Evaluation of a pricing and communications intervention with food wholesalers and small stores to improve supply and demand of healthier foods in Baltimore City

Despite acknowledgement of our country’s current obesity epidemic and its far-reaching health consequences, public health experts have not been able to reduce its prevalence. Of particular concern are individuals living in economically-deprived areas, where access to healthy foods, physical activity outlets, and affordable and/or quality healthcare are low, and access to inexpensive and palatable junk foods is high. Small food stores are primary food sources in under-resourced areas, and as such, are viable targets for intervention. A decade of research has shown that small store intervention programs can effectively increase healthy food availability and shift individual food behaviors. However, none of these interventions have incorporated wholesalers or other food suppliers, which are influential components of the supply chain that typically provide product, marketing, promotional and stocking support. Additionally, no small food store studies have tested the impact of pricing discounts to increase healthy food supply and demand. Testing price reductions on consumer and retailer purchasing behaviors is important for two reasons: 1) food products at small independent stores generally cost more due to low economies of scale, and 2) the customers of these stores are generally low-income and thus, more price-sensitive. As a result, if healthier foods are available, they may not be affordable in small stores. B’More Healthy Retail Rewards (BHRR) (PI: Joel Gittelsohn) was a multi-level intervention trial (2011-2014) that tested the effectiveness of store-directed pricing discounts and health communications, separately and combined, on healthy food purchasing and consumption among low-income small store customers in Baltimore City. This thesis was a sub-study of the BHRR, and focused on the wholesaler and retailer (small food store) component, and assessed outcomes at these levels. Furthermore, it tested the effectiveness of supplier-to-retailer price incentives (as opposed to consumer-directed price promotions), which are utilized frequently in supermarkets to ‘push’ sales of specific items, but used rarely in small urban food stores. Twenty-four trial small food stores (“corner stores”) were randomized to pricing intervention, communications intervention, combined pricing and communications intervention, or control. Stores that received the pricing intervention were to receive a 10-30% price discount on selected healthier food items including drinks, staple foods, and snacks, at the point of purchase from two food wholesale stores during the 6-month trial. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests, and refrigerators. Pre- and post-intervention surveys were completed with the 24 storeowners and assessed changes over time in stocking, sales, and prices of promoted healthy foods, as well as associated storeowner psychosocial factors, compared to control. All intervention groups saw significant increases in total stocking of promoted foods compared to control, and the combined pricing and communications interventions found significant increases in the sales of healthier snacks (baked chips, low-fat granola bars, fruits). The increase in snack sales in the combined stores was seen despite evidence that discounts on these foods were not passed from the retailer to the consumer. Wholesale-level intervention implementation was conducted to assess reach, dose delivered, dose received, and fidelity during the 6-month trial using wholesale sales records, 23 storeowner exposure surveys, and 22 wholesaler visit evaluations. Overall, the wholesale-level communications intervention was implemented well and overall stocking of promoted foods was high, while the wholesale-level pricing intervention implementation was moderate. The intervention was implemented with high reach with 77.8% of intervention storeowners purchasing promoted foods during a 90-day period. Dose delivered and stocking fidelity were high (>90%), while pricing fidelity was moderate (66%). Dose received of specific intervention components ranged from low (36%), in terms of storeowners reported noticing a price decrease on promoted items, to high (100%), in terms of storeowners noticing promoted foods during visits to the wholesaler. Results suggest that store-directed pricing or communications interventions, separately or in combination, are successful in increasing healthy food availability (supply), but that combined approaches may be necessary to increase sales (demand) of healthier foods in small urban food stores. Future interventions should strive to collaborate with additional suppliers, such as delivery vendors and higher-level food distributors and manufacturers, in order to reduce bottlenecks to healthier food access. Researchers should further explore the mechanism by which store-directed price discounts on healthy foods can impact consumer food behaviors in small urban food stores. This study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board