FOOD SHOPPING PATTERNS IN RURAL APPALACHIA: THE ENVIRONMENTAL CONTEXT OF DIETARY BEHAVIOR 141 141 ST ST APHA ANNUAL MEETING ∙ NOVEMBER 2013 Mark Swanson, PhD Christina Studts, PhD Richard Crosby, PhD Department of Health Behavior University of Kentucky College of Public Health
PRESENTER DISCLOSURES Mark Swanson (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: “No relationships to disclose”
UK RURAL CANCER PREVENTION CENTER The Rural Cancer Prevention Center (RCPC) is a planned collaboration of community members, public health professionals, and researchers designed to reduce health disparities associated with cervical, breast, and colorectal cancer among residents of the Kentucky River Health District in Appalachian Kentucky. This presentation is supported by Cooperative Agreement Number 1U48DP001932-01 from the Centers for Disease Control and Prevention (CDC). The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the CDC.
Food Environment and Health • Food environment increasingly recognized as major influence on diet and health • Several studies link food access to health • Both IOM and Healthy People 2020 call for interventions to increase the access of healthy foods to more Americans • Particular challenge in rural America • Many areas are food deserts • Time, transportation costs may make food access even more challenging • Period of rapid change in retail food environment • Consolidation within retail grocery industry • Growth of superstores in grocery sector • Rapid increases in numbers of farmers markets • Interventions at convenience stores, esp in urban areas, widespread
The Appalachian Food Environment • Central Appalachia characteristics • Persistent poverty • Limited transportation access • Low FV consumption • High obesity/overweight • Significant health disparities • Food deserts in Appalachia • Significant portions of the region without healthy food access
Understanding Rural Appalachian Food Shopping • Random dial phone survey (n= 635) • Completion rate = 26.2% • Spoke with adult most responsible for food shopping • Series of questions on shopping patterns, Kentucky River Development District, attitudes, demographics Central Appalachia
VARIABLES OF INTEREST Dependent variable: Store choice for F&V • Questions on % of FV purchased at each of six types of retail food outlets • Warehouse/superstore • Supermarket • Independent grocery • Convenience store • Roadside stand • Farmers market Frequency distribution suggested 6 categories • Supermarket n = 255 (41.1%) • Warehouse n = 134 (21.6%) • Supermarket/warehouse n = 67 (10.8%) • Independent grocery n = 49 ( 7.9%) • Local foods outlet n = 45 ( 7.4%) • Other combinations n = 70 ( 11.3%)
VARIABLES OF INTEREST Independent variables: • Distance to each type of store (in minutes) • Factors in choosing a FV source and attitudes about FV availability, cost, and quality (single Likert-type items) • Household size and structure • Demographics – age, gender, income, marital status, education, employment status
ANALYSIS • Descriptive data on store use • Multinomial logistic regression • Model built based on bivariate logistic associations with p ≤ 0.25 • Dropped “other” category from store categories (n=70). After listwise deletion for missing data (n=14), final sample for analyses = 621 • Final model explains about 20% of the variance • Nagelkerke pseudo R-Square = .20, p = .000 • Very similar models with inclusion of more store categories, use of other distance measures
RESULTS: Shopping characteristics by store type Store Type Shop at Buy at least Buy no FV at Mean distance least 25% of FV at store type in minutes (SD) monthly store type Supermarket 91.5 69.9 15.6% 18.45 (14.73) Warehouse/superstore 82.8 48.5 32.5% 30.45 (21.23) Independent grocery store 48.6 14.0 75.3 10.94 (9.19) Convenience store 37.5 .2 94.7 10.36 (11.62) Roadside stand 32.2 9.6 72.6 15.49 (12.78) Farmers Market 31.5 8.3 74.8 17.93 (16.73)
Multinomial Logistic Regression Model (reference category is supermarket) p OR 95% CI Warehouse .000 0.96 0.95, 0.98 Minutes to nearest warehouse store .000 1.04 1.02, 1.07 Minutes to nearest large supermarket .031 5.25 1.16, 23.77 Takes own car to store .093 0.66 0.41, 1.07 Local foods important factor in store choice .332 0.76 0.44, 1.32 Employee helpfulness important factor in store choice .515 0.85 0.53, 1.38 Cost is primary FV barrier .006 0.50 0.31, 0.82 Availability is primary FV barrier .339 1.25 0.79, 1.99 Taste is primary FV barrier .902 1.03 0.61, 1.74 Home garden is an important food source
Multinomial Logistic Regression Model (reference category is supermarket) p OR 95% CI Warehouse/supermarket equally .086 0.98 0.97, 1.00 Minutes to nearest warehouse store .080 1.02 1.00, 1.04 Minutes to nearest large supermarket .876 1.09 0.37, 3.17 Takes own car to store .016 0.48 0.26, 0.87 Local foods important factor in store choice .237 1.60 0.73, 3.51 Employee helpfulness important factor in store choice .085 1.70 0.93, 3.09 Cost is primary FV barrier .254 0.71 0.39, 1.28 Availability is primary FV barrier .981 1.01 0.56, 1.81 Taste is primary FV barrier .275 1.41 0.76, 2.61 Home garden is an important food source
Multinomial Logistic Regression Model (reference category is supermarket) p OR 95% CI Primarily independent grocery store .491 1.00 0.99, 1.02 Minutes to nearest warehouse store .001 1.04 1.01, 1.06 Minutes to nearest large supermarket .789 0.85 0.25, 2.86 Takes own car to store .450 0.76 0.38, 1.54 Local foods important factor in store choice .271 1.68 0.67, 4.23 Employee helpfulness important factor in store choice .183 0.62 0.30, 1.26 Cost is primary FV barrier .838 1.07 0.55, 2.10 Availability is primary FV barrier .346 0.71 0.36, 1.44 Taste is primary FV barrier .760 1.12 0.55, 2.29 Home garden is an important food source
Multinomial Logistic Regression Model (reference category is supermarket) p OR 95% CI L ocal foods outlet .691 1.00 0.98, 1.01 Minutes to nearest warehouse store .032 1.03 1.00, 1.05 Minutes to nearest large supermarket .563 0.72 0.24, 2.17 Takes own car to store .056 2.35 0.98, 5.64 Local foods important factor in store choice .064 4.07 0.92, 17.96 Employee helpfulness important factor in store choice .804 0.92 0.46, 1.83 Cost is primary FV barrier .751 0.90 0.46, 1.76 Availability is primary FV barrier .242 1.50 0.76, 2.94 Taste is primary FV barrier .489 1.28 0.64, 2.54 Home garden is an important food source
DISCUSSION • Large supermarkets remain the dominant player in the Appalachian retail grocery market • Over 90% of households shop at a supermarket at least monthly • Very few households (15%) never buy FV at a supermarket • Mean distance to supermarkets less than 20 minutes, even in rural Appalachia • Proximity and travel are key variables • Distance (in minutes) to supermarket is important predictor of store selection • As the distance from the supermarket increases, so do the odds of shopping at • warehouse store (OR = 1.04 ; 95% CI: 1.02, 1.06) • independent grocery store (OR = 1.04 ; 95% CI: 1.01, 1.06) • local outlet (OR = 1.03 ; 95% CI: 1.00, 1.05). • While these effect sizes seem small, they represent the change in odds for each additional minute further from the supermarket
DISCUSSION • Proximity and travel (cont) • Use of own car also significantly increases odds of shopping at warehouse store (OR= 5.25; 95% CI:P 1.16, 23.77) • Attitudes about local food near significance as factor in choosing local outlets outlet (OR = 2.35; 95% CI: .98, 5.64). • What wasn’t in the model • Demographics • Income • Education • HH structure (presence of children, number of adults) • Age • Gender • Use of government benefits • Importance of price, freshness, and food safety
IMPLICATIONS FOR INTERVENTIONS • Distance matters • Limits potential of farmers markets, other local foods outlets • Reinforces concept of rural food deserts • Convenience stores or small grocers as healthy eating partners? • Similar average distance • Grocers already selling FV to 25% of respondents, compared to 5% for convenience stores
THANK YOU! Mark Swanson, PhD College of Public Health University of Kentucky Mark.swanson@uky.edu
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