Underlying Drivers of Water and Sugary Drink Consumption in Puerto Rico: A Qualitative Participatory System Dynamics...

Empirical evidence shows that communities experiencing water hardship tend to consume more sugar-sweetened beverages (SSBs); however, the underlying mechanisms are not well understood.

This study aimed to integrate the perspectives of multiple stakeholders across different sectors to develop a shared understanding of the drivers of water and SSB consumption in Puerto Rico, where the majority of residents have experienced water hardship.

A participatory system dynamics modeling approach (Group Model Building) was employed to engage stakeholders across multiple sectors in Puerto Rico to develop a shared understanding of the underlying drivers of water and SSB consumption in Puerto Rico; how these interconnect; and to identify potential leverage points. The Group Model Building workshop was conducted in January 2023, and a parent group discussion was conducted in April 2023.

Stakeholders in San Juan, Puerto Rico, were purposefully recruited from public service (n = 7), commercial sector (n = 3), civil groups (n = 13), and parents (n = 5).

Multiple rounds of feedback and member checking sessions were conducted to synthesize the workshop outputs into an integrated systems map and a set of leverage points.

Stakeholders conceptualized water and SSB consumption in Puerto Rico as outcomes of 2 interconnected subsystems, both shaped by distrust in government. Fear of contaminants in tap and bottled water discouraged water consumption and indirectly increased SSB intake. Aggressive marketing reinforced habitual SSB consumption across generations. Stakeholders identified the following leverage points in Puerto Rico: leverage water infrastructure funding, provide water quality data in real time, and coordinate counter-marketing campaigns targeting SSBs paired with drinking water promotion.

This participatory approach brought together stakeholders from diverse sectors, encouraging them to look beyond individual behaviors of interest. Participants agreed that water would not become a viable alternative to SSBs if water insecurity were not addressed first.