Perceptions of the Food Environment and Access among Predominantly Black Low-Income Residents of Rural Louisiana Communities

The effect of proximity to grocery stores and the pandemic on parents' and youths' perceptions of eating habits in predominately African American rural communities

Background

Rural communities have a disproportionately high level of childhood obesity along with high rates of food insecurity.

Objectives

To assess the eating habits of youth in predominantly African American rural communities and assess the association between proximity to a grocery store and eating habits as well as how the COVID-19 pandemic may have impacted eating habits.

Methods

203 youth and parents completed a 16-item survey. Analyses were performed to assess the effect of having a neighborhood grocery store as well as to compare responses between youth and parents.

Results

Having a neighborhood grocery store was associated with increased consumption of vegetables (F(1,122) = 41.56) and fruits (F(1,121) = 65.05), decreased consumption of chips (F(1,125) = 79.51) and a smaller percentage of overweight youth (χ2(1,125) = 5.03). Parents underestimated the effect of the COVID-19 pandemic on youth eating habits (χ2 (1,198) = 17.88).

Conclusion

Proximity to a grocery store significantly associated with eating habits and weight in the rural communities examined. Given the steady decrease in the number rural grocery stores over the past decade it is important to consider how to improve access to healthy foods in these communities.

Household Food Sourcing Patterns and Their Associations With Food Insecurity in Appalachian Ohio

BACKGROUND

Households experiencing food insecurity may use dynamic strategies to meet food needs. Yet, the relationship between household food sourcing behaviors and food security, particularly in rural settings, is understudied.

OBJECTIVE

To identify food sourcing patterns and their associations with food insecurity among households in rural Appalachian Ohio during the COVID-19 pandemic.

DESIGN

Survey data were collected from a cohort of households in Athens County, OH, in July 2020, October 2020, January 2021, and April 2021.

PARTICIPANTS/SETTING

The sample included 663 households with household food sourcing and food security information for ≥1 survey wave.

MAIN OUTCOME MEASURES

Household food sourcing patterns. Households reported the frequency with which they obtained food from various retailers and charitable sources, classified as supercenters, supermarkets, convenience stores, farmers markets, or charitable sources.

STATISTICAL ANALYSES

Principal component analysis was used to identify food sourcing patterns. Linear mixed models were used to assess changes in food sourcing behaviors over the study period and to determine whether food sourcing behaviors differed according to food security status.

RESULTS

Two patterns were identified: Convenience Stores and Charitable Food and Supermarkets and Farmers Markets, not Supercenters. Relative to July 2020, alignment of households' food sourcing behaviors with the Supermarkets and Farmers Markets, not Supercenters pattern was higher in October 2020 (β .07, 95% CI .02 to .12) and alignment with the Convenience Stores and Charitable Food pattern was lower in April 2021 (β -.06, 95% CI -.11 to -.02). Compared with food-secure households, food sourcing behaviors of food-insecure households were more closely aligned with the Convenience Stores and Charitable Food pattern (β .07, 95% CI .00 to .13); no statistically significant difference in scores was observed for the Supermarkets and Farmers Markets, not Supercenters pattern (β -.07, 95% CI -.15 to .02).

CONCLUSIONS

These findings support efforts to increase access to healthy, affordable options at venues where food-insecure households may be likely to obtain food, such as convenience stores and charitable sources.

Healthy eating and active living policy, systems, and environmental changes in rural Louisiana: a contextual inquiry to inform implementation strategies

BACKGROUND

Healthy eating and active living policy, systems, and environmental (PSE) changes are implemented across the United States through Cooperative Extension. However, translating multisector PSE changes to practice in community settings is challenging and there is a lack of knowledge about barriers and facilitators to PSE changes among state Extension systems using standardized frameworks. Therefore, a research-to-practice partnership effort aimed to identify Louisiana Cooperative Extension Service Family and Consumer Science (LFCS) practitioners' barriers and facilitators to implementing PSE changes in rural Louisiana communities.

METHODS

A qualitative approach using the 2022 Consolidated Framework for Implementation Research (2022 CFIR) was used. Focus group discussions were conducted at five LFCS regional trainings between February and May 2022. All LFCS practitioners with any level of experience implementing healthy eating and active living PSE changes were eligible to participate, with emphasis on understanding efforts within more rural communities. Focus group discussions were audio-recorded and transcribed verbatim. Researchers analyzed qualitative data using the constant comparison method and 2022 CFIR domains and constructs including Inner Setting (LFCS organization), Outer Setting (rural Louisiana communities), Innovation (PSE changes), and Individuals (PSE change implementation actors/partners).

RESULTS

Across the five regions, LFCS practitioners (n = 40) described more barriers (n = 210) than facilitators (n = 100); findings were often coded with multiple 2022 CFIR domains. Reported Inner Setting barriers were lack of formal or informal information sharing and lack of access to knowledge and information. Outer Setting barriers included sustaining and initiating community partnerships and local environmental or political conditions. Individual barriers included a lack of time and expertise, and Innovation barriers included the complex nature of rural PSE changes. Facilitators were mentioned at multiple levels and included community partner buy-in and practitioners' motivation to implement PSE changes.

CONCLUSIONS

Implementation strategies are needed to build on organizational strengths and to overcome multi-level barriers to PSE change implementation among LFCS practitioners. The results from the in-depth contextual inquiry used could serve as a guide for future pragmatic assessment efforts among other state Extension systems or as a model for identifying barriers and facilitators and associated implementation strategies among other public health systems in the U.S. and abroad.

Self-assessed health status and obesity vulnerability in rural Louisiana: A cross-sectional analysis

Rural communities are resource-constrained and at higher risk of obesity and obesity-related conditions. Thus, studying self-assessed health status and underlying vulnerabilities is critical to provide insights to the program planners for effective and efficient planning of obesity prevention programs. This study aims to investigate the correlates of self-assessed health status and subsequently determine the obesity vulnerability level of residents in rural communities. Randomly sampled data were obtained from in-person community surveys in three rural Louisiana counties-East Carroll, Saint Helena, and Tensas-in June 2021. The association of social-demographic factors, grocery store choice, and exercise frequency with self-assessed health was investigated using the ordered logit model. An obesity vulnerability index was constructed using the weights obtained from the principal component analysis. The results show that gender, race, education, possession of children, exercise frequency, and grocery store choice significantly influence self-assessed health status. Around 20% of respondents fall into the most-vulnerable segment and 65% of respondents are vulnerable to obesity. The obesity vulnerability index ranged from -4.036 to 4.565, indicating a wide heterogeneity in the vulnerability level of rural residents. The findings show that the self-assessed health status of rural residents is not promising along with a high level of vulnerability to obesity. The findings from this study could serve as a reference in the policy discussion regarding an effective and efficient suite of interventions in rural communities to address obesity and promote well-being.

Adult food choices in association with the local retail food environment and food access in resource-poor communities: a scoping review

BACKGROUND

There is a growing body of research on local retail food environments globally in both urban and rural settings. Despite this, little research has been conducted on adult food choices, local retail environments, and healthy food access in resource-poor communities. The purpose of this study is therefore to provide an overview of the evidence on adult food choices (measured as dietary intake) in association with the local retail food environment and food access in resource-poor communities (defined as low-income communities and/or households).

METHODS

We searched nine databases for studies published from July 2005 to March 2022 and identified 2426 records in the primary and updated search. Observational studies, empirical and theoretical studies, focused on adults ≤ 65 years, published in English peer-reviewed journals, examining local retail food environments and food access, were included. Two independent reviewers screened identified articles using the selection criteria and data extraction form. Study characteristics and findings were summarized for all studies and relevant themes summarized for qualitative and mixed methods studies.

RESULTS

A total of 47 studies were included in this review. Most studies were cross sectional (93.6%) and conducted in the United States of America (70%). Nineteen (40.4%) studies assessed the association between food choice outcomes and local retail food environment exposures, and evidence on these associations are inconclusive. Associations of certain food choice outcomes with healthy food retail environments were positive for healthy foods (in 11 studies) and unhealthy foods (in 3 studies). Associations of certain food choice outcomes with unhealthy retail food environment exposures were positive for unhealthy foods in 1 study and negative for healthy foods in 3 studies. In 9 studies, some of the food choice outcomes were not associated with retail food environment exposures. A healthy food store type and lower food prices were found to be major facilitators for healthy food access in resource-poor communities, while cost and transportation were the main barriers.

CONCLUSIONS

More research is needed on the local retail food environment in communities in low- and middle-income countries to develop better interventions to improve food choices and access to healthy foods in resource-poor communities.

Food Insecurity, the Food Environment, and COVID-19 in Rural South Carolina

In this study, we explored the relationship between the food environment and food security among rural adults during the COVID-19 pandemic. Researchers, with assistance from community partners, conducted a cross-sectional survey assessing the impact of COVID-19 on food access, food security, and physical activity in 9 rural South Carolina (SC) counties. This survey was administered to a purposive sample (N = 587) from August 2020 to March 2021. The dependent variable was a binary indicator of food insecurity (past 3 months), in accordance with the USDA Household Food Security Survey Module. Independent variables were sociodemographic characteristics, food environment factors (eg, shopping at grocery stores, partial markets, and farmers' markets), and shopping behaviors during the pandemic. Overall, 31% of respondents were food insecure. Food security status differed by income and household composition. Results indicate that the odds of food insecurity were higher for respondents who shopped frequently at partial markets (adjusted odds ratio [AOR] = 1.61, 95% confidence interval [CI]: 1.01-2.56) and shopped more for food before the pandemic than during the pandemic (AOR = 1.68, 95% CI: 1.07-2.64). Findings underscore the importance of examining the relationship between the food environment and food insecurity during COVID-19 in rural settings.

A Call to Reconceptualize Obesity Treatment in Service of Health Equity: Review of Evidence and Future Directions

PURPOSE OF REVIEW

Rates of obesity and associated comorbidities are higher among Black and Latino adults compared to white adults. We sought to provide an overview of both structural and individual factors contributing to obesity inequities and synthesize available evidence regarding treatment outcomes in Black and Latino adults, with an eye towards informing future directions.

RECENT FINDINGS

Obesity disparities are influenced by myriad systemic issues, yet the vast majority of interventions target individual-level factors only, and most behavioral treatments fail to target drivers beyond eating and physical activity. Extant treatments are not equally accessible, affordable, or effective among Black and Latino adults compared with white counterparts. Asset-based, culturally relevant interventions that target the root causes of obesity and address intersectional stress-designed in partnership with intended beneficiaries-are urgently needed. Treatment trials must improve enrollment of Black and Latino adults and report treatment outcomes by race and ethnicity.

Empty Houses, Loose Dogs, and Engaged Citizens: Lessons Learned From Community Participatory Data Collection in Rural Areas

Rural surveys tend to oversample easy to reach populations, which can misrepresent community health needs. To achieve baseline data reflective of the communities served by the high obesity program (HOP), an innovative evaluation plan was created to prioritize equity and reflect the whole community. Principles of Community-Based Participatory Research (CBPR) were used to guide instrument development, research protocols, and data collection. A random sample of addresses created with United States Postal Service records provided a representative list of addresses in three HOP counties in Louisiana. Local data collectors were recruited to go door to door at the selected addresses to collect in-person surveys (N = 682; response rate of 84%). Over a quarter of participants reported using the charitable food system and walking for transportation at least weekly. Collecting door to door data in rural communities presents unique challenges, including abandoned properties, inaccurate address records, loose dogs, and at times, racial tensions and houses far removed from public roads. Lessons learned include the importance of local knowledge, adapting protocols to fit local conditions, and community awareness of the survey. Health practitioners need confidence when they are making data-based decisions about interventions, and one way to provide this confidence is to collect data from a true cross-section of the community. With a plan and in partnership with community members, a probability sample is feasible to collect in rural communities.

A mixed-method systematic review and meta-analysis of the influences of food environments and food insecurity on obesity in high-income countries

Obesity remains a serious public health concern in rich countries and the current obesogenic food environments and food insecurity are predictors of this disease. The impact of these variables on rising obesity trends is, however, mixed and inconsistent, due to measurement issues and cross-sectional study designs. To further the work in this area, this review aimed to summarize quantitative and qualitative data on the relationship between these variables, among adults and children across high-income countries. A mixed-method systematic review was conducted using 13 electronic databases, up to August 2021. Two authors independently extracted data and evaluated quality of publications. Random-effects meta-analysis was used to estimate the odds ratio (OR) for the association between food insecurity and obesity. Where statistical pooling for extracted statistics related to food environments was not possible due to heterogeneity, a narrative synthesis was performed. Meta-analysis of 36,113 adults and children showed statistically significant associations between food insecurity and obesity (OR: 1.503, 95% confidence interval: 1.432-1.577, p < .05). Narrative synthesis showed association between different types of food environments and obesity. Findings from qualitative studies regarding a reliance on energy-dense, nutrient-poor foods owing to their affordability and accessibility aligned with findings from quantitative studies. Results from both qualitative and quantitative studies regarding the potential links between increased body weight and participation in food assistance programs such as food banks were supportive of weight gain. To address obesity among individuals experiencing food insecurity, wide-reaching approaches are required, especially among those surrounded by unhealthy food environments which could potentially influence food choice.

Evaluation of two social norms nudge interventions to promote healthier food choices in a Canadian grocery store

The objective of this study was to determine the impact of two nudge interventions on customers’ produce purchases at a rural Canadian grocery store. A pre- and post-intervention observational study design was used. Sales data were gathered before and after the staggered implementation of two nudge-based interventions to encourage produce purchases: grocery cart dividers to encourage shoppers to fill one-third of their cart with produce and grocery cart plaques with information about how many fruits and vegetables were typically purchased in the store. The proportion of total sales accounted for by produce was compared between baseline and implementation of the first intervention (Phase 1), between implementation of the first intervention and the addition of the second intervention (Phase 2), and between baseline and post-implementation of both interventions together. There was a 5% relative increase (0.5% absolute increase) in produce spending between baseline and post-implementation of both interventions (10.3% to 10.8%, p < 0.001, 95% CI 0.2%, 0.7%). Intervention phase-specific produce spending showed no significant change in the percentage of produce spending from baseline to Phase 1 of the intervention, and an 8% relative increase (0.8% absolute increase) in the percentage of produce spending from Phase 1 to Phase 2 of the intervention (10.3% to 11.1%, p < 0.001, 95% CI 0.5, 1.1%). Simple, low-cost nudge interventions were effective at increasing the proportion of total grocery spend on produce. This study also demonstrated that partnerships with local businesses can promote healthier food choices in rural communities in Canada.

Navigating Hidden Hunger: An Exploratory Analysis of the Lived Experience of Food Insecurity among College Students

College students are a vulnerable population to food insecurity (FI), which has significant implications for academic and health outcomes. The aims of this study were to explore the meaning of FI and its impact on students' lived experiences and food decisions, facilitators and barriers to food access as a student, and students' proposed solutions to address FI. Semi-structured, qualitative interviews were conducted with thirty students from a large, public land grant university in the Southeast United States. Grounded theory methodology was utilized with a constant comparative coding strategy to guide thematic analysis. Nine main themes emerged. Themes included the perceived meaning of FI, students' lived experience with FI, and food related coping strategies and decisions. Facilitators to food access were found to be social-networks and on-campus resources, while barriers to food access included financial burden of higher education, and stigma and social comparison. Proposed solutions to FI aligned with two main themes: food access solutions and information access solutions. Both of these themes included multiple subthemes that provided specific suggestions to address food insecurity for students. The findings aid in understanding the complex lived experience of FI and can inform future efforts to center student experiences, perceptions, and feedback into institutional frameworks to best meet student needs.

Employment Loss and Food Insecurity - Race and Sex Disparities in the Context of COVID-19

INTRODUCTION

Applying an intersectional framework, we examined sex and racial inequality in COVID-19-related employment loss (ie, job furlough, layoff, and reduced pay) and food insecurity (ie, quality and quantity of food eaten, food worry, and receipt of free meals or groceries) among residents in Saint Louis County, Missouri.

METHODS

We used cross-sectional data from adults aged 18 or older (N = 2,146), surveyed by using landlines or cellular phones between August 12, 2020, and October 27, 2020. We calculated survey-weighted prevalence of employment loss and food insecurity for each group (Black female, Black male, White female, White male). Odds ratios for each group were estimated by using survey-weighted binary and multinomial logistic regression models.

RESULTS

Black female residents had higher odds of being laid off, as compared with White male residents (OR = 2.61, 95% CI, 1.24-5.46). Both Black female residents (OR = 4.13, 95% CI, 2.29-7.45) and Black male residents (OR = 2.41, 95% CI, 1.15-5.07) were more likely to receive free groceries, compared with White male residents. Black female (OR = 4.25, 95% CI, 2.28-7.94) and White female residents (OR = 1.93, 95% CI, 1.04-3.60) had higher odds of sometimes worrying about food compared with White male residents. Black women also had higher odds of always or nearly always worrying about food, compared with White men (OR = 2.99, 95% CI, 1.52-5.87).

CONCLUSION

Black women faced the highest odds of employment loss and food insecurity, highlighting the disproportionate impact of COVID-19 among people with intersectional disadvantages of being both Black and female. Interventions to reduce employment loss and food insecurity can help reduce the disproportionately negative social effects among Black women.

Supplemental Nutrition Assistance Program (SNAP)-authorized retailers received a low score using the Business Impact Assessment for Obesity and population-level nutrition (BIA-Obesity) tool

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) supports Americans with lower income to purchase dietary products at authorized retailers. This research aimed to evaluate SNAP-authorized retailers' public commitments in support of nutrition security and to examine differences between traditional grocers and nontraditional (e.g., convenience, drug, dollar) SNAP-authorized retailers' public commitments.

METHODS

Prominent United States (U.S.) SNAP-authorized retailers nationally and in two U.S. states (California and Virginia) were identified based on number of store locations (n = 61). Public information available in grey literature were reviewed and scored using the Business Impact Assessment for Obesity and population-level nutrition (BIA-Obesity) tool. SNAP-authorized retailers were classified as traditional (e.g., grocery) or nontraditional (e.g., non-grocery) retailers. Total BIA-Obesity from 0 to 615, representing low to optimal support) and category scores were calculated for corporate strategy, relationships with external organizations, product formulation, nutrition labeling, product and brand promotion, and product accessibility. Descriptive statistics were used to describe BIA-Obesity scores overall and by category. Mann-Whitney U was used to test for potential differences in median BIA-Obesity total scores between traditional and nontraditional SNAP-authorized retailers (a priori, p < 0.05).

RESULTS

Average total BIA-Obesity scores for SNAP-authorized retailers ranged from 0 to 112 (16.5 ± 23.3). Total BIA-Obesity scores for traditional SNAP-authorized retailers (32.7 ± 33.6; median 25) were higher than nontraditional SNAP-authorized retailer scores (11.2 ± 16; median 5) (p = 0.008). For BIA-Obesity categories, average scores were highest for the category relationships with external organizations (8.3 ± 10.3) and lowest for promotion practices (0.6 ± 2.1).

CONCLUSIONS

Results of this research underscore a dearth of available evidence and substantial opportunity for improvement regarding SNAP-authorized retailer strategies to support nutrition security among Americans with lower income.

What is the availability, affordability, and quality of foods and beverages aligned with dietary guidance in Louisiana Supplemental Nutrition Assistance Program (SNAP) authorized stores?

Healthy food retail strategies are delivered by Cooperative Extension Services in Louisiana to improve public health among communities with lower income. To guide Cooperative Extension Services Programming, the aim of this study was to assess healthy food access among SNAP-authorized stores. This included comparing the availability, affordability, and quality of healthy foods sold in these stores by geography, ownership, and store type. Seventy-five Louisiana SNAP-authorized stores were selected for measurement. Between October 2019 and March 2020 (prior to the COVID-19 national emergency declaration), trained researchers used the Nutrition Environment Measures Survey in Stores (NEMS-S) to assess the availability, affordability, and quality of healthy versus less healthy foods and beverages in 42 SNAP-authorized stores, including: grocery (n = 12, 29%), convenience (n = 17, 41%), drug (n = 1, 2%), dollar (n = 11, 26%), and butcher/meat (n = 1, 2%). Multivariate analysis of variance (a priori, p < 0.05) determined if differences in total NEMS-S scores or subscores existed by geography (urban versus rural), ownership (corporate/chain versus independent), or store type. No urban/rural differences were identified. Corporate/chain SNAP-authorized stores scored higher on average than independent SNAP-authorized stores for the total NEMS-S score (17.2 versus 8.1; p = 0.009) and availability subscore (13.1 versus 6.1; p = 0.02). SNAP-authorized grocery stores scored higher than all other store types (total NEMS-S score 27.6), followed by SNAP-authorized dollar stores (total NEMS-S score 10.7), and SNAP-authorized convenience stores (total NEMS-S score 5) (p < 0.001). Louisiana Cooperative Extension Services should explore ways to scale healthy food retail strategies statewide with a specific emphasis on independent and smaller SNAP-authorized retailers.

Understanding regional food environments: A qualitative exploration of food purchasing behaviour

The characteristics of regional food environments differ from those of urban food environments, however, the importance of these characteristics in shaping food purchasing behaviours is unclear. Using a qualitative descriptive approach, how regional adults use and perceive their food environment and the factors that determine their food purchasing behaviour were explored. Semi-structured in-depth interviews were undertaken with thirteen regional-dwelling Australian adults. Findings suggest regional residents consider a range of factors beyond proximity to home, in deciding where to purchase food. Knowing how people use their food environment will inform contextually-appropriate policy recommendations and interventions to improve regional food environments and healthy purchasing behaviours.

Healthy Eating in Low-Income Rural Louisiana Parishes: Formative Research for Future Social Marketing Campaigns

High rates of obesity and chronic disease exist in the southeastern United States (US). Knowledge about the attitudes, beliefs, and barriers of the rural low-income Louisiana population regarding healthy eating is limited. Focus Group discussions based on the Theory of Planned Behavior (TPB) were conducted in rural parishes (N = 3) with low-income residents of Louisiana (N = 29). Grounded Theory methods and cross-case analysis were used. The participants were primarily single Black females of age 18–30 years who earned a high school diploma, were employed, and had children. Beliefs included healthy eating was physically beneficial, yet financial impacts and the low palatability of healthy foods were barriers. Professional resources for nutrition education were limited which led to reliance on friends, family, and the internet. Friends and family were positive and negative influences on eating choices. Control beliefs included the high prices and low palatability of healthy foods, the wide availability of Energy Dense Nutrient Poor (EDNP) foods, and low motivation to sustain eating behavior changes. Formative research to optimize campaign distribution channels may improve accessibility to social marketing support and healthy eating resources. Persuasive messages that address control beliefs are needed in social marketing campaigns for rural low-income Louisiana environments.

Nutrition Interventions in Low-Income Rural and Urban Retail Environments: A Systematic Review

BACKGROUND

Nutrition interventions promoting healthy food choices aim to address health challenges of residents in low-income environments. Research about the effectiveness of nutrition interventions in low-income populations is limited, particularly for those in rural areas. Behavioral economics (BE) strategies demonstrate effectiveness for improving eating behaviors in some settings. However, the efficacy of BE interventions in retail food stores serving low-income populations residing in rural and urban geographies is nascent.

OBJECTIVE

This systematic literature review aims to identify and compare nutrition interventions implemented in rural and urban low-income retail food stores, including BE strategies when applied.

METHODS

This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reviewers searched five databases for peer-reviewed publications from October 2010 to October 2019. Included studies implemented a nutrition intervention in low-income retail food stores and provided a quantitative outcome evaluation with results separated by rural and urban geography. BE interventions were analyzed based on the MINDSPACE framework for behavior change.

RESULTS

Forty-six separate publications (n = 20 rural, n = 26 urban) in the United States, Canada, Europe, New Zealand, and Australia were included. Researchers independently rated publications as low risk of bias (n = 4), moderate (n = 18), or high risk of bias (n = 24) using the Quality Assessment Tool for Quantitative Studies. Studies (n = 18) demonstrated positive outcomes for customer purchases, store sales, or participant intake of targeted healthy foods. Overall, most effective interventions included point-of-purchase signage (n = 16) and product placement strategies (n = 4 urban). Rural studies included financial incentives combined with participant education (n = 2) and incorporated culturally appropriate messengers and/or symbols (n = 5) to improve healthy food purchases and intake.

CONCLUSIONS

Improved research quality and tailored evidence-based interventions, including BE strategies, are necessary in retail food environments to promote healthy eating behaviors in low-income populations.