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The present study was a RCT design, with a 6-mo intervention and a 3-mo follow-up period. The study was conducted between September and July in 4 Dutch supermarkets. All participants provided written informed consent.
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This study was conducted in collaboration with individual store owners of C and PLUS supermarket chains. These chains had the second- and third-largest market share in the Netherlands, respectively. We recruited supermarkets in areas with no other supermarkets in the vicinity. This approach was used to prevent interference, for example, from competing promotions in other nearby supermarkets.
Owners of these 11 stores were sent a formal letter explaining the rationale of the study. After 1 wk, all of the owners were phoned to inquire about their interest in participation. Four owners could not be reached in time due to holidays.
Three owners were not willing or able to participate. The stores were distributed through 4 different provinces and were located in rural areas population size in villages ranged from to Participants were recruited between July and August For recruitment we used posters, flyers handed out by the cashiers , and advertisements in local newspapers. In total, participants registered see Figure 1.
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After registration, participants were screened for eligibility. Because this study specifically focused on people with a lower SES, we used educational level as a specific selection criterion eg, excluding participants with a higher educational level and where the maximum level was set at completed intermediate vocational education, which is similar to US community college. Income was not used as an indicator for SES because Dutch people are generally reluctant to provide details about their income. Second, participants had to be frequent shoppers in the participating stores.
On the basis of these criteria, participants were registered and sent baseline questionnaires and informed consent forms. Randomization was stratified by store to make sure there was a balance of subjects in each condition across the 4 stores.
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The randomization procedure was blinded. Participants were unaware of the aims of this study but not with regard to allocation of the intervention conditions. Nutrition education comprised provisioning recipe books and telephone counseling. Participants received 2 recipe books: one containing autumn recipes at the start of the trial and one containing winter recipes halfway through the trial in January.
The telephone counseling consisted of 4 telephone calls conducted by a qualified dietitian At least 3 attempts were made to reach participants for each of these calls, including one evening attempt. If a participant could not be reached, new attempts were made in the next counseling round.
The counseling scheme was based on the principles of motivational interviewing MI. The rounds were divided into 2 phases: 1 building motivation for change and 2 strengthening commitment to change MI uses several specific conversation techniques such as asking open questions and reflective listening with the aim to create an open conversation without any counselor bias. The dietitian received 2 full days of certified training in MI to obtain these skills.
Within this MI framework, different theoretical insights were combined to provide a firm education program. Finally, the self-regulatory process action planning eg, specifying when and how to act and coping planning eg, anticipating personal risk situations and planning coping responses beforehand were incorporated 36 , Furthermore, similar discount amounts have been previously used in experimental studies in smaller settings, and it is useful to extrapolate these findings to a real supermarket environment 14 , 25 , The discounts were provided by coupons.
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Coupons were used because this has previously been found to be effective 40 and because this system enabled us to offer discounts in all 4 supermarkets without interfering with the nondiscount intervention groups. Participants were sent discount coupons by mail for 7 types of vegetables and 5 types of fruit every 2 wk with 2 coupons for each item and with changing discount selections. In addition, apples were discounted throughout the entire intervention period, enabling assessment of the effects of a continuous price reduction. Discounts were chosen in line with seasonal availability.
To prevent sharing, each coupon had a maximum amount of produce that could be purchased. Discounted products were mostly fresh produce, but every series also included some canned and frozen products. Fruit juices, vegetable juices, apple sauce, tomato sauce, and potatoes were also excluded from the discount. Data collection took place at 5 time points: baseline, 1 mo after the start of the intervention, at 3 mo, at 6 mo end of the intervention period , and 3 mo after the intervention ended 9 mo.
These measures were based on supermarket cash receipts from the participating supermarkets that were collected at each measurement round during a 2-wk period. This method has been previously validated and found to be an effective measure of household food purchases Second, the supermarket owners provided information on the use of discount coupons in each period. Participants were asked to report some basic personal characteristics see Table 1 , discount coupon use, and frequency of shopping at the participating supermarket and to evaluate the nutrition education where provided.
BMI was measured by self-reported height and weight at baseline. This item index was developed as a direct measure of habit strength and was added because the formation of new behavior may be largely dependent on the strength of current habits Baseline participant characteristics 1. The average age in the Netherlands in was The average household size in the Netherlands in was 2.
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The amount in g purchased for the household during 2 wk in the participating supermarkets measured by cash receipts. Total expenditures on groceries in the participating supermarket 2 wk measured by cash receipts. In , 7. In , Participants received several small gifts to prevent dropout. Second, small gifts were sent to the whole sample, including fridge magnets, tokens for shopping carts, shopping bags, ballpoint pens, and flower seeds. Also, participants received a St Nicholas gift and a Christmas card. The discount coupon reach was examined by using supermarket data showing the number of coupons that were redeemed each time period.
Also, these data were used to examine differences in general coupon use and the use of apple coupons consistently provided during the entire intervention. Supermarket data were supplemented with descriptive questionnaires to obtain coupon use at the consumer level. The nutrition education reach was examined by tracking the phone calls supplemented with descriptive questionnaires. All randomly assigned participants with at least cash receipt measures at baseline and one follow-up measure within the intervention period were included in an intention-to-treat analyses see Figure 1 We analyzed the treatment effects for both outcome measures at each specific time point 1, 3, 6, and 9 mo.
Therefore, these models yielded treatment effects for every time point separately. In addition, we computed crude and adjusted models for both outcomes. Income was not included in the models because this variable had many missing values. However, sensitivity analysis including income showed similar results. We found only one significant dummy interaction term, and therefore it was decided to remove the interaction terms from the models.
Next, sensitivity analyses were conducted on participants for whom the cash receipt measures were considered valid. Participants in the lowest 2. This included a total of 9 participants equally distributed among the study conditions. Cross-price elasticity is defined as the percentage change in the quantity demanded of a certain good in response to a given percentage change in the price of another good These effects were tested by comparing expenditures in non food categories at baseline and at 1 mo for both discount groups.
For the multilevel analyses we used MLWin2. Baseline characteristics are shown in Table 1. Forty-eight participants were excluded from analyses, of which 24 provided valid baseline data. For the remaining characteristics no significant differences were found. Participants in the price discount groups received all discount coupons in line with the intervention protocol.
The percentage of apple coupons handed in was similar to that of the other coupons Figure 2B. Data in the questionnaires indicated a maximum of 3 participants who did not use the coupons. This allows for a top and bottom line of custom printing on the Towa label.
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