The effect of retail store managers on aboriginal diet in remote communities

The Retail Food Sector and Indigenous Peoples in High-Income Countries: A Systematic Scoping Review

Indigenous Peoples in high-income countries experience higher burdens of food insecurity, obesity, and diet-related health conditions compared to national averages. The objective of this systematic scoping review is to synthesize information from the published literature on the methods/approaches, findings, and scope for research and interventions on the retail food sector servicing Indigenous Peoples in high-income countries. A structured literature search in two major international databases yielded 139 relevant peer-reviewed articles from nine countries. Most research was conducted in Oceania and North America, and in rural and remote regions. Several convergent issues were identified across global regions including limited grocery store availability/access, heightened exposure to unhealthy food environments, inadequate market food supplies (i.e., high prices, limited availability, and poor quality), and common underlying structural factors including socio-economic inequality and colonialism. A list of actions that can modify the nature and structure of retailing systems to enhance the availability, accessibility, and quality of healthful foods is identified. While continuing to (re)align research with community priorities, international collaboration may foster enhanced opportunities to strengthen the evidence base for policy and practice and contribute to the amelioration of diet quality and health at the population level.

Development and pilot of a tool to measure the healthiness of the in-store food environment

Objective:

To rigorously develop a tool which enables rapid yet comprehensive appraisal of the consumer food retail environment and provision of real-time feedback to store managers and owners, based on the ‘4Ps’ principles of marketing.

Design:

Multi-stage iterative approach including (1) Systematic literature review; (2) Stakeholder consultation; (3) Assessment of existing tools against identified needs; (4) Tool development; (5) Pilot testing and (6) Transition of tool to mobile application (the Store Scout app).

Setting:

Northern Territory, Australia.

Participants:

Nine remote Aboriginal community food stores; public health nutritionists, retailers, store board directors, Aboriginal community members, government representatives.

Results:

Forty-seven existing tools and thirty-four stakeholder interviews informed the development of the current instrument, which comprised: (1) seven product categories (Fruit & Vegetables, Drinks, Snack Foods, Meals & Convenience Foods, Meat & Seafood, Dairy & Eggs, Breads & Cereals) across the ‘4Ps’ (Product, Placement, Price, Promotion); (2) Store manager questions about context and perceived importance of key principles about the store environment and (3) a scoring and feedback component. The tool was considered feasible and acceptable by all testers.

Conclusions:

The developed tool addresses an unmet need to measure the consumer food retail environment across all 4Ps whilst also incorporating manager perspectives and immediate feedback. Our objectives of developing a comprehensive, feasible and acceptable instrument were achieved during pilot testing. The tool will support implementation of best practice within stores to encourage healthy food choices and has potential for broad application in retail settings locally and internationally, as well as for research purposes.

Effect of nutrition interventions on diet-related and health outcomes of Aboriginal and Torres Strait Islander Australians: a systematic review

OBJECTIVE

To review the literature on nutrition interventions and identify which work to improve diet-related and health outcomes in Australian Aboriginal and Torres Strait Islander people.

STUDY DESIGN

Systematic review of peer-reviewed literature.

DATA SOURCES

MEDLINE, PubMed, Embase, Science Direct, CINAHL, Informit, PsychInfo and Cochrane Library, Australian Indigenous Health InfoNet.

STUDY SELECTION

Peer-reviewed article describing an original study; published in English prior to December 2017; inclusion of one or more of the following outcome measures: nutritional status, food/dietary/nutrient intake, diet-related biomedical markers, anthropometric or health measures; and conducted with Australian Aboriginal and Torres Strait Islander people.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and applied the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project. A purpose designed tool assessed community engagement in research, and a framework was applied to interventions to report a score based on numbers of settings and strategies. Heterogeneity of studies precluded a meta-analysis. The effect size of health outcome results were estimated and presented as forest plots.

RESULTS

Thirty-five articles (26 studies) met inclusion criteria; two rated moderate in quality; 12 described cohort designs; 18 described interventions in remote/very remote communities; none focused solely on urban communities; and 11 reported moderate or strong community engagement. Six intervention types were identified. Statistically significant improvements were reported in 14 studies of which eight reported improvements in biochemical/haematological markers and either anthropometric and/or diet-related outcomes.

CONCLUSIONS

Store-based intervention with community health promotion in very remote communities, fiscal strategies and nutrition education and promotion programmes show promise. Future dietary intervention studies must be rigorously evaluated, provide intervention implementation details explore scale up of programmes, include urban communities and consider a multisetting and strategy approach. Strong Aboriginal and Torres Strait Islander community engagement is essential for effective nutrition intervention research and evaluation.

PROSPERO REGISTRATION NUMBER

CRD42015029551.

Healthy Choice Rewards: A Feasibility Trial of Incentives to Influence Consumer Food Choices in a Remote Australian Aboriginal Community

Poor diet including inadequate fruit and vegetable consumption is a major contributor to the global burden of disease. Aboriginal and Torres Strait Islander Australians experience a disproportionate level of preventable chronic disease and successful strategies to support Aboriginal and Torres Strait Islander people living in remote areas to consume more fruit and vegetables can help address health disadvantage. Healthy Choice Rewards was a mixed methods study to investigate the feasibility of a monetary incentive: store vouchers, to promote fruit and vegetable purchasing in a remote Australian Aboriginal community. Multiple challenges were identified in implementation, including limited nutrition workforce. Challenges related to the community store included frequent store closures and amended trading times, staffing issues and poor infrastructure to support fruit and vegetable promotion. No statistically significant increases in fruit or vegetable purchases were observed in the short time frame of this study. Despite this, community members reported high acceptability of the program, especially for women with children. Optimal implementation including, sufficient time and funding resources, with consideration of the most vulnerable could go some way to addressing inequities in food affordability for remote community residents.

What is known about consumer nutrition environments in Australia? A scoping review of the literature

OBJECTIVE

Food environments can influence food selection and hold the potential to reduce obesity, non-communicable diseases and their inequalities. 'Consumer nutrition environments' describe what consumers encounter within a food retail outlet, including products, price, promotion and placement. This study aimed to summarize the attributes that have been examined in existing peer-reviewed studies of Australian consumer nutrition environments, identify knowledge gaps and provide recommendations for future research.

METHODS

A systematic search of peer-reviewed literature was conducted. Sixty-six studies that assessed an aspect of within-store consumer nutrition environments were included.

RESULTS

Most studies were published from 2011 onwards and were conducted in capital cities and in supermarkets. Studies assessed the domains of product (40/66), price (26/66), promotion (16/66) and placement (6/66). The most common research themes identified were assessment of the impact of area socioeconomic status (13/66), remoteness (9/66) and food outlet type (7/66) on healthy food prices; change in price of healthy foods (6/66); variety of healthy foods (5/66); and prevalence of unhealthy child-orientated products (5/66).

CONCLUSIONS

This scoping review identified a large number of knowledge gaps. Recommended priorities for researchers are as follows: (1) develop consistent observational methodology, (2) consider consumer nutrition environments in rural and remote communities, (3) develop an understanding of food service outlets, (4) build on existing evidence in all four domains of product, price, placement and promotion and (5) determine effective policy and store-based interventions to increase healthy food selection.

What do we know about the diets of Aboriginal and Torres Strait Islander peoples in Australia? A systematic literature review

OBJECTIVE

To provide an overview of published research on the dietary intake of Aboriginal and Torres Strait Islander peoples.

METHODS

Peer-reviewed literature from 1990 to October 2016 was searched to identify studies that measured the dietary intake of Australian Aboriginal and Torres Strait Islander populations. Study quality was assessed using a purposely devised quality appraisal tool. Meta-analysis was not possible due to the heterogeneity in dietary intake assessment methods. A narrative synthesis of study findings, where key themes were compared and contrasted was completed.

RESULTS

Twenty-five articles from twenty studies with outcome measures related to dietary intake were included. Dietary intake was assessed by electronic store sales, store turnover method, 24-hour dietary recall, food frequency questionnaire and short questions. Consistent findings were low reported intakes of fruit and vegetables and high intakes of total sugar and energy-dense, nutrient-poor food and beverages.

CONCLUSIONS

While differences between studies and study quality limit the generalisability of the findings, most studies suggest that the diets of Aboriginal and Torres Strait Islander peoples are inadequate. Implications for public health: A more concerted approach to understanding dietary patterns of Aboriginal and Torres Strait Islander peoples is required to inform policy and practice to improve diet and nutrition.

Fluctuations in money availability within an income cycle impacts diet quality of remote Indigenous Australians

OBJECTIVE

To consider the plausible nutritional impacts of fluctuations in money availability within an income cycle for remote Indigenous Australians.

DESIGN

Community-level dietary intake (energy, micro/macronutrients) and expenditure on foods and beverages (F&B) were estimated over one year for three remote Indigenous Australian communities (Northern Territory, Australia) using monthly F&B transaction data. F&B that were likely to be consumed during a period within an income cycle when money was relatively limited (low money period (LMP) foods) were identified by panel consensus and scenario modelling was conducted to simulate the nutritional outcomes of a range of F&B selection responses to having an LMP.

RESULTS

All scenarios resulted in reduced diet quality during the LMP relative to overall average diet values. Protein and fat energy percentages were reduced and carbohydrate energy percentage increased. Despite reduced expenditure, declines in energy intake were typically buffered due to the reduced energy cost ($AU/MJ) of the LMP diet. The micronutrient profile of the LMP diet was substantially poorer, such that additional key micronutrients dropped below population-weighted Estimated Average Requirements/Adequate Intakes.

CONCLUSIONS

The modelling undertaken herein suggests that even a short period of low money within an income cycle may noticeably contribute to the reduced diet quality of remote Indigenous Australians and exacerbate lifestyle disease risk. Dietary strategies that are designed to respond to diets and expenditure during different income cycle periods, rather than the overall average diet and expenditure, should be considered for improving diet quality and reducing cardiometabolic disease risk in remote Indigenous Australians.

Food security in Nunavut, Canada: barriers and recommendations

OBJECTIVES

The food supply of Inuit living in Nunavut, Canada, is characterized by market food of relatively low nutritional value and nutrient-dense traditional food. The objective of this study is to assess community perceptions about the availability and accessibility of traditional and market foods in Nunavut.

STUDY DESIGN

A qualitative study using focus group methodology.

METHODS

Focus groups were conducted in 6 communities in Nunavut in 2004 and collected information was analyzed.

RESULTS

Barriers to increased traditional food consumption included high costs of hunting and changes in lifestyle and cultural practices. Participants suggested that food security could be gained through increased economic support for local community hunts, freezers and education programs, as well as better access to cheaper and higher quality market food.

CONCLUSIONS

Interventions to improve the dietary quality of Nunavut residents are discussed.

The effect of nutrition education on nutrition-related health outcomes of Aboriginal and Torres Strait Islander people: a systematic review

OBJECTIVE

To determine the effectiveness of nutrition education on improving nutrition-related health outcomes in Aboriginal and Torres Strait Islander people.

METHODS

Databases Medline, Cinahl, Scopus, ProQuest and ATSI Health were searched in September 2013 to identify nutrition education intervention studies in Indigenous Australian populations. Peer-reviewed and grey literature with nutrition-related biochemical or anthropometrical health outcomes were included in a qualitative comparative analysis.

RESULTS

Of 1,162 studies identified from the search, six met inclusion criteria. Three studies were from a remote setting and three from an urban setting. Four of the six education interventions were shown to improve body mass index (BMI) and/or nutritional biochemical indicators. Components of the nutrition education interventions showing greatest effect included cooking skills workshops, group education sessions and store interventions. Community involvement in the program design was most strongly associated with a positive effect on BMI.

CONCLUSION

Nutrition education had some effect in reducing biochemical and anthropometric risk factors for chronic disease in Indigenous Australians.

IMPLICATIONS

Nutrition education can be considered as part of a range of strategies to improve nutrition-related health for Aboriginal and Torres Strait Islander people. Further evidence is needed to strengthen this recommendation.

Factors influencing food choice in an Australian Aboriginal community

We explored with Aboriginal adults living in a remote Australian community the social context of food choice and factors perceived to shape food choice. An ethnographic approach of prolonged community engagement over 3 years was augmented by interviews. Our findings revealed that knowledge, health, and resources supporting food choice were considered "out of balance," and this imbalance was seen to manifest in a Western-imposed diet lacking variety and overrelying on familiar staples. Participants felt ill-equipped to emulate the traditional pattern of knowledge transfer through passing food-related wisdom to younger generations. The traditional food system was considered key to providing the framework for learning about the contemporary food environment. Practitioners seeking to improve diet and health outcomes for this population should attend to past and present contexts of food in nutrition education, support the educative role of caregivers, address the high cost of food, and support access to traditional foods.

The role of remote community stores in reducing the harm resulting from tobacco to Aboriginal people

The objective of this study was to assess the potential for reducing the harm resulting from tobacco use through health promotion programmes run in community stores in remote Aboriginal communities. The Tobacco Project utilised data from 111 stakeholder interviews (72 at baseline and 71 at follow-up after 12 months) assessing presence of sales to minors, tobacco advertising, labelling and pricing. It also involved the assessment of observational data from community stores and comments obtained from 29 tobacco vendors derived from community surveys. Sales of tobacco to minors were not reported in community stores and all stores complied with requirements to display the legislated signage. However, tobacco was accessible to minors through a vending machine and through independent vendors. Only one store displayed tobacco advertising; all stores had displayed anti-tobacco health promotion posters or pamphlets. Pricing policies in two stores may have meant that food items effectively subsidised the cost of tobacco. All stores had unofficial no-smoking policies in accessible parts of the store. Remote community stores complied with existing legislation, aside from allowing access of minors to vending machines. There may still be potential for proactive tobacco education campaigns run through community stores and for a trial assessing the effect of changes in tobacco prices on tobacco consumption.

Does the store-turnover method still provide a useful guide to food intakes in Aboriginal communities?

OBJECTIVE

To consider the application of the store-turnover method as a guide to assess food intake in remote Aboriginal communities.

METHOD

Food sources in a remote Aboriginal island community were documented. The contribution of quantifiable food sources to total community-level fresh fruit and vegetable availability was determined.

RESULTS

The store remains the single largest supplier of fruit and vegetables overall (54%), however its contribution varies depending on the subpopulation of interest. A store-turnover alone may significantly underestimate community-level dietary intake, depending on the contribution of other food sources.

CONCLUSIONS

Changes in the food supply in remote communities, coupled with methodological complexities inherent in the store-turnover method, challenge its application in a contemporary context.

IMPLICATIONS

A simplified version of the store-turnover method is needed that could be widely applied by community people and health practitioners seeking to initiate and monitor interventions to improve diet quality.

Food availability, cost disparity and improvement in relation to accessibility and remoteness in Queensland

This study is the first to describe disparity and change in the food supply between metropolitan, rural and remote stores by Accessibility/Remoteness Index of Australia (ARIA) category. A total of 92 stores (97% response rate) within five aggregate ARIA categories participated throughout Queensland in 2000. There was a strong association between ARIA category and the cost of the basket of basic foods, with prices being significantly higher (20% and 31% respectively) in the 'remote' and 'very remote' categories than in the 'highly accessible' category. The association with ARIA was less marked for fruit and vegetables than for other food groups, but not for tobacco and take-away food items. Basic food items were less available in the more remote stores. Over the past two years, relative improvements in food prices have been seen in stores in the 'very remote' category, with observed increases less than the consumer price index (CPI) for food. Some factors which may have contributed to this improvement are discussed.

Review of the nutrition policy of the Arnhem Land Progress Association

The process of implementation and the effect of the nutrition policy of the Arnhem Land Progress Association (ALPA) were reviewed three years after implementation of the policy in five remote Aboriginal community retail stores in May 1990. In 1993, compliance with the policy varied among stores. Recommended foods were available regularly in most communities; however, promotional and educational components of the policy were not widely implemented. Dietary improvements were evident in those communities where stores most complied with the policy. Some aspects of the ALPA nutrition policy require modification, and renewed commitment to the policy is likely to improve further the diet in the Aboriginal communities involved. The ALPA nutrition policy is a potential model for the development of other local food and nutrition policies in remote Aboriginal communities.