healthym&e Healthier Businesses and Healthier Communities: Monitoring and Evaluation of the Healthy Corner Store Initiative

Transcription

1 healthym&e Healthier Businesses and Healthier Communities: Monitoring and Evaluation of the Healthy Corner Store Initiative The Public Policy Challenge University of Pennsylvania Finals March 2015 Evan Beilin, Master of Social Work Candidate Jennifer Gable, Master of Public Administration and Master of Bioethics Candidate Ivan-Thibault Pham, Master of Mechanical Engineering and Applied Mechanics Candidate Pooja Yerramilli, Doctor of Medicine Candidate

2 Contents Executive Summary... 2 The Problem... 2 The Solution... 2 Public Health and Food Access in Philadelphia... 3 Obesity and Other Nutrition-Related Disease... 3 Healthy Food Access... 3 Corner Stores and Youth Snacking Habits... 3 The Healthy Corner Store Initiative Intervention... 4 Store Owner Incentives... 4 Current M&E... 4 The healthym&e Solution: Figuring out What Works... 5 Why a Tablet Solution?... 5 How it Works: For Store Owners... 6 How it Works: For Program Evaluators Step System Set Up... 8 Implementation... 8 healthym&e Beneficiaries... 9 Corner Store Owners... 9 Community Residents The Food Trust Healthy Food Initiatives Nationwide Budgeting and Timeline for healthym&e In Conclusion

3 healthym&e Healthier Businesses and Healthier Communities: Monitoring and Evaluation of the Healthy Corner Store Initiative Executive Summary The Problem Philadelphia has the highest obesity rates out of the 10 largest cities across the country. Approximately 67.9 percent of adults and 41 percent of youth in Philadelphia are obese. Equity implications are also evidenced by geographic disparities in risk factors. For example, an estimated 70 percent of youth in Northern Philadelphia - which is home to predominantly lower socioeconomic status and minority communities qualify as overweight or obese. i The lack of access to healthy food in primarily lowincome and minority communities makes it difficult for residents of these areas to lead healthy lifestyles, contributing to this epidemic. Residents of these communities tend to utilize corner stores, which predominantly carry inexpensive and high-calorie items as their primary food source. ii In 2004, to address this deficit for the city s most vulnerable and disadvantaged populations, The Food Trust of Philadelphia, in partnership with the City of Philadelphia s Department of Health, established the Philadelphia Healthy Corner Store Initiative (HCSI). This program has successfully increased access to healthy food items in over 650 corner stores found in primarily low-income and minority communities. However, much remains unclear about the success of the program in changing food purchasing decisions and actual consumption of healthy foods in the targeted areas. While external evaluations of the program show that the intervention has increased availability of healthy foods in corner stores iii, they also suggest that implementation of the HCSI had no significant impact on healthy food purchasing trends. iv The Solution healthym&e proposes a monitoring and evaluation system designed to identify the discrepancies between the available supply of healthy foods in HSCI certified healthy corner stores and the demands of the targeted communities in order to establish best practices and revise the program s guidelines. The purchasing data collected through this system will improve the cost-effectiveness of the HCSI with regards to its two goals: promoting healthier communities and healthier businesses. Namely, data will reveal trends on which healthy products are best-selling among the corner stores. Corner storeowners will thus be advised on which healthy items to stock in order to improve their sales and profits, incentivizing the provision of a greater quantity and variety of healthy items. Further, the increased availability of popular healthy items will encourage and increase consumption of these healthy foods, benefitting the overall health of the low-income communities in which the majority of these stores are located. 2

4 Public Health and Food Access in Philadelphia Obesity and Other Nutrition-Related Disease Health care expenditures in the United States have been skyrocketing over the past several decades. Pennsylvania, in particular, has struggled to contain costs, with expenditures reaching $7,730 per capita in 2009, placing the state in the top ten in the United States. v In Philadelphia, and indeed in the rest of the world, one of the most significant drivers of health care expenditures is the rising burden of chronic diseases. The current model of health care focuses on treatment rather than prevention of these diseases, resulting in chronic health care expenditures. Obesity has been shown to cause diabetes, heart disease, osteoarthritis, and some cancers. Of the ten largest cities across the United States, Philadelphia ranked number one in obesity and diabetes rates in Approximately 67.9 percent of adults and 41 percent of youth in Philadelphia are obese. Equity implications are also evidenced by geographic disparities in risk factors. For example, an estimated 70 percent of youth in Northern Philadelphia - which is home to predominantly lower socioeconomic status, African American, and Hispanic communities qualify as overweight or obese. vi Studies have estimated that in 2005, the United States spent $190 billion on obesity-derived health care expenses. Yet the actual economic costs posed by obesity are far greater if the indirect costs of loss of productivity, daily wages, and insurance are considered. vii Healthy Food Access These trends in health issues and rising health care costs may in part be attributed to the availability and accessibility of healthy foods in low-income communities. Corner stores, which are prevalent across Philadelphia among other urban settings, increase access to high-profit items with low nutrition benefits, including packaged chips, candy, and ice cream. viii A study in Hartford, CT suggests that customers who shop at corner stores tend to be of lower socioeconomic status and experience higher rates of food insecurity than those who frequent large supermarkets. ix Corner Stores and Youth Snacking Habits In Philadelphia, the distribution of corner stores near schools, with several stores found within a fourblock radius of any given school, is particularly problematic. Youth visit these stores before and after school and purchase up to 712 Calories per day. The majority of these calories derive from unhealthy items, such as sugary drinks, chips, and candy. Youth may be encouraged to purchase these items due to geographic proximity and affordability, as roughly $1 can purchase 356 Cal at a corner store. x Youth diets are particularly important because they can be habit forming and may contribute to obesity both in childhood and adulthood. Thus, obese children may face heightened risk of cardiovascular disease, type 2 diabetes, and cancer, among other health complications, later in life. xi Therefore, it is critical to assess and address access to healthy foods among vulnerable populations, including low-income communities and school children. 3

5 The Healthy Corner Store Initiative Intervention In 2004, The Food Trust established a program called The Healthy Corner Store Initiative to address the issue of healthy food access in lowincome Philadelphia communities. The project began as a small pilot and has expanded to more than 650 corner stores, primarily targeting zip codes with the lowest income. Forty-eight percent of the stores are located in Tier 1 communities, which have the highest rates of poverty in Philadelphia. Thirty-seven percent and 7 percent of the remaining stores are found in Tier 2 and Tier 3 communities, respectively. xii Store Owner Incentives The Food Trust provides training for store owners on selecting and storing healthy food items as they make the transition into becoming a Healthy Corner Store. The store owners in turn agree to supply at least four new healthy items and to display the marketing and educational materials provided by the Food Trust. Store owners are incentivized to meet these minimum expectations with the potential to receive a $100 participation award each year and training on how to increase profits and reduce food waste. Some corner stores are eligible to receive free storage equipment, such as refrigeration and shelving, to better market their healthy food items. Priority is given to corner stores meeting some or all of the following criteria: xiii Store is located on or near a busy intersection, other businesses, schools, or other public buildings Store is clean, well maintained, and has an organized and well-stocked inventory Store has capacity to accommodate additional inventory SOURCE: Healthy Corner Store Initiative: Overview. (2014) Store owner is interested in providing healthier options to customers, positively engages with customers, and is committed to maintaining the equipment and receiving additional training to participate fully with the program Current M&E Unfortunately, little information is known about the purchasing trends of healthy foods or the success of these corner stores in increasing either their own sales or the consumption of healthy foods among community residents. The Food Trust aims to visit each store participating in the Healthy Corner Store Initiative every six weeks to three months, xiv but our interviews with corner store owners have suggested that these visits are likely to occur only once or twice per year for the majority of stores involved in the program. Further, these visits are meant to check on the types and quality of foods available in the stores, and are not intended to track sales. The Food Trust has installed and implemented expensive point-of-sale (POS) systems in four of the over 650 corner stores enrolled in the Healthy Corner Stores Initiative, in order to track inventory and sales within the stores. External studies have been conducted on the efficacy of the HCSI and, while one evaluation xv showed that the intervention modestly increased availability of healthy foods in corner stores, another xvi suggested that it has had no significant impact on energy and nutrition content of food purchases. 4

6 The healthym&e Solution: Figuring out What Works healthym&e proposes the phased implementation of a technology-based M&E solution to help The Food Trust efficiently gather healthy corner stores sales data, assess the current program effectiveness, and implement changes to improve the Healthy Corner Stores Initiative. This tool will be available for adoption by The Food Trust at a time when their priorities, available resources, and approval of the system s effectiveness all align. Why a Tablet Solution? healthym&e will utilize an easy to use, automated system to monitor purchases made at healthy corner stores. An assessment of distinct technology options suggests that the Shopkeep application on the Apple ipad 2, alongside a Shopkeep BackOffice web monitoring tool, will be the most efficient and cost effective solution. Selecting the best solution for the M&E of the Philadelphia Healthy Corner Stores Initiative required identifying the program needs and desired outcomes. The table below describes the benefits of chosen ipad 2 as the main system hardware. Program Needs Paper Traditional POS Mobile or Tablet 1. Manage large data sets with large numbers of terminals Printing and tracking paper questionnaires is tedious Real-time tracking of survey work is difficult Data can be tracked in real time Data aggregation is automatic Data can be tracked in real time Data aggregation is automatic 2. High data quality Requires data entry introduces another potential source of error Audit of data is a time consuming and complicated process Issues with handwriting readability Can be difficult to correct mistakes. Font readability is not a problem First hand data is collectedno data entry is required Real time prevention of entry of invalid data Font readability is not a problem First hand data is collected - no data entry is required Real time prevention of entry of invalid data 3. Ease of Use Survey questionnaires cannot be changed once deployed without significant cost Can be hefty and cumbersome Difficult to customize user interface Proprietary hardware may cause add-on compatibility issues and additional costs. Difficult to troubleshoot Small physical footprint allows for portability Touch screen is easy to use User interface easy to use and customizable Easily integrated with external hardware 4. Low cost and time commitment No one-time hardware cost Ongoing costs and time spent printing, transporting and storing paper questionnaires Hardware is expensive and can be time consuming to set up May require local computer/database Difficult to train users One time hardware cost Hardware is inexpensive Easy and quick to train users 5

7 1. Manage large data sets with large numbers of terminals: The healthym&e implementation plan described in subsequent sections involves a phased roll out of up to 20 POS systems, all of which would be used to track purchased items in each corner store participating in this program. 2. High Data Quality: In order to provide the Food Trust and the City of Philadelphia with credible and actionable analytics, accurate data must be collected from each participating corner store. 3. Ease of Use: User friendliness of software and hardware is important to gain the support of corner store owners in using a new system, as well as to prevent non-compliance with the program. 4. Low cost and time commitment: healthym&e is able to be almost entirely funded through the $15,000 that will be available through the Penn Public Policy Challenge ($5,000) and the National Public Policy Challenge ($10,000) awards. From the comparison of various data tracking methods, healthym&e proposes the use of a tablet as the sales data collection product. In addition to meeting all program needs, providing a tablet to corner store owners would serve as an incentive to participate in the program. How it Works: For Store Owners The above figure illustrates the checkout process for a purchase at a corner store utilizing the healthym&e system. The process is simple and streamlined. All product prices are stored within the system and calculations are performed by the program. This process removes the burden on corner store owners to remember item prices and calculate transaction costs, which may cause financial 6

8 errors since many corner stores do not currently use bar codes and rely on mental math or handheld calculators. The Shopkeep system also allows corner store owners to use their preferred credit card reader, which will allow them to keep the current system that they already know. An additional benefit is that the card readers already in use by store owners are compatible with EBT cards for people who receive Supplemental Nutrition Assistance Program (formerly known as food stamps ) support. How it Works: For Program Evaluators Shopkeep for program evaluators is a very simple and easy to use interface. Accessing relevant corner store sales data is done through Shopkeep BackOffice, a cloud based inventory management solution. As long as an evaluator has internet access, he or she will be able to see all of the data remotely. This removes the need for physical visits to the store in order to gather data and allows easy access to the data by anyone with the login information. Shopkeep BackOffice provides the evaluator with the ability to quickly access healthy food sales data from all of the corner stores in a single location. The evaluator can mine these data and conduct basic statistical analyses on external statistical software to identify trends in specific healthy product sales. The above figure illustrates the simplicity of accessing corner store data using Shopkeep BackOffice. The process only requires that the user log into the platform with a username and password and select from clearly labeled drop down menus the data type. 7

9 5-Step System Set Up Step Action(s) Notes Labor Required 1. Initial assessment of store infrastructure Ask owners about status of store network (3G) and current POS equipment Cuts costs on extra hardware/services Can be performed at multiple stores simultaneously 30 min/store 1 person/store 2. In-store set up of system Conduct on-site set up of hardware and initial introduction of store owner to devices Can be performed at multiple stores simultaneously Shopkeep will provide on-site set up assistance as needed 1 hr/store 1 person/store 3. In store set up of inventory database Enter commonly purchased inventory into the ipad app Train store owners on how to add items to the inventory and item button to ipad app Store owners will continuously update inventory as they encounter new products being purchased. Can be performed at multiple stores simultaneously.5 day/store 1person/store 4. Testing of system functionality Conduct mock testing of transactions using different payment methods Can be performed at multiple stores simultaneously.5 day/store 1 person/store 5. Training of corner store owners and essential staff Provide initial training of the ipad app and inform owners and staff members of M&E program benefits and requirement Can be performed at multiple stores simultaneously.5 day/store 1person/store Implementation We propose a phased implementation plan, as outlined below, to ensure development (Phase 1), scaling up and appropriate use (Phases 2 and 3), and proposed adoption (Phase 4) of the most effective M&E system. Adoption after Phase 4 is contingent upon the priorities of The Food Trust and availability of funds at the time. Phase 1: Installation of the tablet and accompanying software in four selected stores for a two-month trial period. The selection of these stores will be based on store-specific criteria: Store selection: The four selected stores will be determined based on the suggestions of our advisors at The Food Trust and Philadelphia s Department of Public Health, as well as the following criteria: i. Tier level (stores in Tier 1 communities only) ii. Size of store (limited to smaller stores operated by 1-2 employees) iii. Language spoken by store owner (English) iv. Geographic diversity (multiple regions of Philly, see map on Page 4) A trial period of two months was chosen in order to allot sufficient time for store owners to master the technology. A trial cohort limited to four stores will enable us to perform consistent, weekly check-ins 8

10 with store owners and ensure that they are comfortable with and appropriately utilizing the system. During this period, we will ensure provision of ample technical support, be available to answer questions, maintain positive relationships with owners, and monitor owner compliance with the system, among other activities. Corner store owners will be asked to collect data of all items purchased at the time of exchange, which will include both healthy and unhealthy purchases, as defined by HCSI standards. healthym&e will adjust the monitoring and evaluation system, including technology and support services, based on the feedback and experience of the four pilot corner stores during Phase 1. Advancement to Phase 2 of implementation will require that the stores demonstrate reliable use of the tracking technology. Phase 2: Ongoing utilization of the adopted M&E system in the four pilot corner stores and introduction of the system in 16 additional corner stores over a total period of six months. We will continue making visits to ensure store owners are maintaining Shopkeep system use compliance. These visits will be done at least once each month. During this phase, we will begin using the aggregated data to inform participating healthy corner stores of early identifiable best practices, which will continue throughout the rest of the implementation. Phase 3: Six months of ongoing monitoring of owners usage in 20 total stores, managing owner attrition, and offering continued support for participating owners through consistent check-ins and follow up. Phase 4: Development of a comprehensive review of healthym&e and advocacy for adoption of the system to the Food Trust for the Healthy Corner Store Initiative. We will also work with the Healthy Corner Store Network, which consists of more than 600 members, to promote this information to similar initiatives across the country. healthym&e Beneficiaries Incorporating healthym&e into healthy corner stores in Philadelphia will yield benefits for multiple entities within the city and has the potential to positively influence similar initiatives being pursued in cities across the country. Corner Store Owners Corner store owners who utilize the healthym&e system will be given an opportunity to improve their own sales and profits. healthym&e provides corner store owners with a simple way to keep accurate records of their inventory through an easy to use and customizable system that can be seamlessly integrated into their regular daily activities. The store owners will have access to the data that is automatically compiled into digestible reports that can quickly and clearly identify the best and worst selling items. The Food Trust will also have access to this data for analysis and can use the information gathered from multiple stores to suggest best practices and guidance on the types of items that are most likely to be purchased. Additionally, real-time data will allow the corner store owners and Food Trust staff to evaluate the progress of any future promotional or marketing initiatives for effectiveness and make changes as needed to increase the likelihood of success. 9

11 Community Residents healthym&e will serve as the voice of the community, continuously informing the corner store owners and the Food Trust of their needs. By monitoring what the community does and does not purchase, and by sharing information across stores, it is more likely that corner stores will supply what the community demands. Increased availability of healthy food items that appeal to customers can increase the consumption of healthy foods and alter the tendency to purchase high-calorie, lownutrient items. This is particularly relevant for corner stores near schools where many children and teens stop for snacks before and after school. Increasing the availability of healthy foods that youths actually want to eat can have a positive impact on obesity rates and other illness related to an unhealthy diet. The Food Trust The Food Trust s Healthy Corner Store Initiative has successfully improved availability of healthy food items in low-income and minority communities that face barriers to access. However, in the absence of an accurate and cost-effective monitoring tool, it is difficult to illustrate the impact of the Healthy Corner Store Initiative and helpfully advise corner store owners on the types and quantities of healthy foods that appeal to their customers. We believe that healthym&e can lead to significant cost savings by not only cutting costs in the actual monitoring and evaluations system used, but also in providing consistent data that can improve cost-effectiveness of the program as a whole. The data gathered from healthym&e and the improvements that it will bring to the corner stores will allow the Food Trust to illustrate its success and garner additional support from community partners, funders, and additional corner store owners in the future. Healthy Food Initiatives Nationwide Philadelphia is one of many cities nationwide that supports Healthy Corner Store Initiatives or similar programs. Monitoring and evaluation systems that gather the type of valuable, ongoing purchasing trend information provided by healthym&e is also lacking in these programs. If healthym&e can contribute to more profitable businesses, healthier food choices, and a more cost-effective program, it could be used as a proven model to improve food access initiatives in struggling communities across the country. 10

12 Budgeting and Timeline for healthym&e The healthym&e system will be primarily funded through the Penn Public Policy Challenge award of $5,000 and the National Public Policy Challenge award of $10,000, for a total available budget of $15,000. Additional funds will be requested from University of Pennsylvania student research grants and support from each team member s respective graduate school. Phase Timeline Cost Phase 1 Months 1-2 $1,428 1 Phase 2 Months 3-6 $7,608 2 Phase 3 Months 6-12 $9,480 3 Phase 4 Upon Adoption by Food Trust TOTAL - $18,516 In Conclusion We believe that the implementation of the healthym&e system will contribute to the growth of healthier businesses and healthier communities in Philadelphia. It will serve as a valuable tool to help the Healthy Corner Store Initiative more effectively reach its ultimate goal of making healthy food items available to communities that regularly experience barriers to access. The system also has the potential to serve as a model for improving similar initiatives working to resolve food disparities in other cities. The data collected may provide further insights into generalizable and distinct trends in healthy food consumption, which would inform the continued development of cost-effective healthy food programs across the United States. 1 Two-month calculation based on technology costs: $199(iPad) + $90(2-month Shopkeep subscription at $49/mth) + $60 (2-months of data at $30/mth) = $357 (x 4 stores) = $1,428) 2 Three-month calculation based on hardware cost for 4 additional systems each month + additional monthly subscriptions at $49/mth + additional monthly data costs at $20/mth 3 Six-month calculation of ongoing data/subscriptions for 20 stores with no new additions. Data and Subscriptions for months 7-12: (49*20)+(30*20)=$1,580 x 6 = 9,480 11

13 i Obesity in Philadelphia - Philadelphia Department of Public Health. Retrieved from ii Veur, S., Sherman, S., Lent, M., Mccoy, T., Wojtanowski, A., Sandoval, B.,... Foster, G. (2013). Corner Store and Commuting Patterns of Low-Income, Urban Elementary School Students. Current Urban Studies, 1(4), Retrieved from iii Cavanaugh, E. (2014). Changes in food and beverage environments after an urban corner store intervention. Preventive Medicine, 65. Retrieved from iv Lawman, H. (2014). Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention. Preventive Medicine. Retrieved from v Health Care Expenditures per Capita by State of Residence. The Henry J. Kaiser Family Foundation Retrieved from vi Community Profile: Philadelphia, Pennsylvania - Obesity and Tobacco Use Prevention [Internet]. Centers for Disease Control and Prevention Retrieved from th-pa_philadelphia.htm vii Harvard School of Public Health. Economic Costs [Internet]. Obesity Prevention Source Retrieved from viii Borradaile, K. et al Nov. 1. Snacking in Children: The Role of Urban Corner Stores. Pediatrics. 124(5): doi: /peds ) ix Martin, K. et al Oct. If you stock it, will they buy it? Healthy food availability and customer purchasing behaviour within corner stores in Hartford, CT, USA. Public Health Nutrition. 15(10): Doi: /S x Borradaile, K. et al Nov. 1. Snacking in Children: The Role of Urban Corner Stores. Pediatrics. 124(5): doi: /peds ) xi Childhood Obesity Facts. (2014). Centers for Disease Control and Prevention. Retrieved from xii Healthy Corner Store Initiative: Overview. (2014). Retrieved from xiii Ibid [xii]. xiv Ibid [xii]. xv Ibid [iii]. xvi Ibid [iv]. 12