The multifactorial causes of obesity require multilevel and multicomponent solutions, but such combined strategies have not been tested to improve the community food environment. We evaluated the impact of a multilevel (operating at different levels of the food environment) multicomponent (interventions occurring at the same level) community intervention. The B’more Healthy Communities for Kids (BHCK) intervention worked at the wholesaler (n = 3), corner store (n = 50), carryout (n = 30), recreation center (n = 28), household (n = 365) levels to improve availability, purchasing, and consumption of healthier foods and beverages (low-sugar, low-fat) in low-income food desert predominantly African American zones in the city of Baltimore (MD, USA), ultimately intending to lead to decreased weight gain in children (not reported in this manuscript). For this paper, we focus on more proximal impacts on the food environment, and measure change in stocking, sales and purchase of promoted foods at the different levels of the food system in 14 intervention neighborhoods, as compared to 14 comparison neighborhoods. Sales of promoted products increased in wholesalers. Stocking of these products improved in corner stores, but not in carryouts, and we did not find any change in total sales. Children more exposed to the intervention increased their frequency of purchase of promoted products, although improvement was not seen for adult caregivers. A multilevel food environment intervention in a low-income urban setting improved aspects of the food system, leading to increased healthy food purchasing behavior in children.

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) redemption rates have been declining in many low-income urban settings, potentially related to aspects of the food environment. B’more Healthy Corner Stores for Moms and Kids was a feasibility trial in Baltimore City that aimed to test multiple behavioral economic (BE) strategies in 10 corner stores (intervention = eight stores, comparison = two stores), to evaluate their influence on the stocking and redemptions of WIC foods. Tested strategies included in-person storeowner training, point of purchase promotion, product placement, and grouping of products in a display. All four strategies were feasible and implemented with high reach, dose delivered, and fidelity. Additionally, text messaging was found to be an acceptable form of intervention reinforcement for storeowners. Analyses to assess change in stocking of WIC foods, total sales of WIC foods, and sales of WIC foods to WIC clients, revealed consistent positive changes after implementation of the store owner training strategy, while changes after the implementation of other strategies were mixed. Furthermore, WIC food sales to WIC clients significantly increased after the simultaneous implementation of two strategies, compared to one (p > 0.05). Results suggest that store owner training was the most influential strategy and that the implementation of more BE strategies does not necessarily lead to proportional increases in stocking and sales. Selected BE strategies appear to be an effective way of increasing stocking and sales of WIC foods in small urban food stores.

OPREVENT2 was a multilevel, multicomponent (MLMC) adult obesity prevention that sought to improve access and demand for healthier food and physical activity opportunities in six Native American communities in the Southwest and Midwest. OPREVENT2 worked with worksites, food stores, schools (grades 2–6), through social media and mailings, and with a local community action committee (CAC), in each of the three intervention communities, and was implemented in six phases. We conducted a process evaluation to assess implementation of each intervention component in terms of reach, dose delivered and fidelity. Implementation of each component was classified as high, medium or low according to set standards, and reported back at the end of each phase, allowing for improvements. The school and worksite components were implemented with high reach, dose delivered and fidelity, with improvement over time. The school program had only moderate reach and dose delivered, as did the social media component. The CAC achieved high reach and dose delivered. Overall, study reach and dose delivered reached a high implementation level, whereas fidelity was medium. Great challenges exist in the consistent implementation of MLMC interventions. The detailed process evaluation of the OPREVENT2 trial allowed us to carefully assess the relative strengths and limitations of each intervention component.

B'More Healthy Communities for Kids was a multi-level, multi-component obesity prevention intervention to improve access, demand and consumption of healthier foods and beverages in 28 low-income neighborhoods in Baltimore City, MD. Process evaluation assesses the implementation of an intervention and monitor progress. To the best of our knowledge, little detailed process data from multi-level obesity prevention trials have been published. Implementation of each intervention component (wholesaler, recreation center, carryout restaurant, corner store, policy and social media/text messaging) was classified as high, medium or low according to set standards. The wholesaler component achieved high implementation for reach, dose delivered and fidelity. Recreation center and carryout restaurant components achieved medium reach, dose delivered and fidelity. Corner stores achieved medium reach and dose delivered and high fidelity. The policy component achieved high reach and medium dose delivered and fidelity. Social media/text messaging achieved medium reach and high dose delivered and fidelity. Overall, study reach and dose delivered achieved a high implementation level, whereas fidelity achieved a medium level. Varying levels of implementation may have balanced the performance of an intervention component for each process evaluation construct. This detailed process evaluation of the B'More Healthy Communities for Kids allowed the assessment of implementation successes, failures and challenges of each intervention component.