Applying the socio-ecological model to understand factors associated with sugar-sweetened beverage behaviours among rural Appalachian adolescents

Brittany A. McCormick, Kathleen J. Porter, Wen You, Maryam Yuhas, Annie L. Reid, Esther J. Thatcher, Jamie M. Zoellner

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Objective: The objective of the current study was to identify factors across the socio-ecological model (SEM) associated with adolescents' sugar-sweetened beverage (SSB) intake. Design: This cross-sectional study surveyed adolescents using previously validated instruments. Analyses included descriptive statistics, ANOVA tests and stepwise nonlinear regression models (i.e., two-part models) adjusted to be cluster robust. Guided by SEM, a four-step model was used to identify factors associated with adolescent SSB intake - step 1: demographics (i.e., age, gender), step 2: intrapersonal (i.e., theory of planned behaviour (attitudes, subjective norms, perceived behavioural control, behavioural intentions), health literacy, media literacy, public health literacy), step 3: interpersonal (i.e., caregiver's SSB behaviours, caregiver's SSB rules) and step 4: environmental (i.e., home SSB availability) level variables. Setting: Eight middle schools across four rural southwest Virginia counties in Appalachia. Participants: Seven hundred ninety seventh grade students (55·4 % female, 44·6 % males, mean age 12 (sd 0·5) years). Results: Mean SSB intake was 36·3 (sd 42·5) fluid ounces or 433·4 (sd 493·6) calories per day. In the final step of the regression model, seven variables significantly explained adolescent's SSB consumption: behavioural intention (P < 0·05), affective attitude (P < 0·05), perceived behavioural control (P < 0·05), health literacy (P < 0·001), caregiver behaviours (P < 0·05), caregiver rules (P < 0·05) and home availability (P < 0·001). Conclusions: SSB intake among adolescents in rural Appalachia was nearly three times above national mean. Home environment was the strongest predictor of adolescent SSB intake, followed by caregiver rules, caregiver behaviours and health literacy. Future interventions targeting these factors may provide the greatest opportunity to improve adolescent SSB intake.

Original languageEnglish (US)
Pages (from-to)3242-3252
Number of pages11
JournalPublic Health Nutrition
Issue number11
StatePublished - Aug 2021


  • Adolescents
  • Rural Appalachia
  • Socio-ecological model
  • Sugar-sweetened beverages

ASJC Scopus subject areas

  • Medicine (miscellaneous)
  • Nutrition and Dietetics
  • Public Health, Environmental and Occupational Health


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