 1.5/30 (0.05), 1-2/week as 1.5/7 (0.214), 1/day as 1, 2/day as 2, 3/day as 3, and I don’t believe it causes ill health as 0.     Condition 3: Question asked to examine sleep duration. SSB consumption and sleep duration were correlated. For the ranges, 5-6 hours of sleep was coded as 5.5 hours and 7-8 hours of sleep was coded as 7.5 hours.     DETERMINANTS OF SSB CONSUMPTION 12  Condition 4: Question asked to measure stress level. Stress level was correlated with SSB consumption level.    APPENDIX B: MEASURES     APPDENDIX C: DEMOGRAPHIC QUESTIONS AND DEMOGRAPHIC FIGURES     Demographic Question 1: Gender  DETERMINANTS OF SSB CONSUMPTION 13  Demographic Figure 1: Gender   Demographic Question 2: Year Level     Demographic Figure 2: Year Level      DETERMINANTS OF SSB CONSUMPTION 14 APPENDIX D: INTERVENTIONS      DETERMINANTS OF SSB CONSUMPTION 15 APPENDIX E: FINDINGS  Figure 1E: Summary table on the conditions, the number of students in each condition, average SSB consumption, and variance.   Figure 2E: One way ANOVA single factor summary table with F critical, df,  and p-value. There is a significant difference between the conditions (p<0.05).    Figure 3E: Correlations, t-values, p-values and their corresponding categories. All correlations significant except for belief about ill effects of SSB and SSB consumption (p=0.8965).    Figure 4E: Summary table of the 6 interventions indicating the number of students who voted (count), the sum of the support, the average support, and variance for each intervention. (I1= UBC should regulate sale of unhealthy products; I2= remove SSNs from display, I3= encourage healthier beverage options to be placed at eye level in fridges/vending machines; I4= limit the serving size to less than 250 mL; I5= run a social marketing campaign on health impacts of SSB  DETERMINANTS OF SSB CONSUMPTION 16  Figure 5E: One way ANOVA single factor summary table with F critical, df,  and p-value. There is a significant difference in support between the 6 interventions (p<0.05).   Survey link: https://goo.gl/forms/4hTAFbwVf668ZkTz1         


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