Danish children have a much larger intake of sugar-rich foods and drinks than recommended. This study aimed to (1) explore social aspects and practices of pre-school children’s intake of sugar-rich foods and drinks and (2) evaluate barriers and parental strategies to reduce their children’s intake of sugar-rich foods and drinks employed in connection with the 3.5-month family-centred intervention trial ‘Are you too sweet?’. Intervention components included communication of the recommended maximum intake and reduction strategies, supported by resources encouraging and facilitating behavioural changes. A random sample of families (n = 24) from intervention schools participated in post-intervention semi-structured interviews. A thematic content analysis was conducted, revealing three main domains of social practices: (1) ‘family treats’, including the weekly Danish concept ‘Friday sweets’, (2) ‘everyday treats’, such as sweet snacks in lunch packs, between-meals snacks and soft drink habits and (3) ‘socialized treats’, including treats at special occasions. Parents employed several strategies, most often substitution and portion-size reduction, but also limiting home availability. Families most frequently made changes that were easily adoptable and close to existing routines at home. In conclusion, the intervention components provided families with knowledge and strategies that facilitated behavioural changes towards reducing the intake of sugar-rich foods and drinks. Within public health research and policies, there is widespread consensus that reducing the intake of sugar-rich foods and drinks holds important potential for preventing obesity and related diseases ,2,3, pooAccording to data from the Danish national survey of diet and physical activity, Danish children’s intake of sugar-rich products largely exceeds recommendations , and salDespite numerous studies of parental attitudes, approaches and practices, it remains unclear which strategies are the most effective at securing a diet low in sugar-rich foods and drinks ,21. StruIn order to increase awareness and reduce the high intake of sugar-rich foods and drinks, the ‘Are you too sweet?’ intervention targeting 5–7-year-old children and their families was developed . A famiThis qualitative study was a part of the intervention ‘Are you too sweet?’. The design and methods of the intervention have been described in Bestle et al. 2020 . BrieflyNew official guidelines on the maximum intake of sugar-rich foods, drinks and salty snacks have recently been developed ,28. The The intervention evolved around the school health nurse consultation that is mandatory to offer in Danish pre-schools. In the intervention group, the consultation was extended by 5 min targeting the families’ sugar intake habits. Through a dialogue-based approach, the school health nurse informed the family about maximum limits and possible changes with a focus on the child’s individual habits. The school health nurse’s advice and guidance were based on a preceding registration of the child’s intake of sugar-rich foods and drinks, enabling individualized guidance . TM group ‘Sweet friends of Hvidovre’, used to provide parents with information and ‘reminders’ and build peer-to-peer support among participants. Thus, a broad range of supportive resources was made available to families in a flexible framework where they could select tools, tips and tricks according to their individual needs. At the consultation, each family received a box with home-use tools comprising a booklet with visualizations of the maximum limits, suggestions for behavioural change strategies and tips and tricks for reductions, a deck of cards that could be used for different game activities, a read-aloud children’s book on dental health, a serving size board with reusable stickers illustrating the maximum recommended amount of servings, suggestions for local family activities, three small posters and stickers with the project logo. The aim of the home-use tools was to convey information and strategies in a positive, non-offensive tone of voice to facilitate intake reductions and support behavioural change in the family. As complementary components, an educational app with learning games on dietary and dental health was developed and provided to the participating families to supplement and support the tools in the home-use box. Furthermore, the families were invited to subscribe to the private FacebookThe recruitment of interviewees was conducted with the sample size goal of approximately 25 participants to secure data saturation  and in oThe primary author conducted all interviews using Microsoft Teams  , as COVID-19 restrictions inhibited interviews in participants’ homes. Interviews were semi-structured , employiA thematic content analysis was employed . The anaInterviews lasted between 44 and 77 min, with an average length of 61 min. Nineteen single and five double (both parents) interviews were conducted . InterviIn the analysis, four key themes and a range of sub-themes were identified .Furthermore, a pattern of social practices around sugar-rich foods and drinks emerged that included three different framings of practices related to (1) ‘family treats’, (2) ‘everyday treats’ and (3) ‘socialized treats’. ‘Family treats’ are sugar-rich products consumed in the household with close relatives to create family time, while ‘everyday treats’ comprised sweet snacks and soft drinks linked to everyday life, e.g., afternoon snacks or in the child’s lunch packs, and ‘socialized treats’ included sugar-rich servings at social occasions and celebrations, e.g., birthdays with family or classmates and festive and seasonal gatherings. Different strategies and barriers pertained to these three social contexts and related to the amount, frequency, type and function of the serving of sweet treats. In the following sections, practices, strategies and barriers will be described.In Denmark, especially Friday night, but also Saturday and Sunday are culturally codified as ‘family time’. On Fridays, many families go to grocery stores or sweet shops and buy pick ‘n’ mix sweets for ‘fredagsslik’, which means ‘Friday sweets’. Treats are bought for both children and adults, and the valued tradition was spelled out in the interviews.“Friday sweets are simply a tradition. It has just always been that way, so that would be hard to change. Whether they get an ice cream on a Tuesday or a Wednesday or not at all, that, I think, would not be very important to them. But the Friday sweets are really—it is kind of sacred”,Mother to boy at school A.Thus, many parents cherished the family ‘ritual’ of Friday sweets; they looked forward to it, and so did the children.“You look forward to all those things, or at least [name of the child] does, to arrange it nicely and have a good and cosy time with it”,mother to boy at school D.One of the reasons why Friday sweets became valued among both adults and children was that on Fridays they are ‘allowed’, in the sense that a common strategy is to limit one’s intake of sweets and sugar-rich foods and drinks, and thus reserve it for weekends and holidays.“We have simply declared: “now it is limited to Friday sweets, and that is it”, and he seems to take it quite well”,mother to boy at school A.Some families had chosen not to follow the tradition of Friday sweets as a culturally codified, fixed weekly tradition, but ‘family time’ was still closely related to sweet treats.Strategies for reductions related to Friday sweets and other sweet treats served to create family time were often dependent on existing family rules, e.g., whether families already had decided to omit sugar-rich foods and drinks during the week.“We have rules that at least on weekdays there are no sweets”, father to girl at school C.The Friday sweets practice as such was not questioned in the large majority of families, but the amount and serving sizes were evaluated and at times reduced.“I am glad we have cut back on the intake on Fridays compared to earlier, where it was a huge pile of sweets and then a stomach ache the next day”,mother to girl at school D.Encouraged by intervention materials, some of the families had changed their serving modus, e.g., to portion out servings in small bowls or cups to be aware of and limit how much the children were consuming; this pertained to both Friday sweets and other sweet treats served to create family time. One family changed their Friday habits altogether by introducing ‘Friday fruits’.“Now we have Friday fruits. The kids chip in what fruits we should buy and then they have something a little extra, like cream biscuits or a pancake or something like that, but we always have fruits and something sweet, but it is never sweets”,mother to girl at school C.However, the most common strategies to limit ‘family treats’ were to reduce the portion sizes or to replace (some of the) chocolate, toffee or sweets with healthier alternatives, such as fruits. All of the children in the study brought their own lunch packs for lunch in school. Children thus ate what their parents prepared at home. Lunch packs typically consisted of open-faced sandwiches , vegetables and fruits, and parents often added snacks  as small treats. At two intervention schools, there were rules for foodstuffs not allowed in lunch packs, e.g., cake, sweets or chocolate bars and cordial; the two other schools had no such restrictions.‘Everyday treats’ also included sugar-rich snacks given in the afternoon. In many families, it was common for the child to have a light meal or a snack in the afternoon at home to keep them going until dinner or, e.g., on the way to an after-school activity. This is consistent with snacking patterns in other countries  and is c“I used to prepare a snack platter for him in the afternoon. I guess it was more sweet things than fruit and vegetables. It could be a small bowl with crisps, some chocolate or a chocolate bar. Or it could be a fruit stick”, mother to boy at school B.A third practice related to ‘everyday treats’ was the consumption of soft drinks. Among interviewees, there was clear pattern as to whether families were drinking soft drinks or not. Only a subsample served carbonated soft drinks for their children, and as a general rule, these parents drank carbonated soft drinks themselves on a daily basis. In a few families, children had cordial, while the parents had soda, reflecting a view of cordial being mainly ‘for kids’.“We drink a lot of milk, they have water at school and in kindergarten, and then they can have one glass of cordial for dinner. Well, that is how we do it in our family, right?”,mother to girl at school A.‘Everyday treats’ thus included a range of different social practices linked to the everyday life of the family, but these practices were less culturally codified compared with the practices linked to ‘family treats’.The most common approach to reduce sugar-rich foods in lunch packs and afternoon meals was a substitution strategy, whereby sweet snacks were replaced by healthier alternatives.“I give it more thought now what I put in his lunch pack. I have swopped some of the spreads. He really likes chocolate spread, but now he rather gets fruit cuts, or fruit sticks instead of Kinder milk slices”,mother to boy at school B.In the home-use intervention tools, it was explained how a range of frequently used snacks like granola bars, biscuits and cordial should be categorized as sugar-rich along with more commonly recognized sugar-rich products like chocolate, ice cream and sweets. This awareness of sugar-rich snacks motivated swops and new habits in many families. “Typically, there was a packet of biscuits in the drawer and that was what the kids wanted when they got home from school. They got two-three-four biscuits according to their appetite. Now we realize the amount of sugar in those biscuits and we are happy to have that knowledge”,mother to girl at school C.“We do know that cordial contains sugar, but then you read it and it is a kind of an eye-opener […] Now cordial is only served on weekends”,mother to girl at school D.The availability of healthy snacks at home was key in these substitution strategies, and the real change was often made in grocery shopping habits.“We limit the amount of unhealthy food when we shop for groceries and serve something else. Afternoon snack are bell pepper and fruit instead of fruit sticks, biscuits and the like”,mother to boy at school A.The altered provisioning consisted of two approaches: either one where a stock of healthier ready-to-serve products such as a fruits and berries, nuts, dried fruits or crispbread replaced, e.g., biscuits or granola bars; or an approach where raw vegetables or fresh-cut fruit substituted the sugary snacks. This change was more work-intensive for parents, as it demanded preparation time and planning.“Perhaps we have gotten a little better in preparing veggie snacks and between meals and not necessarily use granola bars or ice cream as our go-to solution. Simply getting these carrot and celery sticks cut (laugh) so that you can serve them in time”,mother to boy at school C.Parents who adopted this approach reflected on the fact that the needed preparation time was closely linked to the overall level of time and resources in the family and thus that there was a risk of slipping back into old habits.“The afternoon meal is healthier, but that is also linked to my parental energy level; if I am tired the servings drop in quality, but in general, meals have improved”,mother to girl at school C.As a rule, whether it was in relation to substitution or availability strategies, parents did not transform family habits in any radical way; they just changed them slightly in a healthier direction, while the actual practices remained close to existing routines. Hence, new habits were old habits, just adjusted to be more in line with the intervention messages. In contrast, changes that demanded more effort, e.g., that parents change their habits, were reported to be harder to implement. Behavioural changes in relation to carbonated soft drinks were the most frequent issue. Parents’ recognition that they were direct or indirect role models for their children motivated them to change habits and reflect on how they could avoid passing on unwanted habits that they have difficulty controlling in their own lives.“I have a guilty pleasure: soda and energy drink. That is my weakness […] And energy drink is the worst; that is really something you should not introduce your children to, right? It makes me think: ‘Wow! My kids should definitely not have energy drink’”,mother to girl at school A.In the families that reduced their daily habitual carbonated soft drink consumption, the behavioural change often also consisted of restricting accessibility. Participants explained that easy access to carbonated soft drinks, e.g., stocks in the fridge or bottles on the dinner table, made reductions in intake challenging, and they thus changed the accessibility.“My husband is very fond of soda. He is crazy about real Coke [with sugar] and we have decided that it does not work! We need to stop that, because [name of child] started to grow fond of it too. It was right there, as an alternative [to water] on the dinner table. So we have cut out soda and cordial completely during the week”,mother to boy at school A.The fact that cordial, both artificially sweetened and sugar-sweetened versions, was to be restricted in line with carbonated soft drinks came as a surprise to participants. Parents used to serve cordial—artificially sweetened and to some extent sugar-sweetened—in good faith, but the increase in knowledge obtained through the intervention materials spurred a motivation for behavioural change.“That is our biggest change: Water on weekdays!”,mother to girl at school D.Restricting cordial might be seen as a substitution strategy in line with the swops made in relation to lunch packs and afternoon snacks, as cordial is substituted by water or milk. Overall, social practices related to ‘everyday treats’ (with carbonated soft drinks as an exception) were perceived as relatively easy to change.“It became clear that there were some things that relatively easy could be swopped with other things”, father to boy at school C.Children’s packed lunches and afternoon snacks (foods and drinks) seemed to be relatively low-hanging fruit in parents’ experience of behavioural change, and new habits could thus be adopted smoothly. The offering of sweet treats and soft drinks during seasonal celebrations like Halloween and Christmas is a cultural tradition in Denmark. At school, it is tradition that a birthday child brings sweets or cake, and as a rule, festive, social occasions are celebrated with sugar-rich products. In Denmark, shared social events and special occasions thus constitute an important social context for serving sweet treats to children.Parents reported that they generally had difficulty in regulating or restricting the serving of sugar-rich foods and drinks outside the home. In relation, when filling in the dietary record that was part of the data collection for the quantitative evaluation of the intervention , many r“I was shocked how little control I have over what my child eats during the day […] I mean we can have a healthy balance [with a limited amount of sweet foods and drinks] at home. But then it is a week with a lot of activities: Baking cake in the after school club, and birthdays in class where friends bring Kinder surprise eggs”,mother to boy at school A.Parents emphasized social gatherings and seasonal celebrations as particularly challenging. These traditions often involve sweet treats and often in amounts that the parents would not offer at home.“Now it is Fastelavn [Danish Carnival tradition in February] and I think it is exaggerated: They have a bun with icing and cream, and cocoa and sweets. Apparently, they need it all. And at birthday celebrations they wallow in sweets again—and cake and the like. In fact, it is more the things that I cannot change that I think should be cut down”,mother to girl at school A.Other interviewees related that seasonal celebrations, especially Halloween, Easter and Christmas, often resulted in large amounts of ‘left-over sweets’: treats and gifts that relatives had brought for parties or social gatherings that subsequently became unwanted stockpiles. “I have used quite some time clearing it all out. The girls have several very ‘generous relatives’ [sarcastic voice], my aunt for example, every year she arrange this Easter hunt, and I mean it is an enormous bag with chocolate eggs”,mother to girl at school A.Another, and related, recurrent topic in parental accounts was sweets and treats served in relation to family relations or social activities. Notably, grandparents were mentioned by the interviewees as a challenge.“The hardest thing right now is Grandma. It is really…[sigh]. When they are at grandma’s place they are spoiled. Preferably with sodas and sweets”,mother to girl at school A.Sugar-rich foods and drinks served in relation to social relations or events outside the home thus played a major part in the children’s intake of sweet treats.Despite their disapproval of the frequent and large amounts of socialized treats served to their children, parents in general did not interfere with social occasions or set special rules for their children in an attempt to limit their intake, e.g., at birthday parties. “I mean we are not the kind of parents that tell our kids: “You are not allowed to eat the treats offered at school”, or tell our parents that they should not serve cake when the grandchildren are visiting. There are other considerations to take into account—both in relation to our kids but also family and friends. Concerns that overrule the guidelines [from the project]”,father to boy at school C.Many parents actively chose not to engage in arguments with their parents (or parents-in-law), as they considered it overly difficult or feared that such critiques could cause disagreements that served no purpose. Others addressed the issue. “I pay more attention to what my parents offer to the girls, and I have asked them to cut down. I have been more outspoken, than before, because I think they exaggerate the treats. Earlier I have been thinking: “We are not there that often, it will be okay,” but this time I raised it and explained that they should not have all kinds of sweets and treats, when we are visiting”,mother to girl at school B.In relation to the school setting, several parents explained that they would have liked to discuss and establish agreements with fellow parents on, e.g., the amount of sugar-rich foods and drinks offered for social class events like birthdays. However, because of the COVID-19 lockdown, parents in many cases did not get to meet one another for the first 7–8 months of their child’s schooling. In Denmark, there is a strong tradition of parents’ involvement in their children’s schooling, and a central principle of Danish education is that pupils attend permanent classes, thus having the same classmates and class teachers for years . WithoutIn the analysis of the interviews, a range of barriers to reducing the intake of sugar-rich foods and drinks was identified. A number of barriers related specifically to ‘family treats’, ‘everyday treats’ and ‘socialized treats’, while other barriers intersected these social practices. In the following sections, barriers will be described and organized in the following categorization: (1) culturally codified practices and social concerns, (2) parents’ personal preferences, (3) parents having disparate views on health, (4) lack of motivation, (5) lack of skill and knowledge and (6) lack of parental resources.Across the different social practices related to sugar-rich foods and drinks, ‘socialized treats’ emerged as very hard to change. Parents experienced a lack of control of and influence on what their child was offered as a main barrier. To impose restrictions and limitations on ‘socialized treats’ in relation to family, classmates, friends and other social relations was perceived as in conflict with social and cultural norms, and social concerns took precedence over the dietary guidelines.A comparable attitude was seen in relation to ‘family treats’. The majority of participants reported that family time and sugar habits were associated. To have family quality time often implied some sort of ’comfort food’ high in sugar. This culturally established norm shaped practices and mindsets notably during weekends and holidays. Several families reported that holidays were special, and that things could ‘go a bit off track’. Families deemed it to be expected and acceptable as long as they got back on track when they returned to everyday life.“It has been a little less strict, because it is the holidays. I mean, that is when they should feel that you have some extra fun together. The holidays are where you should try to relax and have a good time together”,mother to boy at school A.The main approach in families was thus that sugar-rich foods were acceptable and suitable on family occasions, and if they had made changes to reduce intake, they were generally adjustments (most often of portion sizes) and not restructurings of the concept of, e.g., Friday sweets.Likewise, it could be socially difficult merely to omit sweet snacks from packed lunches. Some parents reported that the child found it difficult and sometimes embarrassing to explain to classmates why they did not bring the same foods.“I mean, why are we so strict (laughs) compared to her classmates and what they have in their lunch packs. We talk about why it is this way, because obviously she finds it extremely annoying […] because if she has to explain in class why she is not allowed, e.g., Kinder milk slice or whatever. Then it is easier for her to say: ‘Well, in our family we think it is like sweets, and we only have sweets on Fridays or at special occasions’”,mother to girl at school B.In the interviews, these concerns were only addressed by parents for whom the importance of healthy food outweighed social norms and expectations concerning lunch packs. It might thus not appear as a barrier, but parents’ explicit efforts to omit these products prove it as such.Against this rather complex background of divergent social, cultural and dietary concerns, parents tried to balance health objectives and the importance of belonging in social life, e.g., the unity built with classmates, often evolving around shared meals and sweet treats. However, cultural habits and social norms around sugar-rich foods and drinks constituted a major barrier to reducing the intake of sugar-rich foods and drinks in the context of close relatives, family and friends and other social relations. As mentioned, reductions in intake of both sugar-sweetened and artificially sweetened carbonated soft drinks proved difficult and constituted a major barrier to behavioural change. Changes demanded that parents change their personal habits, as it seemed hypocritical and inconsistent to them to prohibit children to have carbonated soft drinks but continue such consumption themselves.“I drink water all day at work, and when I get home, I just have to have something else, and then it is a bit difficult to say: “No, you cannot have soda, but mom can”, right?”,mother to boy at school B.Parents’ habits were reported to have a large influence on children’s access and consumption patterns, and if they were not motivated to reduce their intake, their children’s intake did not change either. Some families ‘customized’ the guidelines to their own habits. These families approved of the guidelines and the intervention materials as such but made omissions in relation to artificially sweetened beverages.“In our family, we think sugar-free cordial for dinner is okay […] We as parents have a different definition [than the project’s] of what counts as sugar and what does not count as sugar. We don’t include sugar-free soft drinks in the ‘sugar account’. We don’t deem it to be sugar”,mother to girl at school C.However, parents’ preferences also constituted a barrier on a more general level and not only in relation to soft drinks. Interviewees reported similar practices in relation to other preferences of their own.“But it is also because I have chocolate spread myself, and you know… perhaps I should not, but I like it for breakfast. Then obviously, she wants it too, that is fair enough”,mother to girl at school A.Comparable habits were elicited from the interviews, e.g., being fond of ice cream or biscuits and thus having them stored, which often led to children having them as treats on a frequent basis. The same pattern was identified in relation to lunch packs, as parents’ habits influenced decisions concerning what to prepare or serve for one’s child. “I enjoy giving them small treats. Or perhaps not treats but something nice. Sweet biscuits for example, well in fact it often turns out to be some kind of lousy carbohydrates that I have put in […] I think it is because I myself like to have something yummy after my sandwiches”,mother to girl at school C.Parents’ preferences and personal habits, with carbonated soft drinks as a case in point, played a pivotal role in the development of their children’s preferences and constituted a major impediment to reducing the children’s intake of sweet treats.Health perceptions and related practices within families differed significantly across the sample, but in some families, they also differed between parents. One interviewee explained how lunch packs differed markedly based on whether she or her partner prepared them. She made an effort to make lunch packs nice and appetizing, while he was more prone to choose easy-to-prepare solutions. Other mothers reported the same pattern.“They cannot bring small cinnamon rolls and stuff like that […] Fruit sticks, raisins and the like is okay. And they can also bring granola bars, I know they are not particularly… but he gets them quite often. When I do the lunch pack I skip them, but I know my husband gives them (laugh). We are not totally aligned, when it comes to food”,mother to boy at school A.Disparities in attitudes and practices created family dynamics in which parents were pitted against each other in more or less opposed roles, which became a barrier to reducing the intake of sugar-rich foods and drinks.“He is convinced that we are quite well off, I think we could do better (laugh). That said, I do not want to always be the super strict one, but it is always him buying McDonald’s. It is always him that offers an ice cream after dinner. It is never Mom […] my husband is very fond of easy solutions”,mother to boy at school A.“It is entirely me who is responsible for this hustle and bustle of health in our family, [name of husband] he drinks coke and eats crisps”,mother to boy at school B.In all families where parents did not agree on a mutual family approach to the guidelines and ensuing behavioural changes, the disparities led to compromises and inconsistencies.A barrier to the substitution strategy often employed in relation to ‘everyday treats’ was a perceived lack of healthier alternatives to sweet snacks. Parents expressed that they have difficulty navigating the intricacies of ‘healthy snacks’ offered, e.g., in supermarkets. Aware that the industry often labels highly processed products specially designed for children as ‘healthy snacks’, parents were left confused as to whether the products were truly healthy. “I can on a daily basis be confused, what is this? It says that it is apple, but I mean it is not an apple. It is shaped as an astronaut, and honestly, I have no clue what it is”,father to girl at school C.As the intervention materials handed out to the families present only a certain range of examples of serving sizes for the most popular sweet treats  some parents expressed that they felt that they were left ill-equipped for making informed, healthy choices unless they avoided processed, sweet snacks altogether. However, to omit processed, sweet snacks potentially demanded time-consuming preparation of other snacks see .Another barrier identified among a few families was a lack of motivation to make changes due to having ‘skinny’ children. Parents expressed wonder and hesitation when faced with the school health nurse’s advice on reducing intake of sugar-rich foods and drinks.“I was surprised that there was an issue [with sweet foods and drinks], because he is so thin […] he is clearly both small and skinny, so it was hard to believe that he had too much sweets. I mean, I did understand what she was saying, but to go so far as to say that he had too much. I mean, you cannot tell from looking at him”,mother to boy at school B.These interviewees were all mothers who reported having struggled with their children being skinny and accordingly had made an effort to make their children eat a calorie-dense diet. In this context they considered the school health nurse’s instructions irrelevant for them and rejected most of the advice. “When I look at him—I mean his is skinny-skinny. There is not one gram of fat on his body. Therefore, I have not been overly engaged. You know, there are some foods I have replaced, but not a lot”,mother to boy at school A.Other families with children experiencing lack of appetite received the advice positively and conceived of it as placing increased importance on eating a healthy and nutrient-dense diet because their child ate small quantities. Thus, that children were skinny did not arise as a certain barrier to motivation and ensuing changes in behaviour, but only emerged in some families. Limited time and resources determined the engagement and efforts to change habits in many families. Interviewees related how behavioural change required resources and investment in establishing new, healthier habits, thus making changes susceptible to failure if time or resources declined. “We are not there yet. We still need to focus and cannot wriggle out of the risk for backslide. Especially if our mental energy is drained”,father to girl at school C.Several parents raised comparable concerns, and the COVID-19 situation further conditioned sustained changes. Many families experienced that the lockdowns and extended period of home-schooling turned their everyday life upside-down. “The main aim here is to change some routines in our everyday life, but we did not really have ‘an everyday life’, at least not as it used to be [laughter]. That might have made it a bit harder”,mother to boy at school C.In general, families reported that when routines dissolved, normal, healthy patterns regressed, e.g., lunch and snacking choices. In this case, it was due to the COVID-19 pandemic, which was an in all regards an exceptional situation, but the logic and experienced vulnerability to lack of time and resources was a general worry to the majority of families.In a small subset of less advantaged or ‘socially challenged’ families, another more resource-dependent pattern emerged. In all families, parents struggled to preserve their limited resources and tried to prioritize parental core values and translate them into parental practices, trying to balance resources and concerns. However, for families in the aforementioned sub-set, social challenges or lack of time and resources were markedly more severe than in the rest of the sample.“I also think it depends what kind of family you have. If we only had one or two children, it would not have been so challenging for us, because then we would have had the resources and would have been able to stick to it. But now… when the daily hustle and bustle takes over and you get more and more busy, you know, which battles do we choose”,father to boy at school D.Parents were emotionally and practically engaged in mitigating challenges that were of greater importance to them than dietary concerns. Challenges varied but centred on children who for one reason or another were not thriving, such as the son of this interviewee who had been struggling with school avoidance. “I am too exhausted for such things. I need to walk him through the mandatory stuff [curriculum] because he is at home. And he is not having the same input and stimulation that he used to have when he was attending school and the after school club. It is sheer hard work to home-school him”,mother to boy at school A.Parents’ choices are grounded in their everyday realities, where they consider challenges and try to resolve stressful situations and provide care and well-being to their children where they believe it is most needed. Several parents in this group had had higher expectations for the health outcomes of their participation in the intervention, but at the evaluation interview, they recognize that nothing had really changed. “I think perhaps that I could have put in more effort. But then… at the same time I think that the time simply was not there. There has just been too much going on”,mother to boy at school A.These parents did not disapprove of the guidelines as such, but their main parental concern was to provide comfort and support for their children, and they were, therefore, reluctant to enforce reductions in sugar-rich foods and drinks.Across the social practices related to sweet treats and the identified barriers to changes, two different overall interpretations of the guidelines on sugar-rich foods and drinks emerged in the interviews. These two approaches were defined by how parents construed the guidelines in relation to how their parental core values were identified, and they will be described in the following section, along with how these perceptions impacted parental attitudes toward behavioural change and new habits.One approach that accounted for a larger part of the interview sample was a strategy where parents made an effort to pursue the guidelines ‘to the letter’, in the sense that they tried to reduce their child’s intake to the maximum-limit of four weekly servings. The serving size board and the inspiration booklet were designed to make families aware of their children’s intake and facilitate reductions enabled by the logic of servings that could be counted. Although it could be difficult to reduce intake to four servings, it was still their objective.“Sometimes she exceeds the four servings over the course of a weekend. She does”,mother to girl at school B.In order to not exceed the prescribed limit of four servings, it was common that parents improvised and diverged from the determined serving sizes or decided that certain foods or drinks ‘did not count’, e.g., cordial or sweet treats served when spending time with grandparents. The most common way to remain in line with the maximum of four servings was to ‘understate’ the number of actual servings.“My aim has not been to stick strictly to four servings. It has been close to four servings and should one or two more be added without our influence, then that is okay”,mother to girl at school C.As such, the guidelines and the materials designed to support the quantification of intake as ‘servings’ functioned as intended, though parents often made small adjustments in order to make the behavioural changes feasible in their everyday family life settings. In the other approach, parents perceived the guidelines more as a rule of thumb for healthy eating and did not conform to the maximum number of servings but employed the logic of limiting the child’s intake on a more general level. Several interviewees stated that counting sweet servings on a weekly basis seemed futile to them, as weekly intakes differed greatly. Hence, they preferred to employ a broader perspective where they kept track of intakes and tried to balance them on, e.g., a monthly basis. Others deemed the counting and ‘accountant logic’ of four weekly servings to be too rigid. Thus, they kept an eye on the amounts, but without counting servings.“Then you count the different servings and such. That would be too formalized and rigid in my opinion”, mother to boy at school A.Interviewees expressed that the guidelines were relevant and had provided them with a higher awareness and vigilance in relation to their children’s sugar habits, but it was either unfeasible or irrelevant for them to count the actual number of sweet servings. “It has been a wake-up call, and we have greater awareness, but the guidelines are so strict that we did not aim to adopt them (laughter)”,father to boy at school C.The guiding principle of the new guidelines is a clear definition of the food group of sweets, including desserts, biscuits, granola bars, sweet spreads and similar sugar-rich products. The guidelines induced awareness and vigilance regarding these categorizations and prompted concerns as to which food groups should be considered as ‘sweet’ other than obvious items such as sweets and chocolate. “We have used it in assessing quantities and to estimate “what is actually sweet?”. As in, what should be counted in. After all, sweet treats are not just sweets. It is also dried fruits and cakes and—yes, we have used it in that way, rather than: “How many servings does she get a week?””,Mother to girl at school BIn the families that interpreted the guidelines in a more general sense, the intervention materials had sparked family discussions on diet and well-being. These families reported that the materials and tools had served as an inspiration and framework of reference. They appreciated the all-family approach and reported improved health literacy and higher awareness of healthy habits and family routines. Thus, the relatively narrow focus on sugar-rich foods and drinks seemed to have had a ripple effects across other health domains.The ‘Are you too sweet?’ intervention aimed to motivate and facilitate a reduction in the intake of sugar-rich foods and drinks among pre-school children. Based on the thematic content analysis, three key domains of social practices among participants were identified: (1) ‘family treats’, (2) ‘everyday treats’ and (3) ‘socialized treats’. Parental strategies employed to reduce children’s intake included substitutions, portion-size reductions and limiting home availability. Overall, the interviewed families reported perceived changes in a diverse range of practices, notably concerning ‘everyday treats’ and to a lesser extent ‘family treats’, while the fewest changes were seen with regard to ‘socialized treats’. While some families made radical changes, most settled for mere adjustments. Families most frequently made changes when the new practices were easily adoptable and were mere modifications of existing practices, e.g., swopping sweet treats for healthier alternatives in packed lunches and afternoon meals, or reducing portion sizes of ‘family treats’ while leaving the overall concept unchanged. Biscuits, granola bars and other sugar-rich snacks were relatively smoothly substituted by crisp bread, fruit or vegetables in most families, as doing so primarily required parents to shop differently and thus demanded manageable efforts. For some parents, it was still experienced as challenging to find healthier alternatives, illustrating a demand for increased availability of healthy snack foods, e.g., in retail stores or school settings. Changes that demanded more substantial efforts, for instance, that parents change their daily habits by, e.g., reducing their personal intake of carbonated soft drinks, were less common. Other studies investigating successful behavioural changes confirm that making healthy adjustments to existing habits and routines is effective, and participants consider changes which are convenient to implement to be favourable ,40. In aMore codified cultural events encompassed in ‘family treats’ and their related practices, like Friday sweets, demanded other strategies, as the events were socially conceptualized to involve sugar-rich foods and drinks. Friday sweets play an important role in Danish family culture and are integral to ‘family treats’ in many families. Again, behavioural changes more commonly involved adjustments of, e.g., portion sizes, than substitution of sweets with healthier choices or other activities. Families who had chosen to have Friday sweets took pleasure in the tradition and were not motivated to change it drastically. For ‘family treats’ more broadly, the concept of Danish ‘hygge’ carried an important cultural meaning and indicated a cosy time with the family, notably during weekends and holidays. On such occasions, sugar-rich foods, snacks and drinks were an integral part of the ‘cultural script’  and thusCultural norms around celebrations, festive events, and social gatherings where ‘socialized treats’ were served—sometimes in huge quantities—were reported as challenging by participants. Social concerns were reported to be an impediment to reducing intake of sugar-rich foods and drinks. Parents explained that they regularly needed to balance the maximum limits against considerations of social norms. Social concerns most often took precedence over maximum limits, and health concerns were side-lined in favour of following the social norms of commensality and food ways in social relations. Similar findings have been reported in the literature on dietary behavioural changes and reduction of intakes of sugar-rich foods and drinks, notably in relation to family-based childhood obesity prevention e.g., ,44,45). ,45. 44,4The results thus indicate that strategies of substitution, portion size reduction, availability and accessibility of heathy snacks and interrelated new shopping routines can prove effective if the changes are easy to embed in current family practices and only demand small adjustments. However, families experience different barriers to achieving reductions in the intake of sugar-rich foods and drinks that cut across the areas of ‘family treats’, ‘everyday treats’ and ‘socialized treats’. These included (1) culturally codified practices and social concerns, (2) parents’ personal preferences, (3) parents having disparate views on health, (4) lack of motivation, (5) lack of skill and knowledge and (6) lack of parental resources, i.e., trying to balance resources and concerns. That parents’ own preferences were a barrier for their children’s behavioural change became particularly clear in the case of reductions in intake of both sugar-sweetened and artificially sweetened carbonated beverages, as parents’ habits had a huge influence on children’s access to such drinks, and if parents were not motivated to reduce their own intake, children’s intake did not change either. A comparable degree of impediment to change was found in relation to ‘socialized treats’ that due to the cultural codification are closely linked to social norms that overrule dietary concerns. The ‘Are you too sweet?’ intervention was designed as a family-centred, home-based program, and accordingly, intervention components did not provide participants with tools or strategies aiming to reduce intake of sugar-rich foods and drinks in relation to social relations or events outside of the home. Yet, as social norms largely drive individual behaviour , the resTwo overall parental approaches to the recommended maximum intake of sweet treats were identified among interviewees, but despite the differences in the two groups, parents approved of the guidelines and implemented changes to varying degrees. In the paradigm of ‘New Public Health’ ,50, the It is a major strength of the present study that due to the predetermined large sample size (n = 24), a broad representation of different family types among the interviewees was obtained. Different parental practices and strategies in the interview sample enabled a rich and nuanced analysis. Notably, that more socially challenged and vulnerable families were also a part of the sample allowed for insights into this group, their resources and their prioritizations. Yet, fathers are still under-represented among the interviewees despite sustained efforts to recruit them, and in-person interviews would have been favoured over the online versions imposed by the COVID-19 pandemic.However, the fact that the intervention had a follow-up period of 3.5 months and that long-term sustainability of the families’ behavioural changes is thus unknown is a limitation. Another limitation is the potentially limited applicability of the findings in other settings due to the context-specific behaviours linked to particular Danish cultural traditions and norms such as ‘hygge’ and Friday sweets, though similar practices and family values might be found elsewhere . AdditioConsiderations for future interventions and initiatives include strategies for coping with the barriers identified in this study. Cultural and social norms concerning sugar-rich foods and social events and activities  are deeply anchored in cultural scripts and therefore hard to change. However, social norms and dietary practices inevitably change over time, and strategies and policies that hold the potential to influence these changes in a healthier direction are important ,59. FutuThe analysis in this qualitative evaluation showed that reductions in children’ intake of sugar-rich foods and drinks were linked to different domains of social practices. Reductions related to the family’s everyday life (‘everyday treats’) were experienced as relatively smooth adjustments demanding little effort by parents. In contrast, reductions in ‘family treats’ and ‘socialized treats’, proved more difficult, though families reported that strategies of downsizing and portion control had been implemented with success. Yet, ‘socialized treats’ served on special and social occasions carried important normative meaning, and parents found it difficult to apply positive behavioural changes. The results indicate that it is important to tailor intervention messages and tools to be in line with social practices around sweet treats. In this study, it proved effective to provide parents with different reduction strategies so that families could customize behavioural changes that fit with their existing family attitudes and practices.


Background: Attainment of the American Heart Association’s Life’s Simple 7 (LS7) metrics reduces cardiovascular disease (CVD) risk; yet, Black Americans have the lowest LS7 attainment among all communities, the highest rate of CVD mortality, and low clinical trial participation. Social support is positively correlated with chronic disease self-management. Here, we describe the role of social support in a single-arm pilot clinical trial of a community-based lifestyle intervention among Black American men. Methods: The 24-week intervention featured weekly team-based physical activity and LS7-themed education. Seventy-four Black men participated in the intervention; twenty agreed to participate in exit surveys via one of three semi-structured focus groups. Data were transcribed verbatim and analyzed using content analysis framed by House’s social support framework. Results: Participants reported support from both peers and health coaches. The sub-themes of social support among peers were: (1) acknowledgement, understanding, and validation, (2) inspiration, (3) sense of community, (4) fear of disappointing fellow participants, and (5) group synergy. The sub-themes of social support from the health coaches and study team staff included: (1) contemplation of current health status, (2) racial concordance of health coaches and study team staff, (3) investment of the research team, (4) incentives, (5) access to healthcare providers, and (6) the COVID-19 pandemic. Emotional support was the most frequently discussed theme. Conclusions: Social support, especially emotional support, from peers and health coaches was a driver of clinical trial participation among participants. The intervention created a positive social environment and decreased medical mistrust. This intervention may provide a framework by which to facilitate clinical trial participation among Black men. Cardiovascular disease (CVD) remains the leading cause of death in the United States . Among aThe American Heart Association created Life’s Simple 7 (LS7), a seven-metric framework measuring cardiovascular health . The metDespite this disproportionately high burden of CVD, Black Americans continue to be underrepresented in cardiovascular clinical trials ,13,14. ASocial support can improve participation in everyday activities that promote health ,21,22,23To better understand which aspects of social support influence clinical trial participation, this study applied House’s social support theory. Per House, social support can be defined as the “perception and actuality that one is cared for, has assistance available from other people, and that one is part of a supportive social network” . House’sThe lifestyle change intervention, called Black Impact, aimed to improve attainment of LS7 in Black men. Participants in the Black Impact program (described in detail elsewhere ) underweBlack men who had poor or average cardiovascular health  at an annual walk/health fair were recruited into the single-arm pilot Black Impact program . Eligibln = 20 participants) until data saturation was met. Each focus group was guided by an interview protocol to describe the characteristics of feasibility outlined by Bowen et al.  another member of our team who was also doing that with his smoking habit, so [it] was kind of like supporting each other in that aspect. That was a big boost for my mental health, self-esteem, and confidence.”The participants spent 24 weeks in groups. Over time, participants noted that their “brotherhood” and “camaraderie” grew, and became a primary reason that they chose to continue with the study. To explain this sentiment around the “brotherhood”, participants stated that the presence and influence of the other participants provided “motivation” and “excitement”. Some participants said the camaraderie, aside from information on healthy lifestyle, was their primary takeaway from the intervention. One participant remarked that the weekly sessions became a “happy place”, while another commented: “I was going through a divorce, and I was like, I know I need village right now…… [the intervention was] so super vital to getting me through this whole last year [2020] … and the physical health outcomes was just icing on the cake”.Additionally, study participants spoke of instances when they would have missed attending a session of the program but chose to attend because they did not want to “let their brother down.” Others felt their presence in the group was essential, and that their absence may affect the larger group. Others cited the camaraderie between peers as the primary factor holding them accountable, even when outside of the intervention, with one participant stating: “I got to make sure my numbers is good, because if I don’t then I’m letting down brother [name of participant]”. Some participants even took the initiative, unprompted by the research team, to contact members of the group who missed a session and encourage them to attend. One participant sent summaries of that week’s intervention and discussion topics to absent members. For other participants, the social interactions brought about through Black Impact were the catalyst for the formation of long-lasting friendships. Several of the men reported remaining in regular contact with their fellow participants, through Facebook groups, even after the intervention.Another stated the interactions with his peers had “pushed” him to “do more exercise.” Most participants also reported finding themselves “looking forward” to the weekly interventional sessions. Participants who found the initial physical activity sessions to be difficult, found solace in knowing other men were having the same challenges. In particular, one participant reported feeling “embarrassed” at the first exercise-based intervention but was put at ease knowing that his fellow participants, “the brothers”, were also “struggling”. Several men also recounted the impact of the relentless encouragement received from other peers in the intervention. One participant in particular went on to state: “We were always pushing each other, ‘you can do it’, ‘Come on, you can do this’ and then cheering each other on.” This team-based dynamic seemed to be a substantial contributory factor for several of the participants, with one individual explicitly stating: “One of the things that motivates me is just my connection with others and that whole team approach, so I was really looking forward to it, and it helped me.” The persistence of this team-based motivation is unknown; however, several men, even after the intervention, have made plans to go to the gym together, as a group.All four types of social support were identified within House’s framework and will be discussed in this section. Appraisal support includes one sub-theme: (1) contemplation of current health status. Emotional support includes two sub-themes: (1) racial concordance of health coaches and study team staff, and (2) investment of research team. Instrumental support includes two sub-themes: (1) incentives, and (2) access to healthcare providers. Informational support includes one sub-theme: (1) SARS-CoV-2 pandemic.The Black men participating in this study frequently spoke of experiencing a period of introspection regarding their health. Many described this period as when they began to understand the state of their health, for the first time. Some of the men reported realizing the false attribution of their health concerns to the aging process, but after going through the program, achieving quantitative results, and feeling healthier overall, came to an alternate conclusion. Notably, one man in particular stated that he came to realize his drinking habits were contrary to the philosophy of Black Impact. Another stated that the required weekly surveys made him contemplate the state of his health. Others remarked that merely seeing the metrics made them understand the severity of their current health status. Another reported that the intervention has made him want to take the initiative to follow up with his physician: “now that I’ve seen my numbers, I really literally want to go to my doctor.” Other members stated that they have renewed enthusiasm to address their long-term health and personal challenges thanks to the 24-week intervention, as well as the lasting community formed, with one participant stating: “I still have the same challenges that I faced, but it [the program] motivated me, and the brothers motivated me, to continue to do more.”Several men accredited their initial willingness to sign up for the intervention with having a team of researchers that “looked like me” or due to “the doctor being Black”. Notably, others spoke of their hesitancy in participating in a research study at The Ohio State University, a predominately White institution, being alleviated by the presence of a Black research team, with one man in particular stating: “we look at [The] Ohio State University…you got Black players that play on the football team, but when you look in the stands [it’s] White… [but] when you have Blacks actually speaking up on our behalf and coming to us with the information, it makes a major difference”.Moreover, one participant in particular went on to express that he felt better “understood” by the program researchers, as they could better relate to his challenges as a Black man in the United States. Another recounted his experience in a prior clinical trial without Black representation. He is quoted as saying: “I mean some years ago… I was in a diabetes [intervention], it was looking at the effects of exercise and diabetes. Other than the coordinator, there was no one else who looked like me, and I just didn’t get the same type of energy from participating. It was more of a challenge and just wasn’t a good experience ultimately. So, this time around was much better.”A few participants stated they were more likely to “believe” health reports when given from a Black researcher. “I take my information to a health coach, and I say, are these numbers good? She says, ‘oh you’re okay’, she’s giving it to me from a Black perspective and not from a White perspective”. Moreover, several men were also grateful for the regular unprompted check-ins provided by their study teams. “My blood pressure had dropped so low that I passed out… [A health coach], he just stayed with me, he helped me get through… he sat with me, [the] couple hours I was there, and [he] just really seemed to care about my health.”Across all focus groups, the men recounted the consistent attendance and enthusiasm of the study team, in regard to the team’s willingness to engage in workouts with the participants. Many reported this as having a profound and positive impact on them. “A health coach being there at 10 and a half months pregnant…… … and still working hard and helping us as much as [she] could. I was really impressed with [her], and [the other health coaches’] commitment was just out of this world… and that made me want to show up … [They] could have fluffed it off and did the bare minimum, but [they] even got up and worked out with us”. Others pointed out and appreciated the health coaches’ dedication to the men, despite “busy” schedules, with a participant stating: “I know you guys have had your personal lives and you would come to these workouts after having a whole workday”.At the intervention’s onset, all participants were given exercise supplies, such as Garmin watches, resistance bands, and athletic shoes. Many of the men reported using these supplies, even after the program’s conclusion. Others were particularly grateful for these supplies, as they served as instruments to keep the men active at home during the 2020 lockdown caused by the COVID-19 pandemic, in which many gyms were inaccessible. One participant stated: “some of the things that they gave us to help us through this like the [Garmins], the shoes, the workout bands…I think those are all great things to give to us as tools.”Other incentives, such as gift cards, were offered, to encourage participants to fill out surveys. A few of the men remarked that these gift cards made them feel as though the study team valued their time. Others reported enjoying the “perk” of gift cards and felt motivated to complete the surveys as a result. One participant specifically stated: “Something else that I liked was the fact that, with many of these questionnaires and information seeking things that were done…you treated us with gift cards, and I’m always about a gift card”.Study participants reported feeling sincerely cared for the by the study team’s staff, physicians, and nurse practitioner, due to their willingness to spend time with them, address their personal cardiovascular health metrics, and reach out directly to their personal doctors. “One thing that stuck out for me was [health coach] when my BP numbers [weren’t going] down… he pulled me to the side… and asked for my doctor’s information. He actually took time out of his busy day to reach out to my doctor.”Several participants reported feeling relieved and reassured by the ability to receive information on the COVID-19 pandemic in “real time”, by a team of researchers and providers they trusted, a feeling that was only amplified in the face of rampant misinformation. The study team was also able to ease the trepidation felt by many participants surrounding COVID-19 vaccination. Notably, a participant stated that his hesitancy to receive the COVID-19 vaccine was dispelled after an in-depth discussion with a health coach. Others reported similar experiences, with one in particular stating: “[A health coach] was very instrumental in me getting the vaccine, because I was kind of on the fence about it. [He] made me feel better about going ahead and getting it. So, I went ahead and got both vaccines. “After a discussion with a health coach, another participant reported not only getting vaccinated, but also feeling comfortable and empowered to encourage others to do the same. Similarly, another man reported that despite his initial hesitancy in receiving the vaccine, his fears dissipated when he watched a video of a health coach receiving the vaccine.To our knowledge, this is the first study to describe the role of social support in clinical trial participation among Black men. Our study was co-designed using the principles of CBPR that intentionally engage participants and stakeholders. In accordance with a program to improve LS7, this approach has not been adequately studied in Black men . ParticiThe relationship between peers had a positive impact on the participants’ mental health. Amidst the stress of racial turmoil, the men (peers) were able to lean on one another and validate each other’s experiences as a Black man in society. Support from peers has been associated with a reduction in perceived stress among Black men, and this study adds to the evidence supporting this finding . SeveralThe men spoke profusely of the “brotherhood” formed among participants, life as a Black man in America, and the sense of belonging that formed as a result. Their bond expanded so much that some took it upon themselves to update absent members on the intervention’s progression and meet outside of the intervention. Several men spoke about the influence of the brotherhood on their retention and their adherence to the intervention. The men expressed that the brotherhood was particularly important during the COVID-19 pandemic and racial unrest of 2020. The social isolation, as well as emotional turmoil, appeared to be an additional factor bonding them together. For many within the cohort, this aspect of emotional and appraisal social support lessened the burden of discrimination they felt within this distressing time. Perceived racial discrimination has been known to be mitigated by high levels of emotional support , with stThroughout the intervention, the men stated they persisted onwards due to their “team” or felt that they were letting down teammates by not showing up. These findings align with other studies, which also found that peer and/or friend support are facilitating factors in physical activity ,45,46,47Several men expressed that the Black Impact intervention was the first time they truly understood the importance of consistent healthcare, and/or that they were unhealthy. Over the course of the 24-week intervention, many study participants transitioned from the pre-contemplation stage of change to action. This transition is vital, as a significant change in behavior is notoriously difficult to achieve in the precontemplation stage ,53. ThisAcross all focus groups, the men spoke highly of the bond formed with the staff, and the investment of the research team’s health coaches. Several men described negative past experiences with healthcare providers that amplified their wariness of the healthcare system. However, by the intervention’s conclusion, many held a more positive view of healthcare providers and medical researchers, along with a greater sense of trust. According to participants, the formation of the relationship between the research team and the men had a remarkably positive impact on their motivation to participate and adhere to the intervention, as well as their openness to participating in future clinical trials. This finding is congruent with a review study conducted by Otado and colleagues, which revealed that “principal investigators and study coordinators cultivating rapport with participants” was among the most successful retention strategies for clinical trials focused on retaining Black Americans .In our study, the relationship between the health coaches and participants flourished through the existing connection of the community to the African American Male Wellness Agency (AAMWA). For many of the men, this connection to a long-standing community stakeholder laid the foundation on which researcher–participant rapport was built. Our team modeled these interactions in its application of community-based participatory research (CBPR), which has been used to build relationships between communities and researchers ,55,56. TFor many, the racial concordance of the health coaches and study staff was also a major facilitating factor. Several of the men stated feeling more able to rely on information from the research team, because they too understood what it is like to be Black in America. Through shared cultural experiences, the participants were able to bond with the research team. While racial concordance in research teams may not always be possible, it is important to note that that racial concordance is merely an entry way into the development of a deeper relationship with participants and/or patients, and interpersonal relationships between participants and researchers/providers can be fostered when research teams are not racially concordant ,57,58. DSurprisingly, the majority of instrumental support the participants spoke of was not represented by the incentives provided but was rather access to healthcare providers. Repeatedly, the men noted the importance of being able to contact the research team’s providers on a regular basis. Across focus groups, many men spoke glowingly of the care provided. For many, the racial concordance of the providers was again a large factor. These results are in line with recent studies demonstrating that racial concordance between Black patients and their providers improved communication, preventive care and rates of immunizations, and decreased total healthcare expenditures ,63. ThisAcross all focus groups, the men recounted a dramatic increase in their knowledge of CVD and spoke positively of the education they received on exercise, healthy eating, and other metrics involved in CVD, a finding consistent with other CVD interventions . WhetherThis study has four primary limitations. First, by its very nature, qualitative analysis cannot be used to draw conclusions, but only to make inferences. Thus, it is difficult to determine whether these findings can be generalized to other subsets of participants. Secondly, the focus group participants were not significantly different in terms of demographics, education, or socioeconomic status from Black Impact participants who did not take part in the focus groups. However, it is possible that alternate intervention participants may have brought forth differing opinions and inferences on the role of social support in their experience. Next, participants were recruited from a health-related event, so it is feasible that such individuals may be more invested in improving their health when compared to the general population. However, the criteria to participate in the study included less than ideal cardiovascular health, suggesting that participants were not engaged in effective strategies to support their health. Finally, all coders of the data were Black women. This homogeneity among analysts may have skewed the interpretation of the results. However, such homogeneity is not unusual among writers of scientific papers, and great care was taken to reduce any potential bias in the coding process.This study examined the role of social support in a cardiovascular health clinical trial, focused on Black American men. Social support, especially emotional support, from peers and health coaches was a primary driver of participation in the Black Impact trial. Not only did the intervention improve LS7 attainment, but it also created a positive social environment and decreased medical mistrust among the men. Our results highlight the need for transparency, cultural humility, and the facilitation of rapport-building between intervention participants, as well as between participants and researchers. This may provide a framework to facilitate clinical trial participation and improve intervention effects among Black men.