An equity-oriented systematic review of online grocery shopping among low-income populations: implications for policy and research
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Special Article
An equity-oriented systematic review of online grocery
shopping among low-income populations: implications for
policy and research
Angela C.B. Trude , Caitlin M. Lowery, Shahmir H. Ali, and Gabriela M. Vedovato
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Context: Online grocery services are an emerging component of the food system
with the potential to address disparities in access to healthy food. Objective: We
assessed the barriers and facilitators of equitable access to healthy foods in the on-
line grocery environment, and the psychosocial, purchasing, and dietary behaviors
related to its use among low-income, diverse populations. Data Sources: Four
electronic databases were searched to identify relevant literature; 16 studies were
identified. Results: Barriers to equitable access to healthy food included cost and
limited availability of online grocery services in food deserts and rural areas. The ex-
pansion of online grocery services and the ability to use nutrition assistance benefits
online were equity-promoting factors. Perceived low control over food selection was
a psychosocial factor that discouraged online grocery use, whereas convenience
and lower perceived stress were facilitators. Findings were mixed regarding health-
fulness of foods purchased online. Although few studies assessed diet, healthy food
consumption was associated with online grocery use. Conclusion: Researchers
should assess the impact of online grocery shopping on low-income families’ food
purchases and diet.
Systematic Review Registration: PROSPERO registration no. CRD: 42021240277
INTRODUCTION diverse communities in the United States,3–5 which are
more likely to be under-resourced, underserved, and at
In the United States, noncommunicable diseases such high risk for poor diet, food insecurity, and obesity.6
as obesity, type 2 diabetes, and cardiovascular diseases Of note, efforts to address income-related dispar-
disproportionately affect diverse racial and ethnic ities in access to healthy food have focused on improv-
groups, including Black, Hispanic, and Native ing the availability of healthy foods at local food
American populations.1,2 Disparate access to and avail- vendors, including the Healthy Food Financing
ability of healthy food, combined with economic in- Initiatives,7 Staple Foods Ordinances,8 and the Healthy
equality, have contributed to health disparities in Corner Stores Initiatives.9 However, structural barriers
Affiliation: A.C.B. Trude is with the Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA. C.M.
Lowery is with the Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. S.H. Ali is with the
Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, New York, USA. G.M.
Vedovato is with the Institute of Health and Society, Federal University of Sao Paulo, Santos, Sao Paulo, Brazil.
Correspondence: A.C.B. Trude, 411 Lafayette St, New York, NY 10003, USA. E-mail: angela.trude@nyu.edu.
Key words: diet, equity, food purchase, low income, online grocery, policy, Supplemental Nutrition Assistance Program.
C The Author(s) 2022. Published by Oxford University Press on behalf of the International Life Sciences Institute.
V
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (https://
creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium,
provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please
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https://doi.org/10.1093/nutrit/nuab122
1294 Nutrition ReviewsV Vol. 80(5):1294–1310
Rto food access remain because households in low- In a previous scoping review, Jilcott Pitts et al22 de-
income communities may have limited access to reliable scribed barriers and motivators to online grocery shop-
transportation and live disproportionately far from ping. However, few studies included in the review
sources of healthy foods, compared with predominantly focused on diverse populations from low-income back-
White and high-income neighborhoods.10 In response, grounds, which are at greatest risk for health and social
there has been an emerging focus on interventions disparities. Furthermore, the Jilcott Pitts et al22 review
aimed at addressing physical barriers to healthy food by was conducted before the implementation of the OPP
bringing food to people, such as the green cart program and the COVID-19 pandemic. Since then, online gro-
in New York City11 and a virtual supermarket in cery shopping has become more accessible and addi-
Baltimore, Maryland.12 Nevertheless, there is a pressing tional studies on the topic have been published. In the
need to expand and refine these approaches. present systematic review, we aimed to synthesize the
Online grocery shopping is a new and growing existing evidence of the perceptions about and impact
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component of the food system that addresses barriers of online grocery shopping on low-income and diverse
related to physical access to healthy foods. In 2018, populations and to identify opportunities to inform pol-
34% of US shoppers reported purchasing groceries icy and promote equity in the online food retail space.
online at least sometimes.13 Of those, 30% were from Therefore, using an equity lens, we examined online
low-income households (< $40 000 annual household grocery shopping behaviors among diverse, low-income
income) and 64% were parents with children.13 In populations and aimed to answer the following ques-
the United States, from January 2020 to January tions: (1) What are the barriers to and enablers of equi-
2021, online retail sales increased by 39%.14 Specifically table access to healthy food in online grocery services?
for families living in low-income areas who may lack (2) What are the psychosocial, purchasing, and dietary
access to grocery stores and personal vehicles,15 online behaviors associated with online grocery service use
grocery services have the potential to address barriers among families from low-income backgrounds?
related to transportation. However, many underserved
families have not been able to realize the benefits of METHODS
online grocery shopping, due to disparities in technol-
ogy access16 and digital literacy,17 limited delivery serv- This systematic review was registered with the
ices,18 delivery and membership fees, and minimum Prospective Register for Systematic Reviews CRD:
order policies.19 42021240277.
The 2014 Farm Bill mandated a pilot program with
food retailers to test the feasibility of allowing the use of Data sources
Supplemental Nutrition Assistance Program (SNAP)
benefits as payment for online grocery orders.18 The Four electronic databases were searched for applicable
ability to use the SNAP Electronic Benefits Transfer articles: MEDLINE, PsycINFO, Web of Science, and
card online may address barriers related to physical ac- Business Source Ultimate, spanning the public health,
cess to healthy foods and the card provides an alterna- behavioral sciences, and business literature. The system-
tive payment method for purchasing groceries online atic search took place from September 2020 through
for low-income households. Additionally, during the October 2021 and included relevant studies on online
COVID-19 pandemic, online purchasing became a safe, grocery shopping targeting low-income families and di-
socially distanced option to purchase groceries, which verse ethnic or racial populations.
motivated the rapid expansion of the SNAP Online
Purchasing Pilot (OPP) to 48 states and additional Search strategies
retailers.20 The SNAP OPP expansion marked an im-
portant change in online grocery access among low- A search strategy was developed on the basis of Medical
income populations in the United States: redemption of Subject Heading terms and information from key
government benefits online increased to 67 times the articles identified a priori.23–25 Boolean operators were
amount of prepandemic redemptions.21 Although in- used to combine keywords and Medical Subject
creasing use of online grocery services has the potential Heading terms for a more focused search. Three topics
to improve access to healthy foods, understanding bar- were developed on the basis of the study research ques-
riers to its use and possible unintended consequences of tion: online, grocery shopping, and low income. Search
online grocery shopping on food purchases and dietary terms included: online, internet, grocery shopping, gro-
habits among low-income and diverse populations is cery purchasing, food, produce, food assistance,
critical for the development of health- and equity- Supplemental Nutrition Assistance Program, Women
promoting policies. Infants Children Program, low-income, racial, and
Nutrition ReviewsV Vol. 80(5):1294–1310
R
1295ethnic diverse groups. The complete search strategy is in its design, conduct, and analysis, and required the
described in Appendix 1 in the Supporting Information following responses for the JBI tool: “yes,” “no,”
online. “unclear,” “not applicable”; and, for the Mixed Methods
Appraisal Tool and Center for Evidence-Based
Eligibility criteria Management’s too, “yes,” “no,” “can’t tell.” The answer
“yes” means that a given appraisal criterion for satisfac-
This review included interventional or observational tory quality was met. The quality threshold was set by
studies implemented in real-world settings, that used the research team a priori, in which studies scoring be-
quantitative and/or qualitative methods, and were con- tween 60% and 100% were deemed of moderate to high
ducted among low-income populations experiencing quality and were included in the review.
food insecurity, participating in supplemental nutrition
assistance programs (SNAP or the Special Supplemental Evidence synthesis
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Nutrition Program for Women, Infants, and Children
[WIC]), and/or racially or ethnically diverse groups. An adjudication approach informed by the theory of
Outcomes of interest included psychosocial, purchas- planned behavior (TPB)29 and health equity frame-
ing, and dietary behaviors, or equity promotion of ac- work30 was used for evidence synthesis. Domains for
cess to healthy food in the online grocery environment. extraction included methods and findings related to the
No restrictions were placed on geographic location of 4 pillars of the health equity framework (ie, reduce
studies or the date of publication. Systematic, scoping, deterrents, build community capacity, improve social
or narrative reviews; conference or dissertation and economic resources, and increase healthy options)
abstracts; and general information articles were ex- and psychosocial constructs of the theory of planned
cluded. Study selection was completed using Covidence behavior (ie, perceived barriers, attitudes, social norms,
(Melbourne, Victoria Australia), following the methods and perceived behavioral control), in addition to pur-
outlined in the Preferred Reporting Items for chasing and diet assessment and outcomes. Additional
Systematic Reviews and Meta-Analyses guidelines. The data extracted included target population, model or
eligibility criteria are described in Table 1, using the theory, study aims, target foods and food groups, diet
PI(E)COS (population, intervention/exposure, compari- and purchase measures, sample size, study design,
son, outcome, and study design) criteria. methods, results, equity considerations, quality of re-
search, study limitations, and study recommendations.
Data extraction Meta-analysis was not possible owing to the heterogene-
ity of the study designs, exposures or interventions, and
Title, abstract, and full-text extraction were conducted outcomes.
by 2 research assistants independently using Covidence
with a random agreement of 90%. Two reviewers RESULTS
(C.M.L., G.M.V.) analyzed each study independently.
A third author (A.C.B.T.) was available to resolve Search results
disagreements. Backward reference searching of in-
cluded articles was conducted to identify additional The search criteria returned a total of 1612 citations,
papers. which dropped to 466 citations after the removal of
duplicates (Figure 1). Two additional articles were in-
Critical assessment cluded from the bibliographic review. All titles and
abstracts were screened and a total of 43 full-text
The methodological quality of each paper was assessed articles were reviewed for eligibility. Overall, 16 articles
using JBI’s critical appraisal tools,26 which have pub- were included for evidence synthesis, including
lished checklists for most study types (eg, analytical 4 cross-sectional studies,18,31–33 5 mixed-methods stud-
cross-sectional studies, randomized control trials, quali- ies,12,19,24,34,35 3 qualitative studies,36–38 2 case stud-
tative research). No checklist was available from JBI for ies,39,40 and 2 experimental studies.23,41 All studies
mixed-methods studies and case studies. Thus, the were of moderate to high quality after the critical
Mixed Methods Appraisal Tool was used for critical ap- assessment.
praisal of studies using mixed-methods designs27 and
the Center for Evidence-Based Management’s critical Study characteristics
appraisal of a case study was used for case studies.28
The checklists included questions to determine the Studies included in this review were published between
extent to which a study addressed the possibility of bias 2013 and 2021, all conducted in the United States
1296 Nutrition ReviewsV Vol. 80(5):1294–1310
RTable 1 PICOS criteria for inclusion and exclusion of studies
Parameter Inclusion criteria Exclusion criteria
General Published in English
Peer-reviewed publication
Study design Experimental, cross-sectional, quasi-experimental, Reviews, abstracts
qualitative, natural experiments, mixed methods
Population Low-income (defined as living in poverty, food insecure,
participating in supplemental assistance nutrition
programs [SNAP or WIC]) and/or racially or ethnically
diverse populations
Intervention/exposure Online ordering of groceries (supermarkets, grocery
stores, farmers’ markets)
Setting Urban and rural settings Not real-world setting (ie, ordering
from laboratory that does not deliver
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the groceries selected)
Outcomes Psychosocial, purchasing, diet behaviors, or equity
promotion in online grocery environment
Abbreviations: SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, Infants,
and Children.
(Table 2). Nine studies targeted food insecure or low- Barriers and enablers of equitable access to healthy
income, racially diverse populations,12,19,23,31,32,35,39–41 5 foods via online grocery services
were conducted among individuals participating in nu-
trition assistance programs (SNAP or WIC),24,34,36–38 1 Figure 2 summarizes the findings from this systematic
targeted regions with low access to healthy foods or review. This is an equity-oriented framework focused
food retailers,18 and 1 examined US states participating on health promotion in online grocery services building
in the SNAP OPP expansion.33 For most studies on the 4 domains of Kumanyika’s framework for equity
(n ¼ 11), whether the work was informed by a theoreti- in obesity prevention (ie, reduce deterrents, build com-
cal model or theory was not reported. Of those articles munity capacity, social and economic resources, and in-
in which that information was provided (n ¼ 5), 2 stud- crease healthy options).30 Central to the present
ies were based on the theory of planned behavior,24,37 2 conceptual framework are the 4 equity domains that act
on the nudge theory,23,41 and in 1 study, the authors as pillars for policy or systems interventions and com-
used a service ecosystem framework.19 Sample size var- munity capacity to ensure that the online food environ-
ied across the studies depending on whether the study ment supports equitable healthy food availability and
was targeted at the regional (eg, 1250 census tracts in access. In turn, the online food environment influences
the OPP states),18 retailer (eg, 2 retailers34 or 1 re- and is influenced by an individual’s perception of bar-
tailer39), or individual (eg, ranging from 736 to 206 riers, attitudes, and intentions to purchase groceries on-
adults19) levels. Among the studies reporting a nutrition line, in line with the theory of planned behavior.29
outcome (n ¼ 9), 3 focused on specific healthy and un- Equity in online grocery shopping refers to the dif-
healthy food and beverage items,12,23,24 1 looked at ferential impact of policies and retailers’ practices (ie,
fruits and vegetables only,35 and 5 assessed all grocery disparate cost of grocery items online vs in the store19)
items purchased.19,23,31,34,41 on online grocery shopping uptake and healthy food se-
lection among rural and urban populations,18 and
Online grocery services groups of different ages, incomes, and races or ethnici-
ties.39 Five studies included in this review highlighted
The types of online grocery ordering services varied the importance of reducing deterrents to online grocery
across the studies. The majority of the studies (n ¼ 9) shopping to increase uptake and improve the quality of
were conducted in the context of a grocery store or foods purchased by low-income, racially or ethnically
food retailer that accepted orders online and offered diverse populations.18,19,32,39,40 Disparate cost of equiva-
grocery pick-up and/or delivery.18,19,23,24,36–40 Of those, lent grocery items at online retailers was reported in 1
3 studies were implemented with a pick-up option at a study, in comparison with brick-and-mortar vendors in
community location,12,19,35 3 with store pick-up low-income neighborhoods in the United Sates40 In an-
only,32,34,36 and 3 offered pick-up or delivery serv- other study, authors motivated by the SNAP OPP found
ices.23,31,39 Six studies examined topics related to the that grocery ordering and delivery services were rarely
SNAP OPP.18,19,24,39,40 available in rural food deserts.18 Researchers who
Nutrition ReviewsV Vol. 80(5):1294–1310
R
1297Eligibility Criteria
1) Published between 2010-2021
2) Conducted in humans
3) Published in English only
4) From peer-reviewed journals
5) Study design: cross-sectional,
experimental, qualitative, case-study,
mixed methods (no reviews or
Records identified through database searching simulations)
Identification
6) Outcome: psychosocial,
N = 1612
MEDLINE (n = 626) purchasing, diet behaviors, or equity
EMBASE (n = 641) promotion in online grocery
PsycINFO (n = 244) environment
Business Source (n = 101) 7) Target population: Low-income
populations living in poverty, food
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insecure, participating in assistance
nutrition programs (SNAP or WIC),
and/or racially or ethnically diverse
groups.
Records after duplicates removed Duplicate records
(n = 466) excluded
(n = 1146)
Screening
Title and abstract
screened Irrelevant studies excluded
(n = 466) (n = 423)
Full-text articles assessed Full-text articles excluded,
Eligibility
for eligibility with reasons (n = 27)
(n = 43) • Not peer-reviewed (n = 9)
• Not online grocery (n = 10)
• Abstract only (n = 3)
• Review (n = 1)
• Not low income (n = 3)
• Duplicate (n = 1)
Studies included in
qualitative synthesis
(n = 16)
Included
Cross-sectional (n = 4)
Mixed methods (n = 5)
Qualitative (n = 3)
Case study (n = 2)
Experimental (n = 2)
Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of studies included in the systematic
review.61 Abbreviations: SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, Infants,
and Children
examined receipts from 2 retailers serving primarily of considering environmental and social barriers to
low-income communities in Maine found that shoppers SNAP participation, as well as disparate grocery costs
with lower incomes and who enrolled in a nutrition as- and declining purchasing power of SNAP benefits.19 In
sistance program were less likely to shop online than terms of uptake of online grocery services, a case study
their higher-income counterparts.32 Authors of an ana- in Alabama reported that older, rural populations were
lytical essay examining neighborhood variation in not using SNAP online as frequently as younger shop-
SNAP enrollment in NYC highlighted the importance pers were, and that online SNAP purchases made up a
1298 Nutrition ReviewsV Vol. 80(5):1294–1310
RTable 2 Description of the studies included in the systematic review by domains of the equity-oriented framework to promote healthy food purchasing and diet in online
grocery environments targeted at underserved populations
Reference Study design Setting and Online retailer busi- Outcomes Methods Main findingsa Policy implications Quality, %
population ness model
Increase healthy options
R
Appelhans et al Cross-sectional Chicago, IL Home delivery Psychosocial: accept- Psychosocial factors: Online grocery and Online grocery 10026
(2013)31 Adults with children ability of online perceived conve- inequities: higher needs competitive
in an urban food grocery services nience, ease of SSB purchase on- prices, 1-d deliv-
desert (n ¼ 34) Purchase: items pur- use, and satisfac- line; food prices ery, to accept
chased while on- tion; planned fre- perceived to be SNAP, and to be
line grocery quency of future high available for
shopping (in use Online grocery and home delivery
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office) Online purchasing: food assistance:
receipts from gro- most purchases
ceries ordered at composed of pro-
research center tein; F&V and calo-
with study-pro- ric beverages also
vided voucher common
Equity: residents of OPP and online gro-
food desert areas cery: Ability to pay
with SNAP would
influence decision
to buy groceries
online.
Burrington et al Mixed methods New York (rural) Delivery to a com- Psychosocial: im- Psychosocial factors: Online grocery and Nutrition or cooking 7327
(2020)35 Low-income families munity location prove knowledge self-efficacy for inequities: in- classes in combi-
with children at and attitudes to- cooking, attitudes creased children’s nation with a F&V
risk of obesity who ward F&V toward trying new F&V intake, house- Rx program with
qualify for free or consumption foods hold food security online produce
reduced school Purchase: order F&V Online purchasing: at post-online F&V delivery increased
meals (n ¼ 10) from online pro- voucher redemp- ordering F&V access and
duce market tion or online data consumption by
Diet: increase con- monitoring children.
sumption of F&V Diet: daily servings
of F&V consumed
by child and
parents
Equity: rural com-
munities, child-
ren’s eligibility for
free or reduced
school meals;
food-insecurity
screener
(continued)
1299
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1300
Reference Study design Setting and Online retailer busi- Outcomes Methods Main findingsa Policy implications Quality, %
population ness model
Lagisetty et al Mixed methods Baltimore, MD Store pickup and de- Psychosocial: to Psychosocial factors: Online grocery and Allow payment with 7327
(2017)12 Primarily Black livery to commu- evaluate barriers satisfaction with inequities: Ability SNAP for online
women aged 60 nity location to program program, barriers to have commu- grocery delivery
and stakeholders implementation to healthy food nity drop-off/pick- (using hand-held
from Virtual Purchase: self- access up locations and devices at
Supermarket reported change Online purchasing: pay with cash or delivery).
Program (n ¼ 93 due to the self-reported EBT was key to
customers; program change participation.
n ¼ 14 key Diet: perception of Equity: participants Online grocery and
stakeholders) eating more living in low-in- food assistance:
healthfully due to come neighbor- higher purchases
the program hoods (food of F&V and fewer
deserts) snacks and des-
serts, but more jui-
ces and sodas
OPP and online gro-
cery: Participants
were satisfied with
the ability to pay
with SNAP at
delivery.
Reduce deterrents
Brandt et al Cross-sectional Rural and urban Store pickup or Equity in geographic Online purchasing: Online grocery and Ability to use SNAP 7526
(2019)18 food deserts in home delivery. reach of the SNAP Nielsen TD-Linx inequities: Online online may im-
8 US states OPP Database to iden- grocery purchas- prove food avail-
(n ¼ 1250; 13 134 tify SNAP retailers; ing and delivery ability for those in
census tracts) Google to identify were rarely avail- urban food
OPP participation able in rural food deserts, although
and delivery area deserts. access is limited
Equity: rural and ur- in rural areas.
ban food desert
census tracts
Cohen et al Analytic essay NYC, NY Not specified Equity: to examine Equity: measuring Online grocery and Consideration of en- 8026
(2019)40 Individuals with low city and neighbor- SNAP at the com- inequities: dispa- vironmental and
income (eligible hood characteris- munity scale: rate grocery costs social barriers to
but not enrolled in tics that affect Program Access (high costs in gen- SNAP participa-
SNAP) living in 3 SNAP Index for Public trifying tion, disparate
R
Public Use participation Use Microdata neighborhoods) grocery costs and
Microdata Areas Area OPP and online gro- SNAP benefits not
cery: Geographic adjusted for
variation in food higher cost of
prices can be re- living
duced through in-
creased use of
Nutrition ReviewsV Vol. 80(5):1294–1310
online grocers.
(continued)
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Reference Study design Setting and Online retailer busi- Outcomes Methods Main findingsa Policy implications Quality, %
population ness model
Cohen et al Mixed methods NYC, NY Delivery to a com- Psychosocial: shop- Psychosocial factors: Online grocery and Low-income individ- 7327
(2020)19 Low-income, pre- munity location ping practices, and barriers to buying inequities: prices uals are unlikely
R
dominantly Black perceptions of on- healthy and afford- online higher than to fully switch to
adults (n ¼ 466 line shopping able food online, in store online shopping
registered in the Purchase: grocery logistics of grocery Online grocery and unless grocers of-
pilot; survey, purchases before delivery food assistance: fer deals compara-
n ¼ 206; focus and after the pilot Online purchasing: potential cost sav- ble to those in
group, n ¼ 6) Equity: uptake of on- grocery receipt ings online; more store. Community
line grocery analysis (pre- and promotions or dis- input and buy-in
Nutrition ReviewsV Vol. 80(5):1294–1310
shopping post-pilot) counts in store; were key to iden-
Equity: price com- positive experien- tifying and
parison of in-store ces online addressing bar-
vs online prices; OPP and online gro- riers to online
low-income resi- cery: Participants shopping.
dents in food de- wanted online
sert; pilot design stores to have the
with input from same sales and cir-
community culars as local
stores.
Hingle et al Case study Low-income, older Home delivery, de- Equity: to identify Online purchasing: Online grocery and Maintain support for 7028
(2020)39 adults in rural livery to a com- barriers and op- stakeholder inter- food assistance: EBT online post-
Alabama (n ¼ 1 munity location, portunities to im- views and docu- Majority of online COVID and expand
grocery store curbside pickup prove equitable ment review purchases were online access to
chain) and low-in- online access to (proportion of pur- non-SNAP. Older other food assis-
come Hispanic nutrition chases online and rural populations tance programs.
adults in urban programs in store with were not using Work with grocers
California (Double SNAP/EBT) SNAP online as and local partners
Up SNAP Equity: proportion of frequently as to create grocery
Incentive online purchases younger custom- drop-off/pick-up
Program) and program ers who lived in centers in hard-to-
enrollment town. reach rural areas
Zatz et al (2021)32 Cross-sectional Maine Store pickup Equity: sociodemo- Online purchasing: Online grocery and Expand the SNAP 10026
Low-income families graphic differen- retail scanner data inequities: Only OPP to other
with children, pre- ces between (specific code for shoppers were regions and
dominantly non- families who online orders) more likely to retailers; retailers
Hispanic White shopped online vs Equity: have higher to reduce or
(n ¼ 863) grocery in-store Sociodemographic incomes and less waive fees for
shopping at 2 determinants of likely to partici- low-income con-
supermarkets online and in-store pate in SNAP or sumers; marketing
purchases at WIC. campaigns to in-
supermarkets serv- crease awareness
ing low-income of the SNAP OPP
communities
1301
(continued)
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1302
Reference Study design Setting and Online retailer busi- Outcomes Methods Main findingsa Policy implications Quality, %
population ness model
Build on Community Capacity
Coffino et al Experimental New York (urban) Home delivery Purchase: feasibility Psychosocial factors: OPP and online Supports the use of 6926
(2020)23 Adults with food in- and initial efficacy nutrition literacy, shopping: in- “nudges” (ie,
security who do of default online dietary preferen- creased healthful- changing defaults)
not receive SNAP shopping cart on ces, impulsiveness ness of food to promote
benefits (n ¼ 50) quality of foods Online purchasing: purchases using healthier food
purchased (whole the Thrifty Food default cart purchases in on-
grains; F&V; calo- Plan Calculator for options for food line shopping
ries; total fat; satu- price, consump- insecure
rated fat; sodium; tion, and nutrition individuals
cholesterol; fiber) data
Equity: 6-item
household food
security screener
Coffino et al Experimental New York Not specified Purchase: effect of a Online purchasing: OPP and online Nutrition education 7526
(2021)41 Adults with low in- default online Grocery items shopping: by itself may not
come (n ¼ 38), shopping cart on were matched Prefilled shopping be enough to sup-
food pantry quality of foods with nutrient data cart arm had port healthy food
patrons purchased and examined as greater nutrition purchasing by
HEI, total energy, quality (HEI score) SNAP online pur-
and energy and fewer total chasers. Use of
density. calories and en- principles of
Equity: self-reported ergy density com- nudges for
income, education, pared with healthy prefilled
SNAP participa- nutrition educa- grocery carts may
tion, food insecu- tion arm support healthful
rity, and access to purchasing behav-
kitchen and iors among con-
computer sumers with low
income.
Dunn et al Cross-sectional United States: 46 Store pickup or Equity: nationwide Equity: program, re- OPP and online gro- Need to improve 10026
(2021)33 states and home delivery assessment of offi- tailer, health and cery: Most states state communica-
Washington, DC, cial communica- nutrition, and had identified au- tion about the
participating in tion about SNAP communication thorized retailers, SNAP OPP, which
the SNAP OPP OPP accessibility about half informed mainly focused on
3 state-level infor- the SNAP OPP about pickup and basic program
mation sources delivery fees, and and retailer infor-
R
about the SNAP few included in- mation and lim-
OPP formation about ited about
health and nutrition and
nutrition. health.
(continued)
Nutrition ReviewsV Vol. 80(5):1294–1310
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Reference Study design Setting and Online retailer busi- Outcomes Methods Main findingsa Policy implications Quality, %
population ness model
Martinez et al Mixed methods NYC, NY Store pickup and Psychosocial: per- Psychosocial factors: Online grocery and Online grocers or 7327
(2018)24 Adult SNAP home delivery ceptions of and attitudes, behav- inequities: online USDA may need
R
recipients intentions toward ioral control, bar- SNAP purchases to use motivators
n ¼ 148 individuals online grocery riers, motivators, higher in sweets, (eg, increased
(purchase data); shopping and intentions to- salty snacks, and transparency and
n ¼ 35 (focus Purchase: online ward online gro- lower in fruit than customer control)
groups) shopping and the cery shopping. non-SNAP to facilitate up-
use of SNAP online Online purchasing: purchases take of online
sales data from on- Online grocery and shopping among
Nutrition ReviewsV Vol. 80(5):1294–1310
line grocery store; food assistance: SNAP recipients.
purchases from lack of control
itemized receipts over food selection
(planned, but were and sensorial ex-
unable to analyze) perience; concerns
Equity: SNAP recipi- about delivery,
ents in low-income food quality, secu-
zip codes rity, return policies
OPP and online gro-
cery: SNAP online
acceptance was a
motivator. Lack of
awareness and in-
formation about
OPP
Rogus et al Qualitative New Mexico (urban) Store pickup and Psychosocial: behav- Psychosocial factors: Online grocery and Address negative 9026
(2020)37 Adult SNAP recipi- home delivery iors, knowledge, attitudes, subjec- inequities: percep- attitudes to make
ents with children and attitudes of tive norms, per- tion that online online grocery
(n ¼ 18) SNAP recipients ceived behavioral shopping could more appealing to
toward online control benefit elderly or subgroups that
grocery Equity: focus on disabled people could benefit
SNAP participants and those without from the service.
from families with a vehicle
low income Online grocery and
food assistance:
low uptake of on-
line grocery
shopping.
Barriers: cost, quality
control, liking gro-
cery shopping
Motivators: online
features, discounts,
and delivery
1303
(continued)
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Reference Study design Setting and Online retailer busi- Outcomes Methods Main findingsa Policy implications Quality, %
population ness model
Improve social and economic resources
1304
Jilcott Pitts et al Qualitative North Carolina Store pickup Psychosocial: advan- Psychosocial factors: Online grocery and Ability to use WIC 9026
(2020)36 Adult, female WIC tages and disad- perceived advan- inequities: online could help
participants vantages of online tages and disad- Inadequate substi- with linkage to
(n ¼ 7) grocery shopping vantages of in- tutions, fees, lack nutrition educa-
Purchase: impulse store vs online of control over tion programs, im-
purchases purchases; self- item selection, prove access for
reported planned and inability to disadvantaged
vs impulse buys find deals were groups.
Online purchasing: deterrents to us-
online grocery ing online grocery
shopping experi- shopping.
ence (in the office) Participants made
and annotated more impulse pur-
receipts from in- chases online;
store and online most were chips
purchases and candy but
Equity: women with sometimes con-
children enrolled sisted of fruit.
in WIC
Zimmer et al Qualitative East Tennessee Home delivery and Psychosocial: WIC Psychosocial factors: Online grocery and Pilot tests for WIC 906
38
(2020) Adult WIC recipients store pickup participants’ per- perceptions about inequities: Online online ordering;
(n ¼ 23) ceptions about or- online ordering shopping would facilitate WIC food
dering groceries and WIC address transpor- retail operations
online Online purchasing: tation issues and
food shopping ex- barriers related to
perience (in-store shopping with
and online) children.
Equity: focus on WIC
participants
Zimmer et al Mixed methods East Tennessee Store pickup Psychosocial: accept- Psychosocial factors: Online grocery and WIC online is feasi- 7327
34
(2021) Adult WIC recipients ability and feasibil- experience, bar- inequities: ble; need for con-
(n ¼ 24) ity of WIC in online riers, and facilita- Challenges of lo- sistent WIC
grocery service tors of using WIC cating WIC items labeling policies
Purchase: online for online order and using the F&V in store and
shopping (office) and pickup. cash value may re- online
using WIC Online purchasing: duce acquisition of
online order from produce online.
WIC costumer and Online grocery and
transaction food assistance: All
R
receipts from WIC participants placed
retailer an order with WIC
Equity: feasibility and 96% picked
trial of WIC as pay- up the order.
ment for online Mean order total
ordering was $30.60.
Nutrition ReviewsV Vol. 80(5):1294–1310
Abbreviations: EBT, electronic benefits transfer; F&V, fruits and vegetables; HEI, Healthy Eating Index; NYC, New York City; OPP, Online Purchasing Pilot; SNAP, Supplemental Nutrition
Assistance Program; Rx, prescription; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children; USDA, US Department of Agriculture.
a
Online grocery and inequities refers to the potential of online grocery to promote or hinder equity in healthy food access; online grocery and food assistance refers to psychosocial and behav-
ioral factors associated with online grocery shopping among families enrolled in federal food and nutrition assistance programs such as SNAP or WIC; OPP and online grocery refers to factors
associated with the ability to pay for groceries online using nutrition assistance program benefits.
Downloaded from https://academic.oup.com/nutritionreviews/article/80/5/1294/6514637 by guest on 26 June 2022Potenal policy and systems change intervenons
Low availability of online
grocery services in rural
Online Grocery Services communies
Online Food Environment
Increase Healthy Reduce Deterrents Targeted online markeng
Online Produce Market Opons Delivery fees
High costs of healthy foods
Individual level
Perceived Barriers
Planned
Sale Items
Behavior Delivery services
and fees
Atudes
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Social
Norms
Perceived Healthy
Behavioral purchase and
Payment diet
Control Food Selecon
Opons
Fewer
SNAP impulse Improve consumer control
Improve Social and purchases Build on Community over online orders
WIC Economic Resources Capacity Healthy default online cart
Address impulse purchases
Fruit and vegetable
online
prescripon program
Individual and community resources and capacity
Figure 2 Equity-oriented framework to promote healthy food purchasing and diet in online grocery environments targeted at un-
derserved populations. Abbreviations: SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for
Women, Infants, and Children
smaller share of all online purchases (20%) compared means to increase social and economic resources to im-
with in-store purchases (40%).39 Four qualitative studies prove food access for disadvantaged groups.34,36,38
with SNAP and WIC families explored reasons for the In 3 studies, researchers pilot tested approaches to
low use of online grocery programs and all highlighted increase healthy options in the online grocery environ-
the perceived lack of control over grocery selection, es- ment among socially disadvantaged communities.12,31,35
pecially of fresh produce and meats, as one of the major One intervention (Virtual Supermarket Program) facili-
barriers, in addition to cost.24,36–38 tated grocery delivery and SNAP payment at commu-
Study authors recommended future programs and nity hubs for low-income, urban older adults.12
interventions build community capacity to order gro- Participants placed and received grocery orders in des-
ceries online by improving customer control in the on- ignated hubs, including public libraries, schools, and se-
line environment,24 and by improving state nior housing centers.12 The Internet Grocery Service
communication about the SNAP OPP to include nutri- tested the feasibility of a grocery delivery service to in-
tion and health information.33 Two interventions crease access to healthy foods in a low-income urban
intended to build community capacity to select health- food desert by providing vouchers for groceries and de-
ier foods online tested nudges, using a healthy default livery fees.31 Last, an intervention in rural communities
shopping cart.23,41 The pilot program was promising; tested the feasibility of an online produce market where
participants in the intervention arm selected more participants redeemed Fruit and Vegetable Prescription
healthier items than those in the control condition (re- Program vouchers and picked up orders from a com-
ceiving nutrition education materials).23,41 Although munity site.35
provision of health and nutrition information is lacking
in state communications about the online policy,33 Psychosocial factors of the TPB related to online
Coffino et al23,41 empirically demonstrated that con- grocery shopping
sumers benefit from a virtual food environment that is
supportive of healthy food choices. Additionally, 3 stud- In 10 studies included in this review, authors assessed
ies recommended that the US Department of psychosocial behaviors related to online grocery shop-
Agriculture allow the use of WIC benefits online as a ping. In most of these studies (n ¼ 6), psychosocial
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1305domains were assessed qualitatively19,24,34,36–38; quanti- Purchasing and diet behaviors related to online
tative survey items were used in the other 4 grocery shopping
studies.12,23,31,35
Overall, attitudes toward online shopping varied by Of the 11 studies in which researchers assessed online
study. Some authors reported a lack of interest in or food purchasing behaviors,12,19,23,24,31,32,34–36,39,41 con-
low perceived benefit of online shopping.24,37 In others, sumer purchasing data were collected from itemized
participants expressed interest in online grocery serv- store receipts in 7 studies,19,24,31,32,34,36,41 from online
ices, although most seemed to view it as an occasional data monitoring in 1 study,35 from stakeholder inter-
convenience rather than a complete substitute for in- views and document review from a retailer in 1 study,39
store shopping.31,36,38 For example, after the Internet and were self-reported in 2 studies,12,35
Grocery Service intervention, 54.5% of participants In 2 studies, authors quantitatively assessed impulse
responded that they would use the service 1–6 times per buying during online grocery shopping.23,36
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year, 24.3% said they would use it at least monthly, and Participants in 1 study purchased more on impulse on-
only 9.1% reported they would never use it in the line than they did when shopping in a store, although
future.31 not all impulse buys were unhealthy.36 In another study,
Concerns about control over food selection Coffino et al23 did not find a difference in impulse pur-
emerged as a major barrier to uptake of online grocery chases between consumers who received nutrition edu-
services,19,24,36,37 particularly with regard to the quality cation (the control condition) and those who received
of fresh items37 and the potential for losing money on the healthy-default shopping-cart intervention.23
unsatisfactory purchases.19 Perceived high cost of online The impact of online grocery shopping on nutri-
grocery shopping was another barrier to its uptake by tional quality of purchases was mixed. A healthy-default
underserved families. The potential for losing money shopping cart increased the healthfulness of food pur-
on unsatisfactory purchases was a main concern19,36,37; chases and decreased fat, sodium, and cholesterol from
participants cited fees and the relative paucity of deals foods purchased,23 and led to greater overall nutritional
online compared with in-store purchases as disincen- quality.41 The most frequently purchased items in the
tives for online shopping.36 Additionally, the lack of so- Internet Grocery Service pilot were animal proteins,
cial interaction during grocery shopping was another fruits and vegetables, and caloric beverages.31 SNAP
reported deterrent to online shopping, although some Electronic Benefits Transfer online purchases were
participants felt that the benefits offset the loss.38 higher in sweet and salty snacks and lower in fruits
Online grocery ordering was perceived to be less than non-SNAP online purchases in a study24 and had
stressful than in-store grocery shopping among women greater nutritional quality. In other studies, researchers
with children enrolled in WIC, because it eliminated were limited in their ability to quantitatively assess
the need for transportation and addressed the chal- the impact of online grocery services on the healthful-
lenges of shopping in a store with children.38 Although ness of food purchases, because of low uptake of online
the evidence supporting reduced impulse purchases grocery shopping. For example, after a planned ran-
when shopping online is mixed,23,36 participants also domized controlled trial of online ordering failed due
felt that online grocery shopping might result in fewer to low uptake, Martinez et al24 pivoted to a mixed-
impulse buys of both unhealthy (eg, sweet snacks and methods design to understand low use of online serv-
chips) and sometimes healthy (eg, fruits) foods, com- ices. Cohen et al19 did not report on the food types
pared with in-store purchases.38 Additional benefits of that were purchased but noted that online orders
online grocery services identified by participants in- made up a small percentage of dollars spent on food
cluded saving time and delivery of heavy or bulky (3.1%).
items.19 Dietary intake was assessed in only 2 studies. In 1
Both perceived behavioral control and normative study, authors assessed changes in daily servings of
beliefs positively influenced use of online grocery shop- fruits and vegetables among children and their care-
ping during an intervention that was co-created by resi- givers in response to an online food-market program.35
dents of a low-income housing community and The online program resulted in improved self-reported
researchers.19 Participants reported that ordering gro- fruit and vegetable intake among children and de-
ceries online was easier than they had anticipated,19 a creased household food insecurity.35 No dietary change
finding that was echoed by mothers participating in was observed among caregivers. In the other study, self-
WIC in another study.36 Participants also noted that al- reported intake data related to the Virtual Supermarket
though they were generally wary of online shopping, Program were collected.12 Customers reported purchas-
they trusted residents of their community and were ing more fruits and vegetables and sugary drinks since
willing to try the online grocery pilot.19 the start of the virtual program. They also attributed
1306 Nutrition ReviewsV Vol. 80(5):1294–1310
Reating more healthfully and perceived having greater ac- hubs and reduce delivery fees may be a promising strat-
cess to affordable foods due to the program.12 egy to improve access to healthy foods.
The few studies in which online food purchasing
and dietary behaviors were examined among under-
DISCUSSION served populations reported potential increases in both
unhealthier and healthier food choices. Fewer impulse
In this systematic review, we examined the potential for purchases and reduced influence of children on parents’
online grocery services to promote equitable access to buying behavior (ie, “pester power”) in the online envi-
healthy foods among underserved populations. Interest ronment are possible mechanisms to explain fewer un-
in the topic has grown substantially over the past few healthy food purchases online. These findings are also
years, as evidenced by the burgeoning research and the supported by the multiple selves theory, because order-
SNAP OPP. Perceived barriers and TPB constructs as- ing groceries for delivery in the (relatively) distant fu-
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sociated with online grocery shopping identified in this ture predicts more healthy food choices (should-self),
systematic review focusing on low-income, diverse pop- whereas immediate purchases predicts more unhealth-
ulations are consistent with findings from a previous ier food choices (want-self).42,43 Conversely, the poten-
scoping review.22 Furthermore, the perspective afforded tial for targeted online marketing and personalized
by the equity-oriented framework advanced the under- recommendations have been hypothesized to increase
standing of the main deterrents to online grocery shop- unhealthy food purchases online.44,45 Although, to our
ping among low-income and diverse populations (eg, knowledge, the effect of online marketing on unhealthy
perceived high cost) and identified promising strategies food selection has not been empirically tested, various
to build on community capacity (eg, improving cus- simulated, online-grocery, experimental studies have
tomer control over online purchases), opportunities to demonstrated that targeted online marketing of healthy
improve social and economic resources for food access foods and provision of nutrition information were
(eg, allowing use of government benefits online), and promising strategies to improve quality of foods pur-
strategies to increase healthy grocery options (eg, chased in the virtual environment.46–48 On the other
expanding online ordering and delivery services of hand, there is plausible evidence that food and beverage
healthy food vendors). industries have disproportionately targeted marketing
This investigation identified low availability of on- of unhealthy items to low-income, diverse populations
line grocery services in rural communities, perceived across media markets.49–51 Authors of a 2013 study,
high costs, and perceived low behavioral control over which was outside the scope of the present review,
food selection as important barriers to uptake of online assessed the nutritional quality of Bronx, NY–based
grocery services by disadvantaged groups, which could grocery store circulars available online and found that
widen inequities in access to healthy food. The ability to >84% of products advertised on the first page were
pay for groceries online with SNAP benefits was a moti- processed.52 The influence of grocery store circulars on
vator,24,31 making an important case for future research online grocery purchases merits further investigation.
on the expansion of the US Department of Agriculture Given the potential for personalized online marketing
online purchase pilot to other programs such as WIC of unhealthy foods in the online grocery environment,
and the Fruit and Vegetable Prescription Program. Pilot there is a need to better understand existing online mar-
interventions tested strategies to improve healthy-food keting in the virtual grocery environment and to ex-
purchasing that could be incorporated into existing on- plore avenues for interventions to support selection of
line grocery programs, including the default healthy- healthy foods online among underserved populations.
food online grocery cart,23,41 and centralized delivery One mechanism that could explain greater pur-
locations like public libraries and schools in hard-to- chases of healthy items online is through future episodic
reach communities.12,19,35 More research is needed on thinking, which is required for planning grocery shop-
the feasibility of the use of other government benefits ping,53 and aligns with the premise of the TPB to un-
(eg, WIC, Fruit and Vegetable Prescription Program) in derstand behavioral intentions. However, no study in
the online grocery environment as a means to improve this systematic review tested the influence of meal plan-
social and economic resources for access to healthy ning on online grocery purchases of healthy items. In 1
food. Furthermore, researchers should examine and study included in the present review, authors held com-
compare the cost-effectiveness of creating hubs for munity cooking classes as part of an intervention to im-
community grocery pick-up, expanding delivery buf- prove access to fruits and vegetables.35 They reported
fers, and/or creating more supermarkets, with a particu- an increase in fruit and vegetable consumption by chil-
lar focus on rural communities. Partnership with dren.35 In a recent study among a sample of majority
community centers and retailers to create community non-Hispanic White women in Maine, researchers
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1307reported that online purchases were associated with maintain support for SNAP online post-pandemic and
lower spending on sweet snacks and desserts compared to expand online access to other food assistance pro-
with in-store purchases.54 A potential explanation for grams, like WIC.39 Zimmer et al38 highlighted the po-
the findings suggested by the authors included meal tential benefits of online ordering to facilitate WIC food
planning and the shopping lists built in to online gro- retail operations, and Jilcott Pitts et al36 noted that the
cery services.55 Those authors also found that consum- ability to use WIC online could help with linkage to nu-
ers spent more dollars per transaction online compared trition education programs, improving access and food
with in-store shopping.54 Given that affordability of literacy for disadvantaged groups.
food is 1 of the main barriers to healthy diets among All but 2 studies33 included in this systematic re-
low-income populations56 and that disparities in the view collected data before the COVID-19 pandemic,
cost of foods have been found between online and phys- which has affected the food system and families’ pur-
ical stores,19 studies should be conducted to examine chasing and dietary habits.57–59 The pandemic also
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the financial impact of online purchases compared with prompted the US Department of Agriculture OPP’s
in-store grocery purchases on low-income consumers’ rapid expansion to most US states and the inclusion of
spending. Most studies in which the influence of online additional authorized retailers, thus increasing access to
grocery shopping on nutrition outcomes was evaluated online grocery services among underserved popula-
relied on self-reported measures of purchase and diet. tions.21 However, most studies included in this review
Therefore, the impact of online grocery shopping on were conducted prior to the roll out and expansion of
supporting healthy eating practices should be further the OPP when online grocery purchasing surged.60
examined. Investigation of how the ability to use na- Therefore, interest in and uptake of online grocery
tional food and nutrition assistance benefits online shopping among low-income diverse populations pre-
affects healthiness of food selection and dietary behav- sented in this systematic review are likely underesti-
iors is another area that warrants more investigation. mated. Because of the increase in online grocery
shopping uptake, social norms, attitudes, and barriers
Policy and research implications may have shifted, thus necessitating evaluations to ex-
amine changes among underserved populations due to
Studies included in this review highlighted the impor- the pandemic.
tance of research to inform, develop, and evaluate pol-
icy and program efforts in the online grocery Limitations
environment to promote the purchase and consump-
tion of healthy foods among underserved populations. This systematic review has some limitations. First, al-
Findings from various studies underscored the need to though information on online grocery shopping may be
make online grocery services more attractive to low- available in gray literature reports, websites, or other
income groups through improving consumers’ percep- unexamined documents, we focused exclusively on
tion of control over grocery selection24,36–38 and peer-reviewed literature. The exclusive use of peer-
addressing financial barriers by offering deals compara- reviewed literature helps ensure reasonable quality of
ble to those in-store.19,37 the research reported. Second, the use of only peer-
Environmental and social barriers to SNAP partici- reviewed literature may lead to publication bias because
pation exist, especially for low-income populations in studies with negative or null outcomes are less likely to
areas with a high cost of living.40 In 6 studies, research- be published. Third, the tools used to assess quality of
ers explored perceptions and attitudes toward online study varied by study design and may not be compara-
grocery shopping among SNAP participants. ble with each other, although all the tools are widely
Researchers identified barriers to online grocery serv- used and were selected to enhance comparability with
ices and suggested strategies to promote more equitable other reviews. Fourth, studies included in this review
food access for low-income populations, including in- varied methodologically in terms of study design, sam-
creased transparency and customer control,24 competi- ple size, and locale. Only 2 studies had randomized con-
tive prices, 1-day delivery, SNAP Electronic Benefits trolled design; most studies had small and convenient
Transfer online payment acceptance,31 and use of hand- sample sizes. Thus, findings should be interpreted with
held devices to allow for payment at delivery,12 some of caution and may not be generalizable. Yet, the inclusive
which have already been included in the OPP expan- search strategy of a wide array of disciplines using both
sion. Nonetheless, the low availability of grocery deliv- quantitative and qualitative designs is a strength of this
ery service in the US Department of Agriculture– review. Fifth, all studies included in this systematic re-
defined food deserts and rural areas is still a deterrent view were conducted in the United States, despite the
to equitable access to healthy foods.18,39 It is crucial to extensive literature on online grocery shopping in
1308 Nutrition ReviewsV Vol. 80(5):1294–1310
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