Understanding and Promoting Water Consumption Among Children in Aruba Using the Social Network Intervention Approach

SUMMARY IN ENGLISH This summary provides an overview of this dissertation, titled “Understanding and Promoting Water Consumption Among Children in Aruba Using the Social Network Intervention Approach.” The dissertation comprises a general introduction (Chapter 1), followed by three empirical studies, each outlining its aims and findings (Chapters 2, 3, and 4), and ends with a general discussion and conclusion (Chapter 5). Chapter 1—General Introduction Childhood overweight and obesity present a critical public health concern, with the World Health Organization (WHO) estimating that 20% of children and adolescents aged 5 to 19 were overweight or obese in 2022, an increase from 8% in 1990. These unhealthy weights are a problem among Caribbean islands as well. Scientific research and intervention endeavors in the Caribbean region are needed. However, the Caribbean region is underrepresented in these endeavors compared to North America and Western Europe. Within the Caribbean, Aruba is worrisome because health authorities found percentages of overweight and obesity that are twice as high as the WHO’s estimate. To contribute to the United Nations’ Sustainable Development Goals and children’s right to health, this research project aimed to contribute to improving children’s health in Aruba. One of the major factors associated with childhood obesity is the consumption of sugar-sweetened beverages (SSBs). Researchers have found high SSB consumption patterns in the Caribbean. Water represents the only natural calorie-free fluid. Promoting water consumption is a promising strategy for improving health results, such as preventing weight gain and dental cavities. Despite this knowledge, studies worldwide have shown that children consume insufficient amounts of water, which is also the situation in Aruba. This highlights a knowledge gap regarding water consumption promotion in Aruba. Interventions that use social networks are shown to be effective in promoting health-related behaviors, like water consumption. Social network intervention entails appointing individuals as influential peers (e.g., individuals whom other peers respect, want to be like, and regard as good leaders) in a particular network who then spread specific targeted messages or behaviors in their network. Within these social networks, social norms are influential because individuals tend to be receptive to the perceived dietary behaviors (i.e., 121 Summary descriptive norm) and perceived approval or disapproval of the dietary behavior (i.e., injunctive norm) within their social network. The general objective was to investigate the effectiveness of using social network intervention in promoting water consumption among schoolchildren in Aruba. This general objective was structured around three research aims. The first aim was to determine the potential use of social network intervention. The second aim was to identify theory-based water consumption determinants. The third aim was to investigate the effectiveness of an adapted intervention in the context of Aruba. Chapter 2—The Potential of Using Children’s Social Networks at Schools A pilot study was executed to examine the potential of using social network intervention in Aruba. Through replication of the Dutch Share H2O intervention, this study tested the effectiveness of the intervention on Aruban children’s water consumption, SSB consumption, and intentions to drink more water and fewer SSBs. It also tested the potential moderating effect of perceived descriptive and injunctive norms on the results. The Share H2O intervention entailed identifying and training a selected subgroup of children as peer influencers to promote water consumption among children in their school social networks. In the intervention group, children were exposed to peer influencers promoting water consumption, while the children in the control group were not. Findings demonstrated that using social network intervention was promising because it improved water consumption when children experienced approval from their classmates regarding water consumption (i.e., positive moderation effect of injunctive norms). It also decreased children’s SSB consumption. Furthermore, the intervention effectively increased children’s intention to consume fewer SSBs, but it still did not increase children’s intention to consume more water—probably because their water intention scores at baseline measurement were already relatively high. Chapter 3—The Behavioral Determinants of Water Consumption Potential theory-based determinants associated with adolescents’ water consumption in Aruba were examined and compared to those in the Netherlands. Through the application of a model that integrated dominant theoretical perspectives in public health—including theories of planned behavior (attitude, behavioral intentions, norms, perceived behavioral control), social norms (descriptive and injunctive norms), and self-determination theory (i.e., intrinsic motivation)—the most important water consumption determinants were identified. Findings demonstrated that intrinsic motivation, descriptive norms of classmates, attitude, and perceived behavioral control were associated with water consumption among Aruban adolescents. Furthermore, it showed that the association between water consumption and both intrinsic motivation and descriptive norm in Aruba was stronger than in the Netherlands. This implied that it is even more important for Aruban adolescents than Dutch adolescents to be intrinsically motivated or to perceive their friends often consuming water to drink more of it themselves. Chapter 4—The Effectiveness of Kies Awa, a Social Network Evidence-Based Adapted Intervention Promoting Water Consumption Informed by findings from the preceding Aruba-specific studies (Chapters 2 and 3), the social network evidence-based adapted intervention Kies Awa (translation Choose Water) was developed. Key adaptations to the original intervention material entailed adding roleplay and educational materials to fit the Aruban context better. Children in the Kies Awa group were exposed to peer influencers promoting water consumption, while the children in the control group were not. The effectiveness of this Kies Awa intervention on children’s water and SSB consumption was examined, and the moderating effect of descriptive and injunctive norms on the intervention’s effectiveness was examined as well. Findings demonstrated that the evidence-based adapted Kies Awa intervention effectively increased children’s water consumption overall, which was not moderated by social norms. It was also effective in decreasing children’s SSB consumption when children experienced disapproval from their classmates regarding SSB consumption (i.e., injunctive norm) at the start of the intervention. Chapter 5—General Discussion The discussion highlighted that the adapted Kies Awa intervention resulted in a more substantial overall increase in children’s water consumption compared to the previous piloted study. This indicates that social network intervention is effective and indicates the importance of adapting intervention material within social network intervention in underrepresented contexts like Aruba in terms of health interventions. This means incorporating the social environment and context-based adaptations into intervention policy and practice is important. Before discussing the implications and suggestions for future research and intervention practice, the general limitations were addressed. This concerned limited generalizability, self-reported data, and limited measurement points. The chapter pointed out that despite improvements in beverage consumption after Kies Awa, children still did not meet the recommended guidelines regarding non-caloric fluid consumption. To address this challenge, the discussion proposed four interconnected areas for future research and intervention practice: enhancing peer influencers’ water promotion capabilities through co-creation, improving water access in schools, considering the removal of SSBs from school premises, and exploring a synthesized holistic approach. This holistic approach could entail enhancing Kies Awa intervention through co-creation and implementing policy-driven changes in the school environment to facilitate sole access to water. The dissertation highlights that children deserve a fair chance at a healthy childhood by growing up in school environments that encourage an even healthier lifestyle. Therefore, the dissertation concluded by emphasizing children’s global right to a healthy childhood. https://www.publicatie-online.nl/publications/saskia-franken/

Citation

Franken, S. (2025). Understanding and Promoting Water Consumption Among Children in Aruba Using the Social Network Intervention Approach. [Doctoral dissertation, Erasmus University Rotterdam].

URI

https://hdl.handle.net/20.500.14473/1821

Additional Links

https://www.publicatie-online.nl/publications/saskia-franken/