Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework to Advance the Science and Practice of Healthy Food Retail

Although healthy food retail strategies are widely used, there appears to be a limited understanding of the processes and determinants for successful adoption, implementation, and sustainment. To fill this gap, we recommend the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to be used to advance the science and practice of healthy food retail. In this perspective, we: (1) introduce EPIS and describe why it was chosen as a recommended implementation science framework for healthy food retail, (2) highlight healthy food retail evidence supporting EPIS, and (3) discuss research and practice needs moving forward.

Consumer willingness to pay for healthier food products: A systematic review

Food retail strategies to improve the healthiness of food and beverage options may increase purchasing of healthier options and improve diets. Consumer demand for healthier options is an important determinant of the successful implementation and maintenance of healthy food retail interventions. A systematic review of peer-reviewed literature was undertaken to explore whether consumers are willing to pay more for healthier foods and to determine the key factors that influence willingness to pay. Fifteen studies reported the results of 26 experiments providing willingness to pay estimates for healthier food products across a range of food retail environments. Twenty three out of the 26 experiments included in this review (88.5%) found consumers would pay a 5.6% to 91.5% (mean 30.7%) price premium for healthier foods. Studies consistently found a positive willingness to pay for foods with reduced fat and wholegrains with additional fruit and vegetables, while willingness to pay for foods with reduced salt or a combination of low fat and sugar, or salt showed mixed results. Adults over 60 years, females, those living with obesity, and consumers who aim to maintain a healthy lifestyle were more likely to pay a price premium for healthier food, whereas younger consumers, consumers with healthy weight, and consumers with higher levels of education were less likely to pay higher prices. The results of this review contribute to our understanding of consumer preferences for healthier products and provide information to retailers on consumer surplus (benefits) associated with the provision of healthier food alternatives.

Refining the Nutrition Environment Measures Survey (NEMS) for Healthy Community Stores: Adaptations to Capture Alternative Food Retailers and Align with Dietary Guidelines

Inadequate consumption of healthy food is an ongoing public health issue in the United States. Food availability measures of supply versus consumption of healthy foods are disconnected in many studies. There is a need for an objective assessment of the food environment in order to assess how the food supply aligns with the Healthy Eating Index (HEI). Data were collected as part of the Healthy Community Stores Case Study Project, including a refined Nutrition Environment Measures Survey for Healthy Community Stores (NEMS-HCS) and an updated Healthy Food Availability Index that aligns with the Healthy Eating Index (HFAHEI). This paper will focus on the NEMS-HCS development process, findings, and HFAHEI application. All food items were more likely to be found at grocery stores rather than corner stores. Food pricing was often above the Consumer Price Index averages for six food items. The NEMS-HCS assessment better aligned with the HEI because it included a wider variety of meats, frozen fruits and vegetables, and an increased selection of whole grains. HFAHEI scoring was inclusive of non-traditional and alternative community stores with a health focus, making it suitable for use at the local level, especially in neighborhoods where supermarkets and large chain stores are less common.

A Commentary on the Healthy Community Stores Case Study Project: Implications for Retailers, Policy, and Future Research

In the United States, low-income, underserved rural and urban settings experience poor access to healthy, affordable food. Introducing new food outlets in these locations has shown mixed results for improving healthy food consumption. The Healthy Community Stores Case Study Project (HCSCSP) explored an alternative strategy: supporting mission-driven, locally owned, healthy community food stores to improve healthy food access. The HCSCSP used a multiple case study approach, and conducted a cross-case analysis of seven urban healthy food stores across the United States. The main purpose of this commentary paper is to summarize the main practice strategies for stores as well as future directions for researchers and policy-makers based on results from the prior cross-case analyses. We organize these strategies using key concepts from the Retail Food Environment and Customer Interaction Model. Several key strategies for store success are presented including the use of non-traditional business models, focus on specific retail actors such as store champions and multiple vendor relationships, and a stores' role in the broader community context, as well as the striking challenges faced across store locations. Further exploration of these store strategies and how they are implemented is needed, and may inform policies that can support these types of healthy retail sites and sustain their efforts in improving healthy food access in their communities.

Balancing Mission and Margins: What Makes Healthy Community Food Stores Successful

Mission-driven, independently-owned community food stores have been identified as a potential solution to improve access to healthy foods, yet to date there is limited information on what factors contribute to these stores' success and failure. Using a multiple case study approach, this study examined what makes a healthy community food store successful and identified strategies for success in seven community stores in urban areas across the United States. We used Stake's multiple case study analysis approach to identify the following key aims that contributed to community store success across all cases: (1) making healthy food available, (2) offering healthy foods at affordable prices, and (3) reaching community members with limited economic resources. However, stores differed in terms of their intention, action, and achievement of these aims. Key strategies identified that enabled success included: (1) having a store champion, (2) using nontraditional business strategies, (3) obtaining innovative external funding, (4) using a dynamic sourcing model, (5) implementing healthy food marketing, and (6) engaging the community. Stores did not need to implement all strategies to be successful, however certain strategies, such as having a store champion, emerged as critical for all stores. Retailers, researchers, philanthropy, and policymakers can utilize this definition of success and the identified strategies to improve healthy food access in their communities.

Forms of Community Engagement in Neighborhood Food Retail: Healthy Community Stores Case Study Project

Community engagement is well established as a key to improving public health. Prior food environment research has largely studied community engagement as an intervention component, leaving much unknown about how food retailers may already engage in this work. The purpose of this study was to explore the community engagement activities employed by neighborhood food retailers located in lower-income communities with explicit health missions to understand the ways stores involve and work with their communities. A multiple case study methodology was utilized among seven retailers in urban U.S. settings, which collected multiple sources of data at each retailer, including in-depth interviews, store manager sales reports, store observations using the Nutrition Environment Measures Survey for Stores, public documents, and websites. Across-case analysis was performed following Stake's multiple case study approach. Results indicated that retailers employed a wide variety of forms of community engagement within their communities, including Outreach, Building Relationships through Customer Relations, Giving Back, Partnering with Community Coalitions, and Promoting Community Representation and Inclusiveness. Strategies that built relationships through customer relations were most common across stores; whereas few stores demonstrated community inclusiveness where members participated in store decision making. Findings provide a more comprehensive view of the ways local food retailers aim to develop and sustain authentic community relationships. Additional research is needed to evaluate the impact of community engagement activities on improving community health.

Increasing Healthy Food Access for Low-Income Communities: Protocol of the Healthy Community Stores Case Study Project

Improving healthy food access in low-income communities continues to be a public health challenge. One strategy for improving healthy food access has been to introduce community food stores, with the mission of increasing healthy food access; however, no study has explored the experiences of different initiatives and models in opening and sustaining healthy food stores. This study used a case study approach to understand the experiences of healthy food stores in low-income communities. The purpose of this paper is to describe the methodology used and protocol followed. A case study approach was used to describe seven healthy food stores across urban settings in the U.S. Each site individually coded their cases, and meetings were held to discuss emerging and cross-cutting themes. A cross-case analysis approach was used to produce a series of papers detailing the results of each theme. Most case studies were on for-profit, full-service grocery stores, with store sizes ranging from 900 to 65,000 square feet. Healthy Food Availability scores across sites ranged from 11.6 (low) to 26.5 (high). The papers resulting from this study will detail the key findings of the case studies and will focus on the challenges, strategies, and experiences of retail food stores attempting to improve healthy food access for disadvantaged communities. The work presented in this special issue will help to advance research in the area of community food stores, and the recommendations can be used by aspiring, new, and current community food store owners.

Urban Retail Food Environments: Relative Availability and Prominence of Exhibition of Healthy vs. Unhealthy Foods at Supermarkets in Buenos Aires, Argentina

There is growing evidence that the food environment can influence diets. The present study aimed to assess the relative availability and prominence of healthy foods (HF) versus unhealthy products (UP) in supermarkets in Buenos Aires, Argentina and to explore differences by retail characteristics and neighborhood income level. We conducted store audits in 32 randomly selected food retails. Food availability (presence/absence, ratio of cumulative linear shelf length for HF vs. UP) and prominence inside the store (location visibility) were measured based on the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) protocol. On average, for every 1 m of shelf length for UP, there was about 25 cm of shelf length for HF (HF/UP ratio: 0.255, SD 0.130). UP were more frequently available in high-prominence store areas (31/32 retails) than HF (9/32 retails). Shelf length ratio differed across commercial chains (p = 0.0268), but not by store size or type. Retails in the lower-income neighborhoods had a lower HF/UP ratio than those in the higher-income neighborhoods (p = 0.0329). Availability of the selected HF was overcome largely by the UP, particularly in high prominence areas, and in neighborhoods with lower income level, which may pose an opportunity for public health interventions.

Developing a National Research Agenda to Support Healthy Food Retail

The food retail environment is an important driver of dietary choices. This article presents a national agenda for research in food retail, with the goal of identifying policies and corporate practices that effectively promote healthy food and beverage purchases and decrease unhealthy purchases. The research agenda was developed through a multi-step process that included (1) convening a scientific advisory committee; (2) commissioned research; (3) in-person expert convening; (4) thematic analysis of meeting notes and refining research questions; (5) follow-up survey of convening participants; and (6) refining the final research agenda. Public health researchers, advocates, food and beverage retailers, and funders participated in the agenda setting process. A total of 37 research questions grouped into ten priority areas emerged. Five priority areas focus on understanding the current food retail environment and consumer behavior and five focus on assessing implementation and effectiveness of interventions and policies to attain healthier retail. Priority topics include how frequency, duration, and impact of retailer promotion practices differ by community characteristics and how to leverage federal nutrition assistance programs to support healthy eating. To improve feasibility, researchers should explore partnerships with retailers and advocacy groups, identify novel data sources, and use a variety of study designs. This agenda can serve as a guide for researchers, food retailers, funders, government agencies, and advocacy organizations.

Appalachian Store Owners' and Managers' Perspectives on the Role of Their Store in the Community and in Providing Healthier Food to the Community

Appalachian communities have lower access to healthier food sources like grocery stores. Through semi-structured interviews with owner/managers of convenience stores in Appalachian communities, this qualitative study explored perceived roles and business practices of small food retailers using a grounded theory approach. Five themes emerged including strong relationships between stores and customers, the role of the store in community, food and beverage stocking decisions, store owner/managers' perceived demand for healthier options, and federal food assistance program participation. The themes provide insight to store owner/manager perspectives on community-focused and business-focused priorities in Appalachian convenience stores and can inform healthy retail interventions.