Developing an agenda for research about policies to improve access to healthy foods in rural communities: a concept mapping study

Across the life course, access to nutrient-rich food that supports a healthy and active life is an important determinant of population health [1, 2], but there are disparities in accessing healthy, affordable foods across income levels, among certain race/ethnic minority groups, and between rural and urban communities [3‐7]. Although rural areas vary widely across the United States [8‐10], rural residents generally consume fewer health-promoting foods like fruits and vegetables compared to urban or suburban residents [11]. Rural communities also face disproportionately higher risk for nutrition-related chronic diseases such as obesity when compared to urban residents [12‐16]. Indeed, obesity prevalence is 39.6% among rural adults compared to 33.4% among urban adults, and remains significantly higher after controlling for demographics, diet, and physical activity [12]. Even among children, living in rural versus urban communities is associated with being overweight or obese [17].

While “food access” is complex and multi-faceted, evidence suggests individuals’ or communities’ ability to access healthy, affordable foods is influenced by affordability, availability, cultural acceptability, geographic proximity (e.g., how close a retail food outlet is to residential areas), and mobility and transportation options [3, 4, 18‐21]. Research examining the associations between the food environment and health continues to grow [22, 23]. To date, many studies find that residents of rural communities face disproportionate challenges to accessing healthy, affordable foods due to limited infrastructure, long distances to food outlets, and fewer healthy options [20, 24‐29]. Traditional grocery stores are becoming scarce in some rural communities [30], and those that remain may offer fewer healthy food options [31‐33]. Some rural residents shop at local convenience stores (which typically offer more processed and less fresh food) and travel longer distances less frequently for groceries [18, 33‐35]. Despite these challenges, rural residents continue to feed their families through a complex arrangement of grocery stores and alternative or non-traditional food sources such as dollar stores, mass merchandisers (e.g., Walmart), convenience stores, fast food restaurants, mobile venders, and flea markets [36‐38], as well as gardening, hunting, bartering, and reliance on neighbors and friends [18, 21, 38]. To compensate for transportation and proximity challenges, rural families may plan their food shopping around multi-purpose trips into regional hubs or urban centers (a practice known as “trip chaining”) [36], and store or freeze food they purchase in bulk [21].

National, tribal, state, and local efforts increasingly target improved access to healthy foods using a range of environmental and policy strategies such as retail food financing initiatives and land use regulations [39‐46]. Most of these initiatives are focused on urban communities [47], and because rural food access appears to differ from urban food access, some proposed policy strategies may not address the needs of rural communities [48, 49].

Given the interrelated and multi-level determinants of rural food access [11, 45, 50‐52], a comprehensive and systematic approach is needed to plan research to support the development of effective rural food policies. To date, rural food research has not emphasized the impact of policy changes on rural food access, but has focused on individual-level topics such as factors influencing food choice [21], disparities [49], and trip chaining patterns [53, 54], and community-level influences such as non-traditional food retailers [35, 38, 55], food venue types [28, 56], and rural culture and context [47, 57]. In concert with extant research, existing conceptual models of food access [2, 58] do not fully address the influence of macro-level policies on the food choices of rural residents. Thus, there is a need for a detailed map to guide systematic examinations of the multiple levels of determinants of access to healthy foods in rural areas, and a need to prioritize potential research on the policies that might be applied to address these determinants.

This study aims to identify knowledge gaps and policy research needs that have the greatest potential for improving access to healthy, affordable foods in rural communities in the United States through a concept mapping process.

Food access plays a significant role in the nutritional health of the population, and policy strategies are increasingly recognized as important to assuring this access. Such policies must be contextually appropriate [47, 57]. Many of the clusters appearing in the concept maps are similar to extant conceptual models that describe food choice, food security, and nutritional environments [2, 63], but within each cluster there are additional ideas that are unique to rural areas. These can provide direction to rural food policy researchers and are currently serving as a basis for the ongoing work of the NOPREN RFAWG.

Many statements within the clusters illustrate ways the concepts may have a different context in rural areas. For example, transportation concerns are referenced frequently in relation to several clusters. Transportation is often needed for travel to food sales outlets (Healthy Food Retail Availability) and to participate in some state and federal food and nutrition assistance programs (Food and Nutrition Assistance); transportation is also needed to distribute healthy items to rural stores (Local Food Systems) and to move agricultural products to market (Price and Community Economic Development). Collectively, the clusters illustrate the complexity of the inter-related and multi-level factors associated with rural food access. For example, policies that incentivize healthy food retail may not be effective if they simply lead to the opening of new stores because food access in rural communities is associated with other issues: food distribution systems, pricing of healthy foods, and food purchasing behaviors. Moreover, opening new stores in rural communities might have unintended consequences such as increased access to processed food and economic vulnerability for existing local storeowners [4].

Results from this study are informing practice and research about the highest priority work that needs to be done to improve availability of healthy food in rural areas through policy and environmental change [64]. For example, several concepts related to rural economic development were rated as the highest priorities for both policy and policy research. Given the dual importance of food production to rural areas and the need for financial resources to access food in rural areas, economic development as a way of improving access to healthy foods in rural areas is a unique focus for policy research. A sub-group of RFAWG members have focused on this arena. The group conducted a literature review to examine four entrepreneurial food systems innovations (farmers’ markets, community supported agriculture (CSAs), farm to institution programs and food hubs) to determine whether innovations for aggregation, processing, distribution and marketing in local food systems: 1) enabled producers to make a living; 2) improved local economies; 3) provided local residents with greater access to affordable, healthy food; and 4) contributed to greater consumption of healthy food among residents [65].

The opportunity to come together in the RFAWG for this project and the ongoing research network has also focused researchers on the need to build rigorous methods for rural food policy research. To that end, a third RFAWG sub-group is expanding on previous findings [66] to adapt the Common Community Measures for Obesity Prevention” (COCOMO), a set of 24 recommended community-level obesity-prevention strategies for use in rural areas.

It is clear that by starting to consider research questions about economic viability of food retail and the inter-relatedness of community economic development and food access, researchers need to work across disciplines and secure meaningful community involvement [64, 65]. Ideally, these findings serve as a call for multi-disciplinary and collaborative studies that look at the factors associated with rural food access across diverse populations. RFAWG plans to continue to use the concept map as a guide to developing appropriate, testable research questions about policy development and evaluation for food access in rural areas.

As with any study, there are important considerations worth noting when interpreting these findings. First, results reflect the group doing the study. This study describes rural food access and research priorities from the perspective of professionals, which may differ from those of rural residents. To address this limitation, RFAWG members have also been conducting focus groups of rural residents (personal communications, Carmen Byker, January 28, 2014; Wesley Dean, February 1, 2014; Stephanie Jilcott Pitts, January 21, 2014). In addition, many of the professional experts come from the field of public health. Perceptions from a different sample may result in different ideas about rural food access issues and their relative priority for policy development and future research. Reaching across food system “spheres” in this manner is a challenge for both food system and policy research. Finally, the study does not use a particular definition of “rural” or directly address the diversity of communities generally referred to as rural. The strengths of the study include the participatory design, mixed method data collection approaches, visual mapping products, and a sampling approach that aimed to capture perspectives of experts across diverse disciplines, geography, and researcher/practitioner points of view.

This collaborative concept mapping project created a detailed map of clusters of 90 different statements that describe a diverse set of factors associated with food access in rural communities in the United States. Findings from this study have important implications for rural food policy researchers and practitioners because they define the context and determinants of rural food access and the policies that could be effective for rural communities. The maps and other findings can be used to establish a comprehensive research plan to build evidence to guide policy development.

All authors participate in the Nutrition and Obesity Policy Research and Evaluation Network Rural Food Access Working Group (RFAWG). DJ and JS co-chair the group.