How Healthy Is Your Main Street? Adapting an Approach from the UK

Sep 16, 2019 | Michelle Shapiro

By Duncan Stephenson, Deputy Chief Executive, Royal Society of Public Health

In the fall of 2018, the residents of the United Kingdom’s northern city of Grimsby could have been forgiven for choking on their breakfast cereal when they saw in the news that their High Street (UK equivalent of a Main Street), was named by the Royal Society for Public Health (RSPH), as the UK’s unhealthiest.

The ranking of UK High Streets based on how healthy or unhealthy they were formed part of the RSPH Health on the High Street campaign. The starting point for the campaign was the recognition that the environments in which we live, work, play and learn, have a profound impact on shaping our health and wellbeing.

Rather than focusing on environmental factors such as noise, air quality, and safety, Health on the High Street focused instead on the retail environment – some of the “commercial determinants of health” and explored the density, clustering and ultimately the role shops on High Streets had on the choices and ultimately the health of local communities.

The starting point for the campaign was to create a measure to determine the “healthiness or unhealthiness” of a shop – which hadn’t been done before. With input from public health experts and academics, RSPH created a “Richter Scale of Health” that scored businesses on the extent to which each type 1) promoted healthy choices; 2) improved customers’ mental wellbeing; 3) supported community cohesion; and 4) promoted access to health services. Each shop type was scored from +2 to -2 based on each of these four areas, with a resultant total score for the “healthiness” of that particular business. The scoring was done by our panel of experts, as well as the general public, and was underpinned by a literature review.

We developed a score for a range of different business types. Fast food takeaways, payday lenders, bookmakers, off-licenses (liquor stores) and tanning salons scored poorly and were identified as the unhealthiest business types. The healthier businesses included pharmacies, leisure facilities, and cultural venues. Even pubs were scored positively (while they do sell alcohol, they are licensed premises and do support community cohesion to a certain extent).

We published a ranking in 2015 and again in 2018, made up of the healthiest 70 UK towns and cities based on the prevalence of healthy versus unhealthy businesses. Our Health on the High Street reports did not set out to name and shame, but rather to shine a spotlight on the damage being done to the health and wellbeing of local communities from the proliferation and clustering of retail outlets which are widely regarded by both experts and the population at large as being damaging to the public’s health. For example, there is evidence that living in close proximity to a high density of fast food takeaways is linked to higher levels of obesity. We also sought to raise awareness of what policymakers, businesses and communities could do to make their High Streets more health-promoting.

How have High Streets changed and what does this mean?

The 2018 Health on the High Street report repeated the same methodology as the 2015 iteration, but it broadened the scope of retail outlets under consideration. So, in addition to shops like fast food takeaways and pharmacies, the 2018 campaign also included empty shops, vape stores and corner shops (equivalent of Mom and Pop stores). With this addition, Grimsby in the north was found to be the “unhealthiest” High Street in 2018, due largely to the high number (around 1 in 4) of empty shops, which reflects a reduction in vital community assets.

Based on IMD data (Indices of Multiple Deprivation), one of the main lessons from undertaking the Health on the High Street research was the correlation between unhealthy high streets and having lower life expectancy and higher levels of deprivation. This may seem fairly obvious, but if we are to address health inequities, more needs to be done through planning, licensing and fiscal measures to address the high density of unhealthy businesses. Our environments, including our shopping environment, is critically important in shaping the options available for us to maintain a healthy life.

Since the publication of the report in the UK a number of areas identified in the report have developed plans to make their High Streets more health promoting. For example, Walsall in the West Midlands has published a Town Centre Master Plan with the ambition of moving from the 2nd unhealthiest High Street to the UK’s healthiest. A number of cities identified in the report, including Blackpool and Bolton have also applied and successfully secured funding from the UK Government’s “Future High Streets” fund.

Both the 2015 and 2018 UK reports contained a number of policy recommendations. These recommendations covered areas such as planning and licensing, leveling the tax playing field between online and High Street business, as well as what improvements retailers themselves could take to make their offerings more health-promoting. For example, fast food takeaways could be encouraged to fry their products in healthier oils, and provide consumers with clear nutritional and calorie information.

Adapting the model for the U.S.

Such was the impact of the initial report that, with the support of the U.S.-based Robert Wood Johnson Foundation (RWJF) Global Ideas Fund at CAF America, RSPH is working with the University of California, Los Angeles (UCLA) to adapt the Health on the High Street model and methodology for U.S. “Main Streets.”

While many of the issues flagged in the UK’s Health on the High Street campaign resonate with the U.S., there are some notable differences. The UK campaign examined the 70 largest towns and cities based on their “core retail boundary,” however no standard definition across cities exists in the U.S. Therefore, as part of the U.S. project, an agreed definition of what constitutes the Main Street was developed along with what might be understood to be equivalent to a U.S. Core Retail Boundary.

Data collected for the UK study was collected by a commercial company – the Local Data Company. U.S. data on the prevalence of different business types was procured from ESRI ArcGIS’ Business Analyst product, which contains business data from Infogroup and consumer data from U.S. Census Bureau, American Community Survey (ACS) and the U.S. Small-area Life Expectancy Estimates Project (USALEEP).

Another notable difference is the study locations for the U.S. adaption, which reflect the vastly different geography of the U.S. in comparison to the UK (the UK is about the same size as the state of Oregon). In terms of the study locations for the U.S., we will be looking at multiple retail districts in 50 cities of varying population size across the U.S., evenly split by census region; but with a specific focus on California due to the partnership with UCLA.

Finally, the type of retail shops will differ between the U.S. and UK. While there are similarities such as fast food outlets, there are a number of stark differences, not just in which ones will be included, but how they may be scored. In the UK for example, pharmacies were scored positively in terms of their healthiness. In the U.S. however, many pharmacies are different and it is quite common to find cigarettes and sugary food on sale. Conversely, UK vape shops were scored as having a positive influence, to reflect the view that electronic cigarettes are a better alternative for smokers than tobacco. However, the debate around e-cigarettes is very different in the U.S., where there is growing concerns about the harm from vaping and more studies are being undertaken to better understand their impact.

Additionally, there are over 60,000 gun shops in the U.S. (which apparently is more than the number of supermarkets, McDonalds and Starbucks put together), whereas in the UK these are absent from the High Street. Another key difference, in the UK, most high streets have betting shops where the public can gamble on sports events – these are much less prevalent in the U.S.

Despite some differences in approach and methodology, the main output will be similar to the UK version – a ranking of U.S. Main Streets based on the density and healthiness of the businesses found on them. The report will also contain a number of policy recommendations aimed at a wide range of stakeholders, including local and county government, business and others.

The plan is to publish Health on the Main Street in 2020. The reports will be available on both the RSPH and UCLA websites, and may generate some public debate!

Ultimately, we hope that this project will increase awareness through media coverage, and support residents, policymakers and the business community in their quest to make both High Streets and Main Streets more health-promoting.

For more information:

If you would like to find out more about Health on the High Street, please contact Duncan Stephenson, Director of External Affairs and Marketing at the RSPH at [email protected]

Twitter: @DuncanStephens9

The views expressed here do not necessarily reflect the views of CAF America or the Robert Wood Johnson Foundation.


About Michelle Shapiro

Michelle Shapiro was formerly a communication specialist for the Environmental Health & Disability team at NACCHO.

More posts by Michelle Shapiro

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