CHN Research Highlight
"Healthy Stores" Provides a Nutritious Alternative
Store-based environmental obesity intervention promotes healthier food
purchasing and consumption
In inner-city and rural communities, residents have a difficult time accessing healthier food options, which contributes to a higher prevalence of obesity and related chronic diseases. The Center for Human Nutrition's Healthy Stores projects aim to prevent obesity in low-income communities through a series of store-based interventions that increase the supply and promote the purchase of healthier foods. By using a combination of educational psychology, medical anthropology, and social marketing, Joel Gittelsohn, PhD, associate professor with Human Nutrition, launched the store-based interventions that have impacted a range of communities and their ethnic-minority populations.
An Innovative Perspective
Gittelsohn began his career with Human Nutrition working on mainly school-based interventions, such as Pathways, a multi-site obesity prevention trial. Gittelsohn says, "I came out of these programs with the realization that other environmental interventions were needed within the community. You could conduct these programs in the school but what happens when the children go home and do not have access to nutritious foods? Working with local food stores seemed the most logical option—they are located in every community in the world, so there is great potential."
With the Healthy Stores projects, formative research and stakeholder participation are both crucial elements. Researchers first conduct in-depth interviews with store owners, residents, and health staff to identify core cultural and social concepts in order to target messages and understand key behaviors relating to food. A detailed dietary assessment provides the evidence base for choosing the most appropriate healthy foods to promote. This information is presented to community stakeholders through workshops, where community members themselves decide on the foods for promotion, key messages, and intervention strategies.
Gittelsohn says, "Sometimes there seems to be a dissonance in perception that drives the accessibility problem. The stores don't stock healthy food choices because they feel they will not sell well; the residents say they will purchase the foods if the stores would stock them. We have worked through this cycle by negotiating a compromise. If the stores stock the healthy food items, we will promote them in multiple ways to the community to drive purchasing."
Local interventionists are trained to work with store owners to encourage stocking of promoted foods, to put up print materials and to hold interactive sessions with customers and store owners. Participating stores are given training and materials to assist them in supporting the program. With some variation from setting to setting, the Healthy Stores projects use shelf labels to identify healthy foods, conduct cooking demonstrations and taste tests, give away recipe cards, flyers, and posters, and provide point of purchase education to customers. The mass media component generally consists of radio and newspaper ads and promotional videos.
Intervention Pilot Studies and Trials
In 2000, the Healthy Stores project began in the Republic of the Marshall Islands, which had seen a dramatic increase in obesity as its residents had relied more on imported high-fat, high-calorie food sources. Gittelsohn and colleagues, in collaboration with the Ministry of Health and Environment, developed, implemented, and evaluated a three-month pilot intervention trial with 22 large and small food stores, which successfully increased healthy food purchasing among consumers.
In 2003-2004, the Apache Healthy Stores year-long intervention took place in 15 small and large food stores on the White Mountain and San Carlos Apache reservations in Arizona, and was successful in increasing consumption of healthier food options. Healthy Stores programs have also occurred in other Native American communities, First Nations communities and Pacific Islander populations in Hawaii.
Gittelsohn has also initiated the Healthy Stores project closer to home, with nine stores in East Baltimore. "There was a huge need to conduct this intervention right here, and we have an obligation to do this for the local community," Gittelsohn says. "Certain low-income neighborhoods do not have full-scale supermarkets, or people do not have ready access to transportation to travel to those markets. They rely heavily on corner and convenience stores for day-to-day purchases." About three to four students in Human Nutrition work in the Baltimore-based program during the year. The project has received positive feedback from customers and store managers; additional feasibility studies are pending and stores in West Baltimore have been added to the intervention.
For More Information
http://www.healthystores.org/ Website for the project, contains project reports and materials
Article in Johns Hopkins Public Health magazine
Curran S, Gittelsohn J, Anliker J, Ethelbah B, Blake K, Sharma S, Caballero B. Process evaluation of a store-based environmental obesity intervention on two American Indian Reservations. Health Educ Res. 2005 Dec;20(6):719-29.
Gittelsohn J, Anliker JA, Sharma S, Vastine AE, Caballero B, Ethelbah B. Psychosocial determinants of food purchasing and preparation in American Indian households. J Nutr Educ Behav. 2006 May-Jun;38(3):163-8.
Gittelsohn J, Dyckman W, Tan ML, Boggs MK, Frick KD, Alfred J, Winch PJ, Haberle H, Palafox NA. Development and implementation of a food store-based intervention to improve diet in the Republic of the Marshall Islands. Health Promot Pract. 2006 Oct;7(4):396-405.
Jehn ML, Gittelsohn J, Treuth MS, Caballero B. Prevalence of overweight among Baltimore City schoolchildren and its associations with nutrition and physical activity. Obesity (Silver Spring). 2006 Jun;14(6):989-93.