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Exploratory Study on Purchase Intention of Vitamin D Fortified Drinks in Denmark,

Iceland, and the UK

Ainslee L. Erhard, Elizabeth R. Chin, Ezra R. Chomak, Eydis Y. Erlendsdottir,

Federico J.A. Perez-Cueto, Vibeke Orlien
PII: S1878-450X(20)30119-0
DOI: https://doi.org/10.1016/j.ijgfs.2020.100242
Reference: IJGFS 100242

To appear in: International Journal of Gastronomy and Food Science

Received Date: 14 April 2020

Revised Date: 5 July 2020
Accepted Date: 7 July 2020

Please cite this article as: Erhard, A.L., Chin, E.R., Chomak, E.R., Erlendsdottir, E.Y., Perez-Cueto,
F.J.A., Orlien, V., Exploratory Study on Purchase Intention of Vitamin D Fortified Drinks in Denmark,
Iceland, and the UK, International Journal of Gastronomy and Food Science, https://doi.org/10.1016/
j.ijgfs.2020.100242.

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Exploratory Study on Purchase Intention of Vitamin D Fortified Drinks in Denmark,

Iceland, and the UK

Ainslee L. Erhard, Elizabeth R. Chin, Ezra R. Chomak, Eydis Y. Erlendsdottir, Federico J.A.

Perez-Cueto, and Vibeke Orlien*

Department of Food Science, Faculty of Science, University of Copenhagen, Rolighedsvej

26, DK-1958 Frederiksberg C, Denmark

* Corresponding author, Department of Food Science, Faculty of Science, University of

Copenhagen, Rolighedsvej 26, DK-1958 Frederiksberg C, Denmark

E-mail address: vor@food.ku.dk (V. Orlien)

Author statement

Exploratory Study on Purchase Intention of Vitamin D Fortified Drinks in Denmark,

Iceland, and the UK

The authors, Ainslee L. Erhard, Elizabeth R. Chin, Ezra R. Chomak, Eydis Y. Erlendsdottir,

Federico J.A. Perez-Cueto, and Vibeke Orlien, certify that all authors have seen and approved

the revision of the manuscript submitted.

1 Exploratory Study on Purchase Intention of Vitamin D Fortified Drinks in Denmark,

2 Iceland, and the UK

5 Ainslee L. Erhard, Elizabeth R. Chin, Ezra R. Chomak, Eydis Y. Erlendsdottir, Federico J.A.

6 Perez-Cueto, and Vibeke Orlien*

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20 Abstract

21 The objective of this study was to discern if purchase intention of vitamin D fortified drinks is

22 determined by attitudes in Denmark, Iceland, and the UK. An online survey was conducted

23 among adults from these three countries (n = 426) in October, 2019. A cluster analysis revealed

24 three consumer segments; low, medium, and high purchase intention of vitamin D fortified

25 drinks. The low purchase intention segment was characterized by older consumers, a Danish

26 majority, and a higher proportion of omnivores, whereas the medium and high purchase intention

27 segments were younger, and had a higher proportion of Icelanders and vegans. In conclusion,

28 attitudes were found to significantly determine purchase intention across most measures.

29 Attitudes towards vitamin D fortified drinks, such as appropriateness, price, naturalness, and

30 taste may serve as barriers to purchase intention. These findings provide relevant insights for the

31 improvement of public health initiatives in countries characterized by low vitamin D

32 consumption.

33

34 Key words: vitamin D; fortification; supplementation; purchase intention; consumer behavior

35

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36 1. Introduction

37 Cholecalciferol, better known as vitamin D, deficiency is prevalent worldwide with Northern

38 Europeans being particularly susceptible (Pilz et al., 2018). Indeed, Vitamin D deficiency is so

39 widespread in Europe that some researchers consider it a pandemic. Since vitamin D is

40 synthesized by the skin via sunlight, countries at high latitudes are at greater risk for deficiency,

41 especially in the winter months (Clark et al., 2019). Vitamin D can also be obtained from certain

42 dietary sources (notably oily fish), however these foods are not always consumed with enough

43 frequency to sustain sufficient long-term vitamin D levels (Pilz et al., 2018). Long term vitamin

44 D deficiency can lead to osteopenia and osteoporosis in adults, rickets in children, and a range of

45 other non-communicable diseases (Holick & Chen, 2008; Grønborg et al., 2019).

46 Supplementation can effectively increase vitamin D status but only benefits individuals

47 who consume them and reaching all members of a population through supplementation is

48 implausible (Cashman & Kiely, 2016; Grønborg et al., 2019; Clark et al., 2019). Furthermore,

49 the risk of exceeding the upper limit (100 μg or 4,000 IU/day) is a concern when supplementing

50 (Grønborg et al., 2019). Some researchers worry that there may be unknown adverse effects of

51 long-term supplementation since studies have only examined short-term effects (Kiely &

52 Cashman, 2015).

53 As opposed to supplementation, food fortification may be a more effective strategy to

54 meet the requirements of whole populations. However, effectiveness of fortification programs

55 depends on fortifying a wide range of products in order to achieve diversity and efficacy (Kiely

56 & Cashman, 2015). National fortification programs that have been adopted by the U.S., Canada,

57 and Finland have proven as some of the more successful strategies (Pilz et al., 2018). For

58 example, the fortification of dairy products in Finland implemented in the 2000s greatly

3
59 improved vitamin D status in the general population (Boucher, 2012; Jääskeläinen et al., 2017).

60 Denmark, Iceland, and the UK are all countries which struggle with low vitamin D status (Spiro

61 & Buttriss, 2014), yet there have been varying degrees of fortification programs at a national

62 level (Jahn et al., 2019).

63 In several European countries Vitamin D has been added to a wide range of food items

64 such as cereals, bread, cheese, orange juice, and margarine and other fat spreads, however cow’s

65 milk is the most commonly vitamin D fortified good (Cashman & Kiely, 2016; Pilz et al., 2018;

66 World Health Organization, 2006). The recent years have witnessed a shift towards more plant-

67 based diets along with the adoption of plant-based drinks (Sethi et al., 2016). As more consumers

68 switch to non-dairy alternatives, cow’s milk sits in fewer home refrigerators and therefore may

69 not be considered a good standalone fortification vehicle for reaching an entire population (Sethi

70 et al., 2016). Not surprisingly, plant-based milks are also often fortified with vitamin D, and

71 together with dairy beverages, may be considered appropriate vehicles for vitamin D

72 fortification.

73 It is important to identify consumer preferences with respect to taste, perceived health

74 benefits, ethical considerations (i.e. concerns over animal welfare), appropriateness, and price

75 points for which consumers are willing to pay (Turnwald et al., 2019). An insufficient

76 understanding of the customer segment can result in product failure, as may have been the case

77 when fortified dairy products were removed from the shelves in Denmark after only a few short

78 years due to poor sales (Jahn et al., 2019).

79 This study aims to inform food producers and public health authorities of both barriers

80 and methods to improve marketability and vitamin D consumption via food products. Therefore,

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 81 the main objective of the study was to discern if purchase intention of vitamin D fortified drinks

82 is determined by attitude in Denmark, Iceland, and the UK.

83

84 2. Theoretical Background

85 The conceptual base of this study draws upon aspects of the Theory of Planned Behavior

86 (Ajzen, 1985) and Theory of Reasoned Action (Fishbein & Ajzen, 1975) which both posit that

87 attitudes inform intention, which in turn informs behavior. Though there are limitations to these

88 theories, attitudes are still considered key predictors of intentions to purchase products (Jahn et

89 al., 2019). To strengthen the conceptual model and specifically target purchase intention of

90 fortified foods, the mediating effects of problem awareness, personal health engagement, and

91 social norms were considered. Problem awareness – relating here to a consumer's understanding

92 that the population is vitamin D deficient – is an important factor in the acceptance of fortification

93 (Jahn et al., 2019). Interest in healthy eating directly influences nutrition label use while

94 choosing a product in the store (Grunert et al., 2010). Therefore, checking the nutrition facts on

95 food packaging, such as for added vitamin D, serves as an indicator of personal health

96 engagement, though it should be noted that this interest in healthy eating is informed by factors

97 such as age, gender, education, nutritional knowledge, income, and how much time consumers

98 have (O’Neill et al., 2018). An important social norm, in this context, is the cultural acceptance

99 of fortification. For example, Denmark’s social norms towards vitamin D fortification can be

100 reflected in their low dietary intake of vitamin D, relative high intake of vitamin D from

101 supplements, and lack of mandatory vitamin D fortification (Grønborg et al, 2019; Jahn et al.,

102 2019). The full conceptual model is shown in Figure 1.

103

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105 Figure 1. Conceptual model of the factors underlying purchase intention of fortified foods.

106

107 3. Methods

108 3.1 Data collection

109 Data was collected using an online consumer survey structured in four parts:

110 demographic information, milk consumption and purchasing behavior, awareness, attitudes, and

111 purchase intention towards vitamin D fortified foods. Demographic variables included age (y),

112 sex (f/m), nationality, education (less than high school diploma, high school degree, bachelor's

113 degree, master's degree or higher), and diet lifestyle (omnivore, pescatarian, vegetarian, or

114 vegan) (Table 1). Furthermore, data was collected on milk consumption and purchasing

115 behavior, and vitamin D supplementation habits (Table 1). All demographic variables were

116 categorical with the exception of age, which was continuous.

117

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118 The mediating effects of problem awareness, personal health engagement, and social

119 norms were assessed with three separate questions, similarly on a 5-point Likert scale.

120 Measuring problem awareness was modeled after a study by Jahn et al. (2019), and measured

121 with the question: “People do not get enough vitamin D in my country”. Personal health

122 engagement, as indicated by the behavior of checking nutrition labels on milk packaging, was

123 assessed by the question: “It is likely that I would read the nutrition facts on the milk packaging

124 (cow's or plant-based) before buying it”. Social norms about supplementation were measured

125 with the question: “I would rather take a vitamin D supplement than drink milk with added

126 vitamin D (either cow's or plant-based milk)” (Table 2). Attitude questions were operationalized

127 into the following categories: appropriateness, taste, price, naturalness, organics, and availability

128 were modeled after an instrument created by Reipurth et al. (2019). These questions were

129 continuous variables measured with a 5-point Likert scale. They all included anchor words

130 ranging from ‘Strongly disagree’ to ‘Strongly agree’. Examples of these questions include “Cow

131 milk with added vitamin D should be available in supermarkets”; “Milk (cow or plant-based)

132 with added Vitamin D tastes good”; and “Plant-based milk with added vitamin D is natural”

133 (Table 3). Purchase intention questions were modeled after an instrument created by Labrecque

134 et al. (2006) used to assess purchase intention of functional foods. Presently, purchase intention

135 was a continuous variable obtained combining three 5-point Likert questions: "I would like to try

136 milk (cow or plant-based) with added vitamin D"; "I would buy milk (cow or plant-based) with

137 added vitamin D if I happened to see it in a store"; and "I would actively seek out milk (cow or

138 plant- based) with added vitamin D in a store in order to purchase it". For simplicity of the

139 survey, the common word milk was used for both cow’s milk and plant-based milk (and not the

140 correct name plant-based drink).

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141 The questionnaire was developed in English and then translated into Danish and Icelandic

142 by native speakers. It was tested prior to release in order to assure consistency and

143 comprehension. A brief description of the survey, study purpose, and participants’ rights were

144 provided on the first page of the survey, at which point informed consent was also obtained. The

145 Research Ethics Committee for HEALTH and SCIENCE at Københavns Universitet reviewed

146 the authors' methods and approved this research project as complying with their ethical standards

147 (ReF: 504-0112/19-5000). The questionnaire was open to adults (minimum 18 years old) from

148 Denmark, Iceland, and the UK. Three links were provided corresponding to a questionnaire in

149 the respective languages of these countries. Respondents were recruited through convenience

150 sampling via Facebook and distribution of flyers with QR-codes on the University of

151 Copenhagen’s campus. The survey was administered during one week in October 2019 through

152 the platform SurveyXact.

153

154 3.2 Data analysis

155 Data from all three versions of the questionnaire was exported from SurveyXact into Excel and

156 thereafter compiled into one dataset. Answers based on Likert scales were converted to

157 continuous numerical values ranging from 1-5 (strongly disagree to strongly agree). Incomplete

158 surveys were eliminated from the dataset prior to analysis. Data analysis was then performed

159 with RStudio®. Respondents were segmented using k-means cluster analysis based on their

160 answers to the three questions measuring purchase intention. The cluster analysis resulted in the

161 formation of three segments: low purchase intention, medium purchase intention, and high

162 purchase intention. Medians, interquartile range, and Kruskal-Wallis tests were used to describe

163 the continuous variable of age. Percentages and Chi-squared tests were used to describe the

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164 categorical variables. Logistic regression models were fitted to profile the segment

165 characteristics. Dependent variables were segment membership (y/n) and independent

166 explanatory variables were consumers agreement level with statements provided on their

167 attitudes, preferences, and behaviors (Table 2 and 3). Regression models were adjusted for sex,

168 age, nationality, diet, supplementation preference, and “milk” type consumption. For all analyses

169 a significance level of p < 0.05 was used.

170

171 4. Results

172 Figure 2 shows a cluster plot for visual representation of formation of the three purchase

173 intention segments. Table 1 shows the socio-demographic distribution of the total sample divided

174 into the three purchase intention segments. A total of 426 respondents completed the survey, of

175 which, 43% were Danish (n = 184), 33% were Icelanders (n = 142), and 23% were British (n =

176 100). With respect to age, there were statistically significant differences between segments as

177 assessed using the Kruskal-Wallis test (p = < 0.001). The medium and high purchase intention

178 segments had the same median age (29 years old) and therefore it can be deduced that the low

179 purchase intention segment was significantly different than both the medium and high purchase

180 intention. A majority of the respondents were female (n = 333, 78%) which might be attributed

181 to the convenience sampling method used, as the researchers, in part, used personal networks to

182 obtain respondents. Notably, the researchers were masters students and mostly female. Danes

183 made up the majority (n = 59, 61%) of the low purchase intention segment whereas Icelanders

184 made up the largest group (n = 59, 50%) of the high purchase intention segment. There were

185 more omnivores (n = 79, 81%) in the low purchase intention segment and more vegans in the

186 medium (n = 59, 28%) and high purchase intention (n = 31, 26%) compared to the low purchase

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187 intention segment (n = 11, 11%). Also of note, 73% (n = 86) of the participants in the high

188 purchase intention segment were already taking vitamin D supplements.

189

190 Figure 2. The cluster analysis of the purchase intention data resulting in the three segments

191 further described in Table 1.

192

193

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194 Table 1.
195 Socio-Demographic Characteristics of the 3 Purchase Intention Segments

196
197 Note. P-value for age (a continuous variable) calculated with the Kruskal-Wallis test and all other p-
198 values (categorical variables) calculated with the chi-squared test.
199
200 Table 2 shows the participants’ likelihood of belonging to the segments based on

201 awareness as assessed by behavior, preference, and belief. Respondents that would rather take

202 vitamin D supplements were more likely to belong to the low purchase intention segment.

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203 Respondents who believe people from their country do not get enough vitamin D were more

204 likely to belong to the high purchase intention segment. Reading the package’s nutritional facts

205 did not catch specific attention in any segments.

206

207 Table 2.
208 Participants’ Likelihood of Belonging to the Segment Based on Problem Awareness, Personal
209 Health Engagement, and Supplementation Social Norms; Logistic Regression Results.

210
211 Note. All values based on a 5-point Likert scale ranging from ‘Strongly disagree’ to ‘Strongly agree’.
212 Odds ratios (OR)>1 shows a higher likelihood of belonging to a segment per each increasing increment
213 on the Likert scale.
214

215 Table 3 shows respondents’ likelihood of belonging to the segments based on attitudes.

216 Respondents who think both cow’s milk and plant-based drink should have added vitamin D

217 were significantly more likely to belong in the high purchase intention segment. Similarly,

218 respondents were also significantly more likely to belong to this group if they believe fortified

219 milk (either cow or plant-based) should be available in the supermarket, tastes good, and is

220 natural. The perception of taste is one of the driving factors in food choice among European

221 consumers. Danish consumers who thought that plant-based foods taste good were less likely to

222 have a high frequency meat intake (Reipurth et al., 2019). Similarly, a pan-European survey,

223 including the UK and Denmark, indicates that consumers believe that healthy eating

224 compromises taste (Kearney & McElhone, 1999). Respondents were significantly less likely to

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225 belong in the high purchase intention group if they feel fortified cow's milk is expensive,

226 although this variable was not found significant for the other two segments, nor with plant-based

227 drink. There were only two significant findings for the medium purchase intention segment.

228 Respondents were significantly less likely to belong to this group if they believe fortified milk

229 tastes good. Additionally, they were more likely to belong to this group if they believe that

230 fortified cow's milk should be available in the supermarket.

231

232 Table 3.
233 Participant’s Likelihood of Belonging to the Segment Based on Attitudes; Logistic Regression
234 Results.

235
236 Note. All values based on a 5-point Likert scale ranging from ‘Strongly disagree’ to ‘Strongly agree’.
237 Odds ratios (OR)>1 shows a higher likelihood of belonging to a segment per each increasing increment
238 on the Likert scale.
239
240 5. Discussion
241

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242 This study identified three consumer segments based on purchase intention of drinks fortified

243 with vitamin D. As cow’s milk tends to be the most commonly vitamin D fortified good (WHO,

244 2006), expanding to drinks in general by testing for plant-based milk was a natural progression,

245 especially in light of the recent growth in milk alternatives on the market (Sethi et al., 2016). The

246 rationalization was to provide survey participants with a scenario that is not only easily

247 conceivable, but also more plausible to occur in everyday life. The majority of the questions

248 assessing attitudes towards vitamin D fortified drinks were found to significantly determine

249 purchase intention, which is to be expected within the Theory of Planned Behavior framework.

250 These findings can be relevant to improve public health in countries characterized by vitamin D

251 deficiencies.

252 Differences in purchase intention between segments may be in part due to age

253 differences. As seen in Table 1, the medium and high purchase intention segments were similar

254 in age (medians: 29), whereas the low purchase intention segment was significantly older

255 (median: 39). This may be partially explained by prior research which found that older

256 consumers accept familiar foods more easily (Beelen et al., 2017; Laureati et al., 2006). In the

257 present study, when considering vitamin D fortified drinks, the older respondents may have

258 considered them novel, and thus were less likely to purchase. Studies in Finland and Ireland have

259 shown that younger individuals consume fortified products more often than older individuals

260 (Hirvonen et. al, 2012), though others indicate that older consumers may be more willing to

261 accept functional foods, even when that would compromise taste (Poulsen, 1999; Verbeke,

262 2005). Ares and Gambaro (2007) found that different age groups and genders exhibited different

263 preference patterns for functional foods (with varying preferences for carrier food and

264 enrichment type) suggesting that functional foods be tailored to specific groups. Generational

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265 differences in knowledge of and attitudes towards fortified products should therefore be

266 considered when designing marketing and public health awareness campaigns.

267 Differences in diet and milk consumption habits between segments can provide useful

268 insights into consumer segments and guide future action. As seen in Table 1, the majority of

269 vegans and consumers of plant-based drinks belonged to the higher purchase intention segment,

270 whereas the majority of the omnivores and cow’s milk drinkers belonged to the lower purchase

271 intention segment. This suggests that individuals who subscribe to a predominantly plant-based

272 diet may be more open to vitamin D fortified foods. This may also reflect a greater awareness of

273 nutritional deficiency risk among individuals who avoid animal products. These results imply

274 that more effort may be needed on the parts of food companies and/or public health departments

275 when trying to influence omnivores to purchase more vitamin D fortified foods. Possible avenues

276 to do so may include: Increase awareness and knowledge of this consumer group that their diet

277 does not necessarily preclude them from risk of vitamin D deficiency; promoting the notion that

278 vitamin D fortified drinks are equally tasty; and lastly, that no extra effort is required on their

279 part to swap non-fortified products with fortified versions.

280 Despite Denmark’s generally low vitamin D status (Spiro & Buttriss, 2014), the low

281 purchase intention segment is characterized by a Danish majority. In corroboration with this

282 finding, Bech-Larsen and Grunert (2003) found Danish consumers to hold a more negative

283 overall attitude towards functional foods as compared to their Finnish and American

284 counterparts. Respondents who are more likely to take vitamin D supplements also characterize

285 the low purchase intention segment. This supports findings from a previous study wherein a

286 relatively high percentage of the Danish population was reported to take supplements (Tetens et

287 al., 2011). This is in line with Denmark’s historical aversion to voluntary fortification, as some

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288 fortified dairy products were introduced in Denmark in 2011, but only lasted a few years because

289 sales were too low (Jahn et al., 2019). Reasons for the hesitance towards fortification in Denmark

290 are not well researched, though there is preliminary evidence indicating that Danish consumers

291 perceive functional food as unnatural (Poulsen, 1999). This is consistent with the findings of this

292 study, given that consumers in the low purchase intention segment are, in addition to being

293 Danish, also more likely to perceive fortified milk as unnatural.

294 There seems to be confusion amongst laypersons over the role of Vitamin D in the body

295 and ways to obtain it, much of that due to conflicting information from the media. Information

296 from a trusted authority, such as a physician, was the primary knowledge source for most people,

297 especially for women and the elderly (Deschasaux et al., 2016). In the present study, gender did

298 not statistically determine purchase intention segment membership, although it has been shown

299 to be an important factor in other studies. Women have more accurate nutritional knowledge than

300 men with regards to Vitamin D, and in particular concerning the role it plays in bone health and

301 pregnancy. It could be that women are more nutritionally aware because they are an at-risk group

302 for Vitamin D deficiency (Deschasaux et al., 2016). It has been shown that women have a

303 significant influence on the health care attitudes and behaviors of their family. They are also

304 more likely to be the main monitor of health care for men and their children (Norcross et al.,

305 1996).

306 Consumers in this study and others have been found: to have positive associations with

307 the term “natural” in connection to food (Rozin et al., 2012), and to consider “sensory

308 acceptability” an important factor of plant-based milk alternatives (Sethi et al., 2016). Some

309 consumers appear to equate functional foods with tasting worse than conventional foods, as was

310 the case in a survey of Belgian consumers (Verbeke, 2005). Studies show that the taste of plant-

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311 based milk can be a major limiting factor to consumer acceptance (Sethi et al., 2016) and that

312 consumers will prioritize taste over health at the point of purchase (Turnwald et al., 2019). This

313 can be seen in Table 3, where participants are significantly less likely to belong to the low

314 purchase intention segment, the more they agree that fortified drinks: a) are natural and b) taste

315 good (i.e. sensory acceptability).

316 The above are just some of the factors that public health authorities and food producers

317 could consider when looking to improve marketability and consumer acceptance of fortified

318 drinks. Consumer attitudes towards fortified foods are dynamic, especially amidst rapidly

319 changing product availability, thus providing an opportunity for change (Urala & Liisa, 2007).

320 Moreover, attitudes are less stable when the target (i.e. fortified foods) is not familiar (Eagly &

321 Chaiken, 1993). This is encouraging for a country like Denmark, where consumers are relatively

322 unfamiliar with fortification yet could stand to benefit from it. Methods they could employ to

323 effect this change could be: improving perceived personal benefit via media campaigns;

324 removing barriers such as by lowering expense (Wakefield et al., 2010); and labeling products

325 using positive taste-focused language which has recently been demonstrated to encourage

326 healthy food consumption (Turnwald et al., 2019). Furthermore, as many laypeople rely upon

327 health care providers for dietary guidance (Deschasaux et al., 2016), encouraging physicians to

328 consider recommending fortified foods as a good source of vitamin D when appropriate could

329 bring significant change. It is yet to be evaluated whether involving physicians in such dietary

330 advice would be successful.

331 If efforts along these lines proved successful, public health authorities and food producers

332 may increase their population’s likelihood of purchasing vitamin D fortified drinks, thereby

333 improving its nutritional status.

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334

335 5.1 Strengths and limitations

336 This study was strengthened by the facts that there was a substantial sample size (n = 426) and a

337 pre-tested instrument was used to model attitude and purchase intention. To the knowledge of the

338 authors this was the first study that piloted an instrument to evaluate consumer attitudes and

339 intentions towards vitamin D fortified foods across three countries where Vitamin D deficiency

340 is relevant for public health. Although research on attitudes towards fortification of foods in

341 general is available on some populations, as in Australia and New Zealand (Food Standards

342 Australia New Zealand, 2013), it is less clear how consumers feel about the fortification of foods

343 with specific nutrients such as Vitamin D. The findings from this study can build upon the little

344 existing attitudinal research specifically on Vitamin D fortification done by Jahn et al. (2019) in

345 Denmark and Clark et al. (2019) in the UK.

346 The main limitation of this study was that questions measuring purchase intention did not

347 distinguish between cow’s and plant-based milk, which resulted in the inability to define clusters

348 based on milk type. Secondly, the participants were obtained via convenience sampling for this

349 exploratory study. Snowball sampling was used when respondents were added from the social

350 network of existing participants, in Denmark, Iceland, and the UK, three countries where vitamin

351 D deficiency is an important public health issue.

352

353 6. Conclusion

354 In this study, attitudes determined purchase intention across most measures in Danish, Icelandic,

355 and British respondents. Attitudes towards vitamin D fortified drinks, such as appropriateness,

356 price, naturalness, and taste may serve as barriers to purchase intention. Low purchase intention

18
357 was more prevalent among Danes compared to respondents in Iceland and the UK. Future

358 interventions to promote vitamin D intake through fortification should consider consumer

359 awareness and attitudes as factors for success.

360

361 Funding

362 This research did not receive any specific grant from funding agencies in the public, commercial,

363 or not-for-profit sectors.

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Table 1. Socio-Demographic Characteristics of the 3 Purchase Intention Segments
Low purchase Medium purchase High purchase
Total
intention intention intention P-value
(n = 426)
(n = 97) (n = 211) (n = 118)

Age in years (median (IQR)) 38.5 (27.8 - 47.0) 29.0 (24.0 - 41.3) 28.5 (24.0 - 39.8) < 0.001

Sex 0.09

Male (%) 29.9 19.0 20.3 n = 93

Female (%) 70.1 81.0 79.7 n = 333

Nationality < 0.001

Denmark (%) 60.8 44.1 27.1 n = 184

Iceland (%) 19.6 30.3 50.0 n = 142

UK (%) 19.6 25.6 22.8 n =100

Education 0.13
Less than a high school
6.2 2.4 7.6 n = 20
diploma (%)
High school degree or
22.7 31.3 34.7 n = 129
equivalent (%)

Bachelor's degree (%) 40.2 39.8 35.6 n = 165

Master's degree or higher (%) 30.9 26.5 22.0 n = 112

Diet 0.005

Omnivore (%) 81.4 57.8 57.6 n = 269

Pescatarian (%) 3.1 6.6 7.6 n = 26

Vegetarian (%) 4.1 7.6 8.5 n = 30

Vegan (%) 11.3 27.9 26.3 n = 101

Milk consumption < 0.001

Drink cow’s milk (%) 47.4 21.8 16.1 n = 111

Drink plant-based milk (%) 17.5 37.0 44.1 n = 147

Drink both cow and plant-
20.6 35.5 38.1 n = 140
based milk (%)
Drink neither cow nor plant-
14.4 5.7 1.7 n = 28
based milk (%)

Purchasing behaviour 0.11

Buy milk (%) 92.8 93.3 98.3 n = 403

Do not buy milk (%) 7.2 6.6 1.7 n = 23

Vitamin D supplementation 0.01
Take vitamin D supplements
all year-round (%) 24.7 27.4 37.3 n = 126

Take vitamin D supplements

seasonally (%) 29.9 27.0 35.6 n = 128

Do not take vitamin D

45.4 45.5 27.1 n = 172
supplements (%)

Note. P-value for age (a continuous variable) calculated with the Kruskal-Wallis test and all other p-values (categorical
variables) calculated with the chi-squared test.
Table 2. Participants’ Likelihood of Belonging to the Segment Based on Problem Awareness, Personal Health Engagement,
and Supplementation Social Norms; Logistic Regression Results.
Low purchase intention Medium purchase intention High purchase intention
(n = 97) (n = 211) (n = 118)
OR (95% CI) P-value OR (95% CI) P-value OR (95% CI) P-value
It is likely that I would
read the nutrition facts on
the milk packaging (cow's
or plant-based) before 0.79 (0.85-1.12) 0.97 1.02 (0.87-1.19) 0.82 1.00 (0.83-1.21) 0.98
buying it.

I would rather take a

vitamin D supplement than
drink milk with added
vitamin D (either cow's or 2.11 (1.64-2.77) < 0.001 1.04 (0.87-1.23) 0.69 0.53 (0.42-0.66) < 0.001
plant-based milk).

People do not get enough

0.68 (0.50-0.93) 0.01 0.88 (0.69-1.11) 0.27 1.76 (1.31-2.41) < 0.001
vitamin D in my country.

Note. All values based on a 5-point Likert scale ranging from ‘Strongly disagree’ to ‘Strongly agree’. Odds ratios (OR) > 1
shows a higher likelihood of belonging to a segment per each increasing increment on the Likert scale.
Table 3. Participants' Likelihood of Belonging to the Segments Based on Attitudes; Logistic Regression Results.
Low purchase intention Medium purchase intention High purchase intention
(n = 97) (n = 211) (n = 118)

OR (95% CI) P-value OR (95% CI) P-value OR (95% CI) P-value

Cow’s milk should have
added vitamin D.
0.26 (0.18-0.36) < 0.001 1.16 (0.95-1.40) 0.14 2.04 (1.59-2.67) < 0.001

Plant-based milk should have

added vitamin D.
0.17 (0.11-0.25) < 0.001 0.90 (0.74-1.10) 0.31 5.95 (4.05-9.09) < 0.001

Cow’s milk with added

vitamin D should be available
in supermarkets. 0.28 (0.19-0.39) < 0.001 1.27 (1.32-2.02) 0.02 1.65 (1.30-2.11) < 0.001

Plant-based milk with added

vitamin D should be available
in supermarkets. 0.20 (0.13-0.29) < 0.001 1.04 (0.84-1.28) 0.75 3.72 (2.65-5.38) < 0.001

Milk (cow’s or plant-based)

with added vitamin D tastes
good. 0.29 (0.18-0.46) < 0.001 0.74 (0.56-0.97) 0.03 2.99 (2.10-4.36) < 0.001

It is expensive to drink cow’s

milk with added vitamin D.
1.09 (0.72-1.69) 0.68 1.32 (0.99-1.78) 0.06 0.65 (0.47-0.90) 0.01

It is expensive to drink plant-

based milk with added
vitamin D. 0.91 (0.90-1.48) 0.62 1.15 (0.88-1.50) 0.31 0.89 (0.66-1.20) 0.45

Cow’s milk with added

vitamin D is natural.
0.37 (0.25-0.51) < 0.001 1.15 (0.94-1.41) 0.17 1.53 (1.21-1.93) < 0.001

Plant-based milk with added

vitamin D is natural.
0.33 (0.24-0.46) < 0.001 1.11 (0.91-1.35) 0.30 1.75 (1.38-2.24) < 0.001

I prefer milk (cow’s or plant-

based) that is organic over
conventional. 1.26 (0.99-1.61) 0.07 0.87 (0.72-1.04) 0.12 1.02 (0.83-1.26) 0.85

It is difficult to find cow’s

milk with added vitamin D in
the supermarket. 0.71 (0.50-0.99) 0.05 1.18 (0.93-1.50) 0.17 1.00 (0.77-1.31) 0.98

It is difficult to find plant-

based milk with added 0.91 (0.62-1.33) 0.62 1.15 (0.88-1.50) 0.31 0.89 (0.66-1.20 0.45
vitamin D in the supermarket.

Note. All values based on a 5-point Likert scale ranging from ‘Strongly disagree’ to ‘Strongly agree’. Odds ratios (OR) > 1
shows a higher likelihood of belonging to a segment per each increasing increment on the Likert scale.
Exploratory Study on Purchase Intention of Vitamin D Fortified Drinks in Denmark,

Iceland, and the UK

The authors, Ainslee L. Erhard, Elizabeth R. Chin, Ezra R. Chomak, Eydis Y. Erlendsdottir,

Federico J.A. Perez-Cueto, and Vibeke Orlien, declare no conflict of interest.