title: Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results.
abstract: BACKGROUND
  Prepared food sources, including fast food restaurants and carry-outs, are common in low-income urban areas. These establishments provide foods high in calories, sugar, fat, and sodium. The aims of the study were to (1) describe the development and implementation of a carry-out intervention to provide and promote healthy food choices in prepared food sources, and (2) to assess its feasibility through a process evaluation.
  
  
  METHODS
  To promote healthy eating in this setting, a culturally appropriate intervention was developed based on formative research from direct observation, interviews and focus groups. We implemented a 7-month feasibility trial in 8 carry-outs (4 intervention and 4 comparison) in low-income neighborhoods in Baltimore, MD. The trial included three phases: 1) Improving menu boards and labeling to promote healthier items; 2) Promoting healthy sides and beverages and introducing new items; and 3) Introducing affordable healthier combo meals and improving food preparation methods. A process evaluation was conducted to assess intervention reach, dose received, and fidelity using sales receipts, carry-out visit observations, and an intervention exposure assessment.
  
  
  RESULTS
  On average, Baltimore Healthy Carry-outs (BHC) increased customer reach at intervention carry-outs; purchases increased by 36.8% at the end of the study compared to baseline. Additionally, menu boards and labels were seen by 100.0% and 84.2% of individuals (n = 101), respectively, at study completion compared to baseline. Customers reported purchasing specific foods due to the presence of a photo on the menu board (65.3%) or menu labeling (42.6%), suggesting moderate to high dose received. Promoted entrée availability and revised menu and poster presence all demonstrated high fidelity and feasibility.
  
  
  CONCLUSIONS
  The results suggest that BHC is a culturally acceptable intervention. The program was also immediately adopted by the Baltimore City Food Policy Initiative as a city-wide intervention in its public markets.
authors.affiliation: Center for Human Nutrition, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. seulee@jhsph.edu
authors.forename: Seung Hee
authors.initials: SH
authors.lastname: Lee-Kwan
authors.forename: Sonja
authors.initials: S
authors.lastname: Goedkoop
authors.forename: Rachel
authors.initials: R
authors.lastname: Yong
authors.forename: Benjamin
authors.initials: B
authors.lastname: Batorsky
authors.forename: Vanessa
authors.initials: V
authors.lastname: Hoffman
authors.forename: Jayne
authors.initials: J
authors.lastname: Jeffries
authors.forename: Mohamed
authors.initials: M
authors.lastname: Hamouda
authors.forename: Joel
authors.initials: J
authors.lastname: Gittelsohn
mesh_terms: D000329:Advertising; D015142:Baltimore; D057140:Fast Foods / Q000592:standards*; D005240:Feasibility Studies; D005523:Food Supply / Q000592:standards; D006293:Health Promotion; D006801:Humans; D008612:Menu Planning; D018673:Nutrition Policy / Q000331:legislation & jurisprudence; D011203:Poverty; D017064:Process Assessment, Health Care; D012147:Restaurants