food shopping patterns in rural appalachia: the

FOOD SHOPPING PATTERNS IN RURAL

APPALACHIA: THE ENVIRONMENTAL

CONTEXT OF DIETARY BEHAVIOR

141

ST APHA ANNUAL MEETING ∙ NOVEMBER 2013

Mark Swanson, PhD

Christina Studts, PhD

Richard Crosby, PhD

Department of Health Behavior

University of Kentucky College of Public Health

PRESENTER DISCLOSURES

(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

Mark Swanson

“No relationships to disclose”

UK RURAL CANCER PREVENTION

CENTER

The Rural Cancer Prevention Center (RCPC) is a planned collaboration of community members, public health professionals, and researchers designed to reduce health disparities associated with cervical, breast, and colorectal cancer among residents of the Kentucky River Health District in Appalachian Kentucky.

This presentation is supported by Cooperative

Agreement Number 1U48DP001932-01 from the Centers

for Disease Control and Prevention (CDC). The findings

and conclusions in this presentation are those of the

authors and do not necessarily represent the official

position of the CDC.

Food Environment and Health

• Food environment increasingly recognized as major influence on diet and health

• Several studies link food access to health

• Both IOM and Healthy People 2020 call for interventions to increase the access of healthy foods to more Americans

• Particular challenge in rural America

• Many areas are food deserts

• Time, transportation costs may make food access even more challenging

• Period of rapid change in retail food environment

• Consolidation within retail grocery industry

• Growth of superstores in grocery sector

• Rapid increases in numbers of farmers markets

• Interventions at convenience stores, esp in urban areas, widespread

The Appalachian Food Environment

• Central Appalachia characteristics

• Persistent poverty

• Limited transportation access

• Low FV consumption

• High obesity/overweight

• Significant health disparities

• Food deserts in Appalachia

• Significant portions of the region without healthy food access

Understanding Rural Appalachian

Food Shopping

• Random dial phone

survey (n= 635)

• Completion rate = 26.2%

• Spoke with adult most

responsible for food

shopping

• Series of questions on

shopping patterns,

attitudes, demographics Kentucky River Development District,

Central Appalachia

VARIABLES OF INTEREST

Dependent variable: Store choice for F&V

• Questions on % of FV purchased at each of six types of retail food outlets

• Warehouse/superstore

• Supermarket

• Independent grocery

• Convenience store

• Roadside stand

• Farmers market

Frequency distribution suggested 6 categories

• Supermarket n = 255 (41.1%)

• Warehouse n = 134 (21.6%)

• Supermarket/warehouse n = 67 (10.8%)

• Independent grocery n = 49 ( 7.9%)

• Local foods outlet n = 45 ( 7.4%)

• Other combinations n = 70 ( 11.3%)

VARIABLES OF INTEREST

Independent variables:

• Distance to each type of store (in minutes)

• Factors in choosing a FV source and attitudes about FV availability, cost, and

quality (single Likert-type items)

• Household size and structure

• Demographics – age, gender, income, marital status, education, employment

status

ANALYSIS

• Descriptive data on store use

• Multinomial logistic regression

• Model built based on bivariate logistic associations with p ≤ 0.25

• Dropped “other” category from store categories (n=70). After listwise deletion for

missing data (n=14), final sample for analyses = 621

• Final model explains about 20% of the variance

• Nagelkerke pseudo R-Square = .20, p = .000

• Very similar models with inclusion of more store categories, use of other distance

measures

RESULTS: Shopping characteristics by

store type

Store Type Shop at least monthly

Buy at least 25% of FV at store type

Buy no FV at store type

Mean distance in minutes (SD)

Supermarket 91.5 69.9 15.6% 18.45 (14.73)

Warehouse/superstore 82.8 48.5 32.5% 30.45 (21.23)

Independent grocery store 48.6 14.0 75.3 10.94 (9.19)

Convenience store 37.5 .2 94.7 10.36 (11.62)

Roadside stand 32.2 9.6 72.6 15.49 (12.78)

Farmers Market 31.5 8.3 74.8 17.93 (16.73)

Multinomial Logistic Regression Model

(reference category is supermarket)

Warehouse p OR 95% CI

Minutes to nearest warehouse store .000 0.96 0.95, 0.98

Minutes to nearest large supermarket .000 1.04 1.02, 1.07

Takes own car to store .031 5.25 1.16, 23.77

Local foods important factor in store choice .093 0.66 0.41, 1.07

Employee helpfulness important factor in store choice .332 0.76 0.44, 1.32

Cost is primary FV barrier .515 0.85 0.53, 1.38

Availability is primary FV barrier .006 0.50 0.31, 0.82

Taste is primary FV barrier .339 1.25 0.79, 1.99

Home garden is an important food source .902 1.03 0.61, 1.74



Warehouse/supermarket equally p OR 95% CI










Primarily independent grocery store p OR 95% CI














Local foods outlet p OR 95% CI










DISCUSSION

• Large supermarkets remain the dominant player in the Appalachian retail grocery

market

• Over 90% of households shop at a supermarket at least monthly

• Very few households (15%) never buy FV at a supermarket

• Mean distance to supermarkets less than 20 minutes, even in rural Appalachia

• Proximity and travel are key variables

• Distance (in minutes) to supermarket is important predictor of store selection

• As the distance from the supermarket increases, so do the odds of shopping at

• warehouse store (OR = 1.04; 95% CI: 1.02, 1.06)

• independent grocery store (OR = 1.04; 95% CI: 1.01, 1.06)

• local outlet (OR = 1.03; 95% CI: 1.00, 1.05).

• While these effect sizes seem small, they represent the change in odds for each

additional minute further from the supermarket

DISCUSSION

• Proximity and travel (cont)

• Use of own car also significantly increases odds of shopping at warehouse store (OR= 5.25; 95% CI:P 1.16, 23.77)

• Attitudes about local food near significance as factor in choosing local outlets outlet (OR = 2.35; 95% CI: .98, 5.64).

• What wasn’t in the model

• Demographics

• Income

• Education

• HH structure (presence of children, number of adults)

• Age

• Gender

• Use of government benefits

• Importance of price, freshness, and food safety

IMPLICATIONS FOR INTERVENTIONS

• Distance matters

• Limits potential of farmers markets, other local foods outlets

• Reinforces concept of rural food deserts

• Convenience stores or small grocers as healthy eating partners?

• Similar average distance

• Grocers already selling FV to 25% of respondents, compared to 5% for

convenience stores

THANK YOU!

Mark Swanson, PhD

College of Public Health

University of Kentucky

[email protected]

food shopping patterns in rural appalachia: the

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