Department of Clinical Sciences and Nutrition

MSc, Diploma, CertificateIn

Public Health Nutrition

‘And they wonder why Halton’s got issues!’ Focus groups exploring and comparing barriers to accessing healthy and

affordable foods, for parents with children under the age of five years, in Runcorn and Widnes (Halton)

Module Title: Research Project

Module Code: XN7066

Module Tutor: Claire Glazzard

J24450Student J Number

2015-2016Year of Intake

19/09/2016Date submitted

8,760 Word Count

1

Declaration

I confirm that this Research Project is exclusively my own work and I have appropriately

acknowledged and referenced all other work I have used.

I further confirm that the reported word count is accurate.

2

Acknowledgements

This project is part of a larger, three-stage study conducted by Halton Borough Council,

exploring food access within Halton. Stage three of this project, ‘Consulting the Community’,

formed the basis of the current research. With this, I would first like to thank Julia Rosser,

Consultant in Public Health, for introducing me to this project idea and supporting me in the

development of it. I would also like to thank Stephen Burrows, Environmental Health

Officer, for additionally supporting the development process and acting as the secondary

researcher in each of the focus groups.

Furthermore, I would like to thank Claire Hunter, Sheridan Miles and Nikki Adams.

They not only helped to develop the project, but also allowed me to utilise the children’s

centres for the recruitment of participants and as a venue for the focus groups themselves.

Everybody I met within the centres, including the crèche and nursery staff, were so friendly

and supportive and deserve a big thank you as well!

I would also like to thank my supervisor, Claire Glazzard, for all of the support and

guidance given to me throughout every step of my research. I would like to also say thank

you to Stephen Fallows, for his support when applying for ethical approval.

I would also like to thank my housemates, for participating in my pilot focus group and

helping to build my confidence as a qualitative researcher.

And finally, I would like to say big thank you to all of the participants, of whom without

there would be no research project.

Thank you all!

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Portfolio Contents:

Literature Review

Abstract 7

Introduction 8

Table 1 10

Low access and availability to healthy, affordable food 12

High access and availability of unhealthy food 18

Psychological and motivational barriers to purchasing healthy, affordable food 20

Conclusion 24

References 27

Research Article

Title page 33

Rationale for targeted journal 34

Abstract 35

Introduction 36

Method 39

Results 43

Discussion 56

Conclusion 61

References 62

Appendices 67

4

List of Tables

Literature Review

Table 1: Table of research generated from internet-based literature search 10

Research Article

Table 1: Demographic characteristics of participants 43

Table 2: Codes and sample data for ‘High cost to access healthy food locally’ 46

Table 3: Codes and sample data for ‘Children and family situation’ 48

Table 4: Codes and sample data for

‘Dominance of unhealthy food vs healthy food’ 50

Table 5: Codes and sample data for

‘Inadequate guidance/support with healthy diet’ 53

List of figures

Research Article

Figure 1: A diagram summarising the stages of participant recruitment in 40

Runcorn and Widnes

Figure 2: A diagram showing the number of participants originally recruited 41

and the final number of participants that attended each focus group

5

List of Appendices

Appendix 1: Letter of Ethical Approval 68

Appendix 2: Participant Information Sheet 69

Appendix 3: Consent Form 72

Appendix 4: Example of poster promoting research 73

Appendix 5: Photographs of room layout 74

Appendix 6: Structure of focus groups 75

Appendix 7: Data and coded barriers from thematic analysis

Transcript 1: Runcorn 77

Transcript 2: Widnes 85

Transcript 3: Runcorn 93

Transcript 4: Widnes 114

Appendix 8: Spider diagram: Formulating themes from codes during thematic analysis 127

List of abbreviations

GIS – Geographic Information Systems

Km – Kilometres

PHN – Public Health Nutrition

UK – United Kingdom

US/USA – United States of America

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Barriers to accessing a healthy, affordable diet, for individuals with a low financial income

in the UK: A literature review

Abstract

Research suggests that individuals with a low financial income are more likely to experience

barriers to accessing healthy, affordable food than those with a higher financial income.

Consequently, they are more likely to consume a poorer diet and develop diseases

associated with poor nutrition. A variety of dimensions within food access have been

suggested, including factors such as the availability, affordability and cultural

appropriateness of available healthy food. Current research regarding food access within

the UK is limited and as such, this literature review aims to evaluate both UK based and non-

UK based research exploring these dimensions, to better comprehend the barriers to a

healthy diet among low- income groups. Both environmental (e.g. limited physical access,

high cost of healthy food) and individual (e.g. negative attitudes towards health) barriers

were identified across the literature, with suggestions made for future research.

Predominantly, it was concluded that there is a strong need to further explore the barriers

to accessing a healthy diet for low income groups within the UK. This will help make the

most effective recommendations to public health policy and support the improvement of

diets in low income groups, currently vulnerable to the effects of poor nutrition.

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Components of a healthy, balanced diet include a variety of fruits and vegetables

and limited sugar (Public Health England, 2016). The Scientific Advisory Committee on

Nutrition (2011) released guidelines regarding the amounts of each nutrient required to

achieve a healthy diet. Although the diets of the UK as whole currently do not match these

guidelines, it is groups with a low financial income that are known to have one of the

poorest diets (Food Standards Agency, 2007; Public Health England, 2014). For example, it is

reported that low income groups eat more sugar and considerably less fruit and vegetables

than groups with a higher financial income (Food Standards Agency, 2007; Public Health

England, 2014). A report by the UK Institute of Fiscal studies also acknowledges this trend as

an increasing issue of concern (Griffith, O’Connell, & Smith, 2013). This is especially

important as consuming a nutritionally poor diet increases the chance of developing non-

communicable diseases, including cancer and cardiovascular disease, found to present

earlier in lower-income groups (Daborn, Dibsdall, & Lambert, 2005; Dibsdall, Lambert,

Bobbin, & Frewer, 2002).

One explanation behind this trend could be barriers to accessing healthy, affordable

food in areas of low income. A residential area in which the access to and availability of

affordable, healthy food is limited has previously been referred to as a ‘food desert’

(Cummins & Macintyre, 2002). However, the term ‘food desert’ is perhaps too simplistic and

does not consider other aspects within the environment that many restrict access to healthy

food (Bowyer, Caraher, Duane, & Carr-Hill, 2006). Alternatively, the term ‘food access’

encompasses a network of factors that could influence an individual’s access to a healthy

diet e.g. confidence in cooking, appropriateness of food for culture/religion (Bowyer et al.,

2006). Numerous definitions of food access have been formulated; Bowyer et al. (2006)

suggested that ‘food access’ is an umbrella term referring to the level of access to and

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availability, affordability, appropriateness and awareness of a healthy diet. The degree to

which an area has their needs met by local sources of food has also been introduced as a

concept within food access (i.e. accommodation) alongside the perceived quality of those

food sources (i.e. acceptability) (Andress & Fitch, 2016). The psychological and social aspects

that may help or hinder food access can also be considered (Kamphuis, Lenthe, Giskes, Brug

& Mackenback, 2007). Ultimately, each of these factors has the potential to both positively

and negatively impact a person’s access to healthy, affordable food.

UK-based research

A stronger understanding of the relationship between low income individuals and barriers

to food access in the UK would mean a stronger understanding of the ways to improve it

and a stronger foundation on which to base relevant public health policy. Current research

conducted within the UK exploring this relationship is noticeably scarce (Table 1). Of the 19

studies identified in Table 1, only five are based within in the UK, none of which were

conducted in the past five years. As such, this review aims to assess the findings of such

research based both within and outside the UK, to better comprehend the current situation

within the UK and suggest areas for improvement and future research.

9

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Table 1. Table of research generated from internet-based literature search. Key search terms include: ‘food access’,

‘food deserts’, ‘low income’ and ‘UK’.

Method of Data Collection Sample Size

Location of study

Surveys Interviews Focus Groups

Questionnaire GIS Mapping* (or similar)

Person Non-person

Andress & Fitch (2016)

No No Yes No No 30 women (Six focus groups)

N/A West Virginia, USA

Bowyer et al. (2006)

Yes Yes Yes No Yes 65 residents (Eight focus groups –50 females, 15 males)

37 shops(GIS Mapping)

Hackney, London, UK

31 shopkeepers (31 interviews)

Burns et al. (2011) Yes No No No No 2564 residents (50 small areas of Melbourne)

N/A Melbourne, Victoria, Australia

Burns et al. (2007) No No No No Yes N/A 15 supermarkets33 fast food chains

South East Melbourne, Australia

Daborn et al. (2005).

No Yes No No No 11 men N/A Norwich, UK

D'Angelo et al. (2011)

No No No Yes No 175 residents (142 female, 33 male)

N/A Baltimore City, USA

Dibsdall et al. (2002)

No No No Yes No 680 residents (530 female, 150 males)

N/A East Anglia, UK

Donkin et al. (2000)

No No No No Yes N/A 199 shops London, UK

Dubowitz et al. (2007)

No No Yes No No 44 women N/A Massachusetts and Boston, USA

Dubowitz et al. (2015)

Yes Yes No No Yes 1372 main food shopper in household (1016 females, 356 males)

24 shops (in the neighbourhood)

16 shops (not in the neighbourhood)

Pittsburgh, USA

Engler-Stringer et al. (2011)

Yes No No No No 50 women N/A Montreal, Canada

Freedman & Bell (2009)

Yes No No Yes No 37 residents completing survey

33 stores audited Nashville, USA

Hendrickson et al. (2006)

Yes No Yes No Yes Focus groups: 41 residents (27 female, 14 male)

Survey: 796 residents (494 females, 303 males)

25 stores audited Minnesota, USA

Kirkpatrick & Tarasuk (2010)

Yes No No No Yes 484 families N/A Toronto, Canada

Ward et al. (2013) Yes No No No No Four reference families

61 Supermarkets Adelaide, Australia

Winkler et al. (2006).

No No No No Yes N/A 50 areas(including 325 shops)

Brisbane, Australia

Withall et al. (2009)

No Yes No No No 27 adults (26 female, 1 male)

N/A UK

Zachary et al. (2013).

No Yes Yes No No 46 adults (40 female, 6 male)

N/A Baltimore, USA

*Geographic Information Systems (GIS) Mapping refers to a piece of software that allows different geographic locations to

be mapped in relation to each other, on the same data base (Tombarge, 1999).

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Low access and availability to healthy, affordable food

Despite the variation in definitions of food access (Andress & Fitch, 2016; Bowyer et

al., 2006; Kamphuis et al., 2007) the underlying concepts are very similar. Each

definition incorporates the issues of access, availability and affordability of healthy

food. Although it has been found that the prices of healthy food in low income areas

are not necessarily higher than in more advantaged areas (Winkler, Turrell, &

Patterson, 2006), individuals with low financial income have to spend a higher

proportion of their income on food (Ward et al., 2013). With this, the significance of all

these concepts has been explored among different low income groups and cohorts, in

a variety of settings.

For example, one UK-based study conducted by Bowyer et al. (2006)

investigated the availability of four hypothetical food baskets for low income residents

in Hackney (Table 1). The items in each basket were chosen based on focus groups

held within the community and represented a healthy, affordable diet appropriate for

one of four cultures. Bowyer et al. (2006) first used GIS Mapping (Table 1) to assess the

location and distance to different local food sources (e.g. corner shop); a source was

considered ‘accessible’ if it fell within a 0.5km radius to a participant’s home.

Volunteers were recruited to survey the availability of each basket, within these

‘accessible’ food sources. Qualitative methods (interviews) were further utilised to

consult with the local community regarding issues around food access. Overall, results

suggested that some fruit and vegetables were both available and accessible locally,

albeit financially costly and lacking in quality and variety, supporting the concepts of

low ‘accommodation’ and ‘appropriateness’ (Andress & Fitch, 2016) limiting food

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access. Although the basket appropriate for a white, British culture was found to be

the most available and accessible in the local area, the baskets appropriate for other

cultures and ethnicities were considerably less so. As a culturally diverse area, this

study identified this as a key problem for Hackney with regards to food access,

although further research would be needed to assess the current situation and any

improvement since 2006. The study’s use of a mixed methods approach increased the

strength of the results, particularly as GIS Mapping can be an incomplete

representation of food access. For example, the distance criteria for an accessible food

shop is inconsistent across a variety of relevant studies e.g. 1.6km (Donkin, Dowler,

Stevenson, & Turner, 2000), 2km (Freedman & Bell, 2009) and 2.5km (Winkler et al.,

2006) have all been used as distance criteria, across different localities. This raises

questions regarding the reliability and validity of the measure, presenting a difficulty

when comparing studies to one another. Furthermore, assessing physical distance

does not consider the experience or situation of a resident in actually accessing a shop

(e.g. route taken, transport used) (Bowyer et al., 2006). In introducing a qualitative

aspect, personal experiences such as the limited space on public transport within

Hackney (Bowyer et al., 2006) were recognised, which quantitative data alone may

have missed.

Looking outside research within the UK, four of the studies referenced in Table

1 are based within Australia, all of which use quantitative methods in their approach. A

retrospective study by Burns, Bentley, Thornton, and Kavanagh (2011) assessed data

collected in 2003, analysing three factors of food access (financial situation, physical

ability in food shopping and car access) against the demographics collected. Whereas

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Bowyer at al. (2006) had emphasised the significance of culture in food access, Burns

et al. (2011) focused on factors such as age, family structure, income and level of

education. Results found that being a low income (single) parent, living in a

disadvantaged area, was most significantly associated (p<0.001) with a lack of money

for food and limited access to a car (in which to travel to available food sources).

Physical ability to shop negatively affected the older age groups most significantly and

higher education levels were positively associated with better access to food. This

study succeeded in recognising the groups most vulnerable to these barriers

specifically, with a representative sample size of over 2,500 households. Although, the

use of closed questions exclusively may not paint the whole picture of a current

situation. For example, asking about the financial situation of a participant on one

occasion in the last 12 months (Burns et al., 2011) allows no chance for elaboration;

thus, it is difficult to differentiate between participants of which this happened once or

ten times. Based purely on ‘Yes’ or ‘No’ responses, assumptions were made to account

for any gaps in data, further compromising the accuracy of the results. It is

acknowledged that a qualitative approach would be challenging and time consuming

with such a large number of participants. However, this demonstrates the problem in

conducting this nature of research, sacrificing either depth/richness or

quantity/generalisability (Table 1), when a mixed methods approach is not adopted.

A more recent study explored the thoughts and feelings of 30 low income

women registered in a nutritional programme in West Virginia, living in a rural area

(Andress & Fitch, 2016). The inaccessible location of certain food shops and lack of

available transport to travel there were recognised as key problems for these

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participants, alongside the low quality and high cost of healthy food locally. Although

the study by Andress and Fitch (2016) and Bowyer et al. (2006) are based in different

countries, the findings cohere with each other and illustrate how the dimensions of

food access can apply in a range of low income settings. Data from focus groups is

anecdotal; a participant may claim they are ‘About a half an hour, 45 min just one

way’ (Andress & Fitch, 2016, p.152) to a food shop, although the accuracy of this claim

and thus the thematic analysis is not objectively certifiable. However, a further

American-based study by Freedman and Bell (2009) used a mixed methods approach

and found that participants’ subjective awareness of food access (including estimates

of distance) accurately reflected their situation. It would be incorrect to generalise this

finding across all studies. However, it does offer some support towards the reliability

and validity of conclusions drawn from qualitative food access data.

Hendrickson, Smith and Eikenberry (2006) also conducted focus groups to

compare rural and urban food access in Minnesota, alongside a food survey and

inventory. Low income areas were deemed as ‘food deserts’ if they contained 10 food

stores or less, as located using GIS mapping. It is worth noting this as a further example

of inconsistency when defining of ‘accessibility’ in GIS mapping, when comparing

measures and distances utilised on other studies (Bowyer et al., 2006; Donkin et al.,

2000; Freedman & Bell, 2009). As a whole, the study highlighted issues with

affordability of healthy food within the area. The majority of fruits and vegetables

stocked locally were significantly more expensive that those sold in chain

supermarkets, particularly in the urban areas. The opinion that local fruits and

vegetables lacked choice and quality was also present amongst the urban residents

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(Hendrickson et al., 2006). Hence, the long distance to shops that did sell quality

produce was reported as problematic, especially due to scarce availability of public

transport.

Dubowitz, Acevedo-Garcia, Lindsay, Subramanian, and Peterson (2007) also

used focus groups to look at food access and the experiences of low income mothers,

either immigrant or American-born, living in Massachusetts and Boston (Table 1).

Immigrant women reported better access and availability to food within America (in

comparison to the country they were born in). However, the low quality of available

food presented as a barrier across both groups, further supporting findings from other

related studies (Andress & Fitch, 2016; Bowyer et al., 2006; Hendrickson et al., 2006).

In addition, it was recognised that both groups struggled with balancing child care and

a busy family life with purchasing/preparing healthy food, in an environment with

restricted food access. Immigrant mothers tended to perceive the daily preparation of

food as a necessity, compared to American-mothers who generally perceived it as

optional. This addresses the issue of culture in not only effecting the foods purchased,

but also the values and thus eating behaviours of low income individuals (Bowyer et

al., 2006). With this, it could be inferred that American-born mothers would be more

susceptible to the negative effects of the local social dynamic, if they are less driven to

prepare food from scratch on a daily basis. The link between food preparation and

food security was explored by Engler-Stringer, Stringer and Haines (2011), who found

that low income, Canadian women that regularly prepared food from scratch had

higher food security than those who relied more heavily on pre-prepared foods. The

independent and dependent variable were not identified in this relationship. However,

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this study does offer insight into the mediating effect of cooking skills as a barrier, on

the relationship between local environment and an individual’s access to a healthy

diet.

The location of food sources and ability to travel to them is a theme that has

been present amongst all of the literature reviewed around food access so far.

However, it may be those additional factors such as family life (Dubowitz et al., 2007)

and cooking behaviour (Engler-Stringer et al., 2011) that are the driving factors behind

the environments influence on food access, thus diet quality. A recent study by

Dubowitz et al (2015) found the physical location of shops stocking healthy food, with

the ability to access them, as insignificant influencers on the weight/ diet quality of

participants (Table 1). Kirkpatrick and Tarasuk (2010) similarly found that although

affordability of healthy food is understandably an issue for low income families, access

to a healthy diet is not affected by the location of available food shops. Unlike other

studies reviewed (Andress & Fitch, 2016; Bowyer et al., 2006; Burns et al., 2011;

Hendrickson et al., 2006), access to, availability and affordability of fruit and vegetables

were all of little significance for low income participants in a study by Dibsdall et al.

(2002). Nearly half of the sample did not own or have access to a car, but still reported

being able to visit a supermarket weekly; not having a car was not considered to be a

major barrier to a healthy diet. The majority of participants did not perceive the price

of fruits and vegetables as a major barrier to purchasing them. It was only thought of

as an issue for those seeking employment (Dibsdall et al., 2002).

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High access and availability of unhealthy food

The increased availability and accessibility to unhealthy, convenience food is a

key barrier in accessing a healthy diet (Burns & Inglis, 2007). Using GIS mapping, Burns

and Inglis (2007) concluded that certain lower income, deprived areas within

Melbourne had a higher prevalence of fast food sources within reachable distance. The

study used time taken to travel to the fast food outlet as a measure, without

accounting for variation in transport or conditions when travelling (e.g. weather,

traffic); as such, the results are open to error (Burns & Inglis, 2007). Furthermore, it

was not explored whether increased exposure to fast food influences purchasing

behaviour. With this, a further study was conducted by Burns, Bentley, Thornton and

Kavanagh (2015), which found low income individuals in Melbourne, experiencing

barriers to food access, were more likely to purchase fast food. This is potentially

because of the perceived high cost of healthy food versus the perceived low cost of

available, unhealthy food, when shopping on a restricted budget (Ward et al. 2005). A

study based in the UK found low income areas within Glasgow to not have significantly

more fast food source; in fact, less deprived areas were found to have more access to

such outlets (Macintyre, McKay, Cummins, & Burns, 2005). Although this study is dated

and there is a great need for up-to-date research, it suggests again that location (this

time of unhealthy food) may be a significant barrier, but not necessarily the driving

one within the UK. It is acknowledged that Bowyer et al. (2006) noted mainly

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unhealthy food being stocked within the available corner shops in Hackney, as

opposed to fresh, good quality produce. As proposed by a study in America, lower

income individuals lacking access to a car for food shopping have no option but to shop

at the local convenience stores within walking distance, of which stock unhealthy food

e.g. chocolate bars, packets of crisps (D'Angelo, Suratkar, Song, Stauffer, & Gittelsohn,

2011). US-born mothers in the study by Dubowitz et al. (2007) had also expressed the

convenience of fast food/convenience food, when access to larger supermarkets

stocking healthier food is limited.

Psychological and motivational barriers to purchasing healthy, affordable food

As suggested by Kamphuis et al. (2007), there are psychological aspects that may

consequently influence the relationship between food access and the environments.

For example, Zachary, Palmer, Beckham, and Surkan (2013) set out to explain low

income consumer behaviour, based on the theory of ‘situated cognition’ (p.666) which

states that ‘actions are purposeful and context-dependent’ (p.666). In the context of

food access, this suggests that food purchasing behaviours depend on cues and

prompts within the surrounding environment. Combining data from qualitative

interviews and focus groups, it was found that participants had a good understanding

of health and nutrition and favoured eating healthy foods (Zachary et al., 2013).

However, the pressures of having to shop for their family acted as a barrier to these

thoughts being translated into actions, echoing the findings of Dubowitz et al. (2007).

Issues such as time constraints and strict budgeting led to participants evaluating the

price of food and amount needed until the next shop, against the healthiness of the

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food product. Quality of foods was also a key factor in the decision making process, as

local produce was reportedly inadequate, as found in other studies (Andress & Fitch;

Bowyer et al., 2006; Dubowitz et al., 2007; Hendrickson et al., 2006). There were some

limitations to the generalisability of these findings. For instance, results state an

‘indication’ (p.668) that participants are aware of healthy food and diet; however, no

objective measures of knowledge were taken in this study and therefore, it is difficult

to fully appreciate the true level of knowledge throughout the group interviewed

(personal definitions of what is ‘healthy’ may vary considerably) (Zachary et al., 2013).

These results contribute to understanding the psychological determinants of food

access and the thought processes behind food purchases, among low income

individuals.

In contrast, a UK-based study by Dibsdall et al. (2002) explored varying aspects

of food access, including attitudes and knowledge towards consuming a healthy diet.

The study consisted of 680 low income adults, registered with a social housing

association in East Anglia. The study occurred after recognising that even after

implementing methods to improve access/availability of healthy food in the UK,

(including addressing issues such as low cooking knowledge) the trend in low income

groups and low diet quality remained (Dibsdall et al., 2002). A questionnaire was

carried out via post, looking at perceptions of access/availability to, price of and

motivation to consume fruits and vegetables. Although this was not a reflection of the

true fruit and vegetable consumption, this was not the aim of the study. Results found

that the beliefs of participants as to what constitutes a healthy diet did seem not to

match the ‘Five-a-day’ fruit and vegetable guidance from the government (even

20

though participants were aware of these guidelines). Almost 75% of participants

believed they had a healthy diet, even though around 80% did not report consuming

the recommended number of portions. This again presents the issue of objectively

measuring a participant’s knowledge of health nutrition using this form of

methodology (Zachary et al., 2013), but also raised the question as to why participants

held this belief, whilst being aware of the official guidance. Dibsdall et al. (2002) put

forward the idea that guidance around healthy eating, such as the ‘Five-a-day’

campaign (National Health Service, 2015) could potentially be perceived as requiring

both effort and a reduction in preferable foods. As such, Dibsdall et al. (2002) felt

emphasising the consumption of additional fruit and vegetables at no extra effort or

cost would be beneficial.

In relying on participant effort to respond to questionnaires in the post,

response rates were less than a quarter of the target group contacted. It could be

assumed that the sample used was biased, in that those who did response may have

had at least some in interest in health/nutrition in the first instance (Dibsdall et al.,

2002). The financial incentive offered may negate this assumption. As low income

groups are associated with low education/literacy levels, Dibsdall et al. (2002) offered

this as a possible explanation for the low response rates, due to the requirement of

completing a questionnaire. This indicates a further barrier in effectively conducting

large food access studies in hard-to-reach areas, for low income groups.

Groups found to be particularly vulnerable in this study included single,

unemployed individuals, who felt it more difficult to reach and purchase fruit and

vegetables. This finding corresponds with the ‘single-parent’ group identified as

21

vulnerable by Burns et al. (2011). Those in the older age category, although associated

with the perception of a healthier diet, exhibited a lower willingness to change dietary

habits and patterns when necessary. The most vulnerable group identified, however,

were young males, who reported eating the lowest amount of fruit and vegetables and

were found to be the least likely to change their diets, to improve their health.

A study was also conducted at the same time as that of Dibsdall et al. (2002), to

explore the differences in psychological determinants of food access between genders

(Daborn et al., 2005). Daborn et al. (2005) recruited a sample of men exclusively, from

the same social housing association as Dibsdall et al. (2002). Similar to the findings of

Dibsdall et al. (2002), access to fruits and vegetables and the availability/cost of them,

although acknowledged, were not considered the key factors in influencing diet.

Psychological elements of self-efficacy, learnt experience of diet and the ‘it- is-never-

going-to happen-to-me’ approach to ill health, ultimately resulted in low motivation of

men to alter their diet where necessary. It is perhaps because of this that low income

men are more likely than women to develop non-communicable disease, as a result of

poor diet (Daborn et al., 2005), although the study was only able to interview 11 men.

Even as such a vulnerable target group, very little food access research includes male

participants; across all the studies listed in Table 1, all bar Daborn et al. (2005) include

either women only or a sample heavily dominated by female participants. For studies

in Table 1 stating mixed gender samples (Bowyer et al., 2006; D’Angelo et al., 2011;

Dibsdall et al., 2002; Dubowitz et al., 2015; Hendrickson et al., 2006; Withall, Jago, &

Cross, 2009; Zachary et al., 2013) the average percentage of male participants was only

24%. This may be due of factors such as the high likelihood of women being main food

22

shopper in a family household (Dibsdall et al., 2002), but subsequently results in men

being critically under-represented in food access studies.

The most recent UK-based study identified was that from Withall et al. (2009),

in which both medical professionals and non-medical residents of a low income

neighbourhood were interviewed, concerning their thoughts about access to healthy

food. Unlike the themes drawn by Dibsdall et al. (2002), Withall et al. (2009) found the

high cost of healthy food to be problematic for mothers, due to them living on financial

benefits. There was only one male participant within the sample, presumably due to

recruiting via baby/toddler groups (Withall et al., 2009).

Key themes identified here match those found among low income males, by

Daborn et al. (2005). For example, self-efficacy was a crucial issue for the residents,

whose beliefs about the finality of family genetics led to low perceived control over

body weight and thus a lack of motivation to eat a healthy diet. Emulating the findings

of Dubowitz et al. (2007) and Zachary et al. (2013), having children and a busy family

life was reportedly challenging when trying to engage in in healthy eating behaviours.

Health professionals also highlighted the issue of psychological illness (e.g. depression)

in effecting residents’ attitudes and motivation towards a healthy diet in the area,

reflected in the residents mention eating as a coping mechanism for stress (Withall et

al., 2009).

In conclusion, it is clear from reviewing a large sample of research that the

barriers to accessing a healthy, affordable diet for low income individuals are complex

and still not well understood. As current research within the UK is rare, understanding

the relationship in this setting specifically proves even more challenging.

23

One aim of this literature review was to make suggestions to reduce potential

barriers in food access and identify areas for future study. First and foremost, the low

availability of healthy, affordable food across a variety of low income areas has

emerged as a key barrier to accessing a healthy diet (Andress & Fitch, 2016; Bowyer et

al., 2006; Kamphius et al., 2007). Emphasis has been placed on the low quality of

heathy food available locally (Andress & Fitch, 2016) and as such, addressing this issue

in itself may improve the situation for a proportion of low income residents. Ensuring

that local foods sources are not dominated by unhealthy, convenience foods may help

reduce the negative consequences that come from high exposure to unhealthy foods.

For those with a busy family life needing to stay close by for food shopping, it could be

assumed that having high quality fruit and vegetables locally, for example, would

improve their situation considerably.

Going beyond these physical barriers to food access, there appear to also be

underlying psychological issues, exacerbating the negative effects of physical access on

the diet of low income individuals (as suggested by Kamphius et al., 2007). Aspects

such as low perceived behavioural control and low motivation to change behaviour can

be just as, if not more so, damaging to dietary habits than the access to and availability

of the actual food itself. Although Dibsdall et al. (2002) had suggested improvements in

adapting healthy eating guidance around these psychological barriers, the study was

conducted over 14 years ago and as such, it is unlikely to be an accurate reflection of

the current mode of thinking in this target group. Improvements in the psychological

appeal of guidance and support offered around healthy eating opens an additional

area for further study. Recruiting from the groups identified as most vulnerable to

24

both physical and psychological barriers (i.e. ethnic minorities, single parents, men and

the elderly) would be particularly justified.

In addition to suggesting improvements, this literature review also aimed to

look outside the UK, to better comprehend the situation within it. Studies based in

demographically similar countries (i.e. Australia, Canada and America) have found

similar barriers to those five studies (Table 1) based within the UK. However, this

review has also revealed a number of differences, regarding both physical and

psychological barriers to food access, even in just these small number of studies. As

much as the research outside of the UK provides insight and knowledge, it cannot be

assumed that these explanations account for the relationship between food access and

low income groups within the UK. As the potentially fatal consequences of poor diet

continue to effect a variety of low income individuals within the UK, is it of growing

importance to increase the evidence pool within the country in itself. The bulk of

relevant research is dated and there is a fundamental need for further, up-to-date

studies. This will help to better understand barriers to healthy food access relevant in

the UK social dynamic and as such, better inform public health policy to combat it.

25

References

Andress, L., & Fitch, C. (2016). Juggling the five dimensions of food access: Perceptions

of rural low income residents. Appetite, 105, 151-155.

Doi:10.1016/j.appet.2016.05.013

Bowyer, S., Caraher, M., Duane, T., & Carr-Hill, R. (2006). Shopping for food: accessing

healthy affordable food in three areas of Hackney. City University, London.

Burns, C., Bentley, R., Thornton, L., & Kavanagh, A. (2011). Reduced food access due to

a lack of money, inability to lift and lack of access to a car for food shopping: a

multilevel study in Melbourne, Victoria. Public Health Nutrition, 14(6), 1017-

1023. http://dx.doi.org.voyager.chester.ac.uk/10.1017/S136898001000385X

Burns, C., Bentley, R., Thornton, L., & Kavanagh, A. (2015). Associations between the

purchase of healthy and fast foods and restrictions to food access: a cross-

sectional study in Melbourne, Australia. Public Health Nutrition, 18(1), 143-150.

http://dx.doi.org.voyager.chester.ac.uk/10.1017/S1368980013002796

Burns, C. M., & Inglis, A. D. (2007). Measuring food access in Melbourne: Access to

healthy and fast foods by car, bus and foot in an urban municipality in

26

Melbourne. Health & Place, 13(4), 877–885.

Doi:10.1016/j.healthplace.2007.02.005

Cummins, S., & Macintyre, S. (2002). “Food deserts”—evidence and assumption in

health policy making. BMJ, 325(7361), 436–438. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1123946/?tool=pmcentrez

Cummins, S., & Macintyre, S. (2006). Review: Food environments and obesity—

neighbourhood or nation? International Journal of Epidemiology, 35, 100-104.

Doi:10.1093/ije/dyi276

Daborn, C., Dibsdall, L., & Lambert, N. (2005). Understanding the food related

experiences and beliefs of a specific group of low income men in the UK. Health

Education, 105(2), 109-125. http://dx.doi.org/10.1108/09654280510584562

D'Angelo, H., Suratkar, S., Song, H., Stauffer, E., & Gittelsohn, J. (2011). Access to food

source and food source use are associated with healthy and unhealthy food-

purchasing behaviours among low income African-American adults in Baltimore

City. Public Health Nutrition, 14(9), 1632-1639.

http://dx.doi.org.voyager.chester.ac.uk/10.1017/S1368980011000498

Dibsdall, L. A., Lambert, N., Bobbin, R.F., & Frewer, L. J. (2002). Low income consumers’

attitudes and behaviour towards access, availability and motivation to eat fruit

and vegetables. Public Health Nutrition, 6(2), 159–168.

http://dx.doi.org/10.1079/PHN2002412

Donkin, A. J. M., Dowler, E. A., Stevenson, S. J., & Turner, S. A. (2000). Mapping access

to food in a deprived area: the development of price and availability indices.

27

Public Health Nutrition, 3(1), 31-38.

http://dx.doi.org.voyager.chester.ac.uk/10.1017/S1368980000000057

Dubowitz, T., Acevedo-Garcia, D., Salkeld, J., Lindsay, A. C., Subramanian, S. V., &

Peterson, K. E. (2007). Lifecourse, immigrant status and acculturation in food

purchasing and preparation among low income mothers. Public Health

Nutrition, 10(4), 396-404.

http://dx.doi.org.voyager.chester.ac.uk/10.1017/S1368980007334058

Dubowitz, T., Zenk, S. N., Ghosh-Dastidar, B., Cohen, D. A., Beckman, R., Hunter, G. …

Collins, R. L. (2015). Healthy food access for urban food desert residents:

examination of the food environment, food purchasing practices, diet and BMI.

Public Health Nutrition, 18(12), 2220-2230.

http://dx.doi.org.voyager.chester.ac.uk/10.1017/S1368980014002742

Engler-Stringer, R., Stringer, B., & Haines, T. (2011). Complexity of food preparation

and food security status: In low income young women. Canadian Journal of

Dietetic Practice and Research, 72(3), 133-136. Retrieved from

http://search.proquest.com.voyager.chester.ac.uk/docview/904385827?

accountid=14620

Food Standards Agency. (2007). Low income diet and nutrition survey: summary of key

findings. Retrieved from

http://tna.europarchive.org/20110116113217/http://www.food.gov.uk/

multimedia/pdfs/lidnssummary.pdf

28

Freedman, D. A., & Bell, B. A. (2009). Access to healthful foods among an urban food

insecure population: perceptions versus reality. Journal of Urban Health, 86(6),

825–838. http://doi.org/10.1007/s11524-009-9408-x

Griffith, R., O’Connell, M., & Smith, K. (2013). Food expenditure and nutritional quality

over the Great Recession. Retrieved from http://www.ifs.org.uk/bns/bn143.pdf

Hendrickson, D., Smith, C., & Eikenberry, N. (2006). Fruit and vegetable access in four

low income food deserts communities in Minnesota. Agriculture and Human

Values, 23(3), 371-383.

http://dx.doi.org.voyager.chester.ac.uk/10.1007/s10460-006-9002-8

Kamphuis, C. B. M., Lenthe, F. J. V., Giskes, K., Brug, J., & Mackenback, J. P. (2007).

Perceived environmental determinants of physical activity and fruit and

vegetable consumption among high and low socioeconomic groups in the

Netherlands. Health & Place, 13(2), 493-503.

Doi:10.1016/j.healthplace.2006.05.008

Kirkpatrick, S. I., & Tarasuk, V. (2010). Assessing the relevance of neighbourhood

characteristics to the household food security of low income Toronto families.

Public Health Nutrition, 13(7), 1139-1148.

http://dx.doi.org.voyager.chester.ac.uk/10.1017/S1368980010000339

Macintyre, S., McKay, L., Cummins, S., & Burns, C. (2005). Out-of-home food outlets

and area deprivation: case study in Glasgow, UK. International Journal of

Behavioral Nutrition and Physical Activity, 2(16). Doi: 10.1186/1479-5868-2-16

National Health Service. (2015). Why 5 A DAY? Retrieved from

http://www.nhs.uk/Livewell/5ADAY/Pages/Why5ADAY.aspx

29

Powell, L.M., Slater, S., Mirtcheva, D., Bao, Y., & Chaloupkaa, F. J. (2007). Food store

availability and neighbourhood characteristics in the United States. Preventive

Medicine, 44(3), 189-195. Retrieved from

http://www.sciencedirect.com.voyager.chester.ac.uk/science/article/pii/

S0091743506003343

Public Health England. (2014). National diet and nutrition survey: results from years 1-

4 (combined) of the Rolling Programme (2008/2009 – 2011/12): Executive

summary. Retrieved from

https://www.gov.uk/government/uploads/system/uploads/attachment_data/

file/310997/NDNS_Y1_to_4_UK_report_Executive_summary.pdf

Public Health England. (2016). The eatwell guide booklet. Retrieved from

https://www.gov.uk/government/publications/the-eatwell-guide

Scientific Advisory Committee on Nutrition. (2011). Dietary reference values for energy.

Retrieved from

https://www.gov.uk/government/uploads/system/uploads/attachment_data/

file/339317/SACN_Dietary_Reference_Values_for_Energy.pdf

Tombarge, J. (1999). Using management software for geographic information systems

(GIS). The Bottom Line, 12(4), 146-149. Retrieved from

http://search.proquest.com.voyager.chester.ac.uk/docview/219155522?

accountid=14620

Ward, P. R., Verity, F., Carter, P., Tsourtos, G., Coveney, J., & Wong, K. C. (2013). Food

stress in Adelaide: the relationship between low income and the affordability of

30

healthy food. Journal of Environmental and Public Health, 968078.

http://doi.org/10.1155/2013/968078

Winkler, E., Turrell, G., & Patterson, C. (2006). Does living in a disadvantaged area

entail limited opportunities to purchase fresh fruit and vegetables in terms of

price, availability, and variety? Findings from the Brisbane Food Study. Health

& Place, 12(4), 741-748. Doi:10.1016/j.healthplace.2005.09.006

Withall, J., Jago, R., & Cross, J. (2009). Families’ and health professionals’ perceptions

of influences on diet, activity and obesity in a low income community. Health &

Place, 15(4), 1078-1085. Doi:10.1016/j.healthplace.2009.05.006

Zachary, D. A., Palmer, A. M., Beckham, S. W., & Surkan, P. J. (2013). A Framework for

understanding grocery purchasing in a low income urban environment.

Qualitative Health Research, 23(5), 665-678. Doi: 10.1177/1049732313479451

31

‘And they wonder why Halton’s got issues!’ Focus groups exploring and comparing

barriers to accessing healthy and affordable foods, for parents with children under

the age of five years, in Runcorn and Widnes (Halton)

Key words:

Food access Low incomeAvailability Affordability

Word count: 4,395

32

Rational for targeted journal

Chosen journal: Public Health Nutrition (PHN)

Rationale: Topics that ‘identify and analyse behavioural, sociocultural, economic,

political and environmental determinants of nutrition-related public health’ (para. 2)

are of interest to the journal (“Instructions for contributors”, 2016). This current

research explores and evaluates the barriers to accessing healthy, affordable food and

a healthy diet, including financial, social and environmental factors within this. As such,

it ultimately fulfils this criteria. The current research also touches upon other topics

concerning PHN, such as contributing to the pool of knowledge surrounding the

communication of nutritional public health messages and exploring the efficiency of

relevant policies (with regards to both of these acting as a potential barrier to

accessing a healthy diet).

33

Abstract:

Objective: To explore, compare and suggest improvements for the barriers to accessing

healthy and affordable foods, for parents living in areas of high deprivation.

Design: Semi-structured focus groups were conducted with all participants, to discuss

any barriers they had experienced. Focus groups were audio recorded and lasted

approximately 1 hour. Transcripts were written verbatim and common themes were

formulated, using thematic analysis, to identify the key barriers for participants.

Setting: Two low income areas within Halton, UK; Windmill Hill (Runcorn) and Hough

Green (Widnes).

Subjects: 13 mothers with at least one child under the age of five years old (average

age of 32 years). The majority of subjects were unemployed and held a full UK-driving

licence.

Results: Four key themes and two sub-themes were identified: (1) ‘High cost to access

healthy food locally (with the sub-theme ‘Short-shelf life of healthy food locally’); (2)

‘Children and family situation’ (with the sub-theme ’Access to budget shops’); (3)

‘Dominance of unhealthy food vs healthy food’ and (4) ‘Inadequate support/guidance

with healthy diet’. These applied to both areas, with few differences between the

localities noted within themes, of which are discussed.

Conclusions: The main findings suggest that this sample of parents within Halton do

experience barriers to accessing healthy, affordable food and thus are at risk of the

consequences of poor nutrition. Understanding these barriers will help counteract this

risk, in that recommendations can be made to inform relevant public health policy and

improve the situation for Halton residents.

34

Introduction

Consuming a diet lacking in nutrients essential for health is strongly associated

with developing non-communicable disease, such as cancer and stroke (National

Health Service, 2016a). If a diet is high in fat and sugar, this can lead to obesity and a

variety of associated health risks (National Health Service, 2016b). As such, guidelines

are provided for the correct proportions in which to consume different nutrients

(Scientific Advisory Committee on Nutrition, 2011). Failure to meet these

recommendations is amplified most amongst individuals with a low income (Food

Standards Agency, 2007; Public Health England, 2014). On average, low income groups

are consuming around half of the amount of fruits and vegetables recommended, with

a small percentage consuming less than one portion per day (Food Standards Agency,

2007). These groups also report eating more sugary foods than the population as a

whole (Food Standards Agency, 2007).

Halton is classed as area of low income and is one of the most deprived areas in

the country (Department for Communities and Local Government, 2015). A recent

Needs Assessment of Halton echoed the national trend regarding low income groups

and nutrition (Halton Borough Council, 2015), finding approximately 35% of adults in

the obese category, (over 10% higher than the national average) (Health and Social

Care Information Centre, 2015).

The concept of limited food access (Bowyer, Caraher, Duane, & Carr-Hill, 2006)

offers an explanation for the relationship between low income areas and poor diet.

Food access refers to a number of elements that can impact on the ability to purchase

healthy food (Bowyer et al., 2006), such as cost, access to food sources, the availability

35

of food and the appropriateness of this food for an individual’s needs and preferences.

Other influencers of food access include the quality of available food and the

psychological/social processes behind purchasing it (Andress & Fitch, 2016; Bowyer et

al., 2006; Kamphuis, Lenthe, Giskes, Brug, & Mackenback, 2007). A study in America

concluded that low income families unable to access any other food source easily,

besides their local corner shop, were less likely to be of healthy weight and purchase

healthy food products (D'Angelo, Suratkar, Song, Stauffer, & Gittelsohn, 2011). Ward et

al. (2013) also highlighted the difficulties faced by low income families in Australia,

when having to budget for healthy foods alongside other costs of living. The issue of

low income groups having to spend a higher proportion of income on food, compared

to the rest of the country, has also been identified in the UK (Department for

Environment Food & Rural Affairs, 2014) which may have worsened since the

introduction of a stricter government budget in 2015 (Griffith, O’Connell, & Smith,

2013). Aside from the material and physical aspects to food access, the mental

attitudes of low income groups towards eating healthy food could also potentially be a

key barrier to a healthy diet (Dibsdall, Lambert, Bobbin, & Frewer, 2002).

Comprehending the relationship between low income groups and diet is

seemingly complex. An understanding of the barriers towards accessing healthy,

affordable food in Halton specifically is vital, in order to distinguish ways to improve

the situation and ultimately the health status of the area. This is especially important

in the cohorts considered most vulnerable, such as family households with young

children (under the age of five years), of which the nutritional quality of foods

purchased has declined in recent years (Griffith et al., 2013). As such, Objective 1 of

36

this research is to explore the barriers to accessing healthy and affordable foods within

this demographic, within Halton. The study will explore two different areas of Halton;

Windmill Hill in Runcorn and Hough Green in Widnes (Halton Borough Council, 2015).

Objective 2 is to compare and contrast the barriers identified within each of the

locations. Hough Green is classed as on par with the average statistics for Halton,

whereas Windmill Hill is classed as one of the most deprived areas in the local

authority (Halton Borough Council, 2015). Allowing for comparison will help recognise

any aspects that need to be considered when informing future public health policy

across the whole locality. Objective 3 is to inform public health policy by exploring

ways in which any situations could be improved.

37

Method

Recruitment

Participants were recruited using purposive convenience sampling (Collins,

Onwuegbuzie, & Jiao, 2006) based on a set of inclusion/exclusion criteria (Figure 1).

The researcher recruited participants by attending six activity sessions in Windmill Hill

Children’s Centre (Runcorn) and All Saints Upton C of E Children’s Centre (Widnes).

This allowed the researcher a chance to meet potential participants, promote the

research, answer any questions and distribute the participant information sheets

(Appendix 2) and consent forms (Appendix 3). This was reinforced by posters

displayed throughout the centres (Appendix 4) and a post on the children’s centre

Facebook page. A crèche was also pre-booked for the dates and times of the focus

groups, to ensure childcare was not a barrier to participant recruitment.

38

Figure 1. A diagram summarising the stages of participant recruitment in Runcorn and

Widnes

Sample

The final sample consisted of all women with at least one child under the age of five

years. All parents recruited within Runcorn had a postcode within the Windmill Hill

area and parents recruited in Widnes had a postcode within the Hough Green area.

The focus groups were held on different days throughout May/June (2016). A total of

13 participants attended (Figure 2).

39

Two focus groups – All Saints Upton C of E Children’s Centre, Widnes

Two focus groups – Windmill Hill Children’s Centre, Runcorn

Consent Form with Demographic Questionnaire

(Age and employment status)

Inclusion criteria: Individuals with at least one child under the age of five

years AND have local postcode(Exclude non-English speaking

residents)

Recruit purposive convenience sample across six activity sessions: (Maximum of 10 parents per focus

group)

Figure 2. A diagram showing the number of participants originally recruited and the

final number of participants that attended each focus group

Measurement Procedures

The primary researcher facilitated two focus groups within both of the children’s

centres (Appendix 5). A secondary researcher was present to note when there was

change in speaker, any key mannerisms and to audio record each of the sessions. The

average duration of the focus group was one hour for the Runcorn groups and 40

minutes for the Widnes groups. Upon completion of the focus group, each participant

was issued with a £10 ASDA food voucher.

40

Focus Groups

The four focus groups were semi-structured, comprising of five open-ended questions

and a variety of verbal prompts (Appendix 6). The primary researcher identified the

research by Bowyer et al. (2006) as one of the most recent and relevant UK-based

studies. As such, the questions were based around the five dimensions of food access

as outlined by Bowyer et al (2006), whilst offering participants the chance to add any

additional thoughts and ideas around these questions, within the focus groups.

Analysis of focus groups

Each of the four audio recordings were transcribed verbatim and reviewed by the

researcher to achieve a basic understanding of the content. Each participant was also

given one week to read their group transcript before analysis and all participants that

replied reported no inaccuracies or desire to withdraw their data. The transcripts were

inductively coded utilising the stages of thematic analysis (Braun & Clarke, 2006).

Firstly, they were coded for both barriers and enablers to a healthy diet, to better

appreciate the situation of each participant with regards to healthy food access. This

worked as an elimination criteria for certain codes, with regards to their overall impact

on the diet of the participant/group. For the purpose of this research, the coded

barriers only were extracted from this (Appendix 7) and spider diagrams grouping

these codes were produced for both Runcorn and Widnes (Appendix 8). Themes were

then identified from this for each locality, before a final set of common themes was

formulated.

41

Results

Sample

All participants were female (n=13) with an average age of 28 years. The employment

status of the participants varied, with the majority (54%) reporting unemployment.

Table 1. Demographic characteristics of participants (n=13).

42

Demographic characteristic n %

Runcorn Widnes

Gender

Male 0 0 0

Female 9 4 100

Mean age (years) 32 32

Employment

Unemployed

4 3 54

Part-time 2 1 23

Full-time 3 0 23

Driving Licence

Yes 7 2 69

No 2 2 31

Focus Groups

Within both Runcorn and Widnes, four main themes were identified by the researcher

during analysis: (1) ‘High cost to access healthy food locally’ (with the sub-theme

‘Short-shelf life of healthy food locally’); (2) ‘Children and family situation’ (with the

sub-theme ’Access to budget shops’); (3) ‘Dominance of unhealthy food vs healthy

food’ and (4) ‘Inadequate support/guidance with healthy diet’. Each theme is outlined

in relation to its status as a key barrier, with a comparison between Runcorn and

Widnes (Objective 1 and 2).

Theme 1: High cost to access healthy food locally

In both Runcorn and Widnes, the high cost of healthy food available in the local area

was considered a key barrier to purchasing it. The agreement that Co-operative

supermarket is one of the only food shops available locally, but also one of the most

expensive, was more prominent among the Runcorn focus groups. The low socio-

economic status of Runcorn was identified by the parents in these groups. Participant

2 (P.2) felt very passionate about their needs not being met:

P.2: ‘I mean, you know, there’s a big area where it doesn’t have any shops round here…

Co-op, I mean it shouldn’t be a Co-op because I think Co-op is expensive…’

The option of using online supermarket delivery services to counteract this was

explored by each group, however, perceived expense acted as the key barrier to

accessing healthy food in this way (Table 2).

43

This issue of crowded food banks was additionally brought up in the first Runcorn

group:

P.2: ‘…they (the food banks) are really really busy. Really busy…’

Widnes also found the high cost of healthy food locally to be a barrier to purchasing it.

One parent seemed to feel defeated whilst explaining the situation for her and her

family:

P.13: ‘…you can spend like ten pound on just getting like, chicken breast and some,

some veg and stuff and fruit in the house… or you can go to like, McDonalds for like a

couple…a few quid can’t you, so…you obviously end up having stuff left over, but then

it’s like…are you always gonna have time to re-use the stuff that you’ve got left over?

…’

This comment, alongside those made regarding the local fresh fruit and

vegetables going off quickly across both areas, led to the code ‘Short shelf-life of

healthy food locally’ (Table 2) being included as a sub-theme. Parents were having to

consider the cost of fresh food in comparison to the food, thus the money, which

might be wasted if they do not have time to use it.

44

Table 2. Codes and sample data for ‘High cost to access healthy food locally’

Code Example Quotes

Low affordability of healthy food locally

Runcorn: P.3: ‘…as we were saying it’s all like local Co-ops everywhere and most people can’t afford to use them…’

Widnes: P.12: ‘…even if you just go to the local Co-op on, (street name) there (points to the road)…it’s, it’s dear to go in there…(Researcher: Okay)…to, to get anything…’

High cost of online orders

Runcorn: P.3: ‘…I started using ASDA and Iceland delivery, but it’s so expensive…you have to reach a certain amount and I was just buying crap…

Widnes: P.12: ‘…I mean, ASDA do deliver online, but, they charge extra, for the delivery…’

Sub-theme: Short-shelf life of healthy food locally

Runcorn: P.7: ‘…But then, it all goes off before you get time, to, use it all…’

Widnes P.6: ‘…no matter where you go, after a couple of days…everything goes off…’

Even with this, it was acknowledged that affordability and shelf-life are not as much of

an issue with the introduction of budget shops such as Aldi:

45

P.12: ‘There’s only Aldi that’s really cheap for the fruit and veg…you can get like…

umm…a punnet of strawberries…for a pound in Aldi…but you can go elsewhere and

you can pay like two pounds, two pound fifty for a small box of strawberries’

P.6: ‘For fruit and veg, I go to Aldi because it keeps the longest…’

Theme 2: Children and family situation

The family situation of each parent was found to impact, at least in some way,

on their ability to cook healthy food from scratch, purchase healthy food at an

affordable price and consume healthy food within the family home. Parents in both

Runcorn and Widnes reported prioritising the health of their children, but certain

parents expressed the convenience of unhealthy foods as an alternative to cooking,

when the majority of their time is allocated to child care (Table 3). For example, a

parent in Runcorn stated:

P.3: ‘I can’t really cook as well as I used to, because of the little one, ‘cause he’s

just a whirl wind, ‘cause I literally just have to get into the kitchen and get out…’

Participants also stated that having a family made it more difficult to make time for

and attend groups aimed at healthy eating and weight loss, within the local community

(Table 3) .

A strong feeling of anger and frustration towards limited access to budget

shops meant this was identified as a sub-theme (Table 3). This was particularly for

parents that did not have a driving licence, as expressed by P.12 from Widnes:

46

P.12:‘…it’s getting to the supermarket…I will admit, sometimes I have just brought

microwave meals for convenience…even fed my daughter them and…I don’t think that I

should have to do that…I prefer the fresh fruit and veg, but, it’s getting to…get it…’

Although it was claimed that the local bus service is frequent and stops near to the

available budget food shops, parents found great difficulty in utilising it, due to the

limited pram space and high cost of paying for themselves and the children.

Annoyance towards the limited child parking spaces around the budget shops was also

expressed by those parents with a driving license. In Runcorn, for example, P.8 stated

the difficulty when shopping with a car and baby:

P.8: ‘Because its baby space, it’s only got one baby space… ‘

All parents stated or agreed with the difficulty in carrying large numbers of bags back

to the car/back home on the bus, due to the location of such shops. One parent within

Widnes stated:

P.7: ‘…cause then you’ve got to walk all the way out of the (Shopping City) to get out of

it, to get to the car, with all your, twenty bags…’

Table 3. Codes and sample data for ‘Children and family situation’

Code Example Quotes

Family situation (convenience)

Runcorn: P.1: ‘…Sometimes we sit at different times for meals and I prefer mine when she’s (child) in bed…and then I’ll have, like the wrong thing…’

Widnes: P.13: ‘…it’s more convenient to go to like, McDonalds…just to pick something up for yourself…especially when you got a baby and you…need to, be quick and, in between feeds and everything…’

P.12: ‘…I’d rather eat a healthy meal, but, when you’re so busy, it’s just more convenient to order fast food…’

47

Limited access to diet support groups

Runcorn:

Widnes:

P.10: ‘…when you’ve got a baby, your restricted in what you can do…’

P.13: ‘…it’s in the morning, which is fine…but, if it’s in between the feeds, it’s not as easy for me to get to...’

Sub-theme (and codes)–Access to budget shopsLocation of shops

Runcorn: P.3: ‘…they have a lot of shops in the shopping city, like B & M, or Sainsbury’s, anywhere will do anything you need, but as you say, it’s just getting up there…’

Widnes: P.12: ‘…it’s inconvenient for me ‘cause it’s on the main road and then again, it’s getting across the main road…’

Low convenience of public transport (with family)/lack of car

Runcorn: P.3: ‘…you don’t want to get on it (the bus) around 5pm, ‘cause you’ll never get on it…I remember when I didn’t have my car… I had to wait, ‘til the fourth bus (all nod), I was just standing there for like an hour because we just couldn’t get on it…because I had the baby in the pram as well’…’and you’re only allowed two prams on’

Widnes: P.12: ‘…umm, me, no, I have to go into town…I shop…but it’s like getting the bus with a three year old and the pram…and all the bags, getting them back home…and, it’s quite…inconvenient…’

P.12:‘…it is actually easier to go into town but then, it’s not if you’ve got a pram’

Low affordability of public transport (with family)

Runcorn: P.4: ‘…for me to take (name of child), don’t pay for the baby, but, for me to take (name of child), it’s six pounds (other participants gasp) for us to go, to the city…’

Widnes: P.5: ‘…No, I know…it’s four pounds for a weekly…a daily ticket, which you can use all day, or its two fifty, this is into Widnes…its two fifty one way…so you pay, you pay five pound…to get there and back if you didn’t buy the weekly ticket…’

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Theme 3: Dominance of unhealthy food vs healthy food

A high prevalence and ease of access to unhealthy food was identified, particularly in

comparison to the lack of healthy food available (Table 4).

Table 4. Codes and sample data for ‘Dominance of unhealthy food vs healthy food’Code Example Quotes

Low availability of healthy food locally

Runcorn: P.3:’…I would go to Co-op…occasionally they have cheap vegetables and fruits in, but they don’t have a lot, when you go in there, most have them have gone’

Widnes: P.5:’…Fruit and veg shops, they’re…they’re like scarce now, aren’t they, really?’

Low quality of local healthy food

Widnes: P.5: ‘…There you go! (laughs)…that’s my thing…they buy stuff, but, it’s been there since I was a kid, I think…’

P.5:‘…and like the door’s open and when I went in (to the local butchers) there were flies in there…’

High availability of unhealthy foods Runcorn: P.3: ‘That is one thing Runcorn is good for, fast food places…there’s

loads…’

Widnes: P.6: ‘There’s all kinds of takeaways in Widnes…pizza places, Chinese…’

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Affordability of unhealthy food

Runcorn: P.1: ‘I got a pizza…its twenty five pence, so I went back to get another four (laughs)…’

Widnes: P.13: ‘You can just go to the local shop and buy, like, chocolate…for…cheap…’

High access to unhealthy food

Runcorn: P.8: ‘It’s far too easy…(ordering take-away)’

Widnes: P.12: ‘I’d rather eat a healthy meal, but, when you’re so busy, it’s just more convenient to order fast food…’

Preference/family preference for unhealthy food

Runcorn: P.9: ‘…pretty much every Saturday night we’ll be at the chippy, or, KFC or something…’

Widnes: P.13: ‘dry…cashew nuts, or, something like that (laughs), so you know what I mean…but yeah, erm, you don’t get, you don’t like, enjoy it as much, like, I’ll find if you eat it, you’ll eat more, you’ll think, ‘oh, I don’t like this, I’ll have that packet of crisps anyway’

The low quality of local healthy food was discussed in the Widnes groups specifically,

(Table 4) regarding the fresh fruit, vegetables and meat available.

Two parents in the second Widnes groups summarised their perspective of how the

increase in unhealthy, convenience foods is acting a key barrier to accessing a healthy

diet:

P.13: ‘it is obviously access and everything else, as well, but, I think that’s a big thing…

we’ve gotten lazy as we’ve…as we’ve gotten older, sort of thing…’

P.12: ‘Yeah, it is, I think it’s…lifestyle change…with all the obesity and stuff like that, in

children…because of the fast food, convenience…’

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Theme 4: Inadequate support/guidance with healthy diet

Each parent demonstrated at least some understanding towards the components of a

healthy diet (e.g. the consumption of fruits and vegetables) without any prompts from

the researcher. A parent from Runcorn, for example, expressed knowledge of added

sugar within certain food products:

P.8: ‘I think there’s a lot of things that…people think…are healthy and good for you that

aren’t…even things that are low fat…they’re full of sugar’

However, concern towards the lack of sufficient support provided and the ambiguity of

certain healthy eating messages/guidance was identified by the researcher as the final

theme (Table 5).

Each group could name at least one service targeting health and/or well-being

within the local area. However, the low quality of certain services attended and the

high financial cost of subscribing to available diet support groups were highlighted as

problematic. Parents in both Runcorn and Widnes further agreed that local services

providing appropriate support and guidance towards healthy eating were scarce.

Code Example Quotes

Limited guidance around healthy food/diet from schools

Runcorn: P.2: ‘We went…to the children going to reception meeting last night and they were talking about this (packed lunch boxes)…I think the rules are quite contradictory…’

Widnes: P.5:’…(name of child) has brought, like, letters home from school, recently, talking about healthy eating…and things…but that’s just to say that he’s been taught that…not like, telling me about it…’

Limited guidance around healthy food/diet in local area

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Runcorn: P.3: ‘…even if they do have a couple of cooking stuff, it’s not promoted…’

Widnes: P.13: ‘…no one’s put their hand out to say, you know ‘if you need any help, or support with this, this is where you’d come…’

Low quality of sessions available:

Runcorn: P.1: ‘…they gave us like these tins to put it in and by the time you took it home it was all sloppy…’

Widnes: P.12: ‘…Just…with it being a very small room as well, you do feel a bit, claustrophobic…’

Confused guidance around healthy food/diet in media

Runcorn: P.8: ‘I think that’s what it is, and like, how people put up with, all these different, they’re on about five-a-day and all of a sudden it was supposed to be seven-a-day?’

P.7: ‘…you just don’t know what you should be having and what you shouldn’t…’

Low affordability of available weight loss groups

Runcorn: P.10: ‘Yeah, everything you gotta pay for…when you go to Slimming World you’ve got to pay subscription haven’t you’

Widnes: P.12: ‘there’s like, plenty of them, knocking around Widnes…but then you’ve got to pay, like, so much…(weight loss groups)’

Table 5. Codes and sample data for ‘Inadequate guidance/support with healthy diet’

Parents within the Runcorn focus group also expressed confusion around certain public

health advice:

P.11: ‘For me, it, there are just so many mixed messages about what’s good for you,

and what’s the right things to eat and the wrong things…it’s always changing…’

A conversation between P.11 and P.9 within this group demonstrated the thought

pattern that may result from such confusion and the negative impact this could have

on diet quality:

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P.11: ‘…But they say five-a-day, but if you ate five pieces of fruit, that wouldn’t be

particularly good for you because, it’s too much sugar…’

P.9: ‘You might as well just go takeaway (lots of laughter)’

Objective 3: Suggested Improvements

The parents within Runcorn felt that replacing the current local shops with budget

food shops would improve the situation of high cost, short shelf-life and limited access

described across Theme 1, 2 and 3.

P.2: ‘we just need the budget places around here I think…’

The parents within Widnes further suggested ideas regarding the location of food

shops stocking healthy produce:

P.5: ‘er, like more fresh fruit and veg shops…like dotted around’

P.13: ‘...I think, the supermarkets in town are very clustered…and I think it would be

better if they were more sporadic…’

Parents from Runcorn and Widnes had similar ideas towards improving the situation

described in Theme 4:

Runcorn:

P.10: ‘ like, ideas on recipes…like, little cards…you could pick up from places…so if

you’ve got like ideas and recipes, you haven’t got to think about it… even here, or the

doctors or, wherever it is, just that more promotion about it’

Widnes:

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P.13: ‘they should have like recipe cards…just so then you like know…what to and…how

to’…

One parent within Runcorn also suggested that a course targeting both cooking and

budgeting skills could be provided in the local area:

P.11: ‘It would be nice if you could go somewhere and do like a little bit of a course or

something…I heard someone talk about cooking on a budget… I’d be interested in

that…’

Discussion

The current research did identify barriers to accessing healthy, affordable food

for participants within both Runcorn and Widnes (Objective 1). These barriers were

consistent across both localities, although some differences between the areas were

identified (Objective 2). Different suggestions about ways to improve food access

within each area were made (Objective 3). The main findings translated into four key

themes and two sub-themes.

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Theme 1: High cost to access healthy food locally

Theme 1 refers to the perceived financial cost of healthy food in Halton,

particularly from local food sources. This finding supports the concept of affordability

as a key component within food access, for low income groups (Andress & Fitch, 2016;

Bowyer et al, 2006; Kamphuis et al., 2007). A study in America found that healthy

foods stocked locally in areas considered low income were more expensive than in

supermarkets further afield (Hendrickson, Smith, & Eikenberry, 2006). Other studies

have also shown low income parents struggling to financially accommodate for the

cost of healthy food prices (Burns, Bentley, Thornton, & Kavanagh, 2011; Ward et al.,

2013; Withall, Jago, & Cross, 2009). With Theme 1 and the literature it supports (Burns

et al., 2011; Hendrickson et al., 2006; Withall et al., 2009), it is understandable why

participants from both Runcorn and Widnes would not want to accrue additional costs

from an online shopping fee, or to risk potentially wasting any food due to a short-

shelf life (Sub-theme 1). Theme 1 additionally supports a psychological explanation for

food purchases made by low income individuals, which acknowledges the desire to

‘not waste food or money’ (Zachary, Palmer, Beckham, & Surkan, 2013, p.670). The

issue of busy food banks and suggestion to have more budget shops in the local area

was only raised by Runcorn participants. This perhaps reflects the fact that Windmill

Hill is considered one of the more deprived areas in Halton (Halton Borough Council,

2015).

Theme 2: Children and family situation

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Participants in Runcorn and Widnes reported difficulty in balancing family life

with accessing a healthy diet. Family has been presented as a key factor in influencing

food purchases, among low income groups (Zachary et al., 2013). Parents living in

areas of high deprivation have described problems in consuming a healthy diet, due to

a busy family life (Withall et al., 2009), including mothers of varying ethnicities

(Dubowitz, Acevedo-Garcia, Lindsay, Subramanian, & Peterson, 2007). Dubowitz et al.

(2007) found differences in the way cooking is prioritised between ethnicities, in that it

can be part of a culture to prepare a family meal every day. Halton has little cultural

diversity (Halton Borough Council, n.d.); thus, a busy family life was potentially

perceived as more of a barrier for participants in Halton, due to absent cultural

motivations.

Theme 2 also refers to family life limiting physical access to healthy, affordable

food, interacting with the dimension of accessibility (Andress & Fitch, 2016; Bowyer et

al, 2006; Kamphuis et al., 2007). Public transport was considered a big issue,

particularly for the non-driving Halton participants, unable to easily access budget

shops stocking healthy, affordable food. This problem has been recognised among

other low income groups both inside (Bowyer et al., 2006) and outside (Hendrickson et

al., 2006) of the UK. With this, the suggestion to locate supermarkets stocking healthy,

affordable food equally across Widnes appears valid, to make them easily reachable,

without the need for transport.

Theme 3: Dominance of unhealthy food vs healthy food

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Theme 3 first refers to the dimensions of access and availability, with regards to

the location of shops, low availability of healthy, affordable food and high availability

of unhealthy/fast food (Andress & Fitch, 2016; Bowyer et al, 2006; Kamphuis et al.,

2007). This supports a previous study which found low income areas in Australia to be

closer to fast food restaurants and further away from larger supermarkets stocking

healthy, affordable food (in comparison to higher income areas) (Burns & Inglis, 2007).

Research also shows that if an individual has low financial income and/or limited

access to supermarkets not within walking distance (particularly if they do not drive a

car) they are more likely to utilise fast food restaurants (Burns, Bentley, Thornton, &

Kavanagh, 2015) and corner shops stocking unhealthy food products (D'Angelo,

Suratkar, Song, Stauffer, & Gittelsohn, 2011). However, Halton participants who

claimed to access and consume fast foods were both drivers and non-drivers. This

suggests that the convenience and liking of fast food reported by Halton participants

may be the key reasons behind this group consuming it, as participants who could

drive still purchased it, despite being able to easily access healthy, affordable food

further away. Comparable to Theme 1, the high affordability of fast food compared to

healthy food was discussed as a barrier; however, it should be noted here that the

perception of healthy food being more expensive than fast food is perhaps based on

false beliefs (Burns et al., 2015), thus is potentially an individual/social barrier, rather

than a material one. Within the Widnes groups, the quality of healthy food available

locally was reportedly poor, supporting a number of previous studies (Bowyer et al.,

2006; Dubowitz et al., 2007; Hendrickson et al., 2006; Zachary et al., 2013). The subject

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of quality has also been recognised within different dimensions of food access, such as

acceptability (Andress & Fitch, 2016) and appropriateness (Bowyer et al., 2006).

Theme 4: Inadequate support/guidance with healthy diet

The final theme refers to the limited support participants felt they received

with their diets and their confusion towards healthy eating messages. This can be

explained by the concept of ‘awareness’ (Bowyer et al., 2006); even if healthy,

affordable food is available or accessible, an individual may not be able to access a

healthy diet, if they do not understand how to eat healthily. Dibsdall et al. (2002)

found that even though low income individuals were aware of the guidance around

‘Five-a-day’ (National Health Service, 2015), they failed to consume this amount,

suggesting awareness was not influencing diet. Dibsdall et al. (2006) found the biggest

barrier to eating healthily was low motivation and the belief that a healthy diet

requires increased effort. This is perhaps the case for Halton participants, at least in

part, as the suggestions from participants to improve their awareness included recipe

cards in supermarkets (to eliminate the need to think of a recipe, make a list of

ingredients etc.). An interest was also expressed in attending a free cookery course, if

one were available in the Halton area. As recommended by Bowyer et al. (2006) for

participants in Hackney, perhaps supporting the development of cookery skills for low

income groups in Halton would help increase their confidence and motivation to

access a healthy diet.

Limitations

58

It is acknowledged that there are limitations to the present study. Firstly, due

to the qualitative nature of the research, the sample size was small; therefore, it is

difficult to generalise the findings to all parents within Halton (Withall et al., 2015). The

sample could also be considered bias, as all participants were recruited via local

Children’s Centres. However, the centre managers confirmed a high registration rate

to these centres (approximately 90%) within the local community. Therefore, it is likely

the barriers apply to other parents in the area. Further research on a larger scale could

help confirm this. The sample size for Widnes was also considerably smaller than for

Runcorn, although themes were consistent across both areas, with only small

differences noted. As such, it is assumed this did not drastically impact the quality of

the findings, although more focus groups could be held with more participants, to

ensure theoretical saturation is reached (Withall et al., 2015). Finally, all of the

participants were mothers; it has been recognised that studies involving food naturally

attract female participants (Daborn et al., 2005) and thus, efforts could be made in the

future to recruit fathers specifically, to improve the generalisability of the findings.

Conclusion

59

This study contributes to the pool of UK-based research regarding low income

families and food access. Parents with children under the age of five years were found

to experience a variety of barriers to accessing healthy and affordable food. Barriers

were present in the local environment, but were also the consequence of individual

experiences and situations. With regards to addressing these barriers, very few

differences were identified between Windmill Hill (Runcorn) and Hough Green

(Widnes). Therefore, any recommendations to inform public health policy, based on

these findings, would most likely help diminish the negative effects of the reported

barriers in both areas. It would also be beneficial to explore other low income cohorts

within the area, to fully appreciate those susceptible to limited healthy food access,

such as the elderly (Burns et al., 2011). With the dangerous health problems that can

arise from eating a nutritionally poor diet, anything to improve the diets of low income

individuals is of the upmost importance. In making it as easy as possible to access a

healthy diet, the health of low income groups can benefit and inequalities in health can

be reduced.

60

References

Andress, L., & Fitch, C. (2016). Juggling the five dimensions of food access: Perceptions

of rural low income residents. Appetite, 105, 151-155.

Doi:10.1016/j.appet.2016.05.013

Bowyer, S., Caraher, M., Duane, T., & Carr-Hill, R. (2006). Shopping for food: accessing

healthy affordable food in three areas of Hackney. City University, London.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative

Research in Psychology, 3(2), 77-101.

http://dx.doi.org/10.1191/1478088706qp063oa

Burns, C., Bentley, R., Thornton, L., & Kavanagh, A. (2011). Reduced food access due to

a lack of money, inability to lift and lack of access to a car for food shopping: a

multilevel study in Melbourne, Victoria. Public Health Nutrition, 14(6), 1017-

1023. http://dx.doi.org.voyager.chester.ac.uk/10.1017/S136898001000385X

Burns, C., Bentley, R., Thornton, L., & Kavanagh, A. (2015). Associations between the

purchase of healthy and fast foods and restrictions to food access: a cross-

sectional study in Melbourne, Australia. Public Health Nutrition, 18(1), 143-150.

http://dx.doi.org.voyager.chester.ac.uk/10.1017/S1368980013002796

Burns, C. M., & Inglis, A. D. (2007). Measuring food access in Melbourne: Access to

healthy and fast foods by car, bus and foot in an urban municipality in

Melbourne. Health & Place, 13(4), 877–885.

Doi:10.1016/j.healthplace.2007.02.005

61

Collins, K. M. T., Onwuegbuzie, A. J., & Jiao, Q. G. (2006). Prevalence of mixed-methods

sampling designs in social science research. Evaluation & Research in Education,

19(2), 83-101. http://dx.doi.org/10.2167/eri421.0

Daborn, C., Dibsdall, L., & Lambert, N. (2005). Understanding the food related

experiences and beliefs of a specific group of low income men in the UK. Health

Education, 105(2), 109-125. http://dx.doi.org/10.1108/09654280510584562

D'Angelo, H., Suratkar, S., Song, H., Stauffer, E., & Gittelsohn, J. (2011). Access to food

source and food source use are associated with healthy and unhealthy food-

purchasing behaviours among low income African-American adults in Baltimore

City. Public Health Nutrition, 14(9), 1632-1639.

http://dx.doi.org.voyager.chester.ac.uk/10.1017/S1368980011000498

Department for Communities and Local Government. The English Indices of

Deprivation 2015. Retrieved from

https://www.gov.uk/government/uploads/system/uploads/attachment_data/

file/465791/English_Indices_of_Deprivation_2015_-_Statistical_Release.pdf

Department for Environment Food and Rural Affairs. (2014). Family food 2014.

Retrieved from

https://www.gov.uk/government/uploads/system/uploads/attachment_data/

file/485982/familyfood-2014report-17dec15.pdf

Dibsdall, L. A., Lambert, N., Bobbin, R.F., & Frewer, L. J. (2002). Low income consumers’

attitudes and behaviour towards access, availability and motivation to eat fruit

and vegetables. Public Health Nutrition, 6(2), 159–168.

http://dx.doi.org/10.1079/PHN2002412

62

Dubowitz, T., Acevedo-Garcia, D., Salkeld, J., Lindsay, A. C., Subramanian, S. V., &

Peterson, K. E. (2007). Lifecourse, immigrant status and acculturation in food

purchasing and preparation among low income mothers. Public Health

Nutrition, 10(4), 396-404.

http://dx.doi.org.voyager.chester.ac.uk/10.1017/S1368980007334058

Food Standards Agency. (2007). Low income diet and nutrition survey: summary of key

findings. Retrieved from

http://tna.europarchive.org/20110116113217/http://www.food.gov.uk/

multimedia/pdfs/lidnssummary.pdf

Freedman, D. A., Bell, B. A. (2009). Access to healthful foods among an urban food

insecure population: perceptions versus reality. Journal of Urban Health, 86(6),

825–838. http://doi.org/10.1007/s11524-009-9408-x

Griffith, R., O’Connell, M., & Smith, K. (2013). Food expenditure and nutritional quality

over the Great Recession. Retrieved from http://www.ifs.org.uk/bns/bn143.pdf

Halton Borough Council. (n.d.). How does Halton compare with other places in

England? Retrieved from

http://halton.gov.uk/Pages/councildemocracy/pdfs/CensusandStatistics/

HaltonSpineChart.pdf

Halton Borough Council. (2015). Halton joint strategic needs assessment (JSNA).

Retrieved from

http://www4.halton.gov.uk/Pages/health/JSNA/JSNASummary.pdf

63

Health and Social Care Information Centre. (2015). Statistics on obesity, physical

activity and diet: England 2015. Retrieved from

http://digital.nhs.uk/catalogue/PUB16988/obes-phys-acti-diet-eng-2015.pdf

Hendrickson, D., Smith, C., & Eikenberry, N. (2006). Fruit and vegetable access in four

low income food deserts communities in Minnesota. Agriculture and Human

Values, 23(3), 371-383.

http://dx.doi.org.voyager.chester.ac.uk/10.1007/s10460-006-9002-8

Kamphuis, C. B. M., Lenthe, F. J. V., Giskes, K., Brug, J., & Mackenback, J. P. (2007).

Perceived environmental determinants of physical activity and fruit and

vegetable consumption among high and low socioeconomic groups in the

Netherlands. Health & Place, 13(2), 493-503.

Doi:10.1016/j.healthplace.2006.05.008

National Health Service. (2015). Why 5 A DAY? Retrieved from

http://www.nhs.uk/Livewell/5ADAY/Pages/Why5ADAY.aspx

National Health Service. (2016a). Eating a balanced diet. Retrieved from

http://www.nhs.uk/Livewell/Goodfood/Pages/Healthyeating.aspx

National Health Service. (2016b). Obesity. Retrieved from

http://www.nhs.uk/conditions/Obesity/Pages/Introduction.aspx

Instructions for contributors. (2016). Retrieved from

https://www.cambridge.org/core/journals/public-health-nutrition/information

/instructions-contributors

Public Health England. (2014). National diet and nutrition survey: results from years 1-

4 (combined) of the Rolling Programme (2008/2009 – 2011/12): Executive

64

summary. Retrieved from

https://www.gov.uk/government/uploads/system/uploads/attachment_data/

file/310997/NDNS_Y1_to_4_UK_report_Executive_summary.pdf

Scientific Advisory Committee on Nutrition. (2011). Dietary reference values for energy.

Retrieved from

https://www.gov.uk/government/uploads/system/uploads/attachment_data/

file/339317/SACN_Dietary_Reference_Values_for_Energy.pdf

Ward, P. R., Verity, F., Carter, P., Tsourtos, G., Coveney, J., & Wong, K. C. (2013). Food

stress in Adelaide: the relationship between low income and the affordability of

healthy food. Journal of Environmental and Public Health, 968078.

http://doi.org/10.1155/2013/968078

Withall, J., Jago, R., & Cross, J. (2009). Families’ and health professionals’ perceptions

of influences on diet, activity and obesity in a low income community. Health &

Place, 15(4), 1078-1085. Doi:10.1016/j.healthplace.2009.05.006

Zachary, D. A., Palmer, A. M., Beckham, S. W., & Surkan, P. J. (2013). A Framework for

understanding grocery purchasing in a low income urban environment.

Qualitative Health Research, 23(5), 665-678. Doi: 10.1177/1049732313479451

65

Appendices

(Appendix 1 – Appendix 8)

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Appendix 1: Letter of Ethical Approval

Faculty of Medicine, Dentistry and Clinical SciencesResearch Ethics Committee

frec@chester.ac.uk

frec@chester.ac.uk22/03/2016

Jessica BirksSalisbury StreetChester

Dear Jessica

Study title: Focus groups exploring barriers to accessing a healthy diet, for parents with children under the age of 5 years, in Runcorn and Widnes (Halton)

FREC reference: 1146/16/JB/CSNVersion number: 1

Thank you for providing the documentation for the amendments recommended following the approval of the above application. These amendments have been approved by the Faculty Research Ethics Committee.

With the Committee’s best wishes for the success of this project.

Yours sincerely,

67

Professor Ben GreenChair, Faculty Research Ethics Committee

Appendix 2. Participant Information Sheet

Participant information sheet

Focus groups exploring and comparing barriers to accessing healthy and affordable foods, for parents with children under the age of 5 years, in Runcorn

and Widnes (Halton)

You are being invited to take part in a research study. Before you decide, it is important for you to understand why the research is being done and what it will involve. Please take time to read the following information carefully and discuss it with others if you wish. Ask us if there is anything that is not clear or if you would like more information. Take time to decide whether or not you wish to take part.

Thank you for reading this.

What is the purpose of the study?This research is being undertaken with parents with one or more children under the age of 5 years old. It will be investigating key barriers to accessing healthy and affordable food in the community and exploring any improvements that could be made to improve the situation, if necessary.

Focus groups are being conducted in both Runcorn and Widnes. You will be part of one of (at least) four groups who will be participating in the study.

A focus groups consists of a group of people coming together to talk freely to one another and express their thoughts and opinions about a certain topic or issue. In this instance, the discussion will be led by a student researcher (Jessica Birks) and the topic of interest will be food access in either Runcorn or Widnes.

Why have I been chosen?You have kindly volunteered to be a participant in the study, as a parent of at least one child under the age of 5 years.

Do I have to take part?It is up to you to decide whether or not to take part. If you decide to take part you will be given this information sheet to keep and be asked to sign a consent

68

form. If you decide to take part you are still free to withdraw at any time and without giving a reason. A decision to withdraw at any time, or a decision not to take part, will not affect you in any way. You will be free to withdraw your data at any time, up until the point the data in analysed.

What will happen to me if I take part?You will be asked to attend a focus group session on (insert date) at (insert children’s centre), alongside other individuals (minimum of 3, maximum of 9 other participants), who will form the focus group. There will be refreshments on arrival. The focus group will be audio recorded and will last for approximately 1 hour. A second researcher will be present in the room, controlling the audio tape and taking notes on behalf of the main researcher. Once the hour session has been recorded, you will have the chance to ask any questions to the researcher. Once the audio recording has been written up, you will be offered the chance to read the transcript before it is analysed by the main researcher.

What are the possible disadvantages and risks of taking part?There are no disadvantages or risks foreseen in taking part in the study. If any of the topics discussed cause distress or upset, you will be free to leave the focus group at any time.

What are the possible benefits of taking part?By taking part, you will be contributing to the development of future projects and policies that may improve access to healthy food and a healthy diet within the community. You will also receive a food voucher for ASDA Supermarket worth £10 and a goodie bag.

What if something goes wrong?If you wish to complain or have any concerns about any aspect of the way you have been approached or treated during the course of this study, please contact Dean of the Faculty of Medicine, Dentistry & Clinical Sciences, University of Chester, Parkgate Road, Chester, CH1 4BJ, 01244 510000

Will my taking part in the study be kept confidential?All information which is collected about you during the course of the research will be kept strictly confidential so that only the researcher carrying out the research will have access to such information.

Participants should note that data collected from this project may be retained and published in an anonymised form. By agreeing to participate in this project, you are consenting to the retention and publication of data.

What will happen to the results of the research study?

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The results will be written up into a dissertation for my final project of my MSc. Individuals who participate will not be identified in any subsequent report or publication.

Who is organising the research?The research is conducted as part of an MSc in Public Health Nutrition within the Department of Clinical Sciences & Nutrition at the University of Chester. The study is organised with supervision from the department, by Jessica Birks, an MSc student.

Who may I contact for further information?If you would like more information about the research before you decide whether or not you would be willing to take part, please contact:

Jessica Birks: 1500040@chester.ac.uk

Thank you for your interest in this research.

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Appendix 3. Consent Form

Focus groups exploring barriers to accessing a healthy diet, for parents with children under the age of 5 years, in Runcorn and Widnes (Halton) Name of Researcher: Jessica Birks

Age of participant: _____

Male/Female (delete as appropriate)

Employment Status:

Full-time Part-time Unemployed

Other (please state) ____________________________________________

Please initial box

1. I confirm that I have read and understand the information sheet for the above study and have had the opportunity to ask questions.

2. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason and without my legal rights being affected.

3. I confirm I have at least one or more children under the age of 5 years old.

4. I consent to be audio-recorded during the focus groups

5. I agree to take part in the above study.

___________________ _________________ _____________Name of Participant Date Signature

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___________________ _________________ _____________Researcher Date Signature

Appendix 4. Example of poster promoting research

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Appendix 5. Photographs of room layout

Figure 1. Room at All Saints Upton C of E Children’s Centre (Widnes) where focus groups took place

Figure 2. Room at Windmill Hill Children’s Centre (Runcorn) where focus group took place.

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Appendix 6. Structure of focus groups

Semi-structured focus group schedule; topics to be discussed

Average duration of focus group: 1 hour(Tea/coffee/refreshments available on arrival)

Introduction – approx. 5 mins(Audio recording begins) Welcome and thank the participants for attending the session

Ensure everyone knows where the toilets are and they are able to leave at any time during the session to go to the toilet

Are/are not expecting fire alarms; ensure everyone knows the fire evacuation procedure and where the fire exits are

If anyone becomes upset or feels the need to exit the room, feel free to do so – explain separate room next door to go if necessary

Recap and ensure everyone understands why the focus group is being held and that they are free to leave at any time Outline the ground rules:

No derogative comments towards other participants, or will otherwise politely be asked to leave

Give everyone a chance to speak Be respectful to other people’s opinions Everything shared and discussed during the focus group should not be

discussed outside of the focus group

Availability – approx. 10 mins1) What are the types of the foods available to buy around the local area?Prompts

Sorts of foods purchased? Ways to improve?

Access – approx. 10 mins2) Are you able to easily access the available foods/shops?Prompts

Where do you normally shop? Ways to improve?

Affordability – approx. 10 mins3) What are the prices of food like in the local area?

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Prompts Any problems? Ways to improve?

Awareness – approx. 10 mins 4) How confident do you feel about cooking?Prompts

Any current advice received? Ways to improve?

Appropriateness – approx. 10 mins5) Are the foods available appropriate for the eating patterns you follow?Prompts

Any religious/cultural conflicts? Food allergies? Vegetarianism? Portion sizes available? Ways to improve?

Summary – approx. 5 mins Review of main points Any further points? Thank all participants for attending.

(Audio recording finishes)

Appendix 7. Data and coded barriers from thematic analysis

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Transcript 1 (Runcorn):Barriers to accessing a healthy diet

Data Barrier Code(s)Participant 4: There isn’t any… Low availability of healthy food

locallyParticipant 4:…unless you go to the Co-op (pause) just to pick bits up…(short pause)…there’s nothing (short pause) more or less local…that you can go and say, ‘we’ll go there’ or (Participant 1 nods and agrees)…or we’ll go and pick some strawberries or we’ll go and do this or we’ll go and do that…

Low availability of healthy food locally

Participant 4: There’s nothing (all nod and agree)…like that…I mean.

Low availability of healthy food locally

Participant 4: They used to do a fruit and veg here (in the children’s centre) on a Wednesday…and then it just stopped…(Participant 1 – Yeah, it did)…

Low availability of healthy food locally

Participant 2: I think Co-op locally is really expensive

Low affordability of healthy food locally

Participant 2:…you have to travel, how many miles to get to Aldi…four?

Participant 4: you’re looking at…four pounds…on a bus…

Location of shops

Low affordability of public transport (with family)

Participant 3 - I would go to Co-op…occasionally they have cheap vegetables and fruits in, but they don’t have a lot, when you go in there, most have them have gone… We don’t have anything really fresh…like a market…

Low availability of healthy food locally

Low affordability of healthy food locally

Participant 1: Sometimes we sit at different times for meals and I prefer mine when she’s in bed…and then I’ll have, like the wrong thing…

Family situation (convenience)

Participant 2: I’ve got one child who will, really, only eat kiddy meals…

Family preference for unhealthy food

Participant 2: My daughter, literally, she will only have things…like…pasta which is fine, but fish fingers, chicken nuggets…er, you know, the sort of

Family preference for unhealthy food

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little potato things like smiley faces, or, (all nod and agree), I loathe to cook stuff like that, but, I just know, you know that…Participant 1: She’ll eat it.Participant 4: All the time I do (have a problem looking for something they can’t find) because I don’t drive…

Lack of car

Participant 4:…I just buy rubbish…if you wanted ice cream for your tea, I could sort you right out (all burst into laughter)…but I couldn’t actually make a meal out of it…

High availability of unhealthy food locally

Participant 1:…you had to go up, didn’t ya,(in Iceland) and then just do all your shopping and say ‘deliver it’…and it was a nightmare…

Lack of car

Participant 3:…I had to go about six months without a car, which was an absolute nightmare…

Lack of car

Participant 3: I started using ASDA and Iceland delivery, but it’s so expensive…you have to reach a certain amount and I was just buying crap…

Low affordability of healthy food locally

High cost of online orders

Participant 1:…there is nothing round here but the local shop (Co-op)…they (the food) goes so quickly…

Low availability of healthy food locally

Participant 2:…so the last one we brought, which was the really unhealthy one (all laugh)…

(High) availability of unhealthy food

Participant 3:…it’s always ice cream, isn’t it?

High availability of unhealthy food

Participant 2: see, now I would be tricked with the name, I would think that would be a good quality sausage…

Low awareness of healthy food/diet

Participant 1: I got a pizza…its twenty five pence, so I went back to get another four (laughs)…

Affordability of unhealthy food

Participant 2:…so they might not have what you want, but they have a lot of what you don’t want’…

Low availability of healthy food locally

Participant 3:…you don’t want to get on it (the bus) around 5pm, ‘cause you’ll never get on it… I remember when I didn’t have my car and I had to get the bus from the city and I had to

Lack of car

Low convenience of public transport (with family)Family situation (convenience)

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wait, ‘til the fourth bus (all nod), I was just standing there for like an hour because we just couldn’t get on it, (all nod), because I had a baby in the pram as well and..Participant 4:..’cause you’re only allowed two prams on…

Lack of car

Low convenience of public transport (with family)

Family situation (convenience) Participant 3:…and the bus drivers will tell you to get off and stuff if you’ve, if there’s too many prams in there, or they’ll just drive past you…and it can be quite tough depending on the time of day, but I mean, you can get around, but then it’s carrying all those bags…

Lack of car

Low convenience of public transport (with family)

Family situation (convenience)

Participant 2:… I don’t think people should have to pay to get their shopping, as in, pay to get on the bus (all nod and agree)…I, I mean, you know, there’s a big area where it doesn’t have shops round here…Co-op, I mean it shouldn’t be a Co-op because I think Co-op is expensive…

Low affordability of public transport

Low affordability of healthy food locally

Low availability of healthy food locally

Participant 3:…it’s all like Co-ops isn’t it, we’ve got, like, five Co-ops…

Participant 2:…it’s (Co-op) just expensive…

Low affordability of healthy food locally

Participant 2:…they (the food banks) are really really busy. Really busy…

Low affordability of healthy food locally

Participant 2:… it just really bothers me that if, if there are that many people going to the food bank (pause), then there should be something else that’s valuable…as in good value for money…locally…and not a Co-op…(pause)…and if people don’t have good value food, chances are lots of people can’t afford to go on the bus…ummm…you know what I mean…

Low affordability of healthy food locally

Location of shops

Low affordability of public transport

Participant 4:… for me to take (name of child), don’t pay for the baby, but, for me to take (name of child), it’s six

Low affordability of public transport (with family)

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pounds (other participants gasp) for us to go, to the city. (Short pause)…Participant 2:…(sad tone) and imagine if you had to do that every day? (three second pause)…and then not everybody can afford the internet to buy online shopping to get it delivered…

Low affordability of healthy food locally

High cost of online orders

Participant 3:… but you are only allowed to use it three times (the food bank) in like a year or something like that, you’re not allowed to use it that much…..but they are, they are so busy…

Low affordability of healthy food locally

Low availability of healthy food locally

Participant 3:…as we were saying it’s all like local Co-ops everywhere and most people can’t afford to use them…

Low affordability of healthy food locally

Participant 3:… they have a lot of shops in the shopping city, like B & M, or Sainsbury’s, anywhere will do anything you need, but as you say, it’s just getting up there…

Location of shops

Participant 1: …there’s no actual supermarkets are there now, like Tesco has gone, so you’ve sort of got to move away from the shopping centres there…you’ve gotta move out to get anywhere…

Location of shops

Participant 3:…and some people don’t wanna do that, they just want to stay in the city (Participant 1 agrees), you get out of the bus and you’re right in the city, but then you gotta, to go out, to go ASDA, or ALDI or Lidl, you gotta go out, outside and some people don’t like doing that, they’d rather just stay inside the city…

Location of shops

Participant 4:…you have to go out of the shopping centre, you got…like…like and add on bit outside, and, the ASDA is separate, and the Lidl and the Aldi are all separate, so you have to go out of the shopping centre and over the bridges, or whatever, to get there…and up a hill!

Location of shops

Participant 1:…yeah, there’s nothing Location of shops

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really in the shopping bit is there?...it’s only farm foods and…ummm…Iceland.Participant 3:…just get rid of the Co-ops (laugh), put something else …either that, or Co-op really needs to think about if they’re in, like, low, poverty areas, because this is classed as a poverty area…

Low affordability of healthy food locally

Participant 2:… we just need the budget places around here I think…

Low affordability of healthy food locally

Participant 2:… there seems something very unfair about that really, that yeah, that it’s just not really…(short pause)…catered for properly…

Low affordability of healthy food locally

Participant 3:…I can’t really cook as well as I used to, because of the little one, ‘cause he’s just a whirl wind, ‘cause I literally just have to get into the kitchen and get out…(Participant 1 - yeah, it is hard)…I used to love doing fresh fruit and veg all the time, cut it all up and do it for myself, but now, I’ll just get it out of the freezer (laugh)… but vegetables, they are just a little bit more fussy on……tend to buy frozen veg really, just for the speed…definitely more convenient…

Family situation (convenience)

Participant 1:…I would just like to sit down at the table and, you know, we do do that, erm, but sometimes, it is just dead hard and I like, prefer to, have my tea when she’s in bed…

Family situation (convenience)

Participant 1:… so I do just like to do, hers, or sometimes, I’ll cook a healthy meal and just put mine in the microwave and just think, just think I’ll have it later when she’s in bed, you know what I mean?...

Family situation (convenience)

Participant 2:…I’ve got one child who won’t eat any fruit or any veg (short pause)… I’ve got one very very picky eater, who, umm, only sort of nutritional fruit and veg that she will have is things, like, ummm, a smoothie, or ummm, we call it like, a fruity paste, they are like little

Family preference for unhealthy food

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pouches…do you know what I mean (all nod and agree), you know, like the cheap Aldi ones, ummm (pause) they say it’s 100% fruit…ummm, but, she wouldn’t eat any…infact, it almost physically repulses her, to, like, if she sees me eating an apple she’s like ’ugggghh’, that sort of thing, so I don’t do any sort of cooking from scratch for her, unless it’s like, ummm, tomatoey pasta bake…she’ll eat that, sometimes not…Participant 2: I was getting so bogged down with doing three meals for every meal, I just stopped cooking from scratch…

Family situation (convenience)

Participant 2: I think people have to take the bus to that (Slimming World)…Participant 3: most of them (Slimming World) are in the evening aren’t they…

Limited access to diet support groups

Participant 2:…with slimming world, you need a lot of money because you eat so much fruit and veg, that, I’m spending twenty five pounds more a week, just for my fruit and veg, so you have to have money to do it…or it doesn’t work…

Low affordability of healthy food

Participant 3: Well, my doctor just says, ‘eat healthy’

Limited guidance around healthy food/diet in local area

Participant 4:…’you make your SMASH, you put your tuna in…Participant 1: Uggggh (laughs) I don’t do SMASH, you boil potato, you know what I mean?

Limited guidance around healthy food/diet in local area

Low quality of sessions available

Participant 1:…‘they gave us like these tins to put it in and by the time you took it home it was all sloppy and (laughing) the banana had gone all brown and it was like ‘oh, lovely, here you are Daddy’…(all laughs)

Limited guidance around healthy food/diet in local area

Low quality of sessions available

Participant 2:…We eat the same stuff every day, me and the kids, and it’s boring, I hate it, but it’s the only way I can keep the food bill down…

Family situation (convenience)

Low affordability of (healthy) food

Participant 4: but it is the same each Family situation (convenience)

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week, and it is annoying and I hate it, but the kids don’t mind…so I just do it and if I’m feeling depressed, I eat a cake later…(all laugh)..my safe food is cake!Participant 2: ‘We went…to the children going to reception meeting last night and they were talking about this (packed lunch boxes)…I think the rules are quite contradictory…’

Limited guidance around healthy food/diet from schools

Participant 3: That is one thing Runcorn is good for, fast food places…there’s loads

High availability of unhealthy foods

Participant 3:..but yeah, what, we’ve got a McDonalds, a KFC, a burger king and a Pizza hut all within the same facility…and then you’ve got…like, Gregs in the shopping city…(all nod and agree)… ooooh, and Dominoes, because Dominoes is right next to pizza hut isn’t it…and they wonder why Halton’s got issues! (laughs)…and then you go down to the old town and there is just constant pizza places, chippys…

High availability of unhealthy foods

Participant 3: there is a lot of fast food and that, yeah, there is, plenty of takeaways, I mean, you want to order a takeaway and you’ve got…you’re not shy of any takeaway places…there is what…six or eight pizza places in the old town alone…and then chickens…and then so and the sort of person that goes and gets drunk then goes and gets a kebab…

High availability of unhealthy foods

Participant 3:…we’ve got the one Italian and (laughs) twelve pizza places…

High availability of unhealthy foods

Participant 3:… but they do so well though and umm, they have so many of them in the same area…

High availability unhealthy foods

Participant 4:…how do people sit there and say, I mean, my sister in law will do it, and say, and she’ll take the little one, I mean, (quietly) I think they eat out nearly every day…

High availability of unhealthy foods

Participant 3:… There is so much convenience in Runcorn…

High availability of unhealthy foods

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Participant 4:…cause, my husband loves KFC, so she’ll turn up with…a bucket (laughter)…saying ‘we’ve been to KFC, we’ve brought you this’

Family situation (convenience)

Participant 3:…it is scary, and they wonder why we have an issue, you now, they say about weight issues in Runcorn, but it is, there’s too much convenience…people are like ‘I don’t wanna cook, I’ll just go the chippy’ or ‘I’ll just go the..’…if you live in the old town, your sorted for every night for every meal of the week, because there is something down there for everyone, you know, its…

High availability of unhealthy food

Participant 3:…even if they do have a couple of cooking stuff, it’s not promoted…and if everyone, if you would just go the shop and get it from scratch, you could just save so much money, it’s unreal!...

Limited guidance around healthy food/diet in local area

Participant 2:…I think the credit crunch has done that, because, the food, do you remember when food suddenly just rocketed in price…

Low affordability of (healthy) foods

Participant 4:…I think it’s a lot more expensive, the gluten free…I mean, we had, (husbands name) son…he came to visit us…and he, he was staying for the weekend…but he was on his (pause)…’cause he’s got issues with his stomach and that…so they were putting him on a month trial of everything…a month trial of dairy free…a month trial of gluten free…a month trial of this and it’s like ‘uggh’…’I’m coming for the weekend, but I need gluten free’…(sighs) ’right okay’…so we had to go and buy (counts on hands) gluten free pasta, gluten free bread, gluten free this, gluten free cereal…and I’m like ‘you’ve just cost me nearly a weeks shop!...(all nod and agree)…for the weekend!…

Low affordability of appropriate healthy foods

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Coding on Transcript 2 (Widnes):

Barriers to accessing a healthy diet

Data Barrier Code(s)Participant 5: Not many…really…is there?

Participant 6: No

Low availability of healthy food locally

Participant 5: Fruit and veg shops, they’re…they’re like scarce now, aren’t they, really?

Low availability of healthy food locally

Participant 6: Yeah…you’ve got the market haven’t you?Participant 5: Yeah…Participant 6: But, if I’m totally honest with you (Participant 6: I wouldn’t buy it (laughs)) for fruit and veg, I go to Aldi because it keeps the longest…Participant 5: Yeah, exactly…

Short shelf-life of healthy food locally

Participant 6: Everywhere, everywhere else you go…ASDA…no matter where you go, after a couple of days…everything goes off…(Participant 5: They go off within days, yeah…)…

Short shelf-life of healthy food locally

Participant 5: …your fresh chicken and stuff…they’re like…the date…I don’t think the dates on…any supermarket foods are…good really…um…they’re all like, two days, aren’t they…three days…

Short shelf-life of healthy food locally

Participant 6: I think so…see, I’m quite, I’m quite thingy over my meat, ‘cause I work in a butchers…so I don’t…I actually wouldn’t buy from a supermarket anyway…just…’cause you don’t know how long it’s been there…(Participant 5: ‘yeah’)…and…to me…some stuff has too longer date on it…in a supermarket…you know, like your ‘best before’ dates…whereas I know through work…you do only get a couple of days on stuff…and everything that comes into our shop…I know where it’s come from and…that it’s fresh, if you get what I mean…so I, I’m quite strange with meat…

Low quality of local healthy food

Participant 5: Yeah, well, I, I, Low quality of local healthy food

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remember buying…umm…you know the meat deals they have on in the ASDA…the three for ten pounds…I remember buying some, umm, mince…and, it had the shelf date on it of like two days later from when I’d opened it or…the smell…I couldn’t even tell you what it smelt like (Participant 6: yeah, mince smells like a) disgusting…it was like a browny horrible colour…(Participant 6: yeah, it does discolour)…and it really, really, stunk…and when I took it back they were like ‘Oh, well we’ll exchange it for you’ and I was like..’well I don’t really want it anymore’ (both participants laugh)…to be honest…but…Participant 6: Er, you’ve got all the supermarkets, haven’t you really…in…Widnes (Participant 5: yeah)…it’s quite stupid ‘cause they’re all on one another’s door step…Morrisons…Tesco…Aldi…(short pause)…

Location of shops

Participant 5: Yeah, yeah, I’ve used the market, but I don’t really…but er…I brought some, um, tangerines from there once and they weren’t very nice either…they went off within days…so I do use the Aldi…for all my fresh fruit and veg…

Short shelf-life of healthy food locally

Participant 5: Oh yeah…Morrisons and ASDA I have for my fresh fruit and veg, but that’s the same…but…it doesn’t last very long, does it?

Short shelf-life of healthy food locally

Participant 6: No like, I’m the same, generally, I’ll do like a weekly shop, but if there’s odd little bits that I need through the week, then I will just pop to ASDA, pop to Morrisons…like if, if I’m having such and such for tea…like I haven’t got this…like…’cause…without sounding stupid…getting to Aldi…especially if you don’t drive…

Lack of car

Participant 5: (nods and agrees) yeah…it is a nightmare…the road and stuff…Participant 6: The road, the road that

Location of shops

Lack of car

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you’ve got to get across is…even if you drive…trying to get…in and out of Aldi is a bit of a nightmare…so it is easier if your just walking round Widnes, just to pop into Morrisons or just pop to the market (Participant 5: yeah)…just for like an everyday thing…

Participant 5: The Aldi is hard to get to…see I have to get my partner on a weekend to take me…’cause he drives…to the Aldi…and then like you said yourself (to Participant 6)…I have to pick bits up…around…Widnes…it’s alright, but, it’s only a bus journey away…

Lack of car

Family situation (convenience)

Participant 6: I wouldn’t got that far (laughs)…but…I couldn’t live without my car though, I don’t think…Researcher: (Laughs) Why do you say that?Participant 6: ‘Cause it’s just so much easier…isn’t it? Participant 5: Yeah…Participant 6: Especially when you’ve got a baby…Participant 5: Yeah, I know…Participant 6: When you’ve just got to nip here, there and everywhere…I don’t know I think…I think…I think I’d find it quite hard getting on and off buses…Participant 5: Yeah, it is, you have to fight these days to get onto the bus with a push chair (laughs)…

Lack of car Low convenience of public transport (with family)

Participant 5: No, I know…it’s four pounds for a weekly…(tut) a weekly...a daily ticket, which you can use all day, or its two fifty, this is into Widnes…its two fifty one way…so you pay, you pay five pound…to get there and back if you didn’t buy the weekly ticket…

Low affordability of public transport (with family)

Participant 5: (Sighs loudly and laughs) Well, where do I start? (laughs)…yeah, it’s like, umm, buggy space…I mean (name of child) isn’t walking and he is a nightmare the get out the

Low convenience of public transport (with family)

86

pram…and if somebody got on with a wheelchair, I’d be the first, you know, to put my pram down…and get him out, but…the most, umm, arguments I have is with old people with big trolleys…

Participant 5: Right, there was an old lady once…now I am a polite and I usually get up and let people in…you know, try and help…and this lady got on with her weekly shopping, you know like in her trolley…and she was like ‘Move!...Move your pram!...’Take you pram!’…’Tell her!’ you know, to the bus driver, they’re dead awful rude sometimes…and I was about to and then I thought, well no I’m not now, ‘cause you just spoke to me like that, but, I do…have issues with that, and erm, getting on the bus, with the pram, with other prams as well…there’s like a lot of people…I mean I walk in the summer…when it’s nice, I do walk into town, but, there’s not much room on a bus for your shopping either really…is there?

Low convenience of public transport (with family)

Participant 5: ‘er, like more fresh fruit and veg shops, like dotted around, ‘cause there used to be one up here…umm…at the shops there, yeah, but there used to be a butchers, a Sayers and a butchers, and then there used to be a fruit and veg shop next door…and you’ve got the post office, but…have you ever been in the post office? (laughs)…for veg

Participant 5: There you go! (laughs)…that’s my thing…they buy stuff, but, it’s been there since I was a kid, I think (laughter)

Low availability of healthy food locally

Low quality of local healthy food

Participant 5: Yeah, but, there used to be, a lovely fruit and veg shop there and, umm, a butchers…you know…for fresh meat and stuff…Participant 6: Yeah, fresh fruit and veg I probably would, but…I’m like…before

Low availability of healthy food locally

Low quality of local healthy food

87

I started working where I work…I only ever eat chicken…whereas…so if I was doing a spaghetti bolognaise or something like that, the I’d use Quorn mince…’cause I’m one of those people, if I get, a little bit of gristle in anything or a little bit of fat, that’s it, I can’t eat it…and a, a, a, a fish…and, a bone in a fish…I can’t eat it any longer…so but then when…where I work, I see everything…like our mince and stuff, it’s a very very low fat content…whereas I walked into…there’s a new butcher opened…in Widnes…and…

Participant 5: The one on the corner, by the market?

Participant 6: Yeah and, I walked in, just for a little nosey, and, I asked what the fat content was in the meat, in the mince, and she said ‘oh yeah, I think it’s two percent, let me just check’…and I thought ‘two percent….that…that’s, like, the tiniest bit of fat, and I can see fat in the mince’…(laughs)…so next, thing, she comes back and she says ‘yeah, he said, it’s on the packaging’…it was twenty percent fat…(short pause)…so I thought, you got that a little bit wrong…

Low awareness of healthy food/diet

Participant 6: They could be coming from any country…and…there, there’s…no like…butchery skills needed to be in that shop, ‘cause there’s no like cutting of things or anything like that…(short pause)…I thought that by when they first started advertising…over jobs…and all the shops…all the shops open it, I thought it was kind of like what I, what environment I’m used to, that it’s like a nice, local butchers, where you know where everything has come from, and it’s just not at all…so I’ve actually been in that shop once, seen that fat content and thought…’I’m not coming again’!

Low availability of healthy food locally

88

Participant 5: Oh, I didn’t know that…but it’s just all like pre-packaged stuff as well isn’t it…’cause I went in there for a nosey as well…(short pause)…and like the door’s open and when I went in there were flies in there…see, I’m like funny like that as well…like flies, I know everywhere gets flies, but…when, the door was open and it was a dead hot day and there were some flies in there and I was like ‘No’, I’ll have to go…but…

Low quality of local healthy food

Participant 5: Yeah, basically, I, er, yeah, I find, personally myself that, if you wanna eat healthy…it obviously costs you a lot more, doesn’t it? Participant 6: Yeah, yeah…

Low affordability of healthy food locally

Participant 5: I think everything’s the same, isn’t it? If you wanna, If you wanna eat fresh food, for example, like we eat a lot of fresh food…erm…it is, it is more expensive…and it’s like, because I won’t give the children, like, like frozen food…

Low affordability of healthy food locally

Participant 6: Aldi have six items that are a certain price every week…but, but obviously them things change, but…even…price wise, like, I was in Aldi on Saturday and I brought, er, a tub of raspberries and a punnet of strawberries…I think the strawberries were one pound thir…one pound forty nine…and the raspberries were one pound thirty nine…and you walk into ASDA and it’s three pound for a punnet…Participant 5: Yeah, yeah…Participant 6: It’s completely crazy, different prices, depending on where you go…Participant 6: I do…just… tend to really stick to Aldi and ASDA…I find Morrisons…(short pause)…if you go and do a weekly shop in just Morrisons and Tesco and your just buying what your buying the week before from ASDA, then I find it quite dear…

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Researcher: So you do have to go round different places to get different products, including food productsParticipant 5 and 6: yeah

Low affordability of healthy food locally

Low availability of healthy food locally

Participant 5: Yeah, but, as you say, sometimes it’s getting to them (the available farm shops) though, like, you drive, like, they’re out the way aren’t they?...so anyway, like my partner, is only off on a Sunday, so it’s, as I say, I don’t drive so it’s more difficult really…for me to get to places like that…

Participant 5: But yeah, they’re quite, like, out the way, they’re like, down little country lanes aren’t they, like, farm shops and stuff…yeah…

Lack of car

Location of shops

Researcher: Have you attended any support around healthy eating or healthy diet or something like that?Participant 5: NoParticipant 6: NoResearcher: No, okay, any healthy eating messages or anything like that?Participant 5: No

Limited guidance around healthy food/diet in local area

Participant 6: No…I mean…I suppose, like, I get a lot of emails now, off like, (three second pause)…baby groups and

Participant 6: Yeah, they tend to send you recipes, but, not, necessarily recipes I would cook…

Limited guidance around healthy food/diet in local area

Participant 5: Well, from school, (name of child) has brought, like, letters home from school, recently, talking about healthy eating…and things…but that’s just to say that he’s been taught that…not like, telling me about it, you know, it’s just to tell me that basically that’s what they have been teaching them about in school…the healthy eating…the healthy drinking…

Limited guidance around healthy food/diet from schools

Participant 6: Yeah (laughs)…I can see me making a rook of meals and,

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90

and doing them, so she can have them in the freezer, so she can just help herself…but I suppose like…there’s people her age…that obviously have had children, or are having children and stuff like that and…(pause)…their main aim is probably gonna be when that kids eaten, is probably gonna feed that kid chips and chicken nuggets…(Participant 5: Yeah…), because, they don’t know any different…(short pause)…so like maybe, some, like groups (Participant 5: Some like, groups, yeah)…some groups for maybe people that don’t know, just for a little bit of a venture into healthy eating stuff…for them

Participant 6: There’s all kinds of takeaways in Widnes…pizza places, Chinese…Participant 5: There are, yeah, there’s everything

High availability of unhealthy food

Coding on Transcript 3 (Runcorn):

Barriers to accessing a healthy diet

Data Barrier Code(s)Participant 11: I’m still on full pay maternity at the moment so I’m still mainly doing ASDA…

Family situation (convenience)

91

…Because, I can sort of get everything under one…and I don’t have to go to different shops then…otherwise, with having the baby and that, it’s a bit of a hassle…Participant 10: Ummm, well, often, if I can’t get something in Aldi like certain bits for the cupboard then I’ll go to like Tesco or ASDA or somewhere and you do…notice…that price difference, but if it’s something particular that you need you kind of have to pay it to get it…so it depends, you know, what you wanna cook…

Low affordability of healthy foods locally

Participant 8: yeah, you can get in Aldi, but if you start going to ASDA and places…Tesco…is worse, but I think Tesco is, much more expensive than ASDA……that’s when I start picking up flavoured meats and stuff…that I, never…

Participant 9: That you don’t need…

Low affordability of healthy foods locally

Shopping habits

Participant 8: The only thing that I sort of struggle with in Aldi is I, believe it or not, apart from the biscuits, I’m on Slimming World and I, I find the lean meat isn’t…

Participant 9: Yeah, I’m on Slimming World too and I find the same, yeah

Participant 8: But I can get the mince, or, I can get the gammon and the bacon medallions in there, but, I struggle getting the lean meat and…

Participant 8: But yeah, I just don’t buy the meat because other people just get there first…obviously (laughs)

Low availability of appropriate healthy foods

(Accessing the Aldi)Participant 8: I don’t mind it if I’m on my own, it’s not great if I’ve got the baby…

Family situation (convenience)

92

Participant 8: Because its baby space, its only got one baby space…

Participant 8: yeah, ‘cause, it’s like a retail park with one big, outside car park, so everyone, it’s not Aldi’s own car park so…

Location of shops

Participant 8: I can’t imagine shopping without a car…

Participant 7: Well, you wouldn’t be able to, would you? Or get a taxi…or do it online…

Participant 11: Yeah, ‘cause you have to carry your bags and obviously your child as well…

Lack of car

Family situation (convenience)

Participant 8: See people who do it on buses as well, I can’t survive on a bus

Low convenience of public transport (with family)

Participant 8: If I lost my car, I couldn’t shop at Aldi because I would have to do it online…and it would have to be somewhere that did it online…

Researcher: Why would you have to do it online?

Participant 8: …I used to go everywhere on the bus and then when I got a car and had to get on a bus…I hated it…

Participant 11: …I’ve done that once, it was snowing that much and I couldn’t get the car up the road and I had to get on the bus and I thought, never ever again…and if I had shopping and a baby, that would just be, my worst nightmare…

Lack of car

Low convenience of public transport (with family)

Researcher: And how do you find walking?

Participant 8: I wouldn’t know how

Location of shops

93

to, walk…

Participant 11: Occasionally, I’ve walked to the shop, you know the local shop (all say ‘Co-op’), just if like, say, I needed milk, yeah, I’ve just walked to the Co-op and got like an odd thing there, but, I wouldn’t walk any further than that…

Participant 8: It all looks the same, I’ve only lived here a couple of years and, I feel just like I’m in the middle, of, nowhere…(pause)…apart from all the houses (laugh)

Location of shops

Participant 7: It’s like crazy, that, there’s no, shops…

Low availability of healthy food locally

Location of shopsParticipant 10: No shops…I think there’s like…yeah…there’s like a tiny…but it doesn’t have anything in it

Participant 9: It has penny sweets though (all laugh)

Participant 10: yeah, there’s penny sweets and loads and loads of chocolate and fizzy drinks…(all laugh), but, yeah, it barely opens, but yeah, it’s just not very good…very good selection…so yeah, if I’m walking, I’ll walk this way…there’s like a huge load of houses and there’s nothing there…

…but I think it’s still limited anyway…you know with Co-op, but I think, it is a walk to

Low availability of healthy food locally

High availability of unhealthy foods

Location of shops

(All say it is very expensive) (Local Co-op)

Low affordability of healthy foods locally

Participant 7: Well it’s convenience isn’t it?...so, you pay (all participant say ‘yeah’) because you don’t have a choice, to, go anywhere else…(all participants say ‘yeah’)

Participant 10: It costs a fortune…

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Participant 11: I end up going there (the local Co-op) about, three times a week…because I’ll try and plan as much as possible…but I’ve got a teenage daughter…ummm, and, no matter what I buy in, she’ll choose something that I haven’t brought (all laugh) and therefore I always end up needing to go to the shop at least two or three times (pause) and I just end up nipping up there…(pause)…but I end up spending at least a tenner every time (laughs)

Family situation (convenience)

Family preference for unhealthy food

Participant 7: I think milk is like double in Co-op (all participants say yes, no and agree)…like, a four pint of milk it’s about one pound fifty, whereas it’s like eighty nine pence everywhere else…

Participant 10: yeah, I think yeah, they play on the convenience, definitely…

Low affordability of healthy food locally

Location of shops

Participant 10: yeah, it’s probably like, probably like a two mile radius all round

Location of shops

Researcher: so, for that situation that you’ve described, do any of you have any ideas or suggestions about, how that could be improved?

Participant 7: Get more shops…(all laugh)…

Low availability of healthy food locally

Location of shops

Participant 8: There isn’t really a lot of, sort of, local produce shops, there isn’t really many sort of green grocers (Participant 7: No)…or butchers or…

Low availability of healthy food locally

(All participant talk over each other and say ‘really expensive farm shop’)

Low affordability of healthy food locally

Participant 7: But then, it all goes off before you get time, to, use it all…

Short shelf-life of healthy foods locally

Participant 11: Mmmm, I even tried that, that ‘Hello Fresh’ where you get a box delivered…(pause)

High cost of online orders

95

And like, you select the meals you want for the week, but it just worked out too expensive…

Participant 11: Well, it, you get offers on it, so, like, I think initially I paid like fifteen pound for my first box but then…umm…it got dearer to the point where it was about thirty six pounds for a box and, and you’d work it out, it’s really not worth what you’re getting, and they are always sending me more offers now, but I just think no it’s not, it’s not worth it really, because, you had to sort of make the meals for the first three days, otherwise, the stuff would go out of date, or off or, umm, you’d be looking at the dates and you’d have to have a specific meal that night because you don’t, you know, it might go out of date, but you might not feel like that meal so, you know, so, it was too restricting and expensive

Participant 8: I suppose if you’ve got a family as well, that, I suppose if you lived on your own (pause) you might be able to (pause) live a bit better on that, but

Low affordability of online orders

Short shelf-life of healthy foods

Family situation (convenience)

(Graze boxes)Participant 11: you get a free one and then you get stung five pounds a week…(all laugh)…

Low affordability of healthy food locally

Participant 10: You don’t actually realise how much you’re having ‘cause they all seem quite healthy Participant 8:…and then I’d just sit there and eat them on top of my dinner…

Low awareness of healthy food/diet

Participant 7: …I brought a new cook book a few weeks ago, and they use like, instead of like fry light or cooking oil, they use, coconut oil, and I’d never even heard of it, so I were like looking for it in ASDA and it was like six ninety nine…

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96

Participant 8:… It wouldn’t be sin free though, would it?Participant 9: No, I don’t think so…I think you can only use Fry Light, can’t you?

Low awareness of healthy food/diet

Participant 9: but there is a strawberry one there that’s like, nine sins though…the fat free one…in Aldi…

Participant 8: but it doesn’t have…a lot of Lidl stuff isn’t on the app (the Slimming World app), so I struggled when I went to Lidl…

Low availability of appropriate healthy food

Participant 8: Iceland is the only place you can get, Slimming World meals from as well, their range of stuff…

Low availability of appropriate healthy food

Participant 7: You know, one shop which I think is really good but it’s just not accessible, Farm Foods…they have, so many offers, you get a leaflet through the door for money off, like, depending on how much you spend, and they have such good stuff, like, two loaves of Kingsmill for a quid, two four pinters for a quid, but, it’s in shopping city!, like, how are you meant to do a big shop in there!? you can’t take a trolley out of the shop…you need one of them like granny things that you pull (all laugh) to put all your shopping in…or loads of kids to carry all the bags…

Location of shops

Participant 8: I must admit, I’ve been in a couple of times for like, milk, erm, and then I’ve ended up grabbing, like, oooh, I’ll just grab a, bag of that chicken or a bag or a bag of...and you literally, it’s what you can just carry…’cause, your car is usually miles away…

Location of shops

Researcher: So, what is in the Shopping City?

Participant 8: Not, not a lot really, there’s an Iceland and a Farm

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97

Foods…

Participant 7: Yeah, but, food wise, there’s only like, freezer shops…there isn’t like…but, ASDA is literally, like, two minutes away…Participant 7: Can you imagine going there and doing a food shop? You can’t can you, cause you can’t, ‘cause, obviously you can wheel your trolley around the shop, but once you’ve finished shopping, what do you do with your bags? If you’ve done a full shop, you can’t really, you know,

Participant 9: Yeah, ‘cause you’re not allowed to take your trolley’s out, are you, they have like big poles, that you can’t take them out with…

Location of shops

Participant 11: I wouldn’t want to try and do it, er, I think it would be quite difficult…

Participant 8: It would, yeah, with four kids in tow…they should a car park nearer to the…

Participant 7: ‘cause then you’ve got to walk all the way out of the Shopping City to get out of it, to get to the car, with all your, twenty bags…

Participant 11: And I think as well, like, does anyone, like, there’s only Farm Foods and Iceland in there and, I still don’t think I would be able to get everything I needed in there…I’d still need to go to ASDA or somewhere (all Participants nod and agree) to go and get the bits I couldn’t get, so I just, wouldn’t bother…

Location of shops

Family situation (convenience)

Participant 10: ‘Cause I went there and I couldn’t have anything that I needed, and I went to kind of look

Location of shops

98

and see what was there…erm…and...yeah, I was quite surprised with the amount that was in there, but yeah, I wouldn’t go and do, food shopping, it would just be a pain with the parking and then yeah, trying to get things out and yeah, there were shops in there that, you know, I went to and wouldn’t be in Golden Square, so, depending on what I need, I can either go to one or the other…

Participant 10: I think price…and…umm…how quickly it goes off…’cause if you do food shopping for the week…I’ve been to Iceland before and it, the, the, the fruit and veg will, you know, be wilted in a couple of days, and the meat doesn’t have long…

Low affordability of healthy foods locally

Short shelf-life of healthy foods locally

Participant 9: I’ve got some apples in my fridge now and they’ve been there for a week and they’re still…whereas I find like from ASDA they would have been, like soft by now…

Short shelf-life of healthy foods locally

Participant 11: Well, I try, but the thing is, I can’t plan too far ahead, because my daughter, basically does dictate what we have for tea (all laugh) and if I planned something and then she decides she doesn’t want it, then there’s uproar so, I tend to like, in the morning, when I’ll say to her, you know, ‘I’ll check again, ‘is that what you wanted?’, erm, just to make sure, but I can only sort of go maybe two or three days ahead, I couldn’t plan for a whole week…

Family preference for unhealthy food

Participant 7: I do, I just, well, we all have babies, but, I’ve got a baby and he’s like, five months old and he’s starting to be awake a lot more and it’s just like, trying to fit stuff in (pause)…normally, I stand at wok and do a chilli, whereas last night I just threw all the raw ingredients into this like stone ware and I just

Family situation (convenience)

99

chucked it in the oven…which is fine, but then my husband said like ‘what mince did we have in that chilli’ and I were like ‘normal mince’, but it did, it tasted different (laughs)…and I was like ‘don’t moan ‘cause you won’t get that tomorrow, seriously, I’ve had a really hard day…but it just, it just depends on how much time you’ve got, but I do like cookingParticipant 9: Well I’m not a very good cook, but my husbands a chef, so (all laugh a lot) so I don’t need to learn how to cook…

Family situation (convenience)

Participant 10: that’s kind of, the routine I’ve got into, now, but when I go back to work, I think it’s gonna be a bit more difficult and, er, having that time when they’re like, say, five, six’o clock and they’re wanting attention and you can’t just sit all happily in their bouncer while you’re trying to chop up everything…it’s like, umm, yeah (pause) so I think, it’s, it’s great when you’ve got the time, but I think going back four days a week, I’m gonna have to change up how I do it, I still wanna be planned, still wanna be healthy, but it is, always, sort of time conscious as well, so…it’s working for now, yeah…

Family situation (convenience)

Researcher: So, time is an issue for everybody else?(All nod, agree and say ‘yeah’)

Family situation (convenience)

Participant 8: I think, with me, (name of child) is my first…I haven’t got, sort of the experience of juggling, sort of, (name of Participant 7) has got all the kids (long pause)…but yeah for me…it’s…I struggle sometimes I think…’cause like you say, the time as well of, (pause), she’ll go down for her nap, say, at three and get up at five, and then it’s like (pause) trying to sort tea out

Family situation (convenience)

100

and…juggle everything…but usually I’m cleaning or trying to prepare food, knowing that, she’ll get up, or…

Participant 11: But yeah, if tea’s not ready then she, like, she hits like the snack cupboards and crisps and like, just anything she can get her hands on, so, I have to try and think and have hers ready, but then I don’t tend to want to eat until about five, six o’clock, so, there’s that issue with timing really…she’s very impatient (all laugh)

Family situation (convenience)

Family preference for unhealthy food

Participant 9: Er, no, it is sort of for him because he gets home from work at sort of, five o’clock and wants to see (name of child) before we obviously bath him ad put him to bed, so I’m like, I want my tea, ‘cause I’m starving and he’s like, ‘I want to spend time with the baby’ so, really like, I should learn to cook but (all laugh) that would probably solve everything (all laugh) but, no (all laugh)

Family situation (convenience)

Researcher: Okay, so, as far as healthy eating in general, is anyone aware of, or, been in receipt of, any healthy eating messages or support?

(Five second pause)Participant 8: (Says quietly) umm, only, slimming world really…

Limited guidance around healthy food/diet in local area

Participant 10: Yeah, no, I’ve not seen anything, locally, supportive…

Limited guidance around healthy food/diet in local area

Participant 10: when you go to Slimming World you’ve got to pay subscription haven’t you and (pause) everything to try and be healthy and keep yourself motivated… when you’ve got a baby, your restricted in

Low affordability of available weight loss groups

Family situation (convenience)

101

what you can do…Participant 10: I think maybe if, umm, I don’t know who would provide it, but, like, ideas on recipes and umm I think Sainsburys used to do, a while ago, like, little cards didn’t they (all Participants nod and agree), so you know, its things like that you know, you could, you could pick up from places and it’s just, ‘cause you get bored of having the same stuff, so if you’ve got like ideas and recipes, you haven’t got to think about it, for, you know, even here, or the doctors or, wherever it is, just that more promotion about it, and umm (pause) ideas for recipes for me is a big thing, because I’ve got no imagination when it comes to food…

Participant 11: It would be nice if you could go somewhere and do like a little bit of a course or something… I heard someone talk about cooking on a budget… I’d be interested in that…’

Participant 10: But you know, just sort of like, simple meals that you could, like, not basics, but you know, say, like, six, say like meals to make over six weeks or something, you know, just to give you a little bit of, experience and ideas…

Participant 7: Cooking on a Budget’, which obviously, it says it in the title…giving you ideas and showing you were to do it and, you know, where to get it cheap…which would be good, I’d be interested in that, I just never heard owt about it, like…apart from that

Limited guidance around healthy food/diet in local area

Participant 8: Yeah…I think it’s like (short pause)…that’s what it is,

Limited guidance around healthy food/diet in local area

102

‘cause, I watch a lot of cooking programmes and always look at stuff and think, ‘awh, that looks dead nice that’ and then they give you the list of ingredients…

Participant 7: The amount of stuff you have to get…

Participant 8: It’s like fifty things, and I’m sorry but…

Participant 7: Like Jamie Oliver, I’ve got a load of his books…and there is just too many ingredients, it’s just silly…Participant 10: That’s it, like, ASDA doesn’t do that sort of stuff…Aldi certainly doesn’t…and Aldi is so basic…

Low availability of healthy food locally

Participant 7: if they did something like that (healthy cookery sessions/cooking on a budget), I’d definitely be up for it…I think it’s just probably…having enough…cookers…or ovens, or whatever you want to call it, to be able to offer it to a group of people, ‘cause I know in the kitchen here they’ve only got one of them so they wouldn’t be able to do it for everybody to participate, but (pause), I’d definitely be interested in it…

Limited guidance around healthy food/diet in local area

Participant 10…can’t think specifically, but I think generally, umm, you know, being able to get fruit and veg, cheaper, makes it more accessible for people, because, before, if it was cheaper to buy a ready meal, that probably wasn’t as good for you, but now, it’s more, you know, more reasonable to get the fresh fruit and veg, umm…that, that to me has been really good…ummm…but then, the other thing was the shop…being close to and the closest shop being quite expensive…if you wanna walk to the

Locations of shops

Low affordability of healthy food locally

103

nearest shop, there is really limited options there…so, that for me is a big thing…

Participant 7: They do have quite a lot of selection I think…they’re just so expensive…because you know, if you want it, pay for it…

Participant 10: I went in there, I think a few weeks ago to get quinoa because that is something that I use quite a lot and that was about…three pound eighty in there…but, you can’t get it Aldi, but, you can’t get it in Aldi…

Participant 10: So yeah, so those, those things that are not your sort of, run of the mill…umm…they just capitalise on the fact that, that we’ve got a captive audience in the local area…it’s convenience and they can charge what they want…it’s not necessarily…the right thing…

Low affordability of healthy food locally

Participant 8: I used to, I still but some for, my other half when he goes to work…he tends to sort of still have ready meals and things like that…but its stuff like that, its all processed stuff, that I probably shouldn’t, put’s your shopping up, like when you get to the till, you know, it’s all like, your ready-made pizzas and the er…you know…all the rubbishy food…that I can’t eat (laugh)

Family preference for unhealthy foods

Family situation (convenience)

Participant 9: Er, I used to, like, with my husband being a chef, he used to work until eleven o’clock at night, like in his old job, so I would have to have like ready meals myself (lots of laughter)…’can you make me tea before you go’…(lots of laughter)…but now he’s got like this new job, he’s home at five every night…we don’t any more…

Family situation (convenience)

Participant 7: they do like a meal Affordability of unhealthy food

104

deal in ASDA, have you ever seen it?, (all agree)…is it, main, side and pudding six fifty…it’s, it’s really good ‘cause it’s really good value and it’s for a family of four and it works really good for us, and you can get like a big lasagne, or a carbonara or, umm, they do hunters chicken, there’s quite a few, like, different options…then they have like veg, potatoes, or garlic bread for side and then there’s a fruit dessert…I think that that’s like really good value, but, I wouldn’t have it every night of the week, just because, it’s probably not very healthy

Family situation (convenience)

Participant 10: It’s all coming out now! (laughs)…yeah, so we get that on the weekend and that, that’s basically ready meals…it’s the main, side and dessert and it is, a weekend treat isn’t it (everyone nodding)…and you can just do that and its easy, you can just pick it up and chuck it in the oven, so…

Family situation (convenience)

Participant 11: I guess, occasionally, like a takeaway…you know, just, if you can’t be bothered cooking, or…umm…my daughter demanded Dominoes or whatever…I don’t eat Dominoes, I don’t like it, but…

Participant 8: No, Dominoes is nice…(laugh)

Participant 11: But no, she seems to like that so, then, I’ll maybe get a Chinese or something…(short pause)

Participant 10: Dominoes is definitely a hangover…type food, like, can’t be bothered to cook, like, stodge…(other participants agree)

Participant 7: Dominoes, really, is the only take-away that I enjoy…I’ve

Family situation (convenience)

Family preference for unhealthy food

105

had like Chinese and Indian and stuff and I just don’t…no…Participant 8: Dominoes is just too easy for me, ‘cause like, I had the app, and I would just order it lying in bed…(all laugh)…(All participants nod, agree and Participant 11 says ‘yeah, me too’)but yeah…pay for it online…literally, five buttons is all it takes…all you’ve got to do is open the door…

High availability of unhealthy foods

High access to unhealthy food (locally)

Participant 7: They never work though, do they?...the deals don’t work…like…for us…we got one at weekend, that’s why I know (all laugh)…family deal, family deal, ‘cause we started Monday this week, didn’t we (to Participant 10)…erm, family deal, I think it was one large pizza, two personal pizzas which were really small ones, and, a tub of ice cream…we weren’t bothered for ice cream, but I like chips…I wanted chips with it and they don’t include that on the offer…

Family situation (convenience)

Family preference for unhealthy food

Researcher: And your experience of ordering online is:

Participant 10: It’s just too easy…

Participant 8: It’s far too easy…

High access to unhealthy food (locally)

Participant 10: They know what they’re doing…lure you in with the deals, and, make it easy to order it…save your details (all nod and agree)…

Participant 7: They put flyers through the door at mine, I don’t know about you guys, but I get flyers all the time with deals (all nod and agree)…

Participant 10: Yeah, do you get text messages…

Affordability of unhealthy food

High access to unhealthy food (locally)

High availability of unhealthy foods

Participant 9: There’s a chippy in Merdishore that we go to all the

High availability of unhealthy foods

106

time…Participant 8: Yeah, I think there’s quite a lot, the Old Town is full…Participant 7: Yeah, the Old Town, I don’t really know the Old Town…Participant 8: The Old Town is full…Participant 10: We’ve got, er, we’ve got a fish and chip van that comes into the village, yeah, it’s like the back of the, umm, back of the church, er, that does the preschool, and er, every Friday, from five thirty to seven thirty it comes and everyone, there’s just like, for the whole village (lots of laughs)…it’s just like, fish and chips, yeah, it’s just like one of those catering vans…and you go…’oh yeah, it fish and chip Friday’ (laughs)…Participant 8: Yeah, ‘Just Eat’s not great for…if…there’s stuff that we’ve got…the Old Town is full of…

High availability of unhealthy foods

Participant 8: The Old Town is full of them, yeah…Participant 11: There must be at least five…chippys and Chinese…Participant 8: There’s about six or eight kebab, pizza places, yeah, there’s the Indian (pause)…I don’t know if that Italian places does takeaway or not, you know, where (name of place) used to be?...I can’t remember…Participant 11: Yeah, they’ve got a new Tapas restaurant haven’t they?Participant 8: Yeah, there’s a Tapas place as well…they’re all very samey…erm…but yeah…I think the Old Town is pretty much, just, kebab shop, charity shop, chippy (laugh)…kebab shop, charity shop, chippy..(all laugh)

High availability of unhealthy foods

Participant 9: Er, not in the Old Town, but, there is one in (name of place) that we use quite often…Participant 8: That’s nice that one in (name of place)…Participant 9: Yeah, I pretty much

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go to that one every Saturday (all laugh)…Participant 9: Every Saturday, ‘cause I get a weigh in on a Saturday morning (laughs) so Saturday, I’ll like, pig out all day (lots of laughter)…but yeah, pretty much every Saturday night we’ll be at the chippy, or, KFC or something…

Preference for unhealthy food

Participant 8: I eat out more, while I’m not in work actually…I’ve noticed, sort of, while I’m still on maternity leave, ‘cause sometimes…my family will work shifts…or…don’t work…and…there’s quite a lot of people around me who are free during the day, so I do a lot of sort of…’out for lunch’…erm…and my sister works at the (name of café) down the road, and she makes all the cakes, so often it’s like ‘oh, I’m finishing at four, do you wanna come down’ and she’ll buy me, like dinner or tea, ‘cause she gets fifty percent off…so for me, it’s like…something to do at the moment…Participant 11: yeah, I get what you’re saying to be honest, I’ve just…gone out quite a lot when I’m off…it’s just that, like a treat, or a reward, like, I’m trying to like be healthy, but, so I think there should be at least one day, like once a fortnight when I can just eat what I want…and I don’t have to be thinking, oh, how many calories is in that or anything like that, so I just tend to just have it as a day off from the healthy stuff (all laugh)…

Family situation (convenience)

Participant 11: For me, it, there are just so many mixed messages about what’s good for you, and what’s the right things to eat and the wrong things…it’s always changing…erm…so…I always try and like follow, what, they sort of say is the best thing, but, erm, sometimes, it’s just

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so confusing that…Participant 9: Did you see what they said the other day, like, that low fat diets are bad for you?(All talk at once and agree)…Participant 11: That’s what I mean, yeah…like, low carbs aren’t they? Low carbs and er, yeah…Participant 10: There’s always something, isn’t there?

Participant 11: ‘Yeah, everything you gotta pay for…when you go to Slimming World you’ve got to pay subscription haven’t you…’

Low affordability of available weight loss groups

Participant 8: yeah, I mean, I don’t pay too much attention really to (short pause)…the latest thing that’s being said…erm (short pause)…but yeah, I can see why people just don’t have a clue what they’re supposed to be eating or not, like ‘we should all be eating this’, or ‘we shouldn’t be having more than this because it causes this’…(short pause)…you know, at one point, it was ‘you should be drinking a glass of red wine a day’ it was good for you and then it’s not and then it could be this…(lots of laughter)

Participant 8: It’s probably all wrong (laughs), but yeah, it’s stuff like that, like when I see it I just sort of think ‘oh, okay’…and then just carry on as normal…I then don’t eat more of it or less of it…it’s just another one of those things, they’ve just now, thrown out there, so…

Confused guidance around healthy food/diet in media

Participant 8: I think just because it changes, what it is, and I think it’s like a constant scare mongering I think…Participant 9: yeah…Participant 8: It’s never any good messages, it’s all like, ‘you need to stop eating or drinking this because it’s bad for you’…and it’s like,

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everything is bad for you and you know, I don’t like drink or smoke or anything, and I don’t drink heavily, but I can just imagine people who, you know, do smoke and do like to drink every weekend, and, I can’t have this and I can’t have that and I can’t have that…(four second pause)…I think that’s what it is, and like, how people put up with, all these different, they’re on about five-a-day and all of a sudden it was supposed to be seven-a-day?...

Participant 11: But they say five-a-day, but if you ate five pieces of fruit, that wouldn’t be particularly good for you because, it’s too much sugar…Participant 9: ‘Cause yeah, you’re not supposed to blend them, are you?...because they say it’s good for you, but if you make a smoothie, it’s too much sugar and that’s fattening, so…Participant 11: You can’t win, can you?Participant 9: You might as well just go takeaway (lots of laughter)

Low awareness of healthy food/diet

Confused guidance around healthy food/diet in media

Participant 8: I think as well, you see a lot of, erm, I see, I see a lot of it on Facebook and that, people, when you put like tables up, of, you know, British, Italians, Chinese and then it says what kind of things they all eat and, you know, how everyone is much more healthy than us, but the Italians have olive oil on everything and you know, they have this and this and this and we’re fairly sort of strict on what we can and can’t have, but we’re one of the…unhealthiest…nations (all Participants nod and agree)…

Low awareness of healthy food/diet

Confused guidance around healthy food/diet in media

Participant 11: I think like the new, the traffic light, traffic light on labels is more helpful (all participants nod

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and agree) and they were on about, like, putting sugar cubes on things, like, cereals and stuff, ‘cause, you tend to think cereals and stuff are healthy, but, a lot of the time, they’re like, really high in sugar, and if, they would like, actually put, how many cubes of sugar on, you would definitely probably not buy, a lot of the things that have been sold, so I do think, more clear labelling…(all participants nod and agree)…you know, it might not be good for the actual retailer, but, um, for the people buying it, that perhaps don’t read the labels and thing, it’s a lot better, you know and clearer and I think, that would be a lot more helpful as well…Researcher: Yeah…does anybody else think that as well?Participant 7: I do, ‘cause yeah, I don’t read labels…I don’t…look at something and think ‘how many calories’, ‘cause it don’t mean owt to me…we did it yesterday with snack-a-jacks (laughs) but it honestly does not mean anything to me…I know…what I’m allowed to…you know…what, I allow myself to have…but…if you saw a drink that had three sugar cubes and a drink that had one, you’d obviously go for the one that’s got one…’cause some of the stuff like those Innocent Smoothies, that they make out are really good for you and they’ve got all your…daily amounts in…and they’re super expensive…but actually, it would be quite bad for you…erm…there’s…you just don’t know what you should be having and what you shouldn’t…apart from water…people just drink water (laughs)

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Coding on Transcript 4 (Widnes):

Barriers to accessing a healthy diet

Data Barrier Code(s)Participant 12: There’s not many…healthy foods available…(Researcher: Okay)…it’s more, like, junk foods and….

Low availability of healthy foods locally

High availability of unhealthy foods Participant 13: You can just go to the local shop and buy, like, chocolate…for…cheap…and you don’t see many local shops with fruit and veg in…and…stuff like that…

High availability of unhealthy foods

Affordability of unhealthy foods

Low availability of healthy foods locally

Participant 13: Yeah, like, my local, like, small supermarket, you know just to nip somewhere, is just the Morrisons, just on, (name of street), and it’s like, slim pickings…so…if I just

Low availability of healthy foods locally

Location of shops

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need to nip to get something…it’s…it’s quite difficult, so then you have to make like the, the effort to go all, like, the way into town…(short pause)…it’s, it’s not as inconvenient for me ‘cause I drive…

Participant 13: Umm…but…yeah, I mean like, it’s more convenient to go to like, McDonalds…just to pick something up for yourself…especially when you got a baby and you…need to, be quick and, in between feeds and everything…it’s more convenient to do that than to go to the supermarket to pick up…whatever you need, you know, like to make a full dinner…

Family situation (convenience)

Participant 13: and you know, like, it, it’s quite dear as well, if you want, like, the organic stuff and, and stuff like that, it’s quite dear…

Low affordability of healthy foods locally

Participant 12: Umm, me, no, I have to go into town…I shop…but it’s like getting the bus with a three year old and the pram…and all the bags, getting them back home…and, it’s quite…inconvenient…

Lack of car

Low convenience of public transport (with family)

Participant 13: Getting to the shops isn’t that…isn’t too bad…it’s fine…it’s a, it can be a bit of a pain at times, especially when you’ve got, a crying baby, ‘cause (name of child) is only, three months old…(short pause)…getting round the shops with a pram is really (laughs) difficult, is what I find (Participant 12: Yeah, I agree with that one)…yeah, and even like though, you (looks at Participant 12) get the bus, even just like, lugging the carrier bags back to the car, isn’t as…as easy as…as you’d think…

Low convenience of public transport (with family)

Participant 12: And you’ve gotta fold the pram down, with mine being a toddler, you’ve gotta fold the pram down, put that into your shopping trolley so then you’ve hardly got any

Family situation (convenience)

113

room…to put you groceries into…but like, a screaming baby in the front kicking off and yeah, its, its hard work…it really is…Participant 12: If…if I take the pram with me, it’s, it’s really hard, you’ve got to wait for two buses to pass…’cause there’s either wheelchairs or prams on the bus and you can’t get your own pram on the bus…and, my daughters autistic as well, so sometimes, I have to put her in the pram to physically take her out anywhere ‘cause she won’t walk, or, Researcher: Okay…Participant 12: So it, it makes it hard work, you have to wait for like, two buses…you have to wait for an empty bus then, so, your stood for like half an hour, forty five minutes…just…waiting…

Lack of car

Low convenience of public transport (with family)

Researcher: Fair enough…(laughs)…so, you said as well about, the McDonalds…umm…is that the only fast food place nearby?...Participant 13: No…Participant 12: No…there’s KFC and there’s subway at (name of place) as well…

High availability of unhealthy foods

Participant 12: There’s also, umm, a chippy up, there as well, so it’s more convenient to go up for fish and chips rather than…cook…a healthy meal…

Family situation (convenience)

Researcher: Okay…is that something you do quite often?(Three second pause)Participant 13: I’d like to say no, but…(short pause)…sometimes, yeah, it is…’cause it is, it’s just easy…Participant 12: and there’s also the ‘Just Eat’ app on your phone where you can just, order pizzas and stuff…it’s, it’s just convenient…(short pause)…I’d rather eat a healthy meal, but, when you’re so busy, it’s just more

High access to unhealthy food (locally)

High availability of unhealthy food

Family situation (convenience)

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convenient to order fast food…

Participant 12: Yeah, in the local area…you can get it delivered…and it’s…it’s easier…

High access to unhealthy food (locally)

Participant 13: Wh, when you, when you go to buy to buy like healthy food, it’s not as if you just pick up a meal, like, you have to buy all the ingredients to it so…you end up obviously having, like, extras left over, but you can spend like ten pound on just getting like, chicken breast and some, some veg and stuff and fruit in the house…you can end up spending like a tenner…or you can go to like, McDonalds for like a couple…a few quid can’t you, so…it is that…like you obviously end up having stuff left over, but then it’s like…are you always gonna have time to re-use the stuff that you’ve got left over?…

Low affordability of healthy food locally

Affordability of unhealthy food

Short-shelf life of healthy food locally

Participant 12: …and it ends up going mouldy in the fridge…the back of the fridge, it ends up going…mouldy and stuff…

Short shelf-life of healthy food locally

Participant 13: Yeah, I think like, the supermarkets, except for Aldi (Participant 12: yeah, I was gonna say, Aldi, yeah)…the fruit and the veg goes off so quickly, you get a day or two out of it, once you used it once, if that…

Short shelf-life of healthy food locally

Participant 12: There’s only Aldi that’s really cheap for the fruit and veg…you can get like…umm…a punnet of strawberries…for a pound in Aldi…but you can go elsewhere and you can pay like two pounds, two pound fifty for a small box of strawberries, so…

Low affordability of healthy food locally

Researcher: Okay…is Aldi somewhere you shop…quite often?Participant 12: Er no, it’s, it’s inconvenient for me ‘cause it’s on the main road and then again, it’s getting across the main road to…get into the shop…

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115

Participant 12: It’s alright if you’ve got a car, but the bus…you’ve gotta get off the bus and then you’ve got to try and cross, a busy road and…

Location of shops

Low convenience of public transport (with family)

Participant 12: Especially when you’ve got a pram and you just think it’s easier to go to ASDA or Morrisons, ‘cause it stops…right outside of them…

Family situation

Low convenience of public transport (with family)

Participant 12: Yeah, yeah, I agree with that…(short pause)…but, it’s the convenience again of getting to Aldi for me…’cause I don’t drive or know anyone that does drive…so it’s always gonna be, public transport…

Location of shops

Participant 12: They have the same foods, but, it’s dearer in price…I think…it’s like my sister in law went for a chicken in Aldi last week and she paid the same price, but it was, a really large chicken…I went to ASDA and I think I paid…five pound odd and it was only a really small chicken…so for the same price she got extra and it…fed the family…

Participant 13: Yeah, I, I agree with that…like I find that I can do a full shop in Aldi, get all like, my fruit and my veg and my chicken and, you know, all my meat and stuff…and it’ll come to like, twenty five pounds…but if I do that in like, Tesco or ASDA (Participant 12: It’s like forty pound)…you’re looking at like, forty fifty pound…Participant 12: Yeah…Participant 13: There’s a…there’s a massive difference in the price…I find…

Low affordability of healthy food locally

Participant 13: It’s not too…bad for me ‘cause I drive, but…(short pause)…but it is, it’s either, I go to the Morrisons down the road, or, I have to go into town…it’s just not always

Location of shops

Lack of car

116

convenient, and I think, the supermarkets in town are very clustered…(Participant 12: yeah)…and I think it would be better if they were more sporadic…(Researcher: Okay)…erm…my mum lives in (name of place) and they’ve got three Aldi’s in (name of place)…that er…one’s local to her and then there’s two in two different parts of the town…so I think like…it’d be…it’d be better just to…just to scatter the supermarkets around a little bit more…

Participant 12: Make the prices cheaper (laughs)…even if you just go to the local Co-op on, (street name) there (points to the road)…it’s, it’s dear to go in there…(Researcher: Okay)…to, to get anything, so, it, it is actually easier to go into town but then, it’s not if you’ve got a pram and…

Participant 13: I find that the local shops are more expensive than the ones in town as well…(short pause)…they don’t have like offers on (Participant 12: No)…whereas if you go to like ASDA, and get…tea for two of whatever, they don’t really have that…

Low affordability of healthy foods locally

Location of shops

Low convenience of public transport (with family)

Participant 13: It’s more like…you can get like your…what I find, they don’t do much own brand…so if I was to get like, a box of cereal, I’d always get like, Tesco’s own or, whoever’s own…it’s the same and it’s cheaper…but if I needed a box of cereal from Morrisons…it’s Kellogs, and, you pay like three pound for a box of cereal…erm…everything is branded…it’s nothing own brand…(short pause)…is what I find and, it is…like…it’s a lot smaller amount of stuff…you can’t do a full shop in your little Morrisons Local up there…it’s just bits of you need bits…

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117

Participant 12: yeah, I’m the same…even the milk prices…you can pay, like, a pound in the local shop and going to the Co-op it’s like, one pound thirty, I know it’s only thirty pence extra but…it’s still thirty pence

Participant 12: Erm, they, they have actually got a new butchers, but that is, getting into town again and it is quite cheap…it’s facing Morrisons and you can get like, a selection of meat for twenty pounds…and you get loads on it…or you can get the smaller selection for five pounds, but again, it’s getting into town…and he does all the fresh eggs and…stuff like that…it was actually getting into town to get to the butchers…

Location of shops

Participant 13: Same, like, we have, we use a butchers down in Ditton and, but, it’s alright for us ‘cause we drive…so it’s not…so inconvenient…but the only other places really that you, if you wanted fruit and veg is, is in the market, but I, I don’t go there personally…Researcher: Is there a reason for that, or…Participant 13: I just don’t (laughs)…Researcher: Fair enough (laughs)…how about yourself (to Participant 12)…do you use the market?Participant 12: yeah, I’ve used the market but…(short pause)Researcher: But not something you use…Participant 12: No, not something I use regularly…Researcher: Again, is there a specific reason for that?...Participant 12: Inconvenience, basically, yeah…

Location of shops

Participant 12: Maybe, like, umm, the local butchers could start delivering

Lack of car

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and stuff…and that would be easier…for people…who don’t drive…

Participant 12: I mean, ASDA do deliver online, but, they charge extra, for the delivery, so, it’s if you’ve not got…the extra money to pay…Participant 13: You have to wait as well…like a day…Participant 12: If you order it, you have to wait ‘til the next day for it to be delivered…

Participant 12: It is great, but, it’s just waiting and paying the extra to do it…

Low affordability of healthy food locally

High cost of online orders

Researcher: Okay, so umm, cooking…you mentioned briefly about buying fresher foods and the quality, that they go off quickly…are you both confident cooks?...is that something…Participant 13: No (laughs)

Participant 12: I can cook certain meals, but I can’t cook everything…

Low awareness of healthy food/diet

Participant 13: I, I, I…it’s not that I can’t cook…I don’t enjoy it so, I won’t do it, but, my husband cooks, he, he does all the cooking…erm…we do try to cook a meal…but…you know, every night…erm…but obviously he works in the day, so, when he’s finished work, if he’s had like a bit of a rubbishy day…he doesn’t want to then like, cook, cook a full meal so then sometimes we’ll go out, for something to eat, erm…but yeah, we’ll, we’ll, he’ll cook something, all sorts…lasagnes, burritos, pastas…like…allsorts…

Family situation (convenience)

Participant 13: I’ve always said, when I was…when I was little, my mum, never really cooked…once, like, my mum went back to work and me and my sister were older, it tended to be like…whatever you can throw in the microwave…and I, I always thought that cooking is something you were

Family situation (convenience)

119

taught, from, your parents and…I wasn’t…so…that’s why I think…I am and…I do, I will cook, I just…I’m not very good at it, so then, I won’t do it (laughs)…that’s all (laughs)

Participant 13: In our household, because my husband my earns over so much, we’re, pretty much left on our own devices…Participant 12: I think that’s, that’s wrong…Participant 13: And…granted, yeah, he does earn…quite a bit of money, but, I’ve gone from ‘x’ amount…pound a month, to…three hundred…er, five hundred and something pound it is, for maternity leave, which is like, less than half of what I normally take home…(short pause)…I know, obviously, I’ve got my husband to help out, but that…he pays for, like, a lot of the bills and the mortgage and everything, so, whereas, like, they’ll, they’ll…the milk tokens, could just help a bit…but…I understand…why I’m not allowed them…but sometimes it’s just…a bit of a kick in the teeth at times…Participant 12: Yeah…I agree totally with that one…I think you should get it just for the children…just so they can get the fresh…milk and veg…’cause it’s not always, you can’t always afford it whether you work or not…and it’s…it is wrong…

Low affordability of healthy food locally

Participant 12: Umm, it’s just like, the GP, giving advice and then I go and get weighed by the dietician and…she’ll give me advice and support of, what to eat and what not to eat, but again…you don’t always listen and prefer the junk food…

Preference for unhealthy food

Participant 13: I’ve not personally had a…well, I’m not aware of anything to be honest…like, if I asked the health visitor…I see them, they’ll point me in the right direction, but, no one’s put

Limited guidance around healthy food/diet in local area

Low affordability of available weight loss groups

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their hand out to say, you know ‘if you need any help, or support with this, this is where you’d come’…like I wouldn’t know there was a dietician at the doctors…or…anything like that (Researcher: Okay)…so…the only things I know of, is like, the likes of Slimming Word… Participant 12 nods and agrees)…there’s like, plenty of them, knocking around Widnes…but then you’ve got to pay, like, so much…’

Participant 13: Erm, but I do it online, ‘cause, the one by mine, it’s in the morning, which is fine…but, if it’s in between the feeds, it’s not as easy for me to get to…so I do it online and its, its £60 for three months…and then you get like…what you are allowed to eat and all that…it’s worked a little bit, but, I’m not as committed ‘cause I don’t have to go and get weighed in front of people (laughs)…do you know what I mean…erm…but, yeah…it’s alright…

Family situation (convenience)

Participant 12: That’s why, I, I like the dietician, because, it’s confidential and, there’s the one-to-one support and stuff…but, I don’t think many people know about it ‘cause, they’re not putting themselves out there if you know what I mean…the GP refers you so (Researcher: okay)…it’s not like their putting themselves out and…advertising really…it’s just…through the GP…

Limited guidance around healthy food/diet in local area

Participant 13: I think if someone even said, like, ‘I’ll give you a cooking lesson’, I probably would (laughs) go, ‘cause I’d make a show of myself…personally (laughs)

Embarrassment to attend cooking class

Participant 13: I’m not sure, whether like, the Children’s centres do, healthy eating…(two second pause)…kind of

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like…(two second pause)…not lessons, but, you know, talks…but, it’s not as advertised…Participant 12: Umm…they do do, very basic cooking lessons, but, they can only do very basic ones in Ditton because of the facilities…so umm…you can book onto the courses…but only like, five people at a time…but it is, very very, going back to the basics…

Participant 12: Just…with it being a very small room as well, you do feel a bit, claustrophobic and…(Researcher: Okay)…and, there’s only five in there…but it’s a really really tight space, and…

Low quality of sessions available

Participant 13: It’s not so much an issue…its more just…(short pause)…eating the right foods and…and the right things can be brought…but it is, getting to the supermarkets and buying them, sort of thing…(short pause)…but it’s not, anything in particular that needs to be eaten, it’s just, getting the correct things…

Location of shops

Participant 12: Again, it’s getting to the supermarket…(Research: just as a general..)..yeah…(short pause)…I will admit, sometimes I have just brought microwave meals for convenience…even fed my daughter them and…I don’t think that I should have to do that…Researcher: Okay…Participant 12: I prefer the fresh fruit and veg, but, it’s getting to…get it…

Location of shops

Lack of car

Participant 13: Er, we’ve only just got a microwave so (laugh)…er, we do try…we will…cook…or I will cook…but I mean it’s, it’s the more, like snacking, you know…just to get yourself through the day…it’s easier to pick up like a bag of crisps or a chocolate bar, rather than some like…dry…cashew nuts, or, something like that (laughs), so you

High access to unhealthy foods

Preference for unhealthy foods

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know what I mean…but yeah, erm, you don’t get, you don’t like, enjoy it as much, like, I’ll find if you eat it, you’ll eat more, you’ll think, ‘oh, I don’t like this, I’ll have that packet of crisps anyway’…that’s, that’s…it more easier…(short pause)…it’s just convenience…

Participant 13: I think what could be handy…and, I, I don’t think that they do, but like, I’ve seen…(short pause)…I went to Tescos the other day, and I was, I was at the fish counter, and at the side of the fish counter, they had like a small recipe to make like…(short pause)…something, with the fish in…like if…they should have like recipe cards, you know like, by like, the chicken, so you could make like…(short pause)…chicken paella for example…or, you could make a chicken vegetable casserole, you know, like something…that is healthier…that it’s not like, chicken and chips or, you know, in the, in the fruit sections, they have like, you can make something with all these fruits…just so then you like know…what to and…how to…

Limited guidance around healthy food/diet in local area

Participant 13:…so then you’ll know, ‘cause sometimes you walk around the supermarkets…and you just don’t know what to get…(short pause)…we’ve, we’ve tried to have like a food rota, as such, so we know when we go to the supermarkets what to buy…and not everything goes to waste…erm…but I think it would be handy if they could do something…like, like that…’cause it easier to just to throw like a microwave meal in the, in the microwave…or they do like oven ones now aswell…it’s easier to do that, than to get all the ingredients to make like, an actual meal…but I know that they put, a lot of, nasties in it…to keep it…Researcher: Okay…is that something

Limited guidance around healthy food/diet in local area

Family situation (convenience)

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that you…Participant 12: Yeah, yeah, I agree with that, ‘cause, the additives and the e numbers in…ready meals…are, a lot…rather than what you get in your fresh…you know you’re getting it fresh…Participant 12: Teaching the children more about healthy eating, ‘cause I know a lot of children do prefer the junk foods now…mine included…and if you put a piece of veg in front of her, she’ll be like pushing it away…but if you put a piece of veg in front of her and a cake, she’d go for the cake…so I think it’s more about teaching your children about healthy eating as well and why…it’s important to…eat healthily..

Limited guidance around healthy food/diet from schools

Participant 13: I think it’s a lot to do with how we live now, when I was younger, we’d have McDonalds, like, every once in a blue moon, ‘cause my mum and dad couldn’t always afford it, and I think it’s, it’s, it’s, that and now like…(short pause)…there’s a lot more access to money than what there was, when I was little…and I think that that’s it…when I had McDonalds it was like a treat…whereas now I have, like, ‘cause I have like my two nieces, it’s…it’s kind of normal for them sometimes to have that…erm…and I think it’s a lot to do with, how we live now…rather than…Participant 12: Yeah, and when you’re passing them on the bus, my daughter will point and she’ll say ‘oh, McDonalds’…and she knows it McDonalds or KFC, on the other side and there is a lot of fast food…Participant 13: Yeah, it is and like, when my Mum had, my brothers and sisters, she did have to cook a meal every night ‘cause, well, you didn’t have a microwave did’ya? So you had to go to the supermarkets and buy the

High availability of unhealthy food

Affordability of unhealthy food

High access to unhealthy food (locally)

Preference for unhealthy food

Family situation (convenience)

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meals and…I think…it’s a lot to do with…how we live…now…not…(three second pause)…it is obviously access and everything else, as well, but, I think that’s a big thing…we’ve gotten lazy as we’ve…as we’ve gotten older, sort of thing…Researcher: Okay…

Participant 12: Yeah, it is, I think it’s…lifestyle change…with all the obesity and stuff like that, in children…because of the fast food, convenience…rather than paying for, the fresh…yeah, I think it is

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Appendix 8. Spider diagram: Formulating themes from codes during thematic analysis

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