A Mixed Methods Comparison of Urban and Rural Retail Corner Stores

Associations between food and beverage purchases and skin carotenoids among diverse small food retail store customers

OBJECTIVE

To determine if customer purchases at small food stores are associated with healthfulness of the diet as approximated by skin carotenoids.

DESIGN

This is a cross-sectional survey of customers in small food stores regarding demographics and food purchases. Food and beverage purchases were classified as 'healthy' or 'non-healthy' and 'carotenoid' v. 'non-carotenoid' using a systematic classification scheme. Fruit and vegetable intake was objectively assessed using a non-invasive device to measure skin carotenoids. Associations between variables of interest were examined using Pearson's correlation coefficients, t tests and multiple linear regression analyses.

SETTING

Twenty-two small food retail stores in rural (n 7 stores) and urban (n 15) areas of North Carolina.

PARTICIPANTS

Customers of small food stores.

RESULTS

Of study participants (n 1086), 55·1 % were male, 60·0 % were African American/Black and 4·2 % were Hispanic, with a mean age of 43·5 years. Overall, 36 % purchased at least one healthy item, and 7·6 % of participants purchased a carotenoid-containing food/beverage. Healthy foods and beverages purchased included produce, lean meats, 100 % juices, plain popcorn, plain nuts, milk and yogurt. Unhealthy items included non-100 % juices, crackers, chips, candy, cakes and donuts. Purchase of a healthy or carotenoid-containing item was positively associated with skin carotenoid scores (P = 0·002 and 0·006, respectively).

CONCLUSIONS

A relatively small proportion of customers purchased any healthy or carotenoid-containing foods and beverages, and those who did purchase healthy options had higher skin carotenoid scores. Future research should confirm these findings in different populations.

Differences in a Chain Supermarket's Sales to SNAP Shoppers Before and Since the COVID-19 Pandemic

OBJECTIVE

This study 1) compares grocery sales to Supplemental Nutrition Assistance Program (SNAP) shoppers in rural and urban grocery stores and 2) estimates changes in sales to SNAP shoppers in North Carolina (NC) since the pandemic.

DESIGN

Weekly transaction data among loyalty shoppers at a large grocery chain across NC from October 2019 to December 2020 (n = 32; 182 store weeks) to assess nutritional outcomes.

SETTING

North Carolina large chain grocery stores.

PARTICIPANTS

Large chain grocery store/SNAP shoppers.

INTERVENTION

Rural/urban status of the stores and COVID-19 pandemic onset.

MAIN OUTCOME MEASURES

Share of total calories sold from fruits, vegetables, nuts, and legumes (FVNL) with and without additives, sugar-sweetened beverages (SSB), less healthful foods (LHF), and processed meats (PM).

ANALYSIS

Multivariate random effects models with robust standard errors to examine the association of rural/urban status before and since coronavirus disease 2019 with the share of calories sold to SNAP shoppers from each food category. We controlled for county-level factors (eg, sociodemographic composition, food environment) and store-level factors.

RESULTS

We did not find significant rural-urban differences in the composition of sales to SNAP shoppers in adjusted models. There was a significant decrease in the mean share of total calories from sugar-sweetened beverages (-0.43%) and less healthful food (-1.32%) and an increase in the share from processed meats (0.09%) compared with before the pandemic (P < 0.05).

CONCLUSIONS AND IMPLICATIONS

Urban-rural definitions are insufficient to understand nuances in food environments, and more support is needed to ensure healthy food access.

Regional Variation in Hormonal and Metabolic Parameters of White and Black Women With PCOS in the United States

CONTEXT

Ongoing research is needed to determine geo-epidemiologic differences of polycystic ovary syndrome (PCOS).

OBJECTIVE

Determine hormonal and metabolic parameters of women with PCOS in 2 environments.

METHODS

Prospective cohort study.

SETTING

Tertiary-care based specialty clinics in Alabama and California.

PATIENTS OR OTHER PARTICIPANTS

A total of 1610 women with PCOS by National Institutes of Health Criteria from 1987 to 2010.

INTERVENTIONS

Interview, physical examination, laboratory studies.

MAIN OUTCOMES MEASURES

Demographic data, menstrual cycle history, and hormonal and metabolic parameters were collected. Hirsutism was defined as modified Ferriman-Gallwey scores ≥4. Androgen values greater than laboratory reference ranges or >95th percentile of all values were considered elevated (hyperandrogenemia). Metabolic parameters included body mass index (BMI), waist-hip-ratio (WHR), glucose tolerance test, and homeostatic model assessment for insulin resistance (HOMA-IR) scores.

RESULTS

Alabama women with PCOS were younger with a higher BMI. After adjustment for age and BMI, Alabama women with PCOS were more likely hirsute (adjusted odds ratio [aOR], 1.8; 95% CI, 1.4-2.4; P < 0.001), with elevated HOMA-IR scores (adjusted beta coefficient 3.6; 95% CI, 1.61-5.5; P < 0.001). California women with PCOS were more likely to have hyperandrogenemia (free testosterone aOR, 0.14; 95% CI, 0.11-0.18; P < 0.001; total testosterone aOR, 0.41; 95% CI, 0.33-0.51). Results were similar when stratified by White race. In Black women with PCOS, BMI and WHR did not differ between locations, yet differences in androgen profiles and metabolic dysfunction remained.

CONCLUSION

Alabama women with PCOS, regardless of Black or White race, were more likely hirsute with metabolic dysfunction, whereas California women with PCOS were more likely to demonstrate hyperandrogenemia, highlighting potential environmental impacts on PCOS.

Perceived barriers and facilitators to participating in the North Carolina Healthy Food Small Retailer Program: a mixed-methods examination considering investment effectiveness

OBJECTIVE

The North Carolina Legislature appropriated funds in 2016-2019 for the Healthy Food Small Retailer Program (HFSRP), providing small retailers located in food deserts with equipment to stock nutrient-dense foods and beverages. The study aimed to: (1) examine factors facilitating and constraining implementation of, and participation in, the HFSRP from the perspective of storeowners and (2) measure and evaluate the impact and effectiveness of investment in the HFSRP.

DESIGN

The current analysis uses both qualitative and quantitative assessments of storeowner perceptions and store outcomes, as well as two innovative measures of policy investment effectiveness. Qualitative semi-structured interviews and descriptive quantitative approaches, including monthly financial reports and activity forms, and end-of-programme evaluations were collected from participating HFSRP storeowners.

SETTING

Eight corner stores in North Carolina that participated in the two cohorts (2016-2018; 2017-2019) of the HFSRP.

PARTICIPANTS

Owners of corner stores participating in the HFSRP.

RESULTS

All storeowners reported that the HFSRP benefitted their stores. In addition, the HFSRP had a positive impact on sales across each category of healthy food products. Storeowners reported that benefits would be enhanced with adjustments to programme administration and support. Specific suggestions included additional information regarding which healthy foods and beverages to stock; inventory management; handling of perishable produce; product display; modified reporting requirements and a more efficient process of delivering and maintaining equipment.

CONCLUSIONS

All storeowners reported several benefits of the HFSRP and would recommend that other storeowners participate. The barriers and challenges they reported inform potential approaches to ensuring success and sustainability of the HFSRP and similar initiatives underway in other jurisdictions.

Examining commonly used perceived and objective measures of fruit and vegetable access in low-income populations and their association with consumption

Perception-based and objective food access measures are often examined as factors influencing individuals' shopping decisions and dietary habits, but the relative influence of these two factors on behaviors needs further examination. This study sought to (a) determine if perception-based and objective measures of fruit and vegetable (F&V) access were related and (b) examine perception-based and objective access measures as predictors of F&V consumption. Participants were recruited as part of a larger intervention study from 12 sites across three urban North Carolina counties. Perception-based food access measured included self-reported perceptions of convenience, variety, and quality of F&V within a neighborhood. Food outlet density was used as the objective measure. This was derived by summing the total number of geocoded convenience stores, grocery stores, supermarkets, and supercenters located within 1 road network mile of participants' home address. Associations between perception-based and objective measures were examined using Pearson's correlations, and associations of F&V access and intake were examined using linear regression models. Pearson correlations between perception-based and objective measures revealed that F&V variety was associated with supermarkets. Regression results show that perception-based barriers to F&V access were not significantly associated with intake, but supercenter density within 1 mile was significantly associated with decreased F&V intake. Common measures of perception-based and objective measures of food access may not be the best predictor of F&V intake. Understanding the relationships of these factors for lower-income populations can offer guidance for future policies and programs.

Qualitative perspectives of the North Carolina healthy food small retailer program among customers in participating stores located in food deserts

BACKGROUND

The North Carolina Healthy Food Small Retailer Program (NC HFSRP) was established through a policy passed by the state legislature to provide funding for small food retailers located in food deserts with the goal of increasing access to and sales of healthy foods and beverages among local residents. The purpose of this study was to qualitatively examine perceptions of the NC HFSRP among store customers.

METHODS

Qualitative interviews were conducted with 29 customers from five NC HFSRP stores in food deserts across eastern NC. Interview questions were related to shoppers' food and beverage purchases at NC HFSRP stores, whether they had noticed any in-store efforts to promote healthier foods and beverages, their suggestions for promoting healthier foods and beverages, their familiarity with and support of the NC HFSRP, and how their shopping and consumption habits had changed since implementation of the NC HFSRP. A codebook was developed based on deductive (from the interview guide questions) and inductive (emerged from the data) codes and operational definitions. Verbatim transcripts were double-coded and a thematic analysis was conducted based on code frequency, and depth of participant responses for each code.

RESULTS

Although very few participants were aware of the NC HFSRP legislation, they recognized changes within the store. Customers noted that the provision of healthier foods and beverages in the store had encouraged them to make healthier purchase and consumption choices. When a description of the NC HFSRP was provided to them, all participants were supportive of the state-funded program. Participants discussed program benefits including improving food access in low-income and/or rural areas and making healthy choices easier for youth and for those most at risk of diet-related chronic diseases.

CONCLUSIONS

Findings can inform future healthy corner store initiatives in terms of framing a rationale for funding or policies by focusing on increased food access among vulnerable populations.

Associations between shopping patterns, dietary behaviours and geographic information system-assessed store accessibility among small food store customers

OBJECTIVE

To examine associations between geographic information systems (GIS)-assessed accessibility to small food stores, shopping patterns and dietary behaviours among small food store customers.

DESIGN

Residential addresses and customer shopping patterns (frequency of shopping, and previous purchase of fruits and vegetables) were gathered through customer intercept surveys. Addresses were geocoded, and GIS-assessed distance and driving time from the participants' residence to the store were calculated. Dietary status and behaviours were assessed using an objective non-invasive measure of skin carotenoids, the National Cancer Institute Fruit and Vegetable Screener, and items to assess sugary beverage intake. Associations between distance and driving time, demographics, shopping frequency, prior reported purchase of fruits and vegetables at the store and dietary behaviours were examined.

SETTING

Small food stores (n 22) across North Carolina.

PARTICIPANTS

Cross-sectional convenience samples of English-speaking customers aged 18 years or older (n 692).

RESULTS

Participants living closer to the small store had lower income and formal education, were more likely to be Black, more likely to have previously bought fruits and vegetables at the store and more frequently shopped at the store. In adjusted models, skin carotenoids (n 644) were positively associated with distance to the store from home in miles (P = 0·01).

CONCLUSIONS

Customers who lived closer to the stores were more frequent shoppers and more likely to have previously purchased fruits and vegetables at the store yet had lower skin carotenoids. These results support continued efforts to examine how to increase the availability and promotion of healthful foods at small food retail stores.

The Potential for Plant-Based Diets to Promote Health Among Blacks Living in the United States

Plant-based diets are associated with reduced risks of various chronic diseases in the general population. However, it is unclear how these benefits translate to Blacks living in the United States, who are disproportionately burdened with heart disease, cancer, diabetes, obesity, and chronic kidney disease. The objectives of this study were to: (1) review the general evidence of plant-based diets and health outcomes; (2) discuss how this evidence translates to Blacks following a plant-based diet; and (3) provide recommendations and considerations for future studies in this area. Interestingly, although the evidence supporting plant-based diets in the general population is robust, little research has been done on Blacks specifically. However, the available data suggests that following a plant-based diet may reduce the risk of heart disease and possibly cancer in this population. More research is needed on cardiovascular disease risk factors, cancer subtypes, and other chronic diseases. Further, attention must be given to the unique individual, familial, communal, and environmental needs that Blacks who follow plant-based diets may have. Interventions must be culturally appropriate in order to achieve long-term success, and providing low-cost, flavorful, and nutritious options will be important.

One-Year Follow-Up Examination of the Impact of the North Carolina Healthy Food Small Retailer Program on Healthy Food Availability, Purchases, and Consumption

We examined the short-term impact of the North Carolina Healthy Food Small Retailer Program (HFSRP), a legislatively appropriated bill providing funding up to $25,000 to small food retailers for equipment to stock and promote healthier foods, on store-level availability and purchase of healthy foods and beverages, as well as customer dietary patterns, one year post-policy implementation. We evaluated healthy food availability using a validated audit tool, purchases using customer bag-checks, and diet using self-reported questionnaires and skin carotenoid levels, assessed via Veggie Meter™, a non-invasive tool to objectively measure fruit and vegetable consumption. Difference-in-difference analyses were used to examine changes in HFSRP stores versus control stores after 1 year. There were statistically significant improvements in healthy food supply scores (availability), with the Healthy Food Supply HFS score being -0.44 points lower in control stores and 3.13 points higher in HFSRP stores pre/post HFSRP (p = 0.04). However, there were no statistically significant changes in purchases or self-reported consumption or skin carotenoids among customers in HFSRP versus control stores. Additional time or other supports for retailers (e.g., marketing and promotional materials) may be needed for HFSRP implementation to influence purchase and consumption.

Best Practices and Innovative Solutions to Overcome Barriers to Delivering Policy, Systems and Environmental Changes in Rural Communities

To better understand the barriers to implementing policy; systems; and environmental (PSE) change initiatives within Supplemental Nutrition Assistance Program-Education (SNAP-Ed) programming in U.S. rural communities; as well as strategies to overcome these barriers, this study identifies: (1) the types of nutrition-related PSE SNAP-Ed programming currently being implemented in rural communities; (2) barriers to implementing PSE in rural communities; and (3) common best practices and innovative solutions to overcoming SNAP-Ed PSE implementation barriers. This mixed-methods study included online surveys and interviews across fifteen states. Participants were eligible if they: (1) were SNAP-Ed staff that were intimately aware of facilitators and barriers to implementing programs, (2) implemented at least 50% of their programming in rural communities, and (3) worked in their role for at least 12 months. Sixty-five staff completed the online survey and 27 participated in interviews. Barriers to PSE included obtaining community buy-in, the need for relationship building, and PSE education. Facilitators included finding community champions; identifying early "wins" so that community members could easily see PSE benefits. Partnerships between SNAP-Ed programs and non-SNAP-Ed organizations are essential to implementing PSE. SNAP-Ed staff should get buy-in from local leaders before implementing PSE. Technical assistance for rural SNAP-Ed programs would be helpful in promoting PSE.

Baseline Assessment of a Healthy Corner Store Initiative: Associations between Food Store Environments, Shopping Patterns, Customer Purchases, and Dietary Intake in Eastern North Carolina

In 2016, the North Carolina (NC) Legislature allocated $250,000 to the NC Department of Agriculture, to identify and equip small food retailers to stock healthier foods and beverages in eastern NC food deserts (the NC Healthy Food Small Retailer Program, HFSRP). The purpose of this study was to examine associations between food store environments, shopping patterns, customer purchases, and dietary consumption among corner store customers. We surveyed 479 customers in 16 corner stores regarding demographics, food purchased, shopping patterns, and self-reported fruit, vegetable, and soda consumption. We objectively assessed fruit and vegetable consumption using a non-invasive reflection spectroscopy device to measure skin carotenoids. We examined associations between variables of interest, using Pearson's correlation coefficients and adjusted linear regression analyses. A majority (66%) of participants were African American, with a mean age of 43 years, and a mean body mass index (BMI) of 30.0 kg/m². There were no significant associations between the healthfulness of food store offerings, customer purchases, or dietary consumption. Participants who said they had purchased fruits and vegetables at the store previously reported higher produce intake (5.70 (4.29) vs. 4.60 (3.28) servings per day, p = 0.021) versus those who had not previously purchased fresh produce. The NC Legislature has allocated another $250,000 to the HFSRP for the 2018 fiscal year. Thus, evaluation results will be important to inform future healthy corner store policies and initiatives.

A corner store intervention to improve access to fruits and vegetables in two Latino communities

OBJECTIVE

Investments have been made to alter the food environment of neighbourhoods that have a disproportionate number of unhealthy food venues. Corner store conversions are one strategy to increase access to fruits and vegetables (F&V). Although the literature shows modest success, the effectiveness of these interventions remains equivocal. The present paper reports on the evaluation of Proyecto MercadoFRESCO, a corner store conversion intervention in two Latino communities.

DESIGN

A repeated cross-sectional design was employed. Data were stratified by intervention arm and bivariate tests assessed changes over time. Logistic and multiple regression models with intervention arm, time and the interaction of intervention and time were conducted. Supplementary analyses account for clustering of patrons within stores and staggering of store conversions.

SETTING

Three stores were converted and five stores served as comparisons in East Los Angeles and Boyle Heights, California, USA.

SUBJECTS

Store patrons were interviewed before (n550) and after (n407) the intervention.

RESULTS

Relative to patrons of comparison stores, patrons of intervention stores demonstrated more favourable perceptions of corner stores and increased purchasing of F&V during that store visit. Changes were not detected in store patronage, percentage of weekly dollars spent on food for F&V or daily consumption of F&V.

CONCLUSIONS

Consistent with some extant food environment literature, findings demonstrate limited effects. Investments should be made in multilevel, comprehensive interventions that target a variety retail food outlets rather than focusing on corner stores exclusively. Complementary policies limiting the availability, affordability and marketing of energy-dense, nutrient-poor foods should also be pursued.