Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results

Abstract

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.

Food for thought: obstacles to menu labelling in restaurants and cafeterias

“…For example, it will not be possible to provide as much nutrition information on menus as on packaged products without making the menu several pages longer, nor will it be possible to use the same format (13) . To circumvent these problems Lee-Kwan et al (43) provided restaurants with high-quality, attractive menus displaying appealing photographs of their food. Researchers found that both owners and consumers liked the new materials, which led to higher acceptability.…”

Identifying the Effects of Environmental and Policy Change Interventions on Healthy Eating

“…The adjective “obesogenic” has been used to describe environments that promote obesity either through increased energy intake or decreased energy expenditure (66). Obesogenic nutrition environments are spatially patterned such that they co-occur in areas with larger proportions of low-income and minority populations (4, 64, 88) and may thus contribute to socioeconomic and racial disparities in obesity (10, 64, 82). Relying solely on individual-level strategies to change dietary intake and physical activity is not sufficient.…”

“…Relying solely on individual-level strategies to change dietary intake and physical activity is not sufficient. Creating supportive environments for behavior change is also needed, including the evaluation of interrelations between individual and environmental factors to drive a more dynamic and comprehensive approach to obesity prevention (4, 64, 69, 82). A multisectoral, systems-oriented approach is recommended in the 2012 Institute of Medicine (IOM) report on accelerating progress in obesity prevention (56).…”

Dynamics of Implementation and Maintenance of Organizational Health Interventions

“…The third pair of cases comes from the adoption and maintenance of the Baltimore Healthy Carry-Outs (BHC) initiative [25]. This initiative provided a random sample of small food carry-out vendors in a poor Baltimore neighborhood with assistance and incentives to implement healthier menu options and eating opportunities for the local community.…”