Understanding Adolescents' Beliefs About Sugar-Sweetened Beverages

Home , Sweetened beverage

Understanding adolescents’ beliefs about sugar-sweetened beverages using the Theory of Planned Behavior

Thesis

Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the

Graduate School of The Ohio State University

Mallary Nichole St. John, DDS

Graduate Program in Dentistry

The Ohio State University

2019

Thesis Committee

Erin Gross, DDS, PhD, MS, Advisor

Dan Claman, DDS

Rachel Kearney, BSDH, MS

Copyrighted by

Mallary Nichole St. John, DDS

2019

Abstract

Purpose: The purpose of this study was to identify adolescents’ beliefs regarding sugar- sweetened beverage consumption and dental caries using the Theory of Planned Behavior (TPB).

Methods: Adolescents aged 13 to 17, who had been diagnosed with dental caries in the past two years and presented to Nationwide Children’s Hospital for dental care, were recruited for this study. Study participants completed a 70-question questionnaire developed using the TPB to identify their knowledge, attitudes, beliefs and intentions about sugar-sweetened beverage consumption and dental caries. Additional questions regarding caries history and knowledge were asked as well. Participants were categorized into intenders versus non-intenders. Intenders were those who plan to avoid sweet drinks between meals while non-intenders did not.

Following data collection, analyses were conducted to determine which TPB constructs

(behavioral beliefs, normative beliefs, and control beliefs) were different between adolescent intenders and non-intenders.

Results: Seventy-seven patients met the inclusion criteria and participated in this pilot study.

Fifty-three percent were determined to be intender and 47% were non-intenders. Behavioral beliefs- Intenders believed not having sweet drinks between meals would help them avoid having tooth pain (p=0.0185). Similarly, intenders valued protection from new cavities greater than non- intenders (p=0. 0027). Normative beliefs- Intenders cared about the beliefs (p=0.045) and values

(p <0.001) of their dentist in regards to them drinking sweet drinks, yet neither group valued what their friends thought about drinking sweet drinks. Both groups felt their parents were

ii indifferent to their consumption of sweet drinks, yet intenders valued the beliefs of their parents greater than non-intenders (p=0.049). Control beliefs – Intenders agreed they have the control to not drink sweet drinks when they feel stressed about school, whereas non-intenders felt more indifferent when feeling stressed about school (p=0.03). In addition, there was a significance difference found between the two groups if their friends offer them sweet drinks (p=0.01) or if they were making the choice to buy a healthy option instead of a sweet drink (p=0.03), intenders agreed they could say no more strongly than non-intenders who felt more indifferent. Lastly, both groups mean values were close to neither agreed nor disagreed that they would have the support of their family to not buy sweet drinks to have at home, yet a significant difference was found between the two groups (p=0.046). Intenders slightly agreed they would have the support of their family while non-intenders slightly disagreed.

Conclusions: There were differences in the TPB constructs between adolescents who intend to avoid sugar-sweetened beverages and those who do not. Understanding the differences between intenders and non-intenders may help dentists tailor their conversation towards aspects that matter to adolescents most in order to ultimately change their consumption of sugar-sweetened beverages.

iii

Dedication

This document is dedicated to my family and close friends who have always believed in me. I

would not be where I am today without their constant support and encouragement.

Acknowledgments

I would like to thank the members of my research committee for all of their time, encouragement, and expertise in designing and carrying out this project. To Dr. Erin, this project would not have been possible without your continued help and encouragement. Thank you to

Ms. Kearney for helping us with our survey design, and Dr. Dan thank you for your help in setting up Qualtrics. A special thanks to the evening clinic staff and Dr. Gary Judis for their help in making this project possible. I would also like to thank Dr. Benjamin Kwok for his help in the preliminary studies conducted for this project, and Dr. Jeng for her time and efficiency in performing statistical analysis for this project. Lastly, thank you to Alex Sherman for her help in recruiting patients.

Vita

2013……………………………………………………………B.A. Zoology, Miami University

2017…………………Doctor of Dental Surgery, The Ohio State University College of Dentistry

2017 to present……………………………..…………....Resident, Division of Pediatric Dentistry

The Ohio State University and Nationwide Children’s Hospital

Fields of Study

Major Field: Dentistry

Table of Contents

Abstract ...... ii Dedication ...... iv Acknowledgments...... v Vita ...... vi List of Tables ...... viii List of Figures ...... ix Chapter 1. Introduction ...... 1 Chapter 2. Methods ...... 5 Study Population ...... 5 Creation of Research Instrument ...... 5 Measures ...... 6 Demographics ...... 8 Recruitment ...... 8 Analysist ...... 9 Chapter 3. Results ...... 10 Demographics ...... 10 Caries History ...... 11 Caries Knowledge ...... 12 Intention ...... 12 Behavioral beliefs ...... 13 Normative beliefs ...... 15 Control beliefs ...... 15 Additional Questions ...... 16 Chapter 4 Discussion ...... 17 Specific Aims ...... 17 Behavioral beliefs ...... 17 Normative beliefs ...... 18 Control beliefs ...... 19 Additional Questions ...... 20 Bibliography ...... 23 Appendix: Study Questionnaire ...... 25

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List of Tables

Table 1: Mean values for behavioral beliefs ...... 13 Table 2: Mean values for normative beliefs ...... 15 Table 3: Mean values for control beliefs ...... 16

viii

List of Figures

Figure 1: Ethnicity of Participants ...... 10 Figure 2: Type of Inusrance Coverage...... 11 Figure 3: Intenders vs. Non-Intenders ...... 13 Figure 4: Value of protection from new cavities ...... 14 Figure 5: Expentancy of avoiding tooth pain ...... 14

Chapter 1. Introduction

Dental caries is easily preventable, yet it is the most common chronic condition in adolescents aged 12 to 17 years old.1 In fact, it is four times more common than asthma in adolescents.1 Approximately 59% of adolescents have at least one cavity in their permanent dentition.2 According to the American Academy of Pediatric Dentistry’s Guide on Adolescent

Oral Health, there has been a noted increase in caries prevalence during adolescent years.3 There are a number of factors that contribute to this increased risk, including: immature enamel formation, independence to seek care or avoid dental treatment, poor oral hygiene, and diet.3 Diet plays a large role in the caries disease process but is often overlooked. It is known that dental caries is directly associated with the frequency at which one consumes sugar; 4 however, the general public often does not realize the role sugar plays in caries. A large number of adolescents drink sugar-sweetened beverages every day5,6 which can cause dental caries. In a study conducted from 2011-2014 by the CDC, almost two-thirds of youth aged 2-19 consumed at least one sugar-sweetened beverage on a given day.7 In order to ultimately prevent caries in adolescence one must look at the behavior causing the outcome of disease. This can be done by using a psychological behavioral model.

There are multiple psychological behavioral models for studying outcomes of health behaviors. Research has been done to try to determine which model best predicts behavioral outcomes, yet it is difficult to determine the best model given the theories are so different from one another.8,9 While there are several psychological models used in the literature to try and change health behavior, one of the longest standing and often cited theories is the theory of planned behavior (TPB).10,8

The theory of planned behavior is a psychological model used to predict behavioral outcomes in many disciplines.10 TPB is a derivative of the theory of reasoned action which was formed in 1967.11 Creators Icek Ajzen and Martin Fishbein found that by adding another construct of perceived behavior control to their original theory, they were more accurately able to predict intention of the individuals.12 Thus, the Theory of planed behavior is made up of three constructs: attitudes, subjective norms, and perceived behavior control.13

Each construct is broken up into two parts, expectancy and value. For attitudes, the expectancy or behavior belief strength is the extent to which an individual believes their behavior will result in a proposed outcome. In our study, the behavior being studied was avoiding sweet drinks between meals. Several outcomes of this behavior were evaluated, both positive and negative, such as protection from tooth decay or missing the sweet taste. The extent to which one cares about said outcome (i.e: protection from tooth decay) is then rated to determine the value.

The second construct is subjective norms. Subjective norms are defined as the perceived social pressure to carry out a behavior.14 Subjective norms are also made up of two components, normative beliefs and motivation to comply. Normative beliefs are the perceived beliefs an individual has about the beliefs of another individual or group (i.e. dentist, parents, or peers) in regards to the individual carrying out said behavior (i.e. not drinking sweet drinks between meals). The value the individual has for that group’s beliefs is then evaluated as well. This value is referred to as the motivation to comply.14 The last TPB construct is perceived behavioral control. The two components of perceived behavioral control are control beliefs and the influence of each control belief. Control belief are an individual’s perceptions of any barriers or hindrance that may get in the way of carrying out a behavior. The total of the control factors is believed to form one’s perceived behavioral control.11

All of these factors combine to form one’s behavioral intention, the extent to which someone plans to carry out a behavior. It has been found that intention is the strongest predictor of behavioral outcome.14,9 Thus, in order to ultimately change behavior, we have to better understand the individual beliefs that make up the three constructs of behavioral intention.

The depth and breadth of the use of the theory of planned behavior in the health care field is wide and it has been used to study sugar-sweetened beverage consumption. A 2012 study was conducted in southern Virginia which evaluated sugar-sweetened beverage consumption in adults using the TPB.15 It found convenience, availability, cost, and taste were all outcomes with the strongest intention to consume sugar-sweetened beverages.15A similar study was conducted looking at sugar restriction in the Tanzania population of college graduate students.16 This study found a consistent difference between intenders and non-intenders for all three behavior constructs.16 In particular, non-intenders felt they did not have control when they felt tired, bored, or they had enough pocket money to purchase sugar-sweetened beverages.16

For our purposes we wanted to look at the effectiveness of the TPB in the adolescent population. There have been several studies of TPB in adolescents looking at health behaviors such as condom use,17 smoking,18 flossing,19 and drug abuse. 20 Several studies have used the theory of planned behavior to examine adolescent consumption of sugar-sweetened beverages as well, but most are related to obesity outcomes.21 One study found perceived behavioral control at home was the strongest predictor of intention to carry out sugar-sweetened beverage reduction.22

Few, if any, studies have evaluated the link between sugar-sweetened beverages and the risk for dental caries in the adolescent population. One study performed in Uganda looked at individuals at two different points in time and their caries over time in regards to TPB.23 This study found attitudes and perceived behavior control were the strongest predictors of intention.23 Thus, the

3 purpose of our study was to better understand adolescents’ attitudes, subjective norms, and perceived behavioral control regarding sugar-sweetened beverage consumption and dental caries.

Such information will provide insight for dental providers who want to tailor their communication and intervention strategies for adolescents with dental caries attempting to reduce their sugar-sweetened beverage consumption.

The specific aims of this study were to: 1. Conduct a pilot questionnaire to identify adolescents’ beliefs regarding sugar-sweetened beverage consumption and dental caries using the

Theory of Planned Behavior (TPB), 2. Assess what adolescents with dental caries know about their own caries history, and 3. Determine what constructs of the TPB predict the intentions of adolescents to reduce sugar-sweetened beverage consumption.

Chapter 2. Methods

The Human Subject Committee of The Ohio State University, Columbus, Ohio (IRB

2019H0059) approved this study.

Study Population

The sample population consisted of adolescents aged thirteen to seventeen who presented to Nationwide Children’s Hospital or The Ohio State University for a routine dental hygiene or restorative visit. In addition, participants had to be English speaking, healthy, and have been diagnosed with at least one carious lesion in the last two years as was recorded in the Electronic

Health Records. Exclusion criteria included patients who did not speak English, new patients to the dental clinic, recall patients without a history of caries in the last 2 years, and medically compromised patients. The sample population was a population of convenience based on weekly variation of designated time to conduct research by the dental clinic personnel.

Creation of Research Instrument

Preliminary research was performed by this group in order to understand beliefs about dental caries and sugar consumption in the same research population. Fifteen participants from the same population were asked semi-structured interview questions rooted in the Theory of

Planned Behavior’s major constructs of attitudes, subjective norms, and perceived behavioral control. From this research, salient beliefs of participants were extrapolated from transcribed interviews in order to find trends and beliefs of adolescents with caries. This study is not yet published, but it informed some of the additional questions that were added in this pilot questionnaire.24

The survey instrument was designed by combining questions from a published study of sugar avoidance in a college graduate population, 16 questions from previous work from this group and from the guidelines set forth by the creators of TPB14 (Appendix A).

Measures

Behavioral Intention. Participants were asked three questions based on a bimodal scale that ranged from (-2) strongly disagree to (+2) strongly agree. The sum totally of the three intention questions were then calculated. Those greater than zero were classified as intenders while those less than or equal to zero were considered non-intenders.

Behavioral Beliefs. This construct looked at four positive and four negative outcomes of avoiding sugar-sweetened beverages between meals. The extent to which adolescents believed these were outcomes of drinking sweet drinks between meals was scored on a 5-point Likert scale from (1) strongly disagree to (5) strongly agree. A follow up question was asked for each specific positive or negative outcome in order to determine the extent to which participants valued the given behavioral outcome. These questions were scored on a 5 point scale from (1)

Very bad to (5) Very good.

Normative Beliefs. A five point scale was used to assess the expected approval of three different groups (dentists, parents, and friends) in regards to the patient’s consumption of sweet drinks between meals. A score of (1) denoted strong disagreement and (5) being strong agreement. On the same 5 point scale, participants were answered the extent to which they wanted to comply with the beliefs of each individual group.

Control Beliefs. From our previous study work we learned that several participants noted obstacles to avoiding sweet drinks. Thus, participants were asked to answer 10 questions about

6 their perceived control over specific obstacles and their beliefs. For the first seven questions participants were scored given the inverse 5 point Likert scale from (5) strongly disagree to (1) strongly agree in regards to avoiding sweet beverages for negative obstacles. The last three questions were positive actions participants could choose to do to avoid drinking sweet drinks.

Thus, these items were scaled on the traditional Likert scale (1-strongly disagree and 5- strongly agree).

Perceived Behavioral Control. The 10 control beliefs factors were totaled in order to calculate one’s perceived behavioral control. Perceived control could range from 10 to 50.

Past Behavior & Current Behavior. Previous performers were determined by asking participants about their past consumption of sweet drinks. Based on a bimodal scale with (-2) being never and (+2) being always. Previous Performers were those with positive values while previous non-performers were 0 and negative values. Current performers were evaluated on the same scale. In this case, never as (+2) and always was (-2). Those greater than zero were classified as performers while those less than or equal to zero were classified as non-performers.

Additional Questions. An additional seven questions were asked about participants’ education and knowledge about caries. These questions were derived in part from data previously collected by this research group, but did not directly follow the TPB. Three questions asked about caries knowledge and were scaled on a traditional Likert scale with (1) strongly disagree to (5) strongly agree. The other 4 questions asked about caries history. These questions allowed for a yes or no response with the option for I don’t know.

Demographics.

In addition to the survey questions, participants selected their age, gender, and ethnicity.

The remaining demographics were pulled from the electronic medical record. This included the number of months since the child’s most recent hygiene visit, the insurance type (state, private, self-pay), if fluoride varnish was applied at the most recent hygiene visit, if a prescription strength toothpaste was prescribed to the participant in the last two years, and the child’s caries history. Caries history included all carious lesions diagnosed in the last 2 years and the type of caries noted (Incipient caries, pit and fissure caries, smooth surface caries, and interproximal caries).

Recruitment

Eligible study participants were pre-screened from the dental clinic schedule in EPIC.

Participants that met the inclusion criteria were approached in the waiting room or in the dental clinic area and informed about the study. If the parent and adolescent agreed to participate, study personnel would review and obtain written parental permission and HIPAA Authorization from the participant’s guardian. Written assent was then obtained from the participant. A copy of each form was given to the family to keep. Participants were then given the survey instrument on paper or electronically via an iPad. Paper data was input by study personnel into the secure

Qualtrics survey system immediately following completion of the questionnaire. Data from the electronic version of the survey were automatically input in to the Qualtrics system. For each survey, study personnel recorded demographics for the participant from Epic into the Qualtrics survey, thus, linking it to the participant’s responses.

Analysis

Intenders and non-intenders were compared in this study. Intenders were those who scored greater than zero for the three behavioral intention questions, while non-intenders scored less than or equal to zero. Chi-squared analyses were carried out for categorical demographic data as well as for severe caries condition. A t-test was utilized to compare the age of intenders and non-intenders. T-tests were carried out for each question in a given behavioral construct comparing intenders versus non-intenders. For the control beliefs, the sum total gave one’s perceived behavioral and that was also compared by a t-test.

33.8%

Chapter 3. Results.

Demographics Seventy-seven participants met the inclusion criteria and participated in this pilot study. 41.6%

Six of those participants left one or more questions blank on the survey, while the remaining 71

participants complete all questions. The average age of participants was 14.9 years old (SD

±1.38). Fifty-two percent of participants identified as male while forty-eight percent identified as

female. When asked about their ethnicity, 41.6% were Black or African American, 33.8% were

white, 22.1% Other, and 2.6% were Asian (Figure 1).

2.6% Ethnicity

33.8%

41.6%

2.6%

22.1%

Figure 1. Ethnicity of participants.

According to the EHR, the majority of participants had state insurance at 81.8%, while

9.1% had private insurance, 5.2% had no insurance, and 3.9% were unknown (Figure 2).

Type of Insurance Coverage

4% 5% 9%

82%

State insurance Private Insurance No Insurance Unknown

Figure 2. Percent of participants with insurance types.

For 87% of participants their most recent hygiene visit took place within the last 12 months, while 9% took place in the last 13 to 24 months, and 4% were unknown. In addition,

93.5% of participants received a fluoride treatment at their most recent hygiene visit, while 2.5% did not, and 4% were unknown. Only 14% of participants received a prescription for a 1.1% sodium fluoride toothpaste (Prevident), while 82% of participants did not, and 4% were unknown.

Caries History

Along with recording demographic of participants from the electronic health record, the caries history for the last 2 years was also recorded for each participant. We were unable to record caries data for 3 participants. Eighty percent of participants had at least 1 pit and fissure lesion with an average of 1.85 (SD±1.92) lesions. Forty-seven percent of participants were diagnosed with at least on interproximal lesion. The average number of interproximal lesion for this group was 1.67 (SD±2.81). Twenty-two percent were diagnosed with a smooth surface

11 lesion that was not interproximal. Of these, one participant 10 or more smooth surface lesions while the others had 1 to 3 smooth lesions. The mean for smooth surface lesions was 0.3

(SD±1.27). Incipient lesions which were marked as a “watch” on the odontogram were also recorded. Seventy-three percent of participants had at least one incipient lesion, with an average of 3.5 (SD±3.38) watched surfaces.

Caries Knowledge

The majority of adolescents said they know what a cavity is with 92% stating they agreed or strongly agreed with this statement. Similarly, 80% of adolescents stated they know what to do to stop getting cavities, while 15% stated they neither agree nor disagree, and 5% stated they disagree that they do not know how to stop getting cavities. Twenty-two percent of individuals did not know if their dentist had explained to them what causes cavities, and 4% said “No” their dentist had not explained to them what causes cavities. Every participant in this study was diagnosed with at least one carious lesion in the last two year, yet 16% of individuals said “No” they had not had a cavity in the last couple of years and 12% said “I don’t know”. Similarly,

23% of individuals reported not having had a filling done to fix their cavity and 7% reported not know if they had had a filling done or not.

Intention

Of the 77 participants, 53% were found to be intenders in that they intended to not drink sweet drinks between meals while 47% were found to be non-intenders (figure 3). In addition, all demographics were evaluated in relation to intenders and non-intenders and no statistical difference was found between the two groups.

Intention of adolescents to avoid sweet drinks between meals.

Intenders

47% Non-intenders 53%

Figure 3. Intenders vs. Non-intenders.

Behavioral Beliefs

There was a statistically significant difference between intenders and non-intenders in terms of their value of protection from dental cavities (p=0.0027) (Table 1, Figure 4). Similarly, there was a difference between intenders and non-intenders and the extent to which they believe avoiding sweet beverages between meals will protect against tooth pain (p=0.0185) (Table 1,

Figure 5).

Table 1. Mean values and significance of Intenders/Non-Intender in relation to behavioral beliefs for expectancy and value questions.

* Statistical significance noted.

To me protection from new cavities is.

5 – Very Good

4 –Good

3 – Neither good nor bad

2 –Bad

Figure 4. Value of protection from new cavities for intenders and non-intenders.

Not drinking sweet drinks between meals would help me avoid tooth pain.

5 – Strongly Agree

3 – Neither agree nor disagree

1 – Strongly disagree

Figure 5. Expectancy of avoiding tooth pain for intenders and non-intenders.

Normative Beliefs

There was a statistically significance difference between intenders and non-intenders in what they believe their dentist wants them to do in regards to their consumption of sweet drinks

(Table 2). Similarly, a significance difference was found in the extent to which intending adolescents value what their dentist and their parents want them to do (Table 2). There was no statistical significance found between the two groups for the belief that parents or their friends do not want them to drink sweet drinks between meals.

Table 2. Mean values and significance of Intenders/Non-Intender in relation to normative groups for belief intenders/non and value questions.-intenders vs. normative beliefs

Belief Value Non- Non- Intenders P= Intenders P= intenders intenders Dentist 3.9 3.5 0.045* 4.3 3.5 <0.001* Parents 3.6 3.3 0.18 3.9 3.5 0.049* Friends 2.6 2.6 0.51 2.8 2.4 0.16 * Statistical significance noted.

Control Beliefs

For the control belief factors, a significant difference was found between intenders and non-intenders for 4 out of the 10 factors (Table 3). Intenders were more likely to avoid sweet drinks even when stressed about school (p= 0.03). Similarly, intenders felt they could talk to their family and ask them not to buy sweet and their family would agree (p= 0.046). They also felt they could say no to their friends if they offered them sweet drinks (p= 0.01) and they were able to choose healthy snacks instead of sweet drinks (p= 0.03).

Table 3. Mean values and significance for intenders/non-intenders for control beliefs. Non- Intenders P= It is difficult to not drink sweet drinks when…. intenders ~I feel tired. 3.3 3.4 0.77 ~I am bored. 3.5 3.4 0.70 ~I feel sad. 3.7 3.6 0.85 ~I have extra money to spend. 3.0 2.8 0.32 ~I am stressed about school. 3.8 3.2 0.03* ~I am stressed at home. 3.7 3.5 0.58

~I will get cavities no matter what I do. 3.8 3.5 0.28 My family is willing to stop having sweet drinks at home 3.3 2.8 0.046* I can say no if my friends offer me sweet drinks. 4.1 3.5 0.01* I can buy something healthy instead of sweet drinks. 4.1 3.6 0.03* Perceived Behavioral Control 29.4 28.5 0.5 *Statistical significance; ~ inverse Likert scale to calculate PBC (5) strongly disagree, (1) strongly agree.

Additional Questions

The descriptive results of the additional questions were described above. In terms of analyses, there was a statistical significance found for one of the seven questions. “I know what a cavity is” was found to be different between intenders and non-intenders. Intenders are more confident and had an average mean of 4.4 while non-intenders had a mean of 4.08 (p= 0.035).

Chapter 4 Discussion

Specific Aims

From this study we wanted to 1. Conduct a pilot questionnaire to identify adolescents’ beliefs regarding sugar-sweetened beverage consumption and dental caries using the Theory of

Planned Behavior, 2. Determine what constructs of the TPB predict the intentions of adolescents to reduce sugar-sweetened beverage consumption, and 3. Assess what adolescents with dental caries know about their own caries history. From this study we were able carry-out a pilot questionnaire rooted in TPB. From the three constructs of the theory of planned behavior, we learned which factors contribute to adolescents’ intention to avoid sugar-sweetened beverages, and from our additional questions, it was found that not all adolescents are well informed about their caries history.

Behavioral Beliefs

Both groups agreed that not drinking sweet drinks between meals would provide protection from getting new cavities at close to the same average. The mean expectancy for intenders was 4.02 and for non-intenders it was 3.94. In terms of value, Intenders valued protection from new cavities on a larger scale then non-intenders as the difference between the two groups was significant (Table 1). Figure 4 shows that both groups value protection from new cavities; they both feel it is a good with average above three. The difference lies in that intenders feel protection from new cavities is very good with a mean closer to five.

While there was not significant difference, it is interesting to note which outcomes adolescents expect from avoiding sweet drinks between meals. Both intenders and non-intenders disagreed that they would feel like they had a boring diet, feel hungry, or feel left out from their

17 friends if they did not have sweet drinks between meals. Both groups neither agreed nor disagreed that they would miss the sweet taste. This finding is different than a study of adults avoiding sugar-sweetened beverage consumption found taste was a factor for drinking sugar- sweetened beverages.15

Normative beliefs

Both intending and non-intending adolescents felt that their dentist did not want them to drink sweet drinks between meals. The non-intenders had a mean value of 3.5 meaning the majority of non-intenders fell between answering they agree (4) or they neither agree or disagree

(3) that their dentist wants them to avoid sweet drinks between meals. Intenders were found to have a mean of 3.9 which means the majority of intenders agree with this statement about their dentist’s beliefs for them. There was statistical difference found between the two groups in relation to their dentist’s beliefs. Similarly, there was a statistically significant difference found between the two groups in the value they placed on the beliefs of their dentist. Intenders valued doing what their dentist wants them to do greater than non-intenders.

When looking at what adolescents’ believe about their parent’s beliefs, there was no difference between intenders and non-intenders. Intenders had a mean of 3.6 while non-intenders had a mean of 3.3. Thus, both groups are slightly on the positive side of agreeing with the belief that their parents do not want them drink sweet drinks between meals. There was a statistically significant difference, however, between the two groups in the value of doing what their parents want them to do. Thus, intenders value what their parents believe but do not feel their parents truly care if they drink sweet drinks or not. In previous studies, parents were not a normative factor for TPB studies looking at adults as well as graduate students. In the study of adults, doctors and peers were normative factors that influenced adults15, while in the graduate

18 population there was no significant influence from doctors, dentists, relatives, or friends.16 In another study of adolescents’ intention to consume alcohol, parents’ beliefs was the third most predictive factor.25 Thus, adolescents’ perceived beliefs about their parent’s wishes seems to be an area that could be of clinical significance. If parents expressed their concern for their adolescents drinking sweet drinks between meals, intending adolescents may be more inclined to change their behavior.

Teenagers on average said their friends were indifferent to them drinking sweet drinks between meals or they disagreed that their friends thought they should not partake in sweet drinks between meals. For value, all means were below 3.0 indicating adolescent intenders and non-intenders did not value the beliefs of their friends in regards to sweet drinks. This is in contrast to a study of adolescents and their intention to consume alcohol. Adolescents were influenced by peer pressure from their friends as well as their friends’ experience with alcohol.25

Control Beliefs

There was a significant difference found between the two groups in avoiding sweet drinks when feeling stressed about school. Intenders felt they could avoid sweet drinks when feeling stressed whereas non-intenders felt more indifferent. Also of significance, intenders believed their family would stop having sweet drinks at home if they asked them to. In addition, we found that intenders feel they can say no to their friends if offered sweet drinks. This is consistent with the findings we found for normative beliefs in this study in that adolescents intenders and non-intenders are indifferent about the beliefs of their friends in regards to sugar- sweetened beverage consumption. This was different from what was found in regards to friends and refusing alcohol.25 Lastly, the two groups again differed in that intenders felt they had the control to purchase a healthy snack over a sweet drink. Importantly, there was no statistical

19 significance found between the two groups in regards to: feeling sad, tired, bored, stressed at home, or having extra money to spend on sweet drinks. This is interesting in that a study of adults cost was found to be a factor regarding sweet drinks.15 In addition, a study of college graduates found feeling tired and bored as well as having extra pocket money factors between intenders and non-inteders.16 None of these were found to be factors in our adolescent population.

Additional Questions

There were seven additional questions asked to better understand adolescents’ knowledge about their own caries history and beliefs. These questions did not follow the structural format of

TPB but were found to be of significance from previous work done by this group. When asked if their dentist has explained to them what causes cavities, 4% of adolescents said “No” while 21% said “I don’t know.” Another question asked was “Have you had a cavity in the last couple of years?”. Twenty-eight percent of adolescents said “No” or “I don’t know” even though all participants in the study had had at least one carious lesion diagnosed in the last two years.

Thirty percent of participants did not know if they had had a filling done to restore their caries in the last two years. This is of interest in that many of these adolescents may have had local anesthesia for their dental procedures yet do not understand that a permanent restoration was placed because they had a carious lesion. For all of these questions, there was no difference found between intenders and non-intenders. The lack of knowledge about one’s own caries history is of concern because the first step to behavior change is to know and understand one has a disease that requires a change in behavior.

One question that was found to have significance between intenders and non-intenders was “I know what a cavity is.” This difference was not meaningful because both groups on

20 average still agreed they know what causes a cavity. In fact, an overwhelming majority, 92% of respondents, agreed or strongly agreed they know what a cavity is.

From these questions we learned adolescents feel confident they know what a cavity is, yet approximately one fourth do not know they have the disease. Further research needs to be done on how best to communicate to adolescents as dental providers. Long before behavior change can occurs, adolescents must first know they have caries. Secondly, adolescents must then understand that it is the consumption of sugar, often sugar-sweetened beverages, that leads to the disease. It is only then that looking at intending and non-intending adolescents to change their behaviors will be effective. Thus, further research at the most basic level of making sure adolescents understand they have a disease and knowing what causes it is important. For adolescents who already understand these aspects of the disease process, it is important to bring the beliefs of parents into the behavior change as well as trying to eliminate barriers to change such as stress at school, or family members willingness to no have sweet drinks at home.

There were some limitations to this study. Given our sample was a sample of convenience, there was a large number of providers seeing our patient population. As a result, not all children received the same oral hygiene instruction or anticipatory guidance for preventing dental caries. Another limitation of this study is that it took place in a dental setting with a dentist in scrubs asking adolescents to fill out a survey. This lends itself to some bias as teenagers maybe more inclined to answer survey questions how they think their dentist would want them to respond. This could be an area of future research, as the survey could be conducted in a school setting and administered by someone other than dental personnel. Another limitation to this study is that it was conducted at a safety net clinic. Thus, the research results may not be generalizable to private practice pediatric dental offices.

Overall from this pilot study we learned that certain aspects of each TPB construct have an influence on adolescents and their intention to avoid sugar sweetened beverages. We also learned that some adolescents may not know and understand their own caries history. From this information, we hope to survey adolescents on a large scale in order to gain further insight into understanding and better communicating with adolescents as dental providers.

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Appendix

Study Questionnaire TBH Survey When answering these questions, sweet drinks include: Regular Soda/Pop, Juice, Fruit drinks or punches, sweet coffee drinks, sweet tea, lemonade, sports drinks, energy drinks. Sweet drinks does NOT include: Diet or sugar-free drinks. Demographics: 13 14 15 16 17 1. Age o o o o o

Male Female 2. Gender o o

Native Black or American Hawaiian African Indian or or Pacific White American Alaska Asian Islander Other Native 3. Ethnicity o o o o o o

Intention: Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 1. I plan to only have sweet drinks o o o o o during meals. 2. I plan to switch to diet or sugar-free o o o o o drinks. 3. I plan to have water instead of sweet drinks o o o o o in between meals.

Behavioral Belief Strength: Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 1. Not drinking sweet drinks between o o o o o meals would protect me from getting new cavities.

Neither good Very bad Bad nor bad Good Very good 2. To me protection from new o o o o o cavities is…

Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 3. Not drinking sweet drinks between meals would o o o o o allow me to have teeth that look good.

Neither good Very bad Bad nor bad Good Very good 4. To me having teeth that look o o o o o good is…

Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 5. Not drinking sweet drinks between meals would o o o o o help me avoid tooth pain.

Neither good Very bad Bad nor bad Good Very good 6. To me avoiding o o o o o tooth pain is…

Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 7. Not drinking sweet drinks between meals would o o o o o allow me to not have bad breath.

Neither good Very bad Bad nor bad Good Very good 8. To me not having bad o o o o o breath is…

Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 9. Not drinking sweet drinks between meals would o o o o o make me miss the sweet taste.

Neither good Very bad Bad nor bad Good Very good 10. To me missing the taste of sweet o o o o o drinks is…

Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 11. Not drinking sweet drinks between meals would o o o o o be a boring diet.

Neither good Very bad Bad nor bad Good Very good 12. To me having a boring diet o o o o o is…

Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 13. Not drinking sweet drinks between meals would o o o o o make me feel hungry between meals.

Neither good Very bad Bad nor bad Good Very good 14. To me feeling hungry o o o o o between meals is…

Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 15. Not drinking sweet drinks between meals would o o o o o make me feel left out from my friends.

Neither good Very bad Bad nor bad Good Very good 16. To me feeling left out from my o o o o o friends is…

Normative Beliefs & Motivation to Comply Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 1. My dentist thinks I should not o o o o o drink sweet drinks between meals. 2. I want to do what my dentist tells me to do o o o o o about drinking sweet drinks.

3. My parents think I should not drink sweet drinks o o o o o between meals. 4. I want to do what my parents tells o o o o o me to do about drinking sweet drinks. 5. My friends think I should not o o o o o drink sweet drinks between meals. 6. I want to do what my friends tells me to do o o o o o about drinking sweet drinks.

Control Beliefs & Power of Control Factor Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 1. It is difficult to not drink o o o o o sweet drinks when I feel tired. 2. It is difficult to not drink sweet drinks o o o o o when I feel bored. 3. It is difficult to not drink sweet drinks o o o o o when I feel sad. 4. It is difficult to not drink o o o o o sweet drinks when I have extra money to spend. 5. It is difficult to not drink o o o o o sweet drinks when I am stressed about school.

6. It is difficult to not drink sweet drinks o o o o o when I am stressed at home.

7. I will get cavities no matter what I o o o o o do. 8. If I asked them to, my family can o o o o o stop having sweet drinks at our house. 9. If my friends give me sweet o o o o o drinks, I can say no. 10. If I go to the store I can buy something o o o o o healthy instead of sweet drinks.

Past Behavior Almost Half of the Almost Never Never time Always Always 1. During the past 6 months, how often have o o o o o you avoided sweet drinks between meals?

Half of the Never On Occasion time Most days Every day 2. How often do you drink sweet drinks o o o o o between meals?

Attitudes Neither good Very bad Bad nor bad Good Very good 1. Having sweet drinks between o o o o o meals makes me feel… 2. Drinking water in between o o o o o meals makes me feel… 3. Drinking diet or sugar- free drinks o o o o o between meals makes me feel…

Subjective Norms Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 1. Compared to me, other teenagers o o o o o drink more sweet drinks. 2. Other teenagers can stop having sweet drinks o o o o o if they want to. 3. Some people just get a lot of cavities, no o o o o o matter what they drink.

Additional Questions – Neither Strongly Agree nor Strongly Disagree Disagree Disagree Agree Agree 1. I know what a cavity o o o o o is.

2. I know what to do to stop getting o o o o o cavities. 3. I feel confident I know what o o o o o causes cavities.

Yes No I don’t know 4. My dentist has explained what causes o o o cavities to me. 5. I have had a cavity in the last couple of o o o years. 6. I have had a filling to fix my cavity in o o o the last couple of years. 7. I have a cavity right o o o now.