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Baltimore Healthy Stores (BHS)

Implementation

How It Works

Baltimore Healthy Stores has been implemented in supermarkets and in small corner stores, including seven Korean-American independently owned stores. 

Five themed phases were implemented, at about 2 months in duration per phase. Each theme had specific behavioral and environmental objectives, in which certain foods were promoted and minimum standards set for food and beverage stocking and for marketing materials (posters and shelf labels) within stores.  Posters advertised the promoted foods for each phase.  Shelf labels identified foods and beverages that were low-fat (10% DV) and healthy alternatives (e.g., low-fat versus regular mayonnaise).

Formative work for selection of foods to include in the 5 phases

The selection of foods for promotion was based on:

  1. extensive dietary recalls (modified Food Inventory Questionnaires) from community members to identify the foods that contributed the most fat, sugar, and total calories to their diets;

  2. in-depth interviews with key stakeholders; and

  3. community workshops/focus groups to identify affordable and culturally acceptable alternatives.   

The nutrition education component associated with these promotions was based on knowledge questions included in the pre-intervention survey.  The design and key messages of marketing materials (e.g., posters and fliers) were based on feedback from community workshops/focus groups.

The 5 Themes

  • Healthy breakfast: Behavioral objectives focused on increasing low-sugar, high-fiber cereals (< 10% of the daily value of sugar; >10% of the fiber) and low-fat milk (skim, 1%, and 2%).  Environmental objectives included initiating and/or maintaining the stocking of these items.

  • Healthy cooking at home:  Behavioral strategies included promoting the use of cooking spray for eggs, pancakes, and vegetables, and draining and rinsing cooked ground meat to reduce excess fat. Environmental objectives included the availability of cooking spray.

  • Healthy snacks:  Behavioral objectives focused on encouraging the consumption of low-fat snack alternatives, including fresh fruits, low-sugar granola bars and trail mix (

  • Carry-out purchasing:  Behavioral strategies concentrated on choosing whole wheat bread, lean meats (e.g., baked chicken and turkey) and healthier alternatives to high-fat condiments (low-fat or fat-free mayonnaise and mustard). Environmental objectives focused on initiating and/or maintaining the stocking of these items, particularly in small stores with carry-out facilities.

  • Healthy beverages: Behavioral promotions focused on the purchase and consumption of water and diet soda as alternatives to regular soda. Environmental objectives included initiating and/or maintaining the stocking of these healthier beverages.

Intervention components targeting store owners

Store owners are requested to stock minimum quantities of healthy food options, specific to each phase of the intervention.  All store owner intervention materials should be provided in English or in store owners’ language as appropriate.

  • Small monetary incentives ($25-$50) provided per intervention phase to cover initial stocking costs. Incentives were in the form of wholesaler gift cards and/or the provision of small amounts of food for promotion.

  • Nutrition education session/booklet provided to ensure longer sustainability by improving nutrition-related knowledge of corner store owners.

  • Cultural guidelines were developed to assist store owners in building better relationships with community members.

  • Corner store guidelines for providing strategic guidance on food purchasing, stocking, and placing.  Guidelines included practical suggestions about which types of foods the store owners should buy, stock, and promote and placement of foods for easy access.

Intervention Components targeting consumers

In-store intervention materials

  • Shelf labels (lower in fat, lower in sugar, higher in fiber, healthy choice)

  • Informational posters, fliers, giveaways bearing the BHS logo and promoting healthy foods

In-store promotions

  • Incentive cards (buy 3 BHS-promoted foods and get the fourth free)

  • Program staff conducted brief (1-4 minutes) interactive nutrition education sessions at stores approximately twice per month, including:

    • the dissemination of phase-specific nutrition information

    • the use of educational displays

    • the implementation of taste tests

    • the distribution of food samples

    • the promotion of product giveaways

Note: (in small stores, space for this activity at peak shopping times was an issue; this component felt to be essential to give consumers the opportunity to sample healthier options)

  • Nutrition education sessions and marketing were conducted at local community centers, as a means to expand upon the in-store sessions.  Sessions included cooking demonstrations and taste tests, and marketing (e.g., posters and flyers)

  • Posting and distribution of print materials in stores (posters, fliers, shelf labels, etc)

Role of program staff

  • Work with store owners to encourage them to stock healthier food options to be promoted each phase

  • Visit each of the stores regularly (approximately 1 time/week) to conduct intervention

  • Conduct taste tests of promoted foods

  • Distribute food samples, fliers, giveaways

  • Interact with visitors and store owners to explain the promotional and educational messages for each phase and answer inquiries

  • Monitor store compliance with poster and shelf labels availability and visibility standards

  • Monitor store compliance with food and beverage availability standards.

Keys to Success

  • Consider the types and sizes of food stores that are the focus of the intervention and develop intervention components specific to these store types (e.g., smaller stores require smaller print materials and may permit taste tests only, not cooking demonstrations).

  • Initiate store recruitment process with local chapter of grocers’ association

  • Employ program staff that store owners can identify with (language, ethnicity and culture)

  • Use the same program staff throughout the program to establish and maintain strong relationships with store owners and community members

  • Provide store owners with small incentives, at least initially, to encourage stocking of healthy food choices for each phase

  • Be flexible in working with store owners to meet their needs (e.g., the placement of materials and time/location of activities, and the provision of cost-neutral stocking and food preparation strategies)

  • Work with a variety of food suppliers (e.g., vendors, supermarkets, wholesale stores) to resolve the stocking issues.  Wholesale stores and/or large chain supermarkets in the area are frequently the suppliers to the smaller corner stores, and can provide foods at discounts.

  • Conduct taste tests as a means to increase program exposure, trialability, and health. Taste tests were well attended during the BHS programs, and are highly recommended.

  • Provide small giveaways (such as water bottles, refrigerator magnets, etc.) as a means of attracting consumers.  The provision of giveaways provides an appealing mechanism to initiate nutrition education and encourage consumers to try new foods and beverages. 

  • Use shelf labels for the promotion of target foods as a relatively simple way to identify and encourage purchasing of healthy foods. 

  • Maintain the increased availability of initially promoted foods.  Customer demand for promoted products will lead to better sales, which will, in turn, motivate corner store owners to try and stock other healthy foods.  The maintenance of initial stocks, which can be monitored by conducting random post-intervention inspections, is key to program sustainability. 

Barriers to Implementation

  • Intervention strategies have to be adapted to specific types of stores depending on size, layout, and how owners decide to stock foods.

  • Corner store interventions can be labor intensive, demanding frequent visits and high ratio of staff to stores in order to implement interactive sessions.

  • Obtaining store owner support can be difficult because there are often cultural and language barriers to communication. 

  • Small store owners can be hesitant to risk any decrease to sales, and some fear an increase in crime as a result of store crowding during intervention activities.

  • Distributors may be unwilling to regularly deliver fresh foods, given the low demand (and subsequent high cost per delivery), and high crime rates in low-income urban settings.

  • If initial customer demand for healthier products is low, program sustainability is hampered by decreases in sales and store owner willingness to maintain stocks.