Preliminary Evaluation of the Healthy Savings Program: A Novel Health Insurance-Based Wellness Program to Encourage Healthy Food Purchases

Abstract

Objective

Examine level of participation and satisfaction with the Healthy Savings Program (HSP), a program that provides price discounts on healthier foods.

Design

For Study 1, a survey was distributed to a random sample of adults who were invited to participate in a version of the HSP that provided a discount for the purchase of fresh produce and discounts on other healthier foods. In Study 2, interviews were conducted with a convenience sample of adults invited to participate in a version of the HSP that provided price discounts on specific products only (no fresh produce discount).

Setting

The HSP is provided to all employer-based insurance plan members of a large health plan. Employers can choose to enhance the version of the HSP that their employees receive by paying for a weekly discount on fresh produce.

Subjects

Employees in employer groups that receive the enhanced HSP (Study 1) and employees in an employer group (Study 2) that receive the standard HSP.

Results

Among survey respondents in Study 1, 69.3% reported using the HSP card. Most were satisfied with the fresh produce discount and ease of use of program card. Satisfaction was lower for selection of participating stores, amounts of discounts, and selection of discounted products. In Study 2 barriers to the use of the HSP card cited included the limited number of participating stores and the limited selection of discounted products.

Conclusions

Satisfaction with some elements of the HSP was high while other elements may need improvement to increase program use.

INTRODUCTION

Food prices are believed to be a significant barrier to making healthier food choices because foods that are calorie dense and nutrient poor tend to cost less per calorie than foods that are lower in calories and more nutrient dense⁽¹⁾. Experimental studies consistently find that consumers are price-sensitive, and purchase healthier foods when their prices are lower^(2–5).

Healthy eating has the potential to lower health care costs through prevention of chronic diseases such as obesity and diabetes⁽⁶⁾, and thus incentivizing healthy food choices may benefit health insurance companies and employers providing insurance to their employees. However, very little research exists evaluating insurance or employer-based programs that offer financial incentives to purchase healthier foods⁽⁵⁾. Rather, research to date on employer-based incentive programs has focused on evaluation of programs that offer financial incentives for change in a specific behavior (e.g. smoking cessation) or health outcome (e.g. weight loss)⁽⁷⁾.

To our knowledge just one study has evaluated an insurance or employer-based financial incentive program that targets food purchasing behavior⁽⁵⁾. Thus, we carried out an evaluation of one of the first such programs available in the US- the Healthy Savings Program (HSP). The HSP was developed and launched by Solutran, a technology solutions company. HSP participants are given an electronic card that may be swiped at checkout at participating food retailers to receive price discounts on specific healthier foods for which discounts have been negotiated at the time of purchase. Similar to sales circulars distributed by grocery stores, new discounts are offered weekly, and program members are sent a weekly email highlighting foods eligible for savings that week (see Appendix A for example of weekly discounts). The level of savings offered on food products is generally similar to those in sales circulars and paper coupons (e.g. 50 cent discount on a box of Cheerios). But, unlike sales circulars which offer discounts on foods irrespective of their nutritional composition⁽⁸⁾, HSP program discounts are limited to foods that meet specific nutritional criteria⁽⁹⁾. These criteria include being ranked in the healthiest one-third of items in the major food category to which the food belonging. Ratings for rankings are based on the Guiding Stars® nutrition guidance system. The Guiding Stars® is a nutrition guidance program that rates the nutritional quality of food and assigns a score based on a system of credits and debits⁽¹⁰⁾. Using the Nutrition Facts panel (or the USDA’s National Nutrient Database for fresh meat, seafood and produce) the Guiding Stars algorithm determines the amount of essential vitamins, minerals, fiber and whole grains versus saturated fat, trans fat, cholesterol, added sodium and added sugars. The more nutritional value a food has, the higher the score it receives.

To operate the HSP, Solutran partners with food manufacturers, grocery store chains, and health insurers. Food manufacturers pay for the discounts of the specific targeted foods, just as they do for paper coupons. Participating grocery store chains configure their electronic payment systems to accept the program card, so the appropriate discount is provided when the card is swiped at check-out. Health insurers offer the program to members as a health promotion service. The HSP permits an optional enhancement to provide members a weekly $5-$10 discount on fresh produce. This program enhancement requires additional funding that in this case is paid for by employers so that their employees can receive this additional benefit. The exact dollar amount is determined by the employer, who pays for the fresh produce discount.

At the time the studies reported in this paper were conducted, the HSP was being offered to members of a large Midwestern health insurer with 1.5 million members. Participating grocers included several Midwestern grocery store chains. An array of food manufacturers participated to offer discounts on specific foods defined by them as healthier brands.

To our knowledge the HSP is the first to offer price discounts on “healthy” foods on an ongoing basis through a potentially sustainable model with potential for national distribution if effective. The HSP has potential for widespread distribution and sustainability because program costs are spread across multiple market segments, each of which stands to benefit from involvement in the program. For example, food companies use the program for marketing specific foods, and pay for discounts provided for specific food items just as they would through manufacturer coupons. Grocery retailers are motivated to accept the program card at their stores as a means to attract and retain customers. Health insurers are interested in providing the program to their members to improve member satisfaction and potentially promote better member health. Finally, employers benefit by providing the program and paying for the fresh produce benefit, if they choose that option, to promote better employee health.

As a first step in evaluating the HSP, two small-scale studies were conducted. The goals of these evaluation studies were to: 1) Determine the program participation rate and level of participation among those invited to participate in the program, and compare the demographic and health-related characteristics of program participants in comparison to non-participants; and 2) Identify shortcomings of the program that might need to be addressed to maximize participation and level of engagement in the program.

METHODS

Study 1

In Study 1, a survey was distributed to a random sample of 400 adult employees from four worksites (100 from each worksite) (response rate 35%; n=140). The worksites, which encompassed two industry sectors (healthcare and primary/secondary education), were chosen because they opted to offer the enhanced HSP to their employees (employees received a weekly discount on fresh produce of $5-$10 per week. with the exact amount dependent on the employer). Individual telephone interviews were conducted with some (n=40) of the survey respondents. Survey and interview activities were conducted between December of 2014 and March of 2015.

The recruitment process for the survey followed a modified Dillman method⁽¹¹⁾, with an initial mailing followed by two reminder postcards sent 3 weeks apart. The person in the household most responsible for grocery shopping was asked to the complete the survey. A $10 gift card was offered as an incentive.

The survey included three sets of questions. The first set of questions assessed participants’ demographics, nutrition- and health-related behaviors and attitudes. The second set of questions assessed participants’ familiarity and engagement with the HSP. The final set of questions focused on food shopping habits (e.g. stores, frequency, coupon use), technology use (e.g. use of email, social media, smartphones), and level of satisfaction with various aspects of the HSP.

Those who participated in the survey were asked if they would be interested in participating in individual telephone interviews. A $25 gift card was offered as an incentive. The telephone interviews, which were audio-recorded and then transcribed, included a series of open ended questions designed to identify program features participants liked and disliked, and to garner ideas for ways in which the program may be improved. Two sets of questions were used, with each set tailored to participants’ frequency of use of the HSP card. Regular HSP card users (on average 2-3 times per month or more) and limited HSP card users (on average once a month or less, or have discontinued use) were asked one set of questions and the non-users (those who had never used the HSP card) were asked the other set of questions.

Survey data were analyzed using descriptive statistics (means and frequencies). Chi square and t-tests were conducted to compare the demographic characteristics of HSP card users and non-users. To analyze the qualitative data collected from the telephone interviews, each transcript was reviewed by two of the authors (XX and ZZ) to identify themes that emerged within each question. These themes were then used to code participant responses, following Krueger and Casey’s recommended approach to analyzing focus group data⁽¹²⁾.

Study 2

In Study 2, individual telephone interviews were conducted with a convenience sample of adults who worked at large university that offered the HSP to employees choosing the associated health plan, but did not opt to offer its employees the fresh produce benefit. Recruitment and interviews were conducted between February and July of 2015.

Participants were recruited via flyers mailed to employees in university administrative and service units with predominately full-time staff. The flyers stated that the purpose of the study was to gain insight into customer opinions about the HSP. Following a low initial response rate, the flyer was modified to state that the purpose was to explore opinions about a health insurance wellness program. Eligible participants met the following criteria: 1) employee; 2) currently enrolled in health insurance plan offering the HSP; 3) recall having been invited to participate in the HSP; 4) over 18 years of age; 5) fluent in written and spoken English; and 6) have regular access to internet service and email. A $30 gift card was offered as an incentive for study participation.

Participants completed an online survey and a semi-structured telephone interview. The online survey included demographic questions; questions to assess diet-related health behaviors and attitudes; and questions regarding use of the HSP. Telephone interviews were conducted to gather additional information regarding participants’ use of the HSP, barriers to use, and thoughts on how the program could be improved. Interviews were recorded using a digital recording device and then transcribed verbatim to facilitate analysis.

Means and frequencies were calculated using survey and demographic data to characterize the sample. Each transcript from the interviewers was reviewed by two of the authors (YY and ZZ) to identify themes that emerged within each question. These themes were then used to code participant responses, following Krueger and Casey’s recommended approach to analyzing focus group data⁽¹²⁾.

Content was obtained for all participants. The [UNIVERSITY NAME] Institutional Review Board (IRB) approved both research studies.

RESULTS

Study 1

Surveys were returned by 140 of 400 invited to participate (35% response rate). Seventy-four of the survey respondents indicated they might be interested in completing telephone interviews and 40 of 74 completed telephone interviews. Table 1 provides the demographic characteristics of the survey respondents and those who participated in the telephone interviews. Most of the participants in the survey and interviews were female, non-Hispanic whites, and college educated.

Table 1.

Demographic characteristics of survey respondents in Study 1 (n=140), those who participated in one-on-one interviews in Study 1 (n=40), and those who participated in one-on-one interviews in Study 2 (n=32)

	Study 1 - survey % (n)	Study 1 - interview % (n)	Study 2 % (n)
Sex
Female	77.1 (108)	80.0 (32)	93.8 (30)
Male	20.7 (29)	17.5 (7)	6.3 (2)
Race/Ethnicity
Asian	2.9 (4)	5.0 (2)	3.1(1)
African American	2.1 (3)	5.0 (2)	3.1(1)
Hispanic	1.4 (2)	0.0 (0)	3.1(1)
Non-Hispanic White	92.1 (129)	90.0 (36)	90.7 (29)
Other	2.9 (4)	0.0 (0)	0(0)
Age (years)
18-34	21.4 (30)	15.0 (6)	32.3 (10)
35-44	20.0 (28)	22.5 (9)	29.0 (9)
45-54	25.0 (35)	27.5 (11)	12.9 (4)
≥55	31.4 (44)	35.0 (14)	25.8(8)
Highest level of education
High school graduate or some college	14.3 (20)	12.5 (5)	12.5 (4)
Associate degree	9.3 (13)	10.0 (4)	6.3(2)
Bachelor’s degree	36.4 (51)	42.5 (17)	53.1 (17)
Masters, professional or doctoral degree	37.1 (52)	35.0 (14)	28.1 (9)
Annual household income
< $35,000	5.0 (7)	2.5 (1)	6.76 (2)
$35,000-$74,900	26.4 (37)	22.5 (9)	40.0 (12)
≥ $75,000	55.7 (78)	75.0 (30)	53.3 (16)
Household size
1	14.3 (20)	17.5 (7)	12.5 (4)
2	38.6 (54)	40.0 (16)	53.1 (17)
3 to 4	38.6 (54)	37.5 (15)	31.3 (10)
5 to 6	7.1 (10)	5.0 (2)	3.1 (1)
Number of children in household
0	60.7 (85)	75.0 (30)	12.5 (4)
1 to 2	30.0 (42)	22.5 (9)	53.1 (17)
≥3	7.1 (10)	2.5 (1)	34.4 (11)
Body weighta
Normal or underweight	47.1 (66)	57.5 (23)	40.6 (13)
Overweight	29.3 (41)	25.0 (10)	28.1 (9)
Obese	17.9 (25)	17.5 (7)	31.3 (10)

^abased on following body mass index (BMI) cut points: BMI > 30 obese; BMI 25-29.9 overweight; BMI < 25 normal or underweight

Over two-thirds (69.3%) of survey respondents indicated that they had used the HSP card at least once (Table 2), 71.4% had visited the HSP website and 77.9% had received emails from the HSP. Among those who reported using the HSP card, about two-thirds (68%) reported using the card 2 or more times per month over the past six months.

Table 2.

Use of the Healthy Saving Program (HSP) card and program resources among survey participants in Study 1 (n=140)

	% (n)
Ever used HSP card?
Yes	69.3 (97)
No	28.6 (40)
Not sure	2.1 (3)
Frequency of use of HSP card over past 6 months among those who reported using it (n=97)
Never	2.1 (2)
1-6 times in total	19.6 (19)
About 1 time a month	10.3 (10)
2-3 times a month	29.9 (29)
1 or more times per week	37.1 (36)
Not sure	1.0 (1)
Visited HSP website?
Yes	71.4 (100)
No	24.3 (34)
Not sure	4.3 (6)
Ever receive emails from HSP?
Yes	77.9 (109)
No	10.7 (15)
Not sure	11.4 (16)

Among those who reported visiting the HSP website, 68.8% reported using it to access the list of products and discounts; 8% reported using the nutrition information for foods (8.0%), recipes (10.7%), and personal program-based saving records (12.5%).

Those who reported they had used the HSP card were asked a series of questions to assess satisfaction with various aspects of the program (Table 3). Of those who had used the HSP card, most were either somewhat satisfied or extremely satisfied with the fresh produce discount (91.7%) and the ease of using the program card at checkouts (89.7%). Satisfaction was lower for the program’s selection of participating stores, amount of discounts, and selection of discounted products.

Table 3.

Satisfaction with various aspects of the HSP among survey participants in Study 1 who reported using the HSP card (n=97)

	Not at all satisfied %	Somewhat unsatisfied %	Neutral %	Somewhat satisfied %	Extremely satisfied %
Fresh produce discount	0.0	2.1	6.2	21.6	70.1
Ease of use of card at checkouts	0.0	6.2	3.1	19.6	70.1
Selection of participating stores	5.2	18.6	9.3	37.1	29.9
Amount of discounts	1.0	16.5	16.5	38.1	24.7
Selection of discounted products	0.0	18.6	18.6	56.7	6.2

Among those who had not used the HSP card, the most commonly endorsed reasons for not using the card were that the program was not available at the stores at which they regularly shopped (41.9%), they did not usually buy the discounted products (37.2%), and it was hard to know which items were discounted (23.3%)(Table 4).

Table 4.

Reasons for not using the HSP card among survey respondents in Study 1 who reported not using the HSP card (n=43)

	% (n)
Card cannot be used at stores I regularly shop at	41.9 (18)
Do not usually buy the discounted products	37.2 (16)
Hard to know which items are discounted	23.3 (10)
Not enough of a discount	14.0 (6)
Never heard of HSP	9.3 (4)
Never received HSP card	4.7 (2)
Card does not work at check out	0.0 (0)

Compared to non-users, HSP card users were more likely to be female, report frequently using coupons when food shopping, and report shopping regularly at one of the grocery stores participating in the HSP (see Table 5). Reported mean fruit and vegetable intake was significantly higher in HSP card users than non-users.

Table 5.

Comparison of demographic and health characteristics of survey participants in Study 1 who reported using the HSP card (n=97) and those who reported not using it (n=40).

	Used HSP card % (n)	Never used HSP card % (n)	p-value
Sex
Female	82.5 (80)	65.0 (26)
Male	16.5 (16)	32.5 (13)	0.03
Race/Ethnicity
Non-Hispanic white	91.8 (89)	92.5 (37)
Other	8.2 (8)	7.5 (3)	0.88
Age
< 45 years	38.1 (37)	50.0 (20)
≥ 45 years	61.9 (60)	50.0 (20)	0.20
Highest level of education
Less than bachelor’s degree	15.5 (15)	12.5 (5)
Bachelor’s degree or higher	84.5 (82)	87.5 (53)	0.66
Annual household income
< $75,000	28.9 (28)	37.5 (15)
≥ $75,000	71.1 (69)	62.5 (25)	0.32
Use of coupons for food shopping
Never, not often or occasionally	44.3 (43)	70.0 (28)
Frequently or all the time	55.7 (54)	30.0 (12)	0.006
Shop at a grocery store participating in the Healthy Savings Program
Less than once a month	4.1 (4)	32.5 (13)	<0.001
About once a month or more	95.9 (93)	67.5 (27)
Body weight
Normal or underweight	48.5 (47)	42.5 (17)
Overweight or obese	51.5 (50)	57.5 (23)	0.53
Perceived weight status
Overweight	42.3 (41)	40.0 (16)
About the right weight, underweight, do not know	57.7 (56)	60.0 (24)	0.81
History of heart disease, hypertension, diabetes, or high cholesterol
Yes	59.8 (58)	47.5 (19)
No or not sure	40.2 (39)	52.5 (21)	0.19
Fruit and vegetable intake, frequency/day, mean (SD)	3.9 (2.5)	2.5 (1.8)	0.003
Sugar sweetened beverage intake, frequency/day, mean (SD)	0.2 (0.4)	0.2 (0.3)	0.47

Results from one-on-one interviews with those who had used the HSP card

In telephone interviews with participants who had used the HSP card (n=40, 75% of interviewees), two primary themes emerged in response to the question “What do you think of the Healthy Saving Program.” About one-half of the regular users responded in a way that indicated that they liked the program in general (“I think it is good. It is a good idea, for sure.”) A little less than one-half of the respondents indicated they liked discounts on particular items, with the fresh produce discount mentioned most often (“I like it. It saves me money on fresh fruits and vegetables, which I like, and there are usually not coupons available for that, and it allows me to try some new products that I may not have looked at.”) A few people expressed negative impressions of the program, with varying specific concerns (“I am not that impressed with it.”).

When asked about the kinds of foods they had received discounts on using the program card, nearly every respondent mentioned the fresh produce discount. Most participants reported one or more additional food items, with a variety of foods mentioned (e.g. milk, eggs, bread products, popcorn, chicken, etc.). When asked, about half of the respondents reported that the program had caused them to purchase foods that they otherwise would not have purchased. Among those who indicated that the HSP had changed how often they buy a food, fresh produce was the most frequently reported type of food. A couple people mentioned that the program changed the grocery store where they shopped.

When asked about the ease of finding the items eligible for discounts, about one-half said it was easy. However, some people indicated it was hard and a variety of suggestions for improvement were provided.

Nearly everyone reported they find it very easy to use the HSP card in the stores when asked.

Themes that emerged from responses to the question, “What do you like about the Healthy Savings Program” included money savings, especially for produce (“I like the savings on my produce particularly”), and an appreciation for being rewarded for making healthy choices (“It just reinforces healthy eating, so I get a little financial break for eating healthy.”)

Top issues mentioned when asked what they disliked about the program included the limited number of products for which discounts are offered and the limited number of stores participating in the program (“I would say I wish it was at Target”). An assortment of other issues were raised by a small number of participants, including concern that some of the foods are not truly healthy and difficulty locating foods eligible for discounts in the store. When asked for ideas for improving the program and other thoughts and ideas, common suggestions included expanding the number of participating stores and offering discounts on more items.

Results from one-on-one interviews with those who had never used the HSP card

Those who reported never using the HSP card (n=10) were asked what they think of the program. Most said they think it is a good idea, but do not use the card for varying reasons. When asked why they have not used the card the most common reasons provided were that they do not shop at a store that is participating in the program and they do not like the foods eligible for discounts (“I am not fond of the things that are offered, so I do not use it”). When asked for ideas for improving the program a variety of ideas were raised, with the most common being increasing the variety of foods eligible for discounts and expanding the stores participating in the program.

Study 2

Flyers advertising the study were distributed to 724 individuals, and 32 responded and completed an interviewer. Table 1 provides the demographic characteristics of those that participated in the one-on-one interviews in Study 2. To summarize, most were female, non- Hispanic whites, and college educated.

Of the 32 participants, 13 (41%) reported using the HSP card at least once, while 19 reported never using the card. Of those who reported using the HSP card (n=13), three reported using the HSP card one or more times per month, while ten reported using the card a few times total since receiving it.

In the one-on-one interviews, participants were asked to report their general thoughts on insurance companies offering wellness programs to their customers. Overall, the majority of individuals had a positive view of this practice. Many expressed this opinion by citing the societal benefits of wellness programs (“I think it is a wonderful idea. I think it enhances job satisfaction and lowers premiums, both the provider insurance company and also, hopefully, to the employee. It is a real message that the employer cares about the health of the employee.”).

Next, participants were asked whether they believed that decreasing the price of healthy foods would encourage people to buy these foods. Approximately half of participants agreed with this idea (“I do not eat near enough fruit because I cannot afford to buy fruit, and I think if it could be cheaper, I think that would help people like me a lot.”). Some participants expressed uncertainty at whether decreasing price would have an effect on purchasing (“If prices were cheaper… people might look at the healthier choices and make a decision if the prices were less or the same. And then also, some people just like junk food, so… the prices may not be the thing that hinders them from eating better foods. I think there is a range in pricing, and sometimes the barrier is knowledge and education and not necessarily the price."). A few participants disagreed with the idea that decreasing the price of healthy foods would change purchasing behavior (“I think that you either have the incentive to buy healthy foods or you do not. I do not think it is a matter of price.”).

Participants were asked what they thought the goal of the HSP was. Overall, participants were able to accurately describe the program and were familiar with the goals of the program. The most commonly cited goal was to encourage healthy food choices. Participants also stated that product awareness and saving people money were goals of the program. One participant said that the goal of the program was to monitor people’s food purchases for the benefit of the insurance company (“To monitor my spending habits so they can increase my insurance costs. I think the most useful data for insurance companies is probably our spending practices, so I think insurance companies are very interested in knowing what sorts of foods their clients are buying so that they can say ‘hey, you are buying too many chips’ or ‘you are buying too many soft drinks, so we are going to charge you more money for your premium.”).

When asked what foods they would like to see as part of the HSP, most individuals responded by suggesting 1-2 items or types of products. However, approximately one-third of participants suggested 3 or more items or types of products. The majority of individuals specifically cited fresh fruits and vegetables (“I would like to see a coupon like if you buy fresh fruit, you get like a 10% rebate or a 2% rebate on fresh fruits and vegetables, that type of stuff… Because everybody can use it.”). Other themes included wanting other specific items to be added (e.g. fish and other lean meats) and wanting classes of items added (e.g. dairy products, organic foods, store brands) or removed (e.g. fewer canned/packaged foods).

In most interviews participants readily cited barriers to using the HSP card without being asked. The most common barrier to use, expressed by about one-half of the participants, was that the HSP does not include foods and/or brands that the person would like to purchase (“But it is hard, some weeks, to try to find something on there I want.”). Another common theme centered on ease of use being a barrier, with a similar number reporting that it was difficult to know what was on sale each week and that it was difficult to find products in the store. About one-quarter of participants cited the limited number of stores in the program as a barrier to use (“The reason I have not used it is due to the fact that the store near my house … is not on that list.”). Other issues raised by smaller numbers of participants included concern that some of the foods are not truly healthy and that products and brands included in the program are still not affordable after the HSP discount.

When asked what the best change that could be made to the HSP would be, the most frequent response was to change the foods offered by the program. Also, a number of people wanted additional stores added to the program (“Add Target. If that is possible, that would be awesome.”) Improving the ease of use of the program was also a common suggestion.

DISCUSSION

Results suggest that the version of the HSP that includes a weekly discount on fresh produce in combinations with discounts on a variety of healthier packaged food may be well received and utilized. More than two-thirds of survey respondents in Study 1 reported using the HSP card at least once, and among these individuals 78% reported using the card one time per month or more over the 6 months preceding the survey. This level of engagement is on the high end of the range observed with other employer offered health promotion programs⁽¹³⁾. For example, the percent of employees joining employer offered weight reduction programs has been found to range from 14-53% (median 20%) and the percent joining exercise/fitness related programs ranges from 27-84% (median 54%)⁽¹³⁾. However, it is possible that the prevalence of use of the HSP card is over-estimated in the study because the response rate was sub-optimal, and thus findings must be interpreted with caution.

Most who had reported using the HSP card in Study 1 were satisfied with the fresh produce discount and the ease of using the program card at checkout. There were lower levels of satisfaction with the selection of participating stores, the amount of discounts offered, and the selection of products for which a discount was offered. Thus, these are potential targets for program improvements. Expanding participating stores seems particularly important as HSP card use was found to be lower in those who do not shop regularly at participating stores, suggesting room for improvement in participation if additional stores participated in the program.

In Study 2 (one-on-one interviewers with a convenience sample of employees at a worksite that offered a version of the HSP that did not include a weekly discount on fresh produce); program use was much lower than in Study 1 (41% vs. 69%). However, as in Study 1, concerns with the program centered on the limited number of participating stores and the selection of foods for which a discount is offered. Fresh fruits and vegetables were specifically mentioned by most as the types of foods for which a discount should be offered.

The HSP is among the first of its kind. We are aware of only one somewhat similar commercially available program. The HealthyFood program is a cash-back rebate program designed to encourage healthy food purchases by members of a health insurer in South Africa. The program provides a 10%-25% rebate for all healthy foods purchased by health plan members at a participating supermarket chain. More than 6000 food items available in the participating grocery store chain are classified as ‘healthy’ and eligible for the rebate. Results from a quasi-experimental study carried out to evaluate this program suggest the program may lead to increases in the purchasing and consumption of healthier food items and decreases in the purchasing and consumption of less nutritious foods among those who participate in the program^{(5, 14)}. The participation rate in the HealthyFood program was 26% of eligible employees⁽¹⁴⁾, which is somewhat lower than that observed for the HSP in our survey (69% reported using the card at least once). There are a variety of potential explanations for the differences in participation rates between programs (e.g. different study populations, varying structure for program delivery and level of discounts, different methods used to assess program participation).

Although experimental studies consistently find that consumers are price-sensitive, and purchase healthier foods when their prices are lower^(2–5) it is possible that the types of foods for which discounts are provided and the level of discounts provided in HSP are not sufficient to influence the nutritional quality of foods purchased and consumed. Consequently, additional research is needed to evaluate whether the program is effective in increasing the nutritional quality of foods purchased and consumed.

The HSP has the potential to address health disparities if offered to those enrolled in government assistance program such as Medicaid, the Special Supplemental Nutrition Assistance Program for Women Infants and Children (WIC), the Supplemental Nutrition Assistance Program (SNAP), and Head Start. Future evaluation work should evaluate the program in the context of one or more of these programs.

Limitations of the studies reported in this paper include concerns with the representativeness of the samples due to suboptimal response rates to the survey and one-on-one interviews in Study 1, and reliance on a convenience sample in Study 2. It is possible that respondents were systematically different from non-respondents in their use the Healthy Savings Program and their attitudes toward it. More specifically, it is possible that respondents were more apt to be using the program or use it more frequently than non-respondents, and consequently the extent to which the program is used may be over-estimated in the studies. In addition, the generalizability of study findings may be limited since participants in both studies were predominately non-Hispanic white, well educated, and female.

Study strengths include the use of random sampling in Study 1 to obtain a representative sample of employees invited to participate in the HSP at four Midwestern worksites. Another strength is the use of open-ended questions to begin to evaluate a novel program.

In conclusion, findings suggest high levels of satisfaction with some elements of the program (fresh produce discount, ease of use of the HSP card at checkout), while other elements of the program may need improvement to strengthen satisfaction and use of the HSP card. Areas for improvement include expanding the number of stores at which the HSP card may be used; expanding and/or modifying the selection of foods for which discounts are offered; and making it easier to identify discounted foods in the supermarket. Consideration should also be given to better communicating the criteria used to define a food ‘healthy’ enough for inclusion as a food eligible for a price discount.

Appendix A: Example of weekly discounts provided by the Healthy Savings Program

Fresh Produce

• Sunkist® - Minneola Tangelos 3 lb Bag- Save $1.00

• Sunkist® - Lemons 2 lb Bag - Save $1.00

• Sunkist® - Cara Cara Navel Oranges 3 lb Bag - Save $1.00

• Sunkist® - Meyer Lemons 1 lb Bag - Save $1.00

• Sunkist® - Mandarins 2 lb Bag, 3 lb Bag, 5 lb Tray - Save $1.00

• Sunkist® - Navel Oranges 4lb Bag- Save $1.00

• Ocean Mist Farms® - Fresh Vegetables and Greens - Save $1.00 - Select Varieties

• Cut ’N Clean Greens® - Greens - Save $2.00 - Select Varieties

• Sunkist® - Gold Nugget variety Mandarins - Save $1.00

• Cal-Organic Farms® - Organic Rainbow Carrots - Save $1.00 –Select Varieties

• Klondike-Green Giant® Fresh - Potatoes - Save $1.00 - Select 5 Lb Varieties Only

• SUNSET® Produce - Tomatoes, Peppers, & Cucumbers - Save $1.00 - Select Varieties

• Pete’s Living Greens - Greens - Save $2.00 - Select Varieties

• Crispy Green® - Freeze-Dried Fruit - Save $1.00 - Select Varieties

• Opal® Apple - Apples - Save 20% - Max $2.50 Per Promotion

• Wish Farms - Fresh Berries - Save $0.75 - Select Varieties

Meat & Seafood

• Gold’n Plump® - Chicken - Save $1.00 - Select Varieties

Organic & Natural

• Rhythm® Superfoods - Superfood Snacks - Save $1.00 - Select Varieties

Deli

• Yucatan® - Guacamole - Save $2.00 - Select Varieties

Refrigerated

• Eggland’s Best - Eggs - Save $0.50 – Select

• Varieties Old Home® - All Natural Peanut Butter - Save $1.50 - All Varieties

• Catallia™ - Tortillas - Save $0.75 - Select Auténtica Tortillas

• Eggland’s Best - Hard-Cooked Eggs - Save $0.35 - Select Varieties

Dairy

• Stonyfield® Organic Yogurt - Organic Kids & Baby Yogurt Multipacks - Save $2.00

• Stonyfield® Organic Yogurt - Organic Squeezable Yogurt - Save $1.00 - Select 3.5 Oz Varieties

• Kemps® - Select White Milk - Save $1.00 - Select Gallons Only - Limit 2 Offers –

• Old Home® - Sour Cream - Save $0.75 - Select 8-24 Oz

• Varieties Kemps® - Sour Cream - Save $0.75 - Select Varieties

• Old Home® - Small Curd Cottage Cheese - Save $1.00 - Select 12-32 Oz Varieties

• Almond Breeze® - Chilled Almondmilk - Save $1.00 - Select Varieties

• GO VEGGIE® - Cheese Alternatives - Save $1.50 - Select Varieties

• Lifeway® - Low Fat Kefir Drinkable Yogurt - Save $0.75 - Select Varieties

• Stonyfield® Organic Greek Yogurt - Organic Greek Yogurt Large Cups - Save $3.00 - Select 30 & 32 Oz Greek -

• Old Home® - Plain and Vanilla Yogurt - Save $1.50 - Select 32 Oz Varieties Only

Frozen

• Orca Bay® - Seafood - Buy 2 and Save $3.50 - Select Varieties

• Kemps® - Frozen Yogurt - Save $1.00 - Select Varieties

• SmartMade™ by Smart Ones® - Frozen Meals - Save $0.75 - Select Varieties

• Sweet Earth Foods® - FREE Globally-Inspired Frozen Meals - Save Up to $5.99 - Select Varieties

Breads & Baked Goods

• Natural Ovens Bakery™- Bread - Save $1.00 - Select Varieties

• Country Hearth® - Bread - Save $0.50 - Select Varieties

• New England - 100% Whole Wheat and Brown Bread - Save $0.50

• Village Hearth® - Bread - Save $0.50 - Select Varieties

• S. Rosen’s - Bread - Save $1.00 - Select Varieties

• Village Hearth® - English Muffins - Save $0.50 - All Varieties

• Village Hearth® - Bagels - Save $0.50 - All Flavors

• S. Rosen’s - Buns and Rolls - Save $1.00 - Select Varieties

• Artisan Hearth® - Gourmet Rolls - Save $0.50 - All Varieties

• Cruz® - Whole Wheat and Corn Tortillas - Save $2.00 - Select Varieties

• Village Hearth® - Dinner Rolls - Save $0.50 - Select Varieties

Canned Goods

• S&W® - Canned Beans - Save $0.50 - Select Varieties

• La Preferida® - Beans - Save $0.50 - Select Varieties

• Butter Kernel® - Canned Vegetables - Save $0.25 – Select Varieties

• Campbell’s® Well Yes!™ - Well Yes!™ Soup - Save $0.50 – Select

Varieties Condiments & Sauces

• Skippy® - Peanut Butter - Save $0.50 - Select Varieties

• BRIANNAS® - Salad Dressing - Save $1.00 - Select Varieties

Pasta & Grains

• La Preferida® - Rice - Save $1.00 - Select Varieties

• Minute® Rice - Minute® Ready to Serve Rice - Save $0.75 - Select Varieties

• Barilla® Gluten Free - Barilla® Gluten Free Pasta - Save $0.75 - Select Varieties

Cereal & Cereal Bars

• Fiber One™ - Save $1.00 on Two Fiber One® - Select Varieties

• Weetabix® - Cereal - Save $1.00 - Select Weetabix Brands Only

• thinkThin® - Protein & Fiber Hot Oatmeal Bowls - Buy 2 & Save $1.00 - Select Oatmeal Bowls

Baking & Spices

• Lucini® Italia - Extra Virgin Olive Oil - Save $5.00 - Select Varieties

• Red Star® Yeast - Yeast - Save $1.25 - Select Varieties

• Lucini® Italia - Artisan Vinegar - Save $5.00 - Select Varieties

• King Arthur Flour - Flour and Baking Mixes - Save $1.50 - Select Varieties

• Bob’s Red Mill® - Nut Flours - Save $1.50 - Select Nut Flours Only

Beverages

• V8® V-Fusion® - Vegetable and Fruit Juice - Save $1.50 - Select Varieties

• DASANI® - Purified Water - Save $1.00 - Select Singles & Multi-Packs

• Sparkling ICE® - Flavored Sparkling Water - Buy 5 and Save $1.00 - Select Bottle Varieties

Coffee & Tea

• Traditional Medicinals® Tea - Wellness Teas - Save $1.00 - Select 16 Ct Varieties

Crackers & Snacks

• JOLLY TIME® Pop Corn - Microwavable Pop Corn - Buy 2 and Save $1.00

• Food Should Taste Good™ - Save $0.50 on Food Should Taste Good™ - Select Tortilla Chips

Baby Care

• Happy Family® Organics - Baby and Toddler Snacks - Save $0.75 - Select Varieties

Vitamins & Supplements

• Atkins® - Bars - Save $2.00 - Select Varieties