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Live Well Community Market Program

State: CA Type: Promising Practice Year: 2019

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County of San Diego Health and Human Services Agency
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Live Well Community Market Program

San Diego County is California's 2nd largest county and the 5th largest county in the United States, based on population, and spans 4,261 square miles with 18 municipalities and 36 unincorporated towns. The World Health Organization's 3-4-50 concept campaign identified that 3 behaviors (no physical activity, poor diet, and tobacco use) lead to 4 diseases (cancer, heart disease and stroke, type 2 diabetes, and lung disease) and account for over 50% of deaths worldwide (WHO, 2003).[i] With a population of 3.3 million people, approximately 33% of adults in San Diego County are overweight and 26% are obese (CDC, 2013).[ii] With this understanding, Live Well San Diego was created as the County of San Diego's vision for a region that is building better health, living safely, and thriving, aligning the efforts of individuals, organizations, and government to help all San Diego County residents live well.[iii]


Food deserts and food swamps are a problem plaguing many underserved neighborhoods throughout the country. According to Morland, Wing, and Roux (2002)[iv] there is a positive association between being able to meet recommended dietary guidelines and the type of local food environment. In other words, what is and is not available in a neighborhood can be an indication of whether individuals and families can follow recommended dietary guidelines. The 2015-2020 Dietary Guidelines for Americans asserted that there needs to be more solution-oriented strategies to increase access to healthy affordable foods (United States Office of Disease Prevention and Health Promotion, 2015).[v] The guidelines encourage innovative changes to the food retail environment. As a result, public health departments across the country are focused less on individual behavior change and more on positively impacting the food retail environment in underserved neighborhoods, through approaches that address access and affordability of healthy foods. Grocery stores are not always the solution to solving inequities in access to healthy foods. Instead, preestablished markets are a valuable place for interventions. Small-to-medium sized markets are ubiquitous in underserved communities and community members frequent them due to their level of convenience, affordability, and familiarity (Dannefer, Williams, Baronberg, and Silver, 2012[vi]; Raja, Ma, and Yadav, 2008).[vii] In San Diego, a recent study of ethnic markets found this trend to be true (Jossart-Marcelli, Rossiter, and, Bosco, 2017).[viii]


Healthy retail programs provide government agencies and community-based organizations opportunities to support small-to-medium sized markets that are willing to sell healthy foods. Not only do these programs work to build better health for residents, they also assist market owners in developing thriving business models that increase their bottom line. The healthy retail program in San Diego, known as the Live Well Community Market Program (LWCMP), moves beyond increasing access to healthy foods and economic development to also reducing promotion of alcohol and tobacco products while increasing access to active transportation. The LWCMP aims to improve and promote access to healthy affordable foods, increase availability of fresh produce, redesign spaces to promote healthy foods, and connect with community stakeholders to build a healthier food environment for all San Diegans.


The program developed a recognition framework that publicly recognizes markets for their participation and commitment to three varying levels of standards; the third level with the most stringent of requirements. The recognition framework was developed through a strategic working group that includes nutrition, alcohol and tobacco prevention experts, economic development leaders, and active transportation advocates. The framework also underwent branding exercises to determine a name and look that resonates with community partners and market owners. The recognition framework approach is recognized by the California Department of Public Health and the Centers for Disease Control and Prevention as an effective approach to motivate and enable owners to make positive changes in their markets and increase communities' access to healthy foods. This approach has a multitude of other benefits, such as: avoiding duplicative work, gaining access to new resources and expertise, saving time and money, tapping into new networks, aligning priorities, identifying innovative solutions, serving the community more effectively, and having a larger effect on community health.


As a result of this innovative method, various tools were developed, and significant changes made to improve the food retail environment. Since 2016, twenty markets in underserved communities in San Diego were recruited and recognized by the LWCMP and underwent various levels of improvements. Three markets received exterior façade makeovers, two markets are new locations for WIC recipients, two markets source produce from community gardens within proximity to them, one market successfully received a requested crosswalk outside of their location, and the interventions continue.  


http://www.livewellsd.org/content/livewell/home/Topics/healthy-food-systems/lwcmp.html



[i] World Health Organization. (2003). The global strategy on diet, physical activity and health.

[ii] Centers for Disease Control and Prevention, National Center for Health Statistics, Obesity and Overweight, FastStats. (2016).

[iii] County of San Diego Website, 2011. Accessed December 6, 2018 http://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_health_statistics/3-4-50.html

[iv] Morland, K., Wing, S., & Roux, A. D. (2002). The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study. American Journal of Public Health, 92(11), 1761-1768.

[v] United States Office of Disease Prevention and Health Promotion. (2015). Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Retrieved from: http://health.gov/dietaryguidelines/2015-scientific-report/PDFs/02-executive-summary.pdf

[vi] Dannefer, R., Williams, D. A., Baronberg, S., & Silver, L. (2012). Healthy bodegas: increasing and promoting healthy foods at corner stores in New York City. American Journal of Public Health, 102(10), e27-e31.

[vii] Raja, S., Ma, C., & Yadav, P. (2008). Beyond food deserts measuring and mapping racial disparities in neighborhood food environments. Journal of Planning Education and Research, 27(4), 469-482.

[viii] Joassart-Marcelli, P., Rossiter, J. S., & Bosco, F. J. (2017). Ethnic markets and community food security in an urban food desert.” Environment and Planning A: Economy and Space49(7), 16421663. https://doi.org/10.1177/0308518X17700394

Food deserts and food swamps are a problem plaguing many underserved neighborhoods throughout the country. According to Morland, Wing, and Roux (2002)[i] there is a positive association between being able to meet recommended dietary guidelines and the type of local food environment. In other words, what is and is not available in a neighborhood can be an indication of whether individuals and families can follow recommended dietary guidelines. The 2015-2020 Dietary Guidelines for Americans asserted that there needs to be more solution-oriented strategies to increase access to healthy affordable foods (United States Office of Disease Prevention and Health Promotion, 2015).[ii] The guidelines encourage innovative changes to the food retail environment. As a result, public health departments across the country are focused less on individual behavior change and more on positively impacting the food retail environment in underserved neighborhoods, through approaches that address access and affordability of healthy foods. Grocery stores are not always the solution to solving inequities in access to healthy foods. Instead, preestablished markets are a valuable place for interventions. Small-to-medium sized markets are ubiquitous in underserved communities and community members frequent them due to their level of convenience, affordability, and familiarity (Dannefer, Williams, Baronberg, and Silver, 2012[iii]; Raja, Ma, and Yadav, 2008).[iv] In San Diego, a recent study of ethnic markets found this trend to be true (Jossart-Marcelli, Rossiter, and, Bosco, 2017).[v]


San Diego County is a geographically widespread and incredibly diverse community. Due to the local health department's jurisdiction over the entire county, the LWCMP works across the entire region. However, efforts around the LWCMP have historically been focused in urbanized communities within San Diego County, including: City of San Diego, City of National City, and City of El Cajon. Within these cities, the LWCMP focuses on low-income neighborhoods that are disproportionately impacted by chronic diseases and are often more ethnically and racially diverse. Within the City of San Diego, emphasis is on the communities of Mid-City and Southeastern San Diego. These communities are two of the three sub-regional areas (SRAs) that make up the Central Region, one of the six Health and Human Services Agency (HHSA) regions of San Diego County. Both SRAs have high rates of poverty with 25.9% of Mid-City residents and 20.7% of Southeastern residents living below 100% FPL (U.S. Census Bureau, 2012-2016 American Community Survey 5-Year Estimates).[vi] Health Status estimates from the California Health Interview Survey (CHIS) for 2014-2016 indicate that most adult residents in the Central Region are overweight or obese (60.9%).[vii] Table 1 also illustrates the ethnic and racial diversity of these communities.


Table 1. Percent of Race/Ethnicity Group in Central Region, by Sub-regional Area (SRA)

Geography

African American

Hispanic American

American Indian/Alaska Native

Asian

Native Hawaiian/Pacific Islander

White

Mid-City

13%

41%

0%

14%

0%

28%

Southeastern San Diego

14%

53%

0%

19%

1%

10%

Central Region

11%

43%

0%

13%

0%

30%

City of San Diego

6%

30%

0%

17%

0%

43%

Source: U.S. Census Bureau, 2012-2016 American Community Survey 5-Year Estimates. Table B03002: Hispanic or Latino Origin by Race


Similarly, National City is predominantly Latino/Hispanic American (64.4%),[viii] 22.7% of the population is in poverty,[ix] and the city has the highest rate of overweight and obese children in the county at 50% (UCLA Health Policy, 2012)[x]. The fifth largest city in San Diego County, El Cajon, is a rapidly growing community with approximately 60,000 refugees from Iraq, Syria, Afghanistan, and African nations. While rich in diversity and culture, El Cajon has the highest poverty rate in the county. The median household income per capita is nearly $45,000 compared to the county average of $64,000 (U.S. Census Bureau).[xi]


Although Mid-City San Diego, Southeastern San Diego, National City, and El Cajon have unique and varying demographics there is a salient feature amongst all of them: high levels of poverty. Studies have shown that higher rates of food insecurity and hunger occur among lower socioeconomic status individuals, and a strong relationship has been established between food insecurity and poverty (Evans, Jennings, Nehme, Sharma, Hussaini, and Yaroch, 2015).[xii] Residents in all four communities have expressed discontentment in their ability to access fresh fruits and vegetables and a lack of large grocery stores in their communities. However, all four communities also have a number of small and independently-owned markets with a vested interest in the community, making them ideal locations to interject the LWCMP.


Rather than determining what percentage of the target population has been reached by the LWCMP, it is important to look at the distribution of participating markets in the selected communities. The Central Region of San Diego (including Mid-City and Southeastern) represents the most densely populated area of the county (San Diego County, 2018)[xiii] and has the highest density of retailers, especially those that sell tobacco, in the county (California Community Health Assessment Tool, 2016).[xiv] Therefore, the LWCMP is concentrated in this part of the region and is currently partnering with sixteen markets throughout Central San Diego. The LWCMP is also working with two markets in National City and two markets in El Cajon. This reach ensures that target populations from across the region are receiving the benefits of the intervention.


The LWCMP approach is innovative for its holistic approach to the food retail environment. Since the program was initiated by obesity prevention public health professionals, a working group was formed to collect information from tobacco and alcohol prevention subject matter experts on ways to improve upon markets from their specific perspectives. Whereas, alcohol and tobacco prevention professionals are often interacting in the retail space in order to ensure compliance with laws and regulations and are often viewed as punitive, by partnering with the LWCMP their efforts are perceived in a more positive light and additional shared resources can be offered to market owners. Often, it also encourages market owners to do more than the legally required minimum as evidenced by market owners the LWCMP has partnered with who have taken the initiative to remove alcohol and tobacco advertisements and products. The LWCMP's comprehensive framework also limits duplicative efforts and survey fatigue of market owners and their customers. Alcohol and tobacco prevention and nutrition promotion experts all have a stake in improving the retail environment, so the LWCMP recognition framework guarantees coordination amongst all interested parties and thereby has the potential for a greater impact. The recognition framework is informed by local expertise in healthy retail intervention best practices and healthy food access strategies. The program and its framework are grounded in healthy retail best practices and recommendations available in grey literature and empirical studies from the field, most notably by The Food Trust, ChangeLab Solutions, the Public Health Institute, the California Department of Public Health, the Healthy Neighborhood Market Network of the Los Angeles Food Policy Council, and Shop Healthy NYC from the New York City Department of Health and Mental Hygiene with the New York City Center for Economic Opportunity.



[i] Morland, K., Wing, S., & Roux, A. D. (2002). The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study. American Journal of Public Health, 92(11), 1761-1768.

[ii] United States Office of Disease Prevention and Health Promotion. (2015). Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Retrieved from: http://health.gov/dietaryguidelines/2015-scientific-report/PDFs/02-executive-summary.pdf

[iii] Dannefer, R., Williams, D. A., Baronberg, S., & Silver, L. (2012). Healthy bodegas: increasing and promoting healthy foods at corner stores in New York City. American Journal of Public Health, 102(10), e27-e31.

[iv] Raja, S., Ma, C., & Yadav, P. (2008). Beyond food deserts measuring and mapping racial disparities in neighborhood food environments. Journal of Planning Education and Research, 27(4), 469-482.

[v] Joassart-Marcelli, P., Rossiter, J. S., & Bosco, F. J. (2017). Ethnic markets and community food security in an urban food desert.” Environment and Planning A: Economy and Space49(7), 1642–1663. https://doi.org/10.1177/0308518X17700394

[vi] American Community Survey. (2018). https://www.census.gov/programs-surveys/acs/

[vii] 2014-2016 California Health Interview Survey. CHIS 2015-2016 Adult San Diego County Local Health Department File. Los Angeles, CA: UCLA Center for Health Policy Research, July 2018.

[viii] National City. (2010). Demographics. Retrieved from: http://www.nationalcityca.gov/about-us/demographics

[ix] United States Census Bureau. (2017). Quick Facts: National City, California. https://www.census.gov/quickfacts/nationalcitycitycalifornia

[x] UCLA Health Policy. (June 2012). Overweight and Obesity among Children by California Cities. Retrieved from: http://healthpolicy.ucla.edu/publications/Documents/PDF/children2010fs-jun2012.pdf

[xi] United States Census Bureau, QuickFacts San Diego County and El Cajon City, (2016). Available at https://www.census.gov/quickfacts/fact/table/sandiegocountycalifornia,elcajoncitycalifornia/PST045216

[xii] Evans, A., Banks, K., Jennings, R., Nehme, E., Nemec, C., Sharma, S., Hussaini, A., … Yaroch, A. (2015). Increasing access to healthful foods: a qualitative study with residents of low-income communities. The international journal of behavioral nutrition and physical activity12 Suppl 1(Suppl 1), S5.

[xiii] San Diego County. (January 2018). 2016 Demographic Profiles. Retrieved from: https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/CHS/demographics/FINAL_2016_Demographic_Profiles_1.30.18.pdf

[xiv] Stanford Prevention Research Center. (December 2016). California Community Health Assessment Tool. City of San Diego Tobacco Retailers.

Per its logic model, the long-term outcomes or objectives of the LWCMP are to decrease obesity and reduce the risk of chronic diseases related to obesity. The intermediate outcomes are to increase purchases and consumption of healthy foods and beverages and increase physical activity. Lastly, the short-term outcomes are to increase awareness and availability of healthy food and beverage options, to increase access to affordable healthy food and beverages, and to increase access to active transportation.


More specifically, the goals of the LWCMP were largely informed by two different funding sources awarded to HHSA. HHSA received the 1422 State and Local Public Health Actions to Prevent Obesity, Diabetes, and Heart Disease and Stroke which included a deliverable of developing a local healthy retail recognition program and recruitment and implementation of that program at minimum of twelve markets. Additionally, HHSA received Supplemental Nutrition Assistance Program-Education funding from the Nutrition Education and Obesity Prevention Branch of the California Department of Public Health which includes recruitment and implementation of the LWCMP at fifteen markets by the end of fiscal year 2019. HHSA has a strong commitment to supporting community-based organizations, especially in the development and execution of place-based programs and projects such as the LWCMP. Therefore, a local community-based organization (UCSD Center for Community Health) was contracted to support the County's development of the recognition framework and identify key partners. The program's development also included internal HHSA staff from other departments (such as Behavioral Health Services) and internal County staff from other groups (such as the Department of Environmental Health, which is housed outside of HHSA, in the Land Use and Environment Group). The program also greatly benefited from economic development expertise and support provided by the City of San Diego's Economic Development Department through their Storefront Improvement Program Manager and other staff.


The program initiated with convenings of many of the aforementioned stakeholders which evolved into a formalized monthly working group in December 2015. The working group simultaneously developed an assessment tool to identify what elements of markets working group participants were interested in capturing and potentially changing as well as a recognition framework. Results from market assessments in addition to connections in communities helped identify which markets to recruit into the program and which markets needed additional support with alcohol and tobacco compliance. The recognition framework underwent a branding process, in coordination with the working group in October 2016, which resulted in: a stylized guide; a variety of market-suited colorways for price cards, produce cooler banners, and healthy snack stickers available in English, Spanish, and Arabic; and window decals to indicate a market's participation in the LWCMP. Interim products were informally tested amongst market owners to help select the final products such as a logo and the window decals. Development of the recognition framework coincided with recruiting and working with markets to test out elements of the framework and solidify what should be included. Markets were subsequently recognized for their participation at various levels. Simultaneously, Social Advocates for Youth San Diego (a local community-based organization that works on alcohol and tobacco prevention efforts) began annual assessments of over one hundred markets along various business corridors throughout Central San Diego, providing the LWCMP staff with useful information on the state of the food retail environment in various communities and empirical data on where to focus efforts.


As a result of the framework developed, the program created a schematic process. Initially, program staff (which could include HHSA staff, contractors, or alcohol and tobacco prevention colleagues who are part of the working group) visit a store that is referred to them by way of a local business improvement district, community council or planning group, as the result of an assessment, or through another community engagement touchpoint. The first visit is generally less informal, so program staff can get a better understanding of what the market looks like on the ground. The LWCMP has specific criteria that a market must meet to receive services. Markets must: be located in a residential area (within reasonable walking distance to homes, e.g., less than ½ mile); have sufficient customer flow (enough regular business transactions to merit investment); have patronage from neighborhood residents; provide quality customer service; have a clear need for physical transformation; not have a high availability or have no high-quality fresh fruits and vegetables; have a present owner/operator who is on site most days; have market owner buy-in; have regular hours of operation; have an absence of criminal activity in the immediate area; and have an owner/operator with a minimum of two years of food retail experience. If the market meets all eleven criteria, a formal meeting is set-up with the market's owner/operator and an assessment of the market is conducted (if one has not already been completed). Following the first official meeting, once the market's owner/operator has agreed to participate, they receive a program orientation which includes visual depictions of the potential outcomes of participating in the LWCMP. Either during this meeting or at a subsequent meeting, program staff co-develops an action plan with market staff which includes a minimum of three achievable SMART goals, the steps necessary to achieve those goals, and the timeline for each step. It is imperative at this point for both program staff and the market owner/operator to sign the agreement so there is a joint agreement that both parties will work towards achieving the goals outlined. The bulk of the work comes over the next few months to years of working together to make improvements. The types of technical assistance offered to markets include: marketing and merchandising; promoting and increasing demand for healthy fresh foods; market design and layout support; connections to local produce growers and distributors; promoting CalFresh EBT and WIC acceptance; trainings on produce handling, storage, and display; intercept surveys and shopper market research; peer learning and networking with other market operators; connections to community stakeholders; coordinating with other government agencies and programs; and market makeovers. Depending on the level of technical assistance the market receives, the approximate value of in-kind services ranges from $1,500 to $25,000. After some substantive change has been made, such as introducing new produce items, program staff will host an event at the market to draw attention to their commitment to providing healthier items to their community. Events may include, but are not limited to: produce taste tests, customer intercept surveys with incentives for participants, or another similar type of tabling activity. For those markets that make more significant improvements, such as exterior façade changes, program staff work to secure the market earned media through traditional channels such as local news affiliates or they might be featured on the County's external-facing website. Markets are reassessed on an annual basis to showcase progress over time and ensure continued compliance with laws and regulations.


The LWCMP could not function without community collaboration. First and foremost, the inception of the program's framework relied heavily on the input and expertise of individuals outside of HHSA. Similarly, the contractor tasked with implementing key components of the LWCMP (UCSD Center for Community Health) was key to ensuring the LWCMP's success. Most importantly, the LWCMP relies heavily on the involvement and participation of market owners and their staff who are integral to the community they serve. Of utmost importance in ensuring success of market projects led by the LWCMP are relationships with other community stakeholders. HHSA program staff developed relationships with the managers of the business improvement associations in Mid-City and Southeastern San Diego and the Economic Development Manager in the City of National City. These relationships had various positive outcomes. Within the communities in the City of San Diego, it ensured additional resources were provided to markets, especially those undergoing façade improvements. Additionally, as a result of the relationships with City-level staff, HHSA successfully advocated for amending City policy to allow for expedited review of planning projects for markets within Southeastern San Diego. In National City, the relationship with the Economic Development Manager resulted in the LWCMP being promoted and highlighted by City staff when they do outreach to businesses within National City.


The LWCMP has also emphasized the importance of community involvement with specific market projects. A case study of one market's journey illustrates the value of community in the process. In the City of El Cajon, Rema Halal Foods is mostly a halal meat market that was recruited to participate in the LWCMP in June 2016. The market's owner, Alaa Alsadoon, was interested in expanding his operation to meet the needs of his shoppers. The first step the LWCMP staff took was to collect shopper intercept surveys to inform the program and Alsadoon on what they should focus their efforts on. Simultaneously, the LWCMP staff partnered with a local university's (San Diego State University) graphic design professor and her students who were able to provide Alsadoon with pro bono design services. Over a five-week period, a pair of design students worked directly with Alsadoon to develop a new exterior façade design and branding concept with accompanying marketing materials to promote the growth of his business. Following the completing of the design concepts, in August 2017, the LWCMP staff and Alsadoon co-hosted and facilitated a community visioning meeting to see how the proposed market design resonated with the shoppers and residents, and to solicit feedback on how else the market's exterior could be improved. Specific suggestions from community members included: more lighting, new paint, installation of awnings to provide shade, displaying produce outside of the market, signs in Arabic, plants and greenery outside the market, replacing the door, and installing a bike rack. In December of that same year, many of the community's suggestions came to fruition with a community build day. Over sixty volunteers came out through the course of the day to help: paint the building based on the pro bono design concepts, install pull-down shades, build and fill planter boxes, paint the door, and install a bike rack. The event also included free food, provided by Alsadoon and live music to make the event feel even livelier. A similar process was followed for the other large-scale design projects completed by the LWCMP.


The LWCMP is a reimagination of traditional healthy retail programs. It evolved into an interdisciplinary effort focusing on bridging the gaps between and meeting goals in the following areas: food justice, health equity, neighborhood-level economic development, community and civic engagement and collaboration, public health, prevention work, and the local food system. The multi-faceted dynamism of the LWCMP is largely dependent on the input and continued collaboration from internal and external stakeholders, most importantly, the community.

Per its logic model, the long-term outcomes or objectives of the LWCMP are to decrease obesity and reduce the risk of chronic diseases related to obesity. The intermediate outcomes are to increase purchases and consumption of healthy foods and beverages and increase physical activity. Lastly, the short-term outcomes are to increase awareness and availability of healthy food and beverage options, to increase access to affordable healthy food and beverages, and to increase access to active transportation.


Regarding the intermediate outcomes of increasing purchases of healthy foods and beverages, HHSA contracted with an evaluation firm known as Harder+Company to collect and analyze data from four markets participating in the LWCMP to see how participation impacted their fresh produce sales; a form of outcome evaluation. Markets were initially asked to provide sales data for four months, between April 2017 and September 2017. Markets were later asked to share retrospective or historical data from before they began working with the LWCMP to determine a baseline and examine change over time. Unfortunately, the ability to receive data varied significantly depending on the market as evidenced in Table 2.


Table 2. Available Data by Market

Market

Implementation Date

Baseline

April 2017

May 2017

June 2017

July 2017

August 2017

September 2017

Market 1

08/4/16

*

X

X

X

X

X

X

Market 2

11/16/15

*

*

*

X

*

X

*

Market 3

05/17/16

X

*

*

X

X

X

X

Market 4

04/18/16

*

*

*

X

*

*

*

X Data collected

* Data not available


For Market 1, total produce sales ranged from $9,000-$12,000 per month and made up between 20-26% of total sales during the study period. For Market 2, total produce sales jumped from $1,100 in June to $2,800 in August, making up 1.8% and 2.8% of total sales, respectively. Market 3 was the only market where historical data was gathered. According to the sales reports, in April 2016, total produce sales ranged from $6,000-$7,000. Market 3 was recruited to the program in May 2016 and during the months of data collection, the total produce sales ranged from $9,000-$11,000. For Market 4, total produce sales were only collected for one month and were over $47,000, making up 13.4% of the market's total sales.


The primary data available for evaluation purposes was very limiting for drawing any conclusions on the impact of the LWCMP, except for Market 3. The increased total produce sales at Market 3 may be an indication of the success of the LWCMP in supporting the market and in the stated objective of increasing purchases of healthy foods. Nonetheless, the practice provided program staff with insightful takeaways. First and foremost, it is important to collect sales and purchase data prior to making any changes in the market, once a market has agreed to participate in the LWCMP. Additionally, the external evaluation staff likely had a harder time receiving data from the markets because they did not have established relationships with the owners/operators. Although best practice is to have non-program, external evaluators perform evaluation, in this instance the LWCMP staff would be better poised to collect data and do analysis internally. Another consideration, which was explored with some market owners, was to purchase point-of-sale systems for the markets so data collection can be consistent. However, most of the owners were not interested in changing their current systems since it would require inputting their entire inventory, which often includes hundreds of items.


Harder+Company was also contracted to perform customer intercept surveys at grocery stores in Mid-City and Southeastern San Diego to better understand shopping behaviors of shoppers in these target communities and better inform the LWCMP program; a form of process evaluation. Seventy-three customers were surveyed at two different grocery stores (one in each target community). Most surveys (82.9%) were administered in Spanish. For those respondents who said they buy most of their food at grocery stores, their top three reasons for shopping at grocery stores included: proximity to their home, good selection of food items, and cleanliness. Respondents were also asked about their familiarity with markets that participate in the LWCMP. Thirty-five respondents were familiar with the LWCMP participating markets and indicated the same reasons for choosing to shop at those markets: proximity to their home, good selection of food items, and cleanliness.


Customer intercept surveys were also performed at several the participating markets, including those in National City and El Cajon with the intention of collecting information from current shoppers on what items they would like to see at the market. This form of evaluation was used more frequently to inform the program and to encourage market owners/operators to consider adding new products to their inventory, specifically fresh produce when requested by customers.

Due to the substantial outcomes from the LWCMP, HHSA has committed to continuing the program through various funding streams. The LWCMP will continue to operate under the Supplemental Nutrition Assistance Program-Education (SNAP-Ed) dollars distributed by the United States Department of Agriculture by way of the California Department of Public Health. Additionally, HHSA was recently awarded the 1813 Racial and Ethnic Approaches to Community Health grant from the Centers for Disease Control and Prevention. The grant proposal included continued implementation of the LWCMP at additional sites in Mid-City and Southeastern San Diego. As a result of the innovative collaboration with tobacco prevention partners, the LWCMP was also written into newly-released tobacco prevention-related contracts. Because of the comprehensive nature of the program (including tobacco prevention in the recognition framework), tobacco prevention organizations will have the opportunity to work on implementing and expanding the LWCMP into additional regions in San Diego.


The LWCMP's recognition framework has also been identified by the California Department of Public Health (CDPH) as a model practice. When the LWCMP staff first started working on developing the recognition framework, CDPH staff determined that it would be outside of the scope of SNAP-Ed efforts to integrate tobacco and alcohol prevention elements into healthy retail. However, after seeing the development of the framework and teleconferencing into the LWCMP working group, they saw the value of the comprehensive approach. The CDPH developed its own recognition framework, using the LWCMP's as a guide and best practice. They later disseminated this information to various counties who are working to pilot the implementation of the recognition framework. More recently, the CDPH has encouraged coordination and collaboration between the nutrition branches and tobacco prevention branches, supporting shared assessment tools and data. The LWCMP staff were also recently invited to participate on a panel to discuss the local experience of nutrition staff partnering with tobacco staff.


Attempting to persuade business owners to make changes in products, layout, and marketing requires business development skills, strategies, and incentives that can be challenging to acquire within the frame and funding of public health and prevention. Partnering with business improvement associations, community developers, urban designers, city staff in economic development, and community resident groups have proven helpful in gathering the appropriate suite of technical assistance services to market owners. However, market owners are often skeptical of free services offered by these entities and look to the LWCMP staff they already trust before taking advantage of other resources from outside technical assistance providers. LWCMP staff continuously serve as a liaison for market owners/operators. Despite several challenges, the LWCMP staff have excelled in working with market owners and achieved a number of important successes. 

Colleague in my LHD