Background
Overweight and obesity are associated with chronic health conditions such as hypertension, diabetes, cardiovascular disease, and cancer [
1]. In the United States, overweight and obesity rates have steadily increased since 1999 [
2]. Hispanics bear some of the highest burden of the obesity epidemic and the disparities gap is bigger among Hispanics in rural communities [
3]. At the same time, the United States has experienced a significant change in the food environment in the past several decades [
4,
5], and the food environment has emerged as a powerful influence on individuals’ eating patterns, food choices, and diet quality. Food establishments have steadily increased in number resulting in greater availability of processed and convenience foods, and portion sizes have become larger in chain restaurants, fast food outlets, and food stores [
5]. Simultaneously, the number of meals eaten outside the home has also increased, resulting in individuals choosing energy dense foods [
6‐
8]. Food environment studies have examined individuals’ access to food using proximity of their homes to the nearest food store, or density of type of food stores in their communities [
9,
10]. These studies characterized aspects of the food environments that exist within communities. However, a major limitation of these studies is that their findings assumed that all restaurants or food stores of the same type offered the same diet quality, health promotion information, and pricing [
11]. Conversely, studies that examined characteristics of restaurants within the food environment reported variability in the proportion of healthy menu options [
12,
13].
Studies on food environment helped highlight the extent of disparities that exist in resource-limited communities such as rural communities [
14‐
16] and gave way to the rise of the term ‘food desert.’ [
17] However, food availability and food access in rural agricultural communities has been less studied. Specifically, studies examining the availability of healthful foods in rural agricultural communities and community residents’ perception of food availability and access are limited. The goal of this study was to investigate the food environment and food access in four rural agricultural communities using mixed methods: quantitative nutrition environmental assessments of food outlets (food stores and restaurants) and qualitative semi-structured, in-depth interviews with community residents. Both quantitative and qualitative approaches are appropriate in this study as the use of quantitative assessments will reveal the food type and extent of healthy options available in the environment. Qualitative, semi-structured interviews will complement the quantitative findings by providing insight into individuals’ perceptions of and experiences with their food environment.
Discussion
This study found that the overall food environment quality composite scores for both food stores (grocery stores and convenience stores) and restaurants were very low, indicating the limited availability of healthier options in the food environment. There were more convenience stores than grocery stores and more sit-down restaurants compared to fast causal and fast food restaurants in four predominantly Hispanic rural farming communities.
Grocery stores had greater availability of healthier options and better quality produce compared to convenience stores. Qualitative interview results supported this finding, as participants reported having availability and access to fresh food products in chain grocery stores or farming fields. These findings corroborated results from other studies in rural communities in the US and other international setting that grocery stores offer more healthful food selections but are outnumbered by convenience stores [
23‐
25]. Although convenience stores offer fewer varieties of healthful food choices, [
16,
24‐
27] they are also located in more accessible areas, potentially leading to higher customer traffic of neighborhood residents [
24,
27,
28]. A recent study showed that proximity helps individuals build close social ties with food store owners impacting their preference to shop in smaller food stores [
25].
The price of food scores identified in NEMS among grocery stores and convenience stores were similarly low, and considerably lower than the maximum price score of 22. The low price scores indicate that the healthier options were more expensive than regular items. In one of the towns, the grocery store scored lower than the convenience store indicating that although grocery stores carry healthier options, prices are also higher. Interviews showed that food prices and geographic proximity were a big driver of store preference. Thus, if residents feel that prices are similar between grocery stores and convenience stores, residents may prioritize geographic proximity and shop at convenience stores, where fewer healthy food options are available [
29]. In agricultural regions like the communities in this study, participants seem to resort to other options like accessing seasonal produce through networks of friends and families associated with farming industries and adapting their main menus based on produce availability.
Restaurants generally lacked basic practices to encourage more healthful food choices, such as offering healthy entrées and main dish salads, fruits, baked chips, and whole grains. Regardless of restaurant type, the composite scores on healthier options were very low. When compared across restaurant types for healthier options, fast food restaurants scored similarly or healthier to sit-down restaurants. This finding may not be construed as fast food restaurants offering heathier options as it may be a reflection of adherence to the changing regulations on chain restaurants such as providing nutrition information, promotion of healthier foods, lower pricing, and availability of a children’s menu [
30]. Many of the sit-down restaurants in the communities were family-owned; they, therefore, may be slower to adopt new regulations, consequently impacting their overall NEMS-R score. Participants also voiced a preference for buffet typed restaurants for dining out. When faced with a large amount or wide variety of foods such as at a buffet, individuals tend to overeat and the large portion sizes contribute to obesity rates [
31]. Future intervention studies may want to address portion control when eating out at restaurants and how to avoid multiple trips to buffet lines.
Although participants perceived having access to healthier options in their food environment, nearly all of the participants (94%) were overweight or obese. This finding may be indicative that rather than perception of the food environment, the objective environment may have greater impact in their resident’s health as shown in prior studies [
32,
33]. The discordance between the objective environment and the individual’s perception may be a reflection of the relative change in food availability during farming vs. non-farming seasons and/or participants’ “optimism” about their life. Research on Hispanic immigrants has extensively documented their resilience, and their ability to look at life from a positive outlook when faced with challenging circumstances [
34]. Rather than feeling food insecure, participants may feel they have more than what they had in their home country and mobilize social network of family and friends to get help. Future research may want to examine ways to reconcile these differences and explore whether resilience plays a role when resources are limited.
The study had several limitations. The food environment of this study may not be representative of other rural food environments as our study was based in an agricultural region and may not be translatable to other rural areas. Some components of the food environment (e.g., vending machines, worksite cafeterias) were not included. The study also excluded places that were not regularly frequented by the adult population such as school concessions. Additionally, results of NEMS represent one point in time and cannot account for previous or future alterations on restaurant menus, seasonal variations in menu or store items and price, or emergence of new and changing store format.
Acknowledgements
The authors would like to acknowledge the work and dedication of the Community Advisory Board and Steering Committee members as well as the hard work of the staff at the Center for Community Health Promotion.