Abstract
Background
Nutrition interventions promoting healthy food choices aim to address health challenges of residents in low-income environments. Research about the effectiveness of nutrition interventions in low-income populations is limited, particularly for those in rural areas. Behavioral economics (BE) strategies demonstrate effectiveness for improving eating behaviors in some settings. However, the efficacy of BE interventions in retail food stores serving low-income populations residing in rural and urban geographies is nascent.
Objective
This systematic literature review aims to identify and compare nutrition interventions implemented in rural and urban low-income retail food stores, including BE strategies when applied.
Methods
This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reviewers searched five databases for peer-reviewed publications from October 2010 to October 2019. Included studies implemented a nutrition intervention in low-income retail food stores and provided a quantitative outcome evaluation with results separated by rural and urban geography. BE interventions were analyzed based on the MINDSPACE framework for behavior change.
Results
Forty-six separate publications (n = 20 rural, n = 26 urban) in the United States, Canada, Europe, New Zealand, and Australia were included. Researchers independently rated publications as low risk of bias (n = 4), moderate (n = 18), or high risk of bias (n = 24) using the Quality Assessment Tool for Quantitative Studies. Studies (n = 18) demonstrated positive outcomes for customer purchases, store sales, or participant intake of targeted healthy foods. Overall, most effective interventions included point-of-purchase signage (n = 16) and product placement strategies (n = 4 urban). Rural studies included financial incentives combined with participant education (n = 2) and incorporated culturally appropriate messengers and/or symbols (n = 5) to improve healthy food purchases and intake.
Conclusions
Improved research quality and tailored evidence-based interventions, including BE strategies, are necessary in retail food environments to promote healthy eating behaviors in low-income populations.
Keywords
Research Snapshot
Research Question: What are the most effective nutrition interventions in low-income rural and urban retail environments?
Key Findings: Effective interventions (n = 16) included elements designed to focus the customer’s attention on promoted foods; eg, distinctive shelf labels and placement of targeted products at eye level or in prominent areas of the store. In rural stores, price discounts combined with participant education (n = 2) improved the sales of targeted healthy foods. Rural studies included culturally appropriate messengers and/or symbols (n = 5) in successful nutrition interventions; for example, local actors promoted nutrition interventions in radio and television advertisements.
1
, 2
, 3
A high quality, nutrient-dense diet consistent with the 2015-2020 Dietary Guidelines for Americans is recommended to reduce rates of chronic disease and obesity4
, 5
, 6
, US Depts of Health and Human Services and Agriculture
2015-2020 Dietary Guidelines for Americans, 8th edition.
2015-2020 Dietary Guidelines for Americans, 8th edition.
https://health.gov/dietaryguidelines/2015/guidelines/
Date accessed: December 24, 2020
7
; however, many people do not consume a nutritious diet, particularly low-income populations.8
,- Bowman S.
- Clemens J.
- Friday J.
- et al.
Food patterns equivalents intakes by Americans: what we eat in America, NHANES 2003-2004 and 2015-2016. Dietary Data Brief No. 20.
https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/DBrief/20_Food_Patterns_Equivalents_0304_1516.pdf
Date accessed: December 24, 2020
9
Both the rural and urban built environment pose challenges to the consumption of a healthy diet, and these challenges are magnified for low-income residents. Rural and urban areas report poor access to grocery stores that necessitates frequent shopping at gas stations, dollar stores, and corner stores, which may stock lower quantities of fresh produce and healthy foods.10
,11
Some of the barriers to eating healthy foods are unique to geographical location. For example, in rural areas, limited quantity, high prices, low quality, and lack of produce variety are barriers to purchasing and ultimately consuming fruit and vegetables, a marker of dietary quality.12
, 13
, 14
In urban communities, residents report challenges making healthy selections among a vast array of unhealthy choices, as well as frequently purchasing energy-dense nutrient poor (EDNP) foods.11
Food retail interventions at the community level may address the nutrition challenges of rural and urban residents by enhancing the local food environment and thus improving healthful food access and food choices.15
,16
There is limited literature regarding effective nutrition interventions in retail grocery stores that serve the low-income population, particularly for those residing in rural environments.
11
,17
, 18
, 19
, 20
, 21
, 22
, 23
, 24
Gittelsohn and colleagues17
reviewed studies in small food stores that targeted low-income populations, including some rural settings (n = 5); yet, a substantial number of the publications were from the gray literature. All studies in the review reported increases in healthy food availability. In 2016, Adam and Jensen21
reviewed publications set primarily in grocery stores for minority or urban low-income populations, and they reported price incentives in combination with nutrition information and readily available healthy food had positive effects on healthy food purchases. A recent review that included rural studies (n = 4) reported mixed effects of food stocking, product placement, and taste tests on customer purchases of targeted foods.22
Pinard and colleagues11
noted a lack of publications (n = 6) and randomized controlled trials (RCT) in rural small stores and identified the need to research the similarities and differences between rural and urban store environments to inform standardized practices.Researchers use behavioral economics (BE) interventions to target changes in automatic behaviors by altering the store environment where food selection occurs, ie, the choice environment. For example, substituting healthier foods for unhealthy foods at checkout aims to encourage unplanned purchases of healthier foods. BE interventions impede choices made by impulse and habit, so BE strategies are not attenuated by education and income status.
25
BE strategies are shown to be effective for improving healthy food intake in dining settings26
; however, the efficacy of BE interventions in retail food stores serving low-income populations residing in unique rural and urban geographies is not known.26
, 27
, 28
, 29
, 30
, 31
- Houghtaling B.
- Serrano E.L.
- Kraak V.I.
- Harden S.M.
- Davis G.C.
- Misyak S.A.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005-2017.
Int J Behav Nutr Phys Act. 2019; 16: 1-14
Based on the Nudge Theory
32
and research by BE scientists, the MINDSPACE framework for behavior change provides a mnemonic, MINDSPACE, which identifies nine influential drivers of automatic behavior: messenger, incentives, norms, defaults, salience, priming, affect, commitment, and ego.33
In this review, the messenger is a trusted communicator selected to promote the nutrition interventions. Financial incentives stimulate healthy food purchases by eliciting fear that missed discounts will result in monetary losses. Norms rely on social expectations of a group to influence individual purchasing behavior. A default is the option that is offered, such as the portion size of a prepared food for sale. Salience is the use of attention-grabbing interventions, such as placing healthy foods at eye level. Priming uses prompts or cues; for example, floor decals guide the customer to shop in a specific store area. Affect elements, such as a cultural symbols, provoke an emotional response to motivate healthy food choices. When a participant accepts a store giveaway, it may induce a commitment to make a healthy food purchase. Skill development builds ego strength which may increase confidence to improve eating behaviors. This systematic literature review aims to identify and compare nutrition interventions implemented in rural and urban low-income retail food stores, including BE strategies when applied.Methods
This review is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines.
34
The protocol for this review is registered with the International Prospective Register for Systematic Reviews (registration number: CRD 42019114115).Eligibility Criteria
Studies in retail stores located in a low-income rural or urban community were included in the case that they provided quantitative data regarding the outcome(s) of a retail nutrition intervention in the presence of a comparator or not. Studies were excluded in the case that the store was not a physical retail store, lacked data analysis separated by rural and urban geographic location, or omitted a nutrition intervention. Studies regarding discounts or vouchers in conjunction with a nutrition intervention were included. Interventions offering solely financial incentives were beyond the scope of this review. Full-text, English-language articles published between October 1, 2010, and October 31, 2019, were included.
Search Strategy
A librarian provided expertise regarding relevant terms and databases for the search strategy. Search terms included corner store, grocery store, store, healthy, food, nutrition promotion, point of purchase, low socioeconomic, rural, poor, and purchase. Medical subject heading terms included health promotion, rural population, and (low) income. Terms consistent with the Dietary Guidelines for Americans, such as increase whole grains, increase fruit and vegetables, and decrease sugar-sweetened beverages were included. One author searched for peer-reviewed literature on Academic Search Complete, Agricultural Online Access, PubMed, Essential Reference Tool for Economics Literature, and the Cumulative Index of Nursing and Allied Health Literature databases. Hand searching of reference lists from previous literature review publications and retrieved articles was performed to augment the database searches.
One author conducted a gray literature search of the Proquest database and websites, including the Healthy Corner Store Initiative, US Department of Agriculture, Centers for Disease Control and Prevention, World Health Organization, and Google for articles between October 2010 and October 2019. One author notified organizations about the inclusion criteria via e-mail, including The Food Trust, researchers, and government agencies with healthy retail programs. Gray literature was obtained from a tier 1 or tier 2 source, and the inclusion criteria were the same as peer-reviewed publications.
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Both authors conducted a full-text review after screening the gray literature and agreed on the included articles. Gray literature is summarized in the results section.Study Selection and Data Extraction
One author screened each peer-reviewed publication by title and abstract for inclusion in the full-text screening. Two authors independently reviewed each full-text publication and agreed on those for inclusion in the review. One author developed a data extraction form, and two faculty and two graduate students in the Nutrition and Food Science Department at Louisiana State University reviewed it for completeness. Reviewers piloted the data extraction form using five diverse studies, and one author revised it multiple times. One author completed the data extraction by hand and then entered the data into three spreadsheets (one for publication characteristics, one for categorization into the MINDSPACE framework, and one for store-directed interventions), and a second author verified the information. Disagreements between reviewers were resolved by consensus and contacting study authors as needed.
One author extracted the following data from each publication: program name and location, including geographical classification as rural, remote, or urban; description of study participants (ie, age, number in each group, and selection method); store number and type; research aim; study design; intervention components that were classified into MINDSPACE elements for analysis; store-directed interventions (eg, type; length; and content of training for owner, manager, and staff; incentives for store owner or manager; equipment; and improvements to store interior or exterior); outcome measures and targeted foods; findings; and participant education. Store-directed interventions consisted of in-store strategies such as training staff or providing equipment and strategies which were directed to suppliers to promote targeted foods in the store. Store-directed interventions are important to food safety, food marketing, customer perception of store quality, and sales. For example, adequate refrigeration is required to stock a variety of healthy foods, including dairy products and produce.
Methodological Quality Assessment
Two reviewers independently assessed the risk of bias of peer-reviewed studies using the Quality Assessment Tool for Quantitative Studies (QATQS) by the Effective Public Health Practice Project.
36
This included the assessment of selection bias, study design, confounders, blinding, data collection methods, withdrawals and dropouts, intervention integrity, and analysis.36
Sections were graded using the QATQS Dictionary, which results in a weak (high risk of bias), moderate (medium risk of bias), or strong (low risk of bias) score for each criteria and a global quality score based on the number of individual weak scores for the publication. Any disagreements were agreed on through consensus. Studies that received an overall weak quality score (ie, high risk of bias) remained in the review. The QATQS was used to analyze study effects and to assess the cumulative score relative to existing reviews.Results
Of the 638 peer-reviewed records initially screened, 124 were selected for full-text review to determine eligibility resulting in the inclusion of 46 publications distinctly separated by rural and urban geography (n = 20 rural, n = 26 urban) (Figure 1). The publications were obtained through database searching (n = 5 rural, n = 16 urban), hand searching (n = 13 rural, n = 10 urban), and experts in the field (n = 2 rural). Studies were located in Australia (n = 3), Canada (n = 5), Denmark (n = 2), France (n = 1), New Zealand (n = 1), the Netherlands (n = 1), and the United States (n = 33, including 10 in Baltimore, MD). There were three programs that published more than one study: Healthy Foods North (HFN),
37
, 38
, 39
, 40
B’More Healthy Communities for Kids (BHCK),41
, 42
, 43
and Get Healthy Philly.- Trude A.C.
- Surkan P.J.
- Anderson Steeves E.
- Pollack Porter K.
- Gittelsohn J.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Public Health Nutr. 2019; 22: 1300-1315
44
,45
Six studies occurred in remote locations, eg, remote indigenous Australia46
,47
and the Nunavut and the Northwest Territories of Canada,40
, 41
, 42
, 43
and these were analyzed with the rural studies. Study duration ranged from 2 days- Trude A.C.
- Surkan P.J.
- Anderson Steeves E.
- Pollack Porter K.
- Gittelsohn J.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Public Health Nutr. 2019; 22: 1300-1315
48
to 3 years.49
Rural sample sizes ranged from 136 women of childbearing age37
to 1,637 interview participants,50
whereas urban sample sizes ranged from 14851
to 14,620 participants.45
The mean age for adults in the studies that reported it was 43.3 years. Ages ranged from children categorized as 5 to 12 years old45
to one 89-year old in a rural study.52
Six of the publications included children and/or adolescents,41
,42
,53
, 54
, 55
, 56
and female subjects comprised the majority of participants except in one urban corner store initiative.45
Figure 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the literature search and study selection for the systematic review on nutrition interventions in low-income rural and urban retail environments. Agricola = Agricultural Online Access. Econolit = Essential Reference Tool for Economics Literature. CINAHL = Cumulative Index to Nursing and Allied Health Literature.
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Store types were diverse, including cooperative-owned food stores in some rural and remote areas.
37
, 38
, 39
, 40
,46
,47
,57
Types of retail stores are discussed in Table 1 with other pertinent study data, such as program name, location, store type and quantity, description of sample, intervention(s), key findings, and the risk of bias score. Nutrition and store outcomes are included in Figure 2.Table 1Key characteristics of studies and risk of bias scores using the Quality Assessment Tool for Quantitative Studies
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in the systematic literature review of nutrition interventions in low-income rural and urban retail environments (listed by rural/urban location in alphabetical order)| Reference and year | Program name | Country | Store number and type | Study design | Description of sample | Intervention components | Key findings | Risk of bias score |
|---|---|---|---|---|---|---|---|---|
| Rural | ||||||||
| Ayala and colleagues, 2013 58 | Healthy Life: Today and Tomorrow | United States | N = 4; tiendas | Delayed treatment-controlled study | n = 179 customers (baseline) and n = 111 adult (post) customers recently immigrated from Mexico to Central North Carolina | Employee and manager training in Spanish; food marketing campaign with POP; food demonstrations; audio novella; environmental changes | Positive trend for consuming additional fruits and vegetables (P ≤ 0.06). Decreased self-efficacy for consuming more fruits (P ≤ 0.01) and vegetables (P ≤ 0.06) | Moderate |
| Bains and colleagues, 2014 38 | Healthy Foods North | Canada | N = 10; 5 food stores, 3 convenience stores, and 2 control stores. (includes co-op stores) | Quasi-experimental | N = 136 women of child-bearing age recruited from 3 communities in Nunavut and 3 communities in the Northwest Territories | Lifestyle and prevention program to promote healthy foods and physical activity and to de-promote unhealthy foods in stores, community sites, and the media | Increased intake of vitamin A (β 558.23, 95% CI 179.86 to 936.59) and vitamin D (β 89.23, 95% CI 3.86 to 174.60) Reduced population with intakes below the adequate intake level | Moderate |
| Brimblecombe and colleagues, 2017 46 | Stores Healthy Options at Remote Indigenous Communities | Australia | N = 20; community stores (includes co-op stores) | Stepped-wedge randomized controlled trial | N = 20 stores in remote indigenous communities of the Northwest Territory | A 20% discount on fresh and frozen fruit and vegetables, bottled water, and artificially sweetened carbonated beverages. Included consumer education to increase intake of fruit, vegetables, and water and to decrease intake of SSBs | Increased purchases of fruit and vegetables combined (P = 0.0031) and after the discount ended (P = 0.0033). Consumer education resulted in an increase for vegetable purchases during the discount (P = 0.014) | Strong |
| Butler and colleagues, 2011 47 | NA | Australia | N = 1; community store (co-op) | Case study | 1 store in a remote indigenous community | Removal of the 3 highest-selling sugar-sweetened WBBs from the local store | Total annual volume of sugar-sweetened WBB purchases decreased by 50% | Weak |
| Gittelsohn and colleagues, 2013 59 | Navajo Healthy Stores Program | United States | N = 10; supermarkets, trading posts, convenience stores | Randomized controlled trial | N = 276 (baseline) and n = 145 (post) Navajo Indian adult customers | Healthier food availability, in-store education with educational displays, posters, shelf labels, and radio announcements in Navajo and English | Body mass index trended toward a decrease. No significant differences in any outcomes between groups | Weak |
| Gustafson and colleagues, 2018 48 | NA | United States | N = 1; supermarket | Controlled trial | N = 653 receipts from customers on the Rosebud Sioux Reservation in Mission, SD | Narrow PDP, broad PDP, and no PDP conditions. “Food is Good Medicine” labels were placed on all targeted healthy foods | Shoppers in the narrow prompt condition purchased more healthy foods (P < .01) and spent more on healthy foods (P < .05) and fresh produce (P < 0.05) than controls | Moderate |
| Hardin-Fanning and Gokun, 2014 52 | NA | United States | N = 2; grocery stores | Cross-sectional pilot study | N = 311 adult customers in intervention stores located in Breathitt county, KY | 4-wk print media campaign; $5 grocery store voucher; local heart healthy food branding; a 1-day community grocery store event | Associations between labeled food purchase and older age (P = 0.003) and female sex (P = 0.01). | Weak |
| Jernigan and colleagues, 2019 50 | THRIVEm | United States | N = 8; convenience stores | Cluster-controlled trial | n = 1,637 pre-intervention n = 1,204 post-intervention Native Americans living in Chickasaw and Choctaw Nations of Oklahoma | Increased healthy food availability and implemented in-store placement, promotion, and reduced pricing interventions | No change to fruit and vegetable reported intake. No difference between pre- and post-NEMS (adapted) | Weak |
| Jilcott Pitts and colleagues, 2018 60 | North Carolina Healthy Food Small Retailer Program | United States | N = 13; small stores | Controlled trial with matched controls | n = 5 unfunded stores (preintervention), n = 4 stores that received HFSRP funds and n = 4 control stores (postintervention); customers (n = 279 baseline, n = 223 post) intercepted after purchase | Allocated money for refrigeration equipment, display shelving, and other equipment necessary for stocking nutrient-dense foods | The Healthy Food Supply Score in the intervention stores was higher than in the control stores (P = 0.04). No change in self-reported consumption, skin carotenoids, or healthy food purchases | Moderate |
| Kolahdooz and colleagues, 2014 40 | Healthy Foods North | Canada | N = 10; 5 food stores, 3 convenience stores, and 2 control stores. (includes co-op stores) | Quasi-experimental | N = 332 adult food preparers from 3 communities in Nunavut and 3 communities in the Northwest Territories | Lifestyle and prevention program to promote healthy foods and physical activity and to de-promote unhealthy foods in stores, community sites, and in the media | Decreased intake of de-promoted foods (P ≤ 0.05) and use of unhealthy preparation methods in intervention communities (P < 0.0001) | Moderate |
| Liu and colleagues, 2017 61 | Plate It Up Kentucky Proud | United States | N = 17; grocery stores or supercenters | Cross-sectional survey | N = 240 customers in rural Appalachia Kentucky who took a recipe card or sample in the store | Social marketing campaign included the promotion of targeted foods with fruit and vegetable displays, Plate It Up Kentucky Proud materials, discounts, recipe samples, and recipe cards | Participants who reported a recipe influenced the purchase of ingredients found in a store food sample were more likely (P = .04) to consume fruit 2 to 3 times per week | Weak |
| Martínez-Donate and colleagues, 2015 62 | Waupaca Eating Smart | United States | N = 2; grocery stores | Randomized community pilot study | Intervention n = 96 (pre) n = 203 (post); control n = 99 (pre) n = 203 (post) adult customers intercepted at grocery stores in 2 rural, Midwest communities | Social marketing campaign, including social media; store displays, food samples, recipes for bundled meals, and healthy eating tips; involved local Nutrition and Physical Activity Coalition | Increased perceived healthiness of the food purchased in the intervention community (P = 0.022). Average NEMS score declined in stores | Moderate |
| Mead and colleagues, 2013 37 | Healthy Foods North | Canada | N = 10; 5 food stores, 3 convenience stores, and 2 control stores. (includes co-op stores) | Quasi-experimental | Intervention n = 246 (pre and post); control n = 133 (pre and post) adult food preparers from 3 communities in Nunavut and 3 communities in the Northwest Territories | Lifestyle and prevention program to promote healthy foods and physical activity and to de-promote unhealthy foods in stores, community sites, and the media | Decreased purchases of unhealthy foods (P = 0.0019) and improved food-related attitudes and behaviors (P < 0.001) in intervention communities. No influence on body mass index | Moderate |
| Pakseresht and colleagues, 2014 39 | Healthy Foods North | Canada | N = 10; 5 food stores, 3 convenience stores, and 2 control stores (includes co-op stores) | Quasi-experimental | Intervention n = 172 (pre and post), control n = 91 (pre and post) adult food preparers from 3 communities in Nunavut and 3 communities in the Northwest Territories | Lifestyle and prevention program to promote healthy foods and physical activity and to de-promote unhealthy foods in stores, community sites, and the media | Decreased energy intake (P = 0.0001) and increased vitamin A (ß 232.38, 95% CI 104.04 to 360.72) and vitamin D (ß 53.46, 95% CI -1.88 to 108.80) intake in intervention communities | Moderate |
| Palermo and colleagues, 2016 63 | Improving retail access to fresh fruit and vegetables project | Australia | N = 21; small grocery stores | Mixed methods pre–post evaluation | N = 21 rural small stores in Victoria, Australia | Financial and material incentives (including equipment) to retailers to stock fruit and vegetables, cooking demonstrations, giveaways, fruit and vegetable boxes, recipe and loyalty cards, business innovation expertise, and social marketing program | Increased range of fruits and vegetables stocked over time (P = 0.028). Collection of sales data was challenging because retailers were unwilling to supply this information. Most small store retailers had manual sales records | Weak |
| Rushakoff and colleagues, 2017 64 | Healthy2Go | United States | N = 10; country stores | Quasi-experimental | N = 10 stores located in the Cumberland Valley of Appalachian Kentucky; n = 287 (baseline), n = 281 (follow-up) community residents within 10 miles of stores | Inventory and store improvements; a food label reading guide for managers; POP materials; promotional events | Increased availability of produce, dairy, and some grains, no change in meat, and decreased whole-wheat bread and healthy cereals. Increased likelihood of people to purchase healthy foods at country stores (P = 0.05) | Weak |
| Steeves and colleagues, 2015 65 | Maryland Healthy Stores | United States | N = 8; small food stores | Quasi-experimental pilot intervention | N = 8 small food stores in Charles County, MD | Increased stocking and promotion of 12 healthier items that were equivalent in price to their replacements | Positive trends in stocking the promoted foods and in the storeowners’ perceived ability to sell healthier items | Moderate |
| Toft and colleagues, 2017 66 | Part of Project SoLn | Denmark | N = 5; supermarkets | Controlled trial | Intervention stores n = 2; control stores n = 3 on the island of Bornholm, Denmark | A 20% discount on fruit and vegetables combined with improved shelf space allocation or improved shelf space allocation only | Discount increased sales of fruit and vegetables (P = 0.010). Improved space allocation alone did not increase sales | Weak |
| Waterlander and colleagues, 2013 67 | NA | the Netherlands | N = 4; supermarkets | Randomized controlled trial | n = 199 (baseline), n = 151 (post) low SES customers in rural provinces of the Netherlands | A 50% discount on fruits and vegetables, 50% discount plus nutrition education, or nutrition education only | The discount + education and discount only groups purchased more fruit and vegetables (P < 0.001) and reported more participants with sufficient consumption of fruit and vegetables (P = 0.03) | Strong |
| Winkler and colleagues, 2016 57 | Part of Project SoLn | Denmark | N = 28; supermarkets (included co-ops) | Quasi-experimental with matched controls | Intervention stores (n = 4) in Bornholm, Denmark; control stores (n = 24) in Bornholm or Odsherrod, Denmark | Substitution of sugar confectionary with healthy, convenient snacking options at 1 checkout counter per store | No significant difference in the sales of sugar confectionary in the healthy checkout line | Moderate |
| Urban | ||||||||
| Adjoian and colleagues, 2017 68 | Shop Healthy | United States | N = 3; supermarkets | Observational pilot study | N = 2,131 adult customers who paid for groceries in 3 supermarkets in the South Bronx, NY | Converted 1 standard checkout line to a healthy checkout line | 4% of total customers bought at least 1 item in the healthy checkout line. A higher proportion of customers using the healthy checkout line bought healthy items | Weak |
| Bihan and colleagues, 2012 69 | NA | France | N = 50; supermarkets | Randomized controlled trial | N = 302 low-income adults aged 18-60 y in Bobigny | Nutrition advice from a dietitian for both groups; a monthly fruit and vegetable voucher or no voucher | After 3 mo, mean fruit and vegetable consumption increased in advice group (0.62 ± 1.29 times/day; P = 0.0004) and vouchers group (0.74 ± 1.90; P = 0.002). Vouchers group decreased the risk of low fruit/vegetable consumption. (P = 0.008). No change in vitamin C and β-carotene levels | Weak |
| Blakely and colleagues, 2011 70 | Supermarket Healthy Options Pilot | New Zealand | N = 8; supermarkets | Randomized controlled trial | N = 1,104 European, Pacific, or Māori shoppers in Wellington who shopped with the electronic food scanner system | A 12.5% discount on healthier foods and/or tailored nutrition education, including group education for Māori and Pacific Islander participants | No overall association of price discounts or nutrition education with percent energy from saturated fat or healthy food purchasing. Association of price discounts with healthy food purchasing by ethnicity and percent energy from saturated fat during the first 6 mo (0.79 kg/wk increase, 95% CI 0.43 to 1.16) | Weak |
| Bleich and colleagues, 2012 53 | NA | United States | N = 4; corner stores | Case crossover design (variant) | N = 1600 beverage sales to Black adolescents aged 12-18 y in corner stores located in low-income neighborhoods of Baltimore, MD | Randomly posted 1 of 3 signs near the beverage cooler with the calorie information: 1) Absolute calorie count, 2) Percentage of total recommended daily intake, 3) Physical activity equivalent | Providing any calorie information significantly reduced the odds of SSB purchases. (odds ratio 0.56, 95% CI 0.36 to 0.89). Presenting the calorie information as a physical activity equivalent significantly reduced odds to purchase an SSB. (odds ratio 0.51; 95% CI 0.31 to 0.85) | Moderate |
| Bleich and colleagues, 2014 54 | NA | United States | N = 6; corner stores | Case crossover design (variant) | N = 4,516 sales to Black adolescents aged 12-18 y in corner stores located in low-income neighborhoods of Baltimore, MD | Randomly posted 1 of 3 signs near the beverage cooler with the calorie information: 1) Absolute calorie count, 2) Number of teaspoons of sugar, 3) Number of minutes running to burn off the calories, and 4) The number of miles walking to burn off the calories | Providing calorie information reduced the total number of purchased beverage calories and was associated with reduced purchases of SSBs and fewer purchases of a SSB >16 oz (P < 0.05). After removing the signs, SSB purchases remained lower than baseline (P < 0.05). | Moderate |
| Budd and colleagues, 2017 71
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial. Public Health Nutr. 2017; 20: 3349-3359 | Baltimore Healthy Retail Rewards | United States | N = 26; 24 corner stores, 2 wholesale stores | Randomized controlled trial - factorial design | N = 24 corner stores located in low-income Baltimore neighborhoods with >75% African American population | 10%-30% price discount on healthier food items and/or a communication intervention | Pricing only, communications only, and combined groups saw a 3.6 (95% CI 1.3 to 5.9; P = 0.002), 2.5 (95% CI 0.7 to 4.3; P = 0.007), and 3.5 (95% CI 0.8 to 6.2; P = 0.012) unit score increase in stocking of promoted foods. No change in total sales of targeted foods | Weak |
| Cavanaugh and colleagues, 2014 44 | Part of Get Healthy Philly | United States | N = 246; corner stores | Observational evaluation | n = 177 (baseline) and n = 195 (follow-up) corner stores enrolled with HCSI and located in high poverty areas of Philadelphia | Incentives (monetary, equipment, and business training) offered for basic and high intensity store conversion levels | Increased availability of fruit over time in conversion stores: apples (P = 0.005), oranges (P < 0.001), and grapes (P < 0.004) | Weak |
| Dannefer and colleagues, 2012 72 | Healthy Bodegas Initiative | United States | N = 55; bodegas | Before and after evaluation | n = 294 (baseline) and n = 323 (follow up) customers in 55 bodegas in south Bronx and East New York City; n = 46 managers (baseline and post) completed survey | Assistance from the Healthy Bodega Initiative to improve the stock and purchase of healthy foods | Increased number of stores met healthy stocking criteria (P < 0.001). Owners (78%) reported the intervention helped to increase sales of healthier items. Sales data were not available | Weak |
| Foster and colleagues, 2014 73 | NA | United States | N = 8; supermarkets | Cluster randomized controlled trial | N = 8 supermarkets located in low-income, high-minority neighborhoods in Philadelphia, PA, and Wilmington, DE | Implemented marketing strategies: 1) Multiple facings of targeted items, 2) Prime placement, 3) Signage, 4) Secondary placement, 5) Cross-promotion, and 6) Taste testing and free samples | Increased sales of 1% milk (P = 0.0014), skim milk (P = .0078), 2 of 3 targeted frozen meals (P = 0.0326 and P = 0.0074), and chilled bottled water at the checkout line (P = 0.0002) | Strong |
| Franckle and colleagues, 2018 51 | Choose Well/Elige Bien Beverage Program | United States | N = 1; supermarket | Randomized controlled trial | N = 148 adults who spoke English or Spanish and had at least 1 child aged <18 y living in the home in Chelsea, MA | Traffic label system for beverages that were categorized as containing the most (red) to least (green) added sugar; 5% discount on groceries and $25/mo for not buying beverages in the red category | The proportion of the intervention group that purchased category red SSBs decreased significantly by 9% more per month than control (P = 0.002) | Weak |
| Futrell Dunaway and colleagues, 2016 74 | NA | United States | N = 1; corner store | Case study | n = 200 (baseline) n = 123 (follow-up) customers in a corner store in a low-income neighborhood in New Orleans, LA | Addition of a produce cooler, promotional materials, taste tests of fresh fruit, articles in neighborhood newsletter. | Fresh fruit and vegetable stocking increased 16%. Sweetened beverage stocking declined 12%. | Weak |
| Gittelsohn and colleagues, 2017 41 | B’more Healthy Communities for Kids | United States | N = 55; corner stores | Randomized controlled trial | n = 385 children aged 10-14 y, n = 387 caregivers in dyads (predominantly African American) residing in low-income food desert zones of Baltimore, MD | Intervention phases: healthy drinks, healthy snacks, and healthy cooking methods; wholesaler discount for stocking targeted foods; store owner incentives to stock and promote B’more Healthy Communities for Kids products; educational sessions; social media | No change in total sales of promoted foods. The wholesaler reported increased sales of promoted beverages and snacks. Increased stocking of promoted foods and beverages in corner stores (P < 0.01) | Moderate |
| Gudzune and colleagues, 2015 75 | NA | United States | N = 2; corner stores | Case study with pre- and post-evaluation | N = 2 urban farms paired with corner stores in low-income neighborhoods of Baltimore, MD | Collaboration of farmers and storeowners on selection and quantity of fresh produce to sell in stores; monetary incentive to assist store with payment of produce costs | 1 pair increased the mean number of produce varieties stocked (P < .01) and sold 86% of delivered product. Key factors were community support, adequate refrigeration to prevent spoilage, and store competition | Weak |
| Lawman and colleagues, 2015 45 | Part of Get Healthy Philly | United States | N = 192; corner stores enrolled in the HCSI located in high-poverty areas of PA | Quasi-experimental | n = 8,671 (baseline) and n = 5,949 (follow-up) customers who were intercepted at corner stores | Incentives (monetary, equipment, and business training) offered for basic and high-intensity store conversion levels | No significant changes in energy or nutrient content of purchases from baseline to follow-up, between high and basic conversions, or between sex and age groups over time | Strong |
| Lent and colleagues, 2014 55 | NA | United States | N = 24; corner stores | Randomized controlled trial | N = 767 students in grades 4 to 6 from 10 schools in low-income minority neighborhoods in Philadelphia, PA | Healthy snack intervention targeting bottled water and prepared fruit salad. Included nutrition education sessions, a social marketing campaign, and corner store initiatives | No significant differences in energy content and nutrient content for intercept purchases, body mass index, or the prevalence of obesity between groups at baseline or Years 1 and 2 | Weak |
| Minaker and colleagues, 2017 76 | Food Retail Environments Shaping Health Study | Canada | N = 1; corner store | Mixed methods pilot study | Store sales from 1 corner store located in low-income housing area of Toronto | Management training on business fundamentals, merchandising, and promotions; purchase and installation of new coolers and shelving | Monthly sales revenue of fresh produce had an increased trend. Store sales had an increased trend the day after distribution of social assistance checks, but sales of fruit and vegetables did not | Weak |
| Ortega and colleagues, 2016 77 | Proyecto MercadoFRESCO (Fresh Market Project) | United States | N = 8; corner stores | Repeated cross-sectional evaluation design | Latino primary food purchasers and preparers (n = 1,035 pre-intervention, n = 1,052 post-intervention) living in East Los Angeles and Boyle Heights, CA | Makeovers of interior and exterior of store, product placement strategies, social marketing promotions, refrigeration equipment to display fruits and vegetables, store owner training | Perceptions of food accessibility and corner stores improved over time in intervention and control groups (P < 0.01). No significant effects on patronage, purchasing, or the consumption of healthy foods | Moderate |
| Paek and colleagues, 2014 78 | FIT Store Program | United States | N = 4; corner stores | Pilot study - repeated cross-sectional design | n = 421 (preintervention), n = 329 (postintervention) low-income, ethnically diverse adults shopping in neighborhood FIT corner stores in Grand Rapids, MI | Small grants for equipment; store manager training to identify sources of healthy foods; onsite nutrition information materials | Three FIT stores improved their total NEMS-S availability scores. Healthy food purchases increased by self-report. FIT awareness increased (P = .05) and monthly bean and nut consumption increased (P < 0.01) | Weak |
| Shin and colleagues, 2015 56 | Baltimore Healthy Eating Zones | United States | N = 21; corner stores | Clustered randomized controlled trial | n = 242 dyads (baseline), n = 152 youth aged 10-14 y and n = 161 caregivers (follow-up). African American youth–caregiver dyads residing in low-income areas of Baltimore, MD | Intervention phases: healthful beverages, healthful breakfast, cooking at home/healthful lunch, healthful snacks, and healthful options at carryout restaurants. POP materials and nutrition education | Youth body mass index decreased (P = 0.04). Body mass index for age decreased in girls (P = 0.03). No changes in customer purchases of targeted foods or food preparation methods | Moderate |
| Surkan and colleagues, 2016 79 | Eat Right - Live Well! | United States | N = 2; supermarkets | Quasi-experimental | N = 2 supermarkets in low-income, primarily African American neighborhoods in Baltimore, MD | Increased stocking and shelf labels/signage to identify promoted foods, taste tests, advertisements in store circulars, staff training, and community outreach events | The difference in sales of promoted products compared with sales in preintervention years was more favorable in the intervention store than the control | Moderate |
| Sutton and colleagues, 2019 80 | Nutrition Education and Obesity Prevention Program | United States | N = 6 grocery stores | Cross-sectional survey | N = 1,101 adult store patrons who spoke English or Spanish | Mass media campaign; POP materials, food demonstrations; taste-tests to promote fruit, vegetables, and other healthy food and beverages | In sample with exposure to 1 visual, women spent more on fruit and vegetables (β 0.07, 95% CI 0.01 to 0.13; P = 0.029). Participants enrolled in SNAP reported spending 6% more on fruit and vegetables than SNAP nonparticipants. (β 0.06, 95% CI 0.00 to 0.12; P = 0.046) | Weak |
| Thorndike and colleagues, 2017 81 | NA | United States | N = 6; corner stores | Randomized corner store pilot study | N = 575 adult customers in corner stores located in Chelsea, MA | Provided display shelving, refrigerators, improvements to location and presentation of produce, and education for storeowners and managers by a produce consultant | WIC sales of fruits and vegetables increased (P = 0.036). Positive trend for WIC participants reporting increased purchases of fruits and vegetables | Weak |
| Trude and colleagues, 2018 42 | B’more Healthy Communities for Kids | United States | N = 55; corner stores | Group randomized controlled trial | n = 534 (baseline), n = 401 (follow-up) African American children aged 9-15 y residing in Baltimore, MD | Intervention phases: healthy drinks, healthy snacks, and healthy cooking methods; wholesaler discount for stocking targeted foods; store owner incentives to stock and promote B’more Healthy Communities for Kids products; educational sessions; social media | Increased healthier food and beverage purchases (P < 0.05). Decreased consumption of calories from sweets for the older intervention youth (P < 0.05). No influence on SSBs or fruit and vegetable consumption | Moderate |
| Trude and colleagues, 2019 43
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers. Public Health Nutr. 2019; 22: 1300-1315 | B'more Healthy Communities for Kids | United States | N = 50 corner stores | Group randomized controlled trial | N = 533 African American caregivers of children aged 9-15 y | Intervention phases: healthy drinks, healthy snacks, and healthy cooking methods; wholesaler discount for stocking targeted foods; store owner incentives to stock and promote B’more Healthy Communities for Kids products; educational sessions; social media | No significant effect on caregivers’ food-related behaviors. High social media exposure was associated with increased daily fruit intake (3.16 ±.92; 95% CI 1.33 to 4.99) | Weak |
| Wensel and colleagues, 2018 82 | B’more Healthy Corner Stores for Moms and kids | United States | N = 10; corner stores | Randomized controlled trial | N = 10 WIC-authorized corner stores in low-income areas of Baltimore, MD | Implemented BE strategies: storeowner training in 3 languages, POP promotion, product placement, grouping of products | Sales of infant foods to WIC-eligible customers increased after 2 BE strategies (P < 0.05) | Moderate |
| Woodward-Lopez and colleagues, 2017 49 | Part of Healthy Eating and Active Living | United States | N = 9; small stores | Pre- and post- intervention without control | Zone 1 pre n = 159, post n = 163; Zone 2 pre n = 155, post n = 151; Zone 3 pre n = 391, post n = 418. Customers intercepted at small stores located in under-resourced neighborhoods in Northern California | Included complete remodeling of some stores, store layout improvements, technical assistance related to produce and marketing, community events, incentives, taste tests, food demonstrations, and signage | Decreased purchases of sweets and chips (P < 0.05) and increased purchases of fruit and vegetables (P < 0.05). Results varied by zone and store. Decreased purchases of targeted SSBs were offset by increased purchases of other SSBs | Weak |
a POP = point of purchase.
b SSB = sugar-sweetened beverage.
c NA = not applicable.
d WBB = water-based beverage.
e PDP = point-of-decision prompt.
f NEMS = Nutrition Environment Measures Survey.
g HFSRP = Healthy Food Small Retailer Program.
h SES = socioeconomic status.
i HCSI = Healthy Corner Store Initiative.
j SNAP = Supplemental Nutrition Assistance Program.
k WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
l BE = Behavioral Economics.mTribal Health and Resilience in Vulnerable Environments.nProject Sundhed & Lokalsamfund.
Figure 2Nutrition and store outcomes for studies included in the systematic literature review of nutrition interventions in low-income rural and urban retail environments.
| Nutrition outcomes |
| Customer purchases of targeted foods 37 ,41 , 42 , 43 ,
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers. Public Health Nutr. 2019; 22: 1300-1315 45 ,48 ,49 ,51 , 52 , 53 , 54 , 55 , 56 ,60 ,64 ,67 ,68 ,70 ,72 ,77 ,78 ,80 ,81 |
| Intake of targeted foods and/or energy and nutrient consumption 38 , 39 , 40 , 41 , 42 , 43 ,
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers. Public Health Nutr. 2019; 22: 1300-1315 45 ,50 ,58 ,60 ,61 ,64 ,67 ,69 ,77 ,78 |
| Sales of targeted foods 41 ,46 ,47 ,57 ,66 ,71 ,
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial. Public Health Nutr. 2017; 20: 3349-3359 72 , 73 , 74 , 75 , 76 ,79 ,81 ,82 |
| Body mass index 37 ,55 ,56 ,59 ,60 |
| Food-related attitudes and behaviors 37 ,59 ,62 |
| Changes in food preparation methods 37 ,40 ,43 ,
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers. Public Health Nutr. 2019; 22: 1300-1315 56 |
| Obesity prevalence 55 |
| Store outcomes |
| Store environment 41 ,44 ,49 ,50 ,58 ,60 ,62 , 63 , 64 , 65 ,71 ,
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial. Public Health Nutr. 2017; 20: 3349-3359 72 ,74 ,75 ,77 ,78 ,82 |
| Storeowner participation 64 ,65 |
| Storeowner attitudes 71 ,
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial. Public Health Nutr. 2017; 20: 3349-3359 72 |
Nutrition-related outcomes, including customer purchases (a proxy for intake) and the intake of targeted foods were assessed by self-report,
37
, 38
, 39
, 40
, 41
, 42
, 43
,- Trude A.C.
- Surkan P.J.
- Anderson Steeves E.
- Pollack Porter K.
- Gittelsohn J.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Public Health Nutr. 2019; 22: 1300-1315
51
,52
,56
,58
,60
,64
,67
,69
,77
customer interview,45
,49
,50
,55
,61
,80
and in-store observation.53
,54
,68
When included, researchers measured participant height and weight except in one study where they were self-reported.60
Vitamin status was assessed by testing skin carotenoid levels60
and obtaining blood samples to measure vitamin C, β-carotene, α-tocopherol, γ-tocopherol, and erythrocyte folate levels.69
Store sales were assessed by stock reports,47
storeowner reports,41
,71
,- Budd N.
- Jeffries J.K.
- Jones-Smith J.
- Kharmats A.
- McDermott A.Y.
- Gittelsohn J.
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.
Public Health Nutr. 2017; 20: 3349-3359
72
,82
cash register receipts,48
,67
inventory calculations,74
,75
reports from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC),81
wholesaler sales data,41
and electronic sales data,46
,51
,57
,66
,70
,73
,76
,79
which included collection by handheld scanners70
and loyalty cards.51
Researchers assessed the store environment most frequently by audit, and in some cases adapted the Nutrition Environment Measures Survey.
41
,44
,50
,62
,64
,78
Targeted foods in the low-income rural and urban retail stores are listed in Figure 3. The consumption of traditional foods, including caribou, seal, and fish by the indigenous people of Nunavut and the Northwest Territories of Canada, was encouraged to counter the nutrition transition, ie, when increased intake of EDNP imported foods resulted in decreased intake of nutrient dense, lower-energy foods.37
, 38
, 39
, 40
,83
Figure 3Targeted foods and beverages of the included studies in the systematic literature review of nutrition interventions in low-income rural and urban retail environments.
| Foods promoted | Foods discouraged |
|---|---|
| Beans and legumes 41 ,50 ,52 ,60 ,78 | EDNP snacks 42 ,43 ,
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers. Public Health Nutr. 2019; 22: 1300-1315 49 ,57 ,64 ,74 |
| Bottled water 41 , 42 , 43 ,
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers. Public Health Nutr. 2019; 22: 1300-1315 44 , 45 , 46 ,51 ,55 ,56 ,59 ,64 ,65 ,68 ,71 ,
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial. Public Health Nutr. 2017; 20: 3349-3359 72 , 73 | Sugar-sweetened beverages 42 ,43 ,
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers. Public Health Nutr. 2019; 22: 1300-1315 46 ,47 ,49 ,51 ,53 ,54 ,73 |
| Fish and seafood 37 , 38 , 39 , 40 , 41 ,50 ,52 ,59 ,60 ,71
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial. Public Health Nutr. 2017; 20: 3349-3359 | |
| Foods containing whole grains 41 , 42 , 43 ,
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers. Public Health Nutr. 2019; 22: 1300-1315 44 , 45 ,52 ,56 ,59 ,60 ,64 ,65 ,71 ,
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial. Public Health Nutr. 2017; 20: 3349-3359 72 , 73 ,78 | |
| Frozen meals 73 | |
| Fruit, vegetables, and 100% juice 37 , 38 , 39 , 40 , 41 , 42 , 43 ,
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers. Public Health Nutr. 2019; 22: 1300-1315 44 , 45 , 46 ,48 , 49 , 50 ,52 ,55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70
|