BackgroundPrepared food sources, including fast food restaurants and carry-outs, are common in low-income urban areas. These establishments provide foods high in calories, sugar, fat, and sodium. The aims of the study were to (1) describe the development and implementation of a carry-out intervention to provide and promote healthy food choices in prepared food sources, and (2) to assess its feasibility through a process evaluation.MethodsTo promote healthy eating in this setting, a culturally appropriate intervention was developed based on formative research from direct observation, interviews and focus groups. We implemented a 7-month feasibility trial in 8 carry-outs (4 intervention and 4 comparison) in low-income neighborhoods in Baltimore, MD. The trial included three phases: 1) Improving menu boards and labeling to promote healthier items; 2) Promoting healthy sides and beverages and introducing new items; and 3) Introducing affordable healthier combo meals and improving food preparation methods. A process evaluation was conducted to assess intervention reach, dose received, and fidelity using sales receipts, carry-out visit observations, and an intervention exposure assessment.ResultsOn average, Baltimore Healthy Carry-outs (BHC) increased customer reach at intervention carry-outs; purchases increased by 36.8% at the end of the study compared to baseline. Additionally, menu boards and labels were seen by 100.0% and 84.2% of individuals (n = 101), respectively, at study completion compared to baseline. Customers reported purchasing specific foods due to the presence of a photo on the menu board (65.3%) or menu labeling (42.6%), suggesting moderate to high dose received. Promoted entrée availability and revised menu and poster presence all demonstrated high fidelity and feasibility.ConclusionsThe results suggest that BHC is a culturally acceptable intervention. The program was also immediately adopted by the Baltimore City Food Policy Initiative as a city-wide intervention in its public markets.

Objective Small food store interventions show promise to increase healthy food access in under-resourced areas. However, none have tested the impact of price discounts on healthy food supply and demand. We tested the impact of store-directed price discounts and communications strategies, separately and combined, on the stocking, sales and prices of healthier foods and on storeowner psychosocial factors. Design Factorial design randomized controlled trial. Setting Twenty-four corner stores in low-income neighbourhoods of Baltimore City, MD, USA. Subjects Stores were randomized to pricing intervention, communications intervention, combined pricing and communications intervention, or control. Stores that received the pricing intervention were given a 10–30% price discount by wholesalers on selected healthier food items during the 6-month trial. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests and refrigerators. Results All interventions showed significantly increased stock of promoted foods υ. control. There was a significant treatment effect for daily unit sales of healthy snacks (β = 6·4, 95% CI 0·9, 11·9) and prices of healthy staple foods (β = −0·49, 95% CI −0·90, −0·03) for the combined group υ. control, but not for other intervention groups. There were no significant intervention effects on storeowner psychosocial factors. Conclusions All interventions led to increased stock of healthier foods. The combined intervention was effective in increasing sales of healthier snacks, even though discounts on snacks were not passed to the consumer. Experimental research in small stores is needed to understand the mechanisms by which store-directed price promotions can increase healthy food supply and demand.

BackgroundLow-income black residents of Baltimore City have disproportionately higher rates of obesity and chronic disease than other Maryland residents. Increasing the availability and affordability of healthy food are key strategies to improve the food environment and can lead to healthier diets. This paper describes B’More Healthy: Retail Rewards (BHRR), an intervention that tests the effectiveness of performance-based pricing discounts and health communications, separately and combined, on healthy food purchasing and consumption among low-income small store customers.Methods/designBHRR is 2x2 factorial design randomized controlled trial. Fifteen regular customers recruited from each of 24 participating corner stores in Baltimore City were enrolled. Food stores were randomized to 1) pricing intervention, 2) communications intervention, 3) combined intervention, or 4) control. Pricing stores were given a 10-30% price discount on selected healthier food items, such as fresh fruits, frozen vegetables, and baked chips, at the point of purchase from two food wholesale stores during the 6-month trial. Storeowners agreed to pass on the discount to the consumer to increase demand for healthy food. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests, and refrigerators. Primary outcome measures include consumer food purchasing and associated psychosocial variables. Secondary outcome measures include consumer food consumption, store sales, and associated storeowner psychosocial factors. Process evaluation was monitored throughout the trial at wholesaler, small store, and consumer levels.DiscussionThis is the first study to test the impact of performance-based pricing and communications incentives in small food stores, an innovative strategy to encourage local wholesalers and storeowners to share responsibility in creating a healthier food supply by stocking, promoting, and reducing costs of healthier foods in their stores. Local food wholesalers were involved in a top-down, participatory approach to develop and implement an effective and sustainable program. This study will provide evidence on the effectiveness of price incentives and health communications, separately and combined, among a low-income urban U.S. population.Trial registrationClinicalTrials.gov: NCT02279849 (2/18/2014).

Results suggested specific foods to improve the bundling of healthy combination meals. The selection of preferred promotion foods is important in the success of environmental nutrition interventions.