Fruit and vegetable access in four low-income food deserts communities in Minnesota
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Agriculture and Human Values (2006) 23:371–383 Ó Springer 2006
DOI 10.1007/s10460-006-9002-8
Fruit and vegetable access in four low-income food deserts communities in
Minnesota
Deja Hendrickson,1 Chery Smith,2 and Nicole Eikenberry3
1
School of Public Health, University of California, Berkeley, California, USA; 2Department of Food Science and Nutrition,
University of Minnesota, FScN 225, 1334 Eckles Ave, St. Paul, Minnesota, USA; 3Independent Scholar
Accepted in revised form October 12, 2004
Abstract. Access to fruits and vegetables by low-income residents living in selected urban and rural Minnesotan
communities was investigated. Communities were selected based on higher than state average poverty rates, limited
access to grocery stores, and urban influence codes (USDA ERS codes). Four communities, two urban and two
rural, were selected. Data were gathered from focus group discussions (n = 41), responses to a consumer survey
(n = 396 in urban neighborhoods and n = 400 in rural communities), and an inventory of foodstuffs
available at stores located in all the communities and at large grocery stores in neighborhoods adjacent to
the urban communities. In the two urban neighborhoods, a significant number of foods (26% and 52%)
were significantly more expensive than the Thrifty Food Plan’s (TFP) market basket price (MBP). Addi-
tionally, a significant number of foods in the two rural communities were more expensive (11% and 26%).
In focus groups, participants identified major barriers to shopping in their community to be cost, quality of
food, and food choice limitations. Results of the food inventory show that foods within the communities
were costly, of fair or poor quality, and limited in number and type available, supporting complaints
verbalized by focus group participants. Through focus groups and surveys, participants expressed concern
that healthy food choices were not affordable within their communities and believed that people in their
community suffered from food insecurity. The absence of quality, affordable food for low-income residents
in these four Minnesota communities prevents or diminishes their ability to choose foods that help maintain
a healthy lifestyle.
Key words: Food deserts, Fruits and vegetables, Low-income consumers, Minnesota, Rural communities, Urban
communities
Abbreviations: ERS – Economic Research Service; MBP – Market Basket Price; TFP – Thrifty Food Plan; USDA –
United States Department of Agriculture; NAICS – North American Industry Classification Systems
Deja Hendrickson is currently a graduate student at the University of California and working towards obtaining her
MS in nutrition in order to become a registered dietitian.
Chery Smith, PhD, MPH, RD, is an associate professor in the Department of Food Science and Nutrition at the
University of Minnesota with research interests in the dietary behavior of low-income and homeless people, comm-
unity and international nutrition, and food systems.
Nicole Eikenberry is a Registered Dietitian and recently completed her MS in the Department of Food Science and
Nutrition, University of Minnesota, with primary research emphasis on food access and food choice for low-income
Minnesotan adults.
Introduction (USDHHS, 2003). Research suggests that these indi-
viduals are exposed to lifelong levels of excessive
Individuals who have limited incomes have higher environmental and physical stress that may contribute to
mortality and morbidity rates than the general population the increased prevalence of chronic disease, including
and are more likely to belong to a minority population heart disease, cancer, and diabetes (Friedrich, 2000;372 Deja Hendrickson et al.
Veenema, 2001). While consuming a well balanced diet living in four communities with limited grocery store
has been shown to be valuable in fighting against disease access and with household incomes below the state
(Ness and Powles, 1997; Van Duyn and Pivonka, 2000), average (Eikenberry and Smith, 2004, 2005). It will
those living on low incomes may have limited access to examine: (1) the results of a food survey of local stores;
the right types of foods in the necessary quantities. (2) consumer responses made regarding food access
It is well established that fresh fruits and vegetables during focus group sessions conducted in the selected
contribute vitamins, minerals, antioxidants, fiber, and communities; and (3) responses to questions pertaining to
phytochemicals to the diet. It has been suggested that food access from a consumer survey. Participants from
regular consumption of these foods has been associated low-income households were recruited for focus group
with a decreased risk of diabetes, cardiovascular disease, discussions with the assistance of professionals living in
cancer, and obesity (Ness and Powles, 1997; Van Duyn the communities and by posting flyers in stores, com-
and Pivonka, 2000; Joshipura et al., 2001; Bazzano et al., munity centers, and Laundromats. Survey participants
2002). However, low-income minority individuals were recruited at grocery stores, community centers,
consume less fruits and vegetables than is currently soup kitchens, Laundromats, and by word-of-mouth.
recommended (Kratt et al., 2000; Resnicow et al., 2001). This study was approved by the University of Minne-
The absence of these foods in the diets of low-income sota’s Institutional Review Board for human studies.
people may be contributing to the higher prevalence of
morbidity and mortality rates seen in this population Study communities
(Olson, 1999; Alaimo et al., 2001; Townsend et al.,
2001). Four communities – two rural and two urban – were
Social and physical surroundings have been deter- selected based on four criteria. These included: (1) lim-
mined to be important factors when assessing the diets of ited access to grocery stores as identified by the North
low-income people (Ross, 2000; Edwards et al., 2001; American Industry Classification System’s (NAICS)1
Morland et al., 2002). Koh and Caples (1979) suggest codes; (2) higher than state-average poverty levels; (3)
that the ability of persons living in poverty to acquire having urban influence codes, as defined by the Eco-
healthy food is hampered by a financial situation that nomic Research Service (ERS) of 1 (urban) or 7, 8, or 9
places fresh fruits and vegetables out of the range of (rural)2; and (4) civic engagement around food issues.
plausible purchases. Stores located in areas with high Urban study locations were identified in Minneapolis-
concentrations of poor residents are likely to stock foods based neighborhoods. To determine areas that had a
that are of lesser quality but are more effective at filling higher than state-average estimate for the percentage of
up the family. Koh and Caples (1979) found that fresh residents living in poverty, we reviewed poverty esti-
fruits and vegetables were considered highly desirable by mates in 1997 for people of all ages for Minnesota
poor urban residents but were not purchased regularly counties, school districts, small area estimates, and
because they were seen to be an impractical and unaf- neighborhoods. The size, type, and number of grocery
fordable means of providing the family with enough bulk stores within each neighborhood were identified.
to satisfy hunger. Koh and Caples also reported that high Neighborhoods identified as ‘‘food deserts’’ were then
fat and high starch foods could be purchased in large considered for the study.
quantities for relatively little money and, for this reason, The term ‘‘food desert’’ is used differently by different
were more likely to be purchased (Ibid.). researchers. According to Lang and Rayner (2002), food
The purpose of this study was to investigate food deserts are places where few or no consumer food
access issues for low-income residents living in urban sources are available. However, Cummins and Macintyre
and rural Minnesota. Specifically, the study (a) examined describe food deserts as ‘‘poor urban areas where resi-
the actual foods available in these communities by sur- dents cannot buy affordable, healthy food’’ (2002: 436),
veying the food on store shelves and (b) obtained, using thus using the term to describe the type and nutrient
qualitative and quantitative methods (i.e., focus groups quality of foods available, rather than the type, size, and
and surveys), consumer perceptions on food availability number of stores available to community members. For
within selected communities. this study, urban areas with 10 or fewer stores and no
stores with more than 20 employees were considered
food deserts. In the two urban areas there were a total of
Methods 14 stores (n = 4; n = 10), and in the two rural areas there
were a total of nine stores (n = 4; n = 5).
Research design The number of stores in each neighborhood was
determined by creating a map using the store addresses
This report is a component of a larger study that inves- entered into a geographic information system software
tigated access to food for urban and rural Minnesotans package (ESRI Inc. Redlands, CA. ArcGIS 8.0, 2002)Food access issues for low-income residents in Minnesota 373 displaying the streets of Minneapolis, the neighborhood structure dedicated to decreasing food insecurity for at boundaries, and the store locations. In the selected urban risk groups. This paper will focus on urban and rural study areas, ‘‘mom and pop’’ corner markets, or ethnic food access issues and not on issues pertaining to civic stores such as Hispanic or Middle Eastern specialty engagement. stores, were the norm. Additionally, stores tended to be small and often lacked air conditioning and refrigeration. Development of the food survey tool for grocery stores The smaller stores also lacked the space necessary to stock a wide variety of both pre-packaged and fresh To assure that all stores throughout the state were judged foods. However, the larger stores located in the urban on the same criteria, one survey was developed and used areas tended to have adequate refrigeration, a comfort- in all four communities. The survey was prepared with a able ambient temperature, and were generally able to focus on determining whether the residents of the se- stock a wider variety of foods. In the end, two geo- lected areas were able to afford foods needed to meet the graphically distinct urban areas were identified. One was daily nutritional recommendations set forth by the gov- located in South Minneapolis, while the other was lo- ernment without substantially hampering household fi- cated in North Minneapolis. The stores located in the nances. rural areas tended to be quite a bit larger than the urban All foods included in the survey were separated into the stores and were more comparable in size to a small chain- following major categories: fresh fruit; fresh vegetables; store than to the ‘‘mom and pop’’ stores found in the canned and frozen fruit and vegetables; fresh breads, urban areas. These stores usually had ample refrigeration cereals, and other grain products; dry breads, cereals, and and space to dedicate to a larger selection of food. other grain products; fresh meat and meat alternatives; However, in rural areas one large store tended to serve canned and frozen meat and meat alternatives; fats and the needs of an entire county; neighborhood stores were oils; and sugars and sweets. An optional section included rarely found. spices, mixes, and sauces. The original survey had an In rural areas, county boundaries were used to identify additional section in which foods were further examined communities. Only ERS codes of 7, 8, or 9 were con- based on their classification as organic or sustainable. sidered, thus identifying rural counties not adjacent to Because only a few stores in the rural areas and no stores metropolitan areas and having populations between in urban areas carried organic products, this paper will 2,500 and 10,000 residents. US Census data were used to focus on conventionally grown goods. identify counties with higher than average poverty levels Food items were selected for the survey based on their (US Census Bureau, 2002). To determine areas that had inclusion in the Thrifty Food Plan (TFP), a governmental higher than state average estimate for the percentage of meal plan that sets national standards for low cost, residents living in poverty, we examined poverty esti- nutritious foods (Lino, 2001). TFP foods recently have mates for people living in Minnesota counties (1997 been separated into one of 12, age gender appropriate data), along with 1997 small area estimates (school dis- market baskets meant to reflect current governmental tricts) and neighborhood level data (US Census Bureau, recommendations, consumer intake data, food con- 2002). The communities ultimately selected for this sumption data, and pricing data. All TFP market baskets project included two urban neighborhoods in a metro- represent the total pounds of food per week necessary to politan area with ERS codes of 1 and two rural counties successfully adhere to the Food Guide Pyramid. with ERS codes of 8 and 9. The most economical price for each food found in the Lastly, assessments were made to examine the level of store was recorded on the survey. This meant the lowest civic engagement within each community. Civic price option was often found in bulk quantities as stan- engagement can be defined as the active participation by dardized pricing was calculated by converting all foods community members in public affairs and enlightened examined into price per pound. The average price per self-interest, shown through an awareness of the interests pound of selected foods was then compared against the of others (Putnam, 1993). To determine the level of civic TFP market basket prices (MBP) per pound for May engagement, key informant interviews were conducted 2002. Surveys were conducted during the same season to with regard to food activity. Key informants included: maximize comparability of the sites. In order to stay as extension specialists; political leaders; nutrition, food, uniform as possible across the state, no substitutions and health assistance program directors and coordinators; were allowed and no additions were made. and key health care providers living and working in the Each food included in the survey was judged based on communities. All potential communities were rated on a the unit of measure available, quality (when applicable), scale of 1–7 for perceived activity of civic groups and and price. Brand names were recorded and served to organizations focused on solving community food signal whether or not the food was available. If no food problems. These included food shelves, food coalitions, for a particular category was available, it was given a and community gardens as well as having an infra- score of zero to indicate that it was missing.
374 Deja Hendrickson et al.
Food quality data were established using two different Development of consumer survey
criteria. For packaged foods, the expiration date was used
as a measure of the quality of the food inside. Foods with Themes from the focus group analysis were used to de-
expired dates were deemed ‘‘past date.’’ All other foods velop a self-administered food choice and access survey.
were labeled as ‘‘fresh/edible.’’ When expiration dates The survey was examined by a panel of expert reviewers
were not available, as in the case of fresh fruits, for content and face validity prior to its implementation.
vegetables, and some meats, a subjective measure was Additionally, the survey was pre-tested in all four com-
employed. All foods displaying obvious signs of rot or munities (n = 27) for readability; internal consistency
loss of freshness were labeled ‘‘overripe.’’ Foods that had was examined using Cronbach alpha coefficients. The
a loss of freshness but were not rotting were ‘‘slightly scores ranged from low acceptable to excellent and from
overripe’’; all other food was ‘‘fresh/edible.’’ 0.50 to 0.87 (Ary et al., 2002). The survey was revised
slightly based on Cronbach levels and reviewer and
Consumer focus groups participant comments. This report will examine con-
sumer response to specific questions regarding the
Fifteen focus groups (n = 90) were conducted in the availability of food in their community. Data were col-
identified communities according to standard procedures lected using a 5-point Likert Scale with responses
(Morgan and Kruger, 1998). Nutrition professionals and described as ‘‘strongly agree,’’ ‘‘agree,’’ ‘‘unsure,’’
community leaders (n = 49) and community residents ‘‘disagree,’’ and ‘‘strongly disagree.’’ Twelve questions
(n = 41) were included from the study communities. specifically dealing with food availability and accessi-
Focus group questions were developed by the research bility issues were taken from that survey for use in this
team and were semi-structured, open-ended questions paper (Table 1). The answers to these questions were
with prompts. Experts in the field reviewed these for used in establishing the participant’s knowledge of what
content. Topics included access to commercial food constitutes a healthy meal and ability to purchase healthy
sources and food assistance programs, healthy eating, foods. The responses of urban residents then were
food choice behavior, types and extent of community compared to those of rural residents to determine whether
food problems, and community engagement in solving those of similar income classes shared similar barriers to
food problems. The moderators were trained by Kruger, a healthy eating and to examine how the urban influence
nationally recognized expert in focus group methodology affected food choice.
and evaluation. The sessions lasted between 60 and
90 min and were facilitated by the same two trained
investigators, with one serving mainly in the role of Results
moderator and the other as recorder. Focus groups were
audio taped and transcribed verbatim. Codes were iden- Grocery store survey
tified and text was then coded using QSR NUD*IST
Vivo (NVIVO, Australia, 2000). For the purposes of this Data were collected from 14 of 15 urban grocery stores
paper, the text for all codes pertaining to grocery stores, originally recognized as existing in two urban neigh-
variety and quality of foods, and retail food purchases borhoods located in North and South Minneapolis. (One
was examined to identify consumer’s perceptions on the store was deleted from the urban list because it burned
benefits and barriers of shopping in their neighborhoods/ down the week of investigation.) Two large chain gro-
communities. Participants received a small stipend. cery stores located nearest to the two urban neighbor-
At the beginning of each focus group, participants hoods, but outside of the designated areas, were also
were asked to fill out a survey designed to capture examined in order to compare prices, quality, and
information regarding the quality and price range of quantity of foods available to people living in adjacent
foods found in the stores located in their communities. neighborhoods not designated as food deserts. In the two
The information obtained from this survey also provided rural counties, nine stores (n = 4, n = 5) were also sur-
insight into which stores were frequented most often and veyed. Because entire counties were used to define
how the participants traveled to the store. The stores community in rural areas, both rural communities had
within each community were listed on a form, followed one small to medium sized, well-stocked store and a
by five choices for quality of food (poor, fair, good, very couple of small convenience store/gas station establish-
good, great) and price range of food (inexpensive ($) to ments. No ethnic stores were found in the area. Resi-
very expensive ($$$$$)). Additionally, participants were dents of rural areas mostly reported shopping in their
asked how they got to the store. Their choices were drive, county and only traveled occasionally outside the county
walk, bus, taxi, public van, and delivery service. If they for grocery shopping. Therefore, a large chain grocery
did not use the store listed, they were asked to write store in an adjacent county was not surveyed for com-
‘‘DK’’ (don’t know/didn’t use) next to store name. parative prices.Food access issues for low-income residents in Minnesota 375
Table 1. Differences between urban and rural residents’ answers to selected survey questions.a, b
Survey questions Urban (n = 396) Rural (n = 400) P-value
Mean ± SDc Mean ± SD
Crime in my community makes it harder for me to get 0.62 ± 1.19 1.36 ± 0.68 0.000
food.
Fresh fruits and vegetables are available in my com- 0.79 ± 1.04 1.30 ± 0.68 0.000
munity.
Canned fruits are available in my community. 1.02 ± 0.86 1.38 ± 0.59 0.720
Transportation problems make eating healthy hard for 0.12 ± 1.26 0.96 ± 0.96 0.000
me.
Cost makes healthy eating hard for me. )0.10 ± 1.30 0.45 ± 1.22 0.011
I would eat more fruits and vegetables if they didn’t go )0.56 ± 1.16 )0.24 ± 1.16 0.129
bad so often.
People in my community never go hungry. )0.02 ± 1.22 )0.04 ± 0.90 0.611
There are enough food stores in my community. 0.47 ± 1.27 0.66 ± 1.18 0.000
The cost of healthy eating is higher in my community )0.49 ± 1.09 )0.12 ± 1.07 0.000
than other places.
The food available to my in my community is safe to eat. 0.72 ± 0.96 1.13 ± 0.72 0.000
The healthy food choices in my community are afford- 0.22 ± 1.20 0.55 ± 0.96 0.000
able.
I do most of my food shopping within my community. 0.63 ± 1.16 1.21 ± 0.85 0.000
I would eat healthier food if the community stores of- )0.55 ± 1.07 )0.13 ± 1.05 0.000
fered more healthy options.
a
Based upon independent sample t-test.bAnswers on scale ranged from ()2 to +2); )2 = Strongly Disagree; )1 = Disagree;
0 = Unsure; +1 = Agree; + 2 = Strongly Agree.cSD = standard deviation.
Table 2 shows the comparison of price per pound of Table 3 reports the quantity of foods available in the
selected foods in urban and rural communities with TFP two urban neighborhoods and compares it to the food
MBP. This table provides graphic information pertaining available in the large outlying supermarkets. As marked
to each area of Minnesota studied and reveals consider- earlier, rural stores were not compared to a chain
able differences between neighborhoods located in both supermarket because the stores in the area were large
urban and rural Minnesota. In the urban areas studied, 9 enough to house several different types of produce, and
of 17 (53%) foods present in one urban Minneapolis chain supermarkets were not located near any of the
neighborhood were significantly more expensive than the county lines. In the urban neighborhoods, there was a
MBP. Only one type of food was significantly less significant difference in both the amount and type of
expensive than the MBP. Apples were only available in fruits and vegetables available in stores and supermar-
one store in the neighborhood and broccoli was not kets. While there were several different types of fresh
available in any of the stores. Therefore neither of these fruits and vegetables to choose from in the supermarkets,
foods was included in the analysis of food available in such choices were markedly limited in the markets and
this neighborhood. In the other urban Minneapolis grocery stores of the urban neighborhoods. Additionally,
neighborhood, 6 of 19 (32%) foods were significantly the stores located within the neighborhood boundaries
more expensive than the MBP. No food in this neigh- that did sell fresh fruits and/or vegetables stocked only
borhood was significantly less expensive than the MBP. one or two pieces of each item, and they were usually of
In the rural areas studied, 2 of 19 (11%) foods in one poor quality.
county were significantly more expensive than MBP and
three were significantly less expensive. Lastly, 4 of 19 Consumer focus group data
(21%) foods in the other rural area were significantly
more expensive than the MBP, while only one food was Participants (n = 41) of the consumer focus groups dis-
significantly less expensive. cussed food access issues for their immediate neighbor-
Although several foods were below the MBP across hoods and communities and identified reasons for as well
counties, food in urban neighborhoods was, on average, as barriers to shopping in their area. Participant demo-
more expensive than food in rural counties. However, graphic data are shown in Table 4. The major differences
two-thirds of the foods that were higher than the MBP in between the rural and urban samples were the age and
rural communities were not staple foods; the reverse was racial composition of the groups, with the rural sample
true in urban areas. having a higher percentage of elderly and Caucasians376 Deja Hendrickson et al.
Table 2. Comparison of price per pound of selected foods in urban and rural communities using ANOVA.
Food Market basket price Urban area #1 Urban area #2 Rural county #1 Rural county #2
Apples 0.92a – 1.44a 0.97a 0.83a
Bananas 0.52a 0.87a 0.67a 0.49a 0.61a
Oranges 0.85a 2.36b 1.57a 0.79a 0.94a
Frozen O.J. 1.82a 2.48b 1.90a 1.71a 1.48c
Broccoli 1.04a – 1.19a 0.79b 1.18a
Potato 0.51a .43b .78a .32c 0.47a,b
Tomato 1.33a 1.41a 1.78a 1.44a 1.19a
White bread 1.01a 1.72b 1.46c 1.30c 1.27a
White flour 0.41a .47b 0.38a,c 0.31c 0.34a
White rice 0.47a 1.09b 0.75c 0.58a 0.61b
Spaghetti 0.90a 1.17a 1.00a 0.85a 0.90a
1% milk (gallon) 2.82a 1.57a 2.92a 2.84a 3.30c
Skim milk (gallon) 2.82a 1.48a 1.79b 2.80a 3.23b
Ground beef 1.74a 2.16a 1.88a 1.33a 2.06a
Whole chicken 1.09a 1.39a 1.74a 1.02a 1.21a
Eggs (dozen) 1.00a 1.22b 1.16b 0.90a 0.92a
Tuna 1.98a 2.15b 2.45b 2.02a,b 1.87a,b
Peanut butter 1.96a 2.87b 2.49b 1.81a 1.80a
White sugar 0.32a 3.34b 2.38c 1.79d 1.84d
a–d
Numbers in rows sharing the same superscript are not significantly different from each other. Significance was measured at
P = 0.005.
participants than the urban sample. The urban sample and I do shop at the smaller places sometimes, just to
was comprised mainly of Caucasian, Native American, give money to them, kind of you know, I keep that in
and African-American residents. The main reasons given mind or whatever, because I think that places like
for shopping in their community included convenience, smaller places need to be supported, like smaller family
time, lack of transportation, and support for the neigh- businesses...
borhood businesses. As one individual explained, lack of
This sense of community support was found in both
transportation keeps her shopping in the community.
urban and rural communities.
I grew up kind of like in a small town on a farm, and Many urban dwellers identified barriers to shopping
you know sometimes I go to the store for my within the community, including economic reasons,
aunt....Sullivan’s cause that’s where I go, it’s no where quality of food issues, and food choice limitations. In-
near as good as what’s on 60th and Nicollet (a major deed, one participant expounded on the above quote, ‘‘If
grocery store). But I’m not going to go to 60th and you can afford it.’’ The respondent found small family
Nicollet ‘cause I don’t have a car.... businesses too expensive to support. Another resident
stated, ‘‘They get whatever they can at these stores...I
Support for local business also keeps some shopping
think it’s a rip-off. I’ve seen moms take their food stamps
in the neighborhood. As one participant stated,
and buy 100 dollars worth of food and just hardly get
Ya, I wouldn’t go to Cub or Rainbow just because I nothing....’’ Another common complaint verbalized by
think they are kind of like bigger chains or whatever participants living in urban areas was the lack of variety
and I don’t know, it makes me feel gross or whatever. of fruits and vegetables found at stores in the area. As
Because I think those kinds of places take away from, one said,
Table 3. Mean numbers of types of fruits and vegetables available in two, low-income urban communities in Minnesota, compared
to the mean types of fruits and vegetables in a supermarket in an adjacent community.a
Community N Mean type of vegetables P-value Mean type of fruits P-value
Urban community #1 8 6 0.00 3 0.00
Supermarket in adjacent neighborhood 1 66 37
Urban community #2 6 14 7
Supermarket in adjacent neighborhood 1 56 0.20 36 0.16
a
Based upon independent sample t-test.Food access issues for low-income residents in Minnesota 377 Table 4. Focus group subject’s sample characteristics. Characteristics All subjects (n=41) Urban subjects (n=22) Rural subjects (n=19) Gender Male 14 (34%) 7 (32%) 7 (37%) Female 27 (66%) 15 (68%) 12 (63%) Age (years) 18–29 9 (22%) 5 (23%) 4 (21%) 30–49 13 (32%) 7 (32%) 6 (32%) 50–64 9 (22%) 7 (32%) 2 (11%) 65–74 1 (2%) 1 (4%) 0 75+ 9 (22%) 2 (9%) 7 (36%) Race African-Americans 6 (15%) 6 (27%) 1 (5%) Caucasian 23 (56%) 10 (46%) 13 (68%) Native American 6 (15%) 5 (23%) 1 (5%) Hispanic 2 (5%) 0 2 (11%) Other 3 (7%) 0 2 (11%) Education
378 Deja Hendrickson et al.
store for groceries (85% and 90%, respectively), to eat.’’ Members of both urban and rural communities
whereas urban residents walked most frequently (40% disagreed with the following statements: (1) ‘‘Healthy
and 60%, respectively), or took a bus to the store (30% food choices in my community are affordable’’; (2)
and 15%, respectively). ‘‘People in my community never go hungry’’; and (3) ‘‘I
would eat healthier food if the community stores offered
Consumer survey data more healthy options.’’ Additionally, 23% of the survey
respondents gardened and felt that having their own
Urban (n = 396) and rural (n = 400) consumers were garden promoted healthier eating habits in their house-
surveyed regarding the food availability within their holds. The urban group was found to consume more
communities (see Table 1). Sample characteristics of fruits and vegetables than their rural counterparts. The
consumers are shown in Table 5. Consistent with the majority of these respondents were primarily white and
focus groups, rural participants tended to be Caucasian, had incomes at the higher end of the low-income range.
had higher income (though still below the mean state
income levels), and were slightly older, (with a mean age
of 48 years compared to 41 years for urban consumers). Discussion
Rural community members were significantly more
likely to agree with the following survey questions than The key findings from this multifaceted study are: (1)
their urban counterparts: (1) ‘‘Crime in my community food costs are higher than the average TFP market basket
makes it harder for me to get food’’; (2) ‘‘Fresh fruits and prices in areas with the highest poverty levels; (2) con-
vegetables are available in my community’’; (3) sumer perception of price and quality varied by location;
‘‘Transportation problems make eating healthy hard for (3) the quality of food available in these areas is inferior
me’’; (4) ‘‘Cost makes healthy eating hard for me’’; (5) and inedible in many cases; (4) quantity and variety are
‘‘There are enough food stores in my community’’; and more limited in these areas; and (5) rural community
(6) ‘‘The food available to me in my community is safe members identified more barriers regarding access to
Table 5. Survey subject demographics.
Characteristics All subjects (%) Urban subjects only Rural subjects only
(n = 796) (%) (n = 396) (%) (n = 400)
Gendera,c
Male 37.9 43.8 32.1
Female 62.1 56.2 67.9
Race/Ethnicitya,c
African-American 26.1 52.2 0.5
American-Indian 12.2 23.7 1.0
Asian 1.0 1.8 0.3
Caucasian 55.4 16.3 94.0
Hispanic 2.5 1.5 3.5
Other 2.7 4.6 0.8
Income (Monthly)a,c
Less than $500 (1) 22.3 36.5 8
$500–1000 (2) 28.3 36.5 20.2
$1000–1500 (3) 18.4 14.5 22.2
$1500–2000 (4) 15.0 7.5 22.5
More than $2000 (5) 16.0 4.9 27.1
Income (Monthly)b,d 2.7 ± 1.4 2.1 ± 1.1 3.4 ± 1.3
Education level completed a,c
8th grade or less (1) 7.8 8.1 7.6
9–11th grade (2) 18.0 25.1 10.8
High school diploma/GED (3) 39.6 39.8 39.3
Tech. certif./Assoc. degree (4) 9.9 7.6 12.1
Some college (5) 16.3 15.0 17.6
College graduate (6) 8.5 4.3 12.6
Education level completeda,d 3.3 ± 1.4 3.1 ± 1.3 3.6 ± 1.4
Ageb,d 44.9 ± 17.5 40.9 ± 13.5 48.8 ± 19.9
a
Data shown are frequency data.bData shown are means and standard deviation.cChi-square analysis shows statistical significance
between urban and rural subjects.dT-test analysis shows statistical significance between urban and rural subject means.Food access issues for low-income residents in Minnesota 379 food than did urban members. While the price of foods fruits and vegetables fresh, and most of the smaller varied throughout the four communities, urban people markets did not have air conditioning. When these more frequently felt that the quality and variety of food in conditions are compounded with hot humid weather, their neighborhood stores was poor, whereas rural people fruits and vegetables deteriorate quickly. Consistent with tended to be more satisfied, but their access suffered due this, almost none of the stores in the urban areas to transportation problems. Because of poor food quality, stocked fresh fruits or vegetables that could be classified high priced food, and lack of food choice, urbanites were as ‘‘fresh/edible.’’ In fact, participants in our study did more likely to shop out of the neighborhood. not feel that they would eat more fruits and vegetables The stores included in this study sold food at signifi- if given the opportunity (Eikenberry and Smith, 2004). cantly higher prices than has been determined by the This is a sentiment that corroborates evidence that MBP, pushing many staple food items (e.g., bread, eggs, people from the lowest socioeconomic classes consume milk) out of an affordable price range for low-income fewer fresh fruits and vegetables than the rest of the urban residents. Our results show that the lowest income other Americans (Kant et al., 1991). While it is known households pay more for the food they purchase than that decreased consumption of fruits and vegetables higher income households. This is consistent with other among low-income urban dwellers is linked to socio- findings in the literature (Jones and Mustiful, 1996; economic status and psychosocial factors such as McDowell et al., 1997). Furthermore, Chung and Meyers participation in social networks and support groups (1999) found that people who do not have access to large (Lindstrom et al., 2001), we have shown that the quality chain stores pay more for their food and that those living of food available also plays a role. Even if the families in poor neighborhoods are less likely than those living in living in the vicinity of these stores had the money to more affluent neighborhoods to have access to large spend on fresh fruits and vegetables, their choices might chain grocery stores and therefore spend a greater per- not last much beyond the day they were purchased. centage of their limited resources on food. Based on the Rather, it appears from the survey results and from research of Morris et al. (1992) the actual cost of the focus group sessions that most fresh and canned fruits MBP of food in urban areas can be 15% higher in and vegetables are obtained through available food supermarkets, 26% higher in medium stores, and 38% programs operating in these areas such as soup kitchens higher in small stores. In our study, more urban dwellers and food shelves. From our survey data, we found that reported that fewer fruits and vegetables were available 53% of the urban sample used food shelves and 41% in their neighborhood and that healthy foods were not used food stamps to increase their household food affordable. Our urban areas stores were generally very supply. Thus, food assistance programs appear to play small, had only a few employees, and were frequently an instrumental role in supplementing the diet of low- ethnic food stores catering to a specific segment of the income individuals (Eikenberry and Smith, 2005). By population. For instance, one store sold Middle Eastern contrast, the quality of fresh fruits and vegetables did and African foods and catered to the newer Somali and not appear to be a barrier to consumption for residents Ethiopian immigrants. These stores had limited amounts living in the rural areas, with nearly every store stocking of food and tended to be more expensive than the larger ‘‘fresh/edible’’ fruits and vegetables. The majority of the grocery stores located in the adjacent neighborhoods. stores in these areas employed proper refrigeration The stores in the rural areas were larger, had more techniques to keep the foods as fresh as possible until employees, and sold food that could be considered the time of purchase. Residents of the rural areas were ‘‘mainstream,’’ all factors that can explain why prices in cognizant of the fact that stores stocked fresh fruits and the rural areas were more likely to conform to the MBP vegetables and more strongly agreed with the statement guidelines. that ‘‘fresh fruits and vegetables are available within my In every community we examined, we found fresh community’’ than did urban residents. produce to be equal to or less expensive than the MBP A small number of urban and rural participants iden- for these foods, and our survey showed that neither tified gardening as a supplemental source of produce urban nor rural residents felt that fresh fruits and veg- from mid-summer to mid-fall. In urban neighborhoods, etables were unaffordable or unavailable to them. One private gardens and community gardens were used, but possible explanation for this is that the study was con- how much actual food they contributed to individual ducted at the height of summer, when prices for many households was not measured. Additionally in focus fruits and vegetables are generally lower (Perez and groups, some reported using WIC vouchers at the Pollack, 2003). Another reason that residents felt they farmers market to obtain fresh produce. In rural areas, could afford fruits and vegetables was that many were some participants also reported keeping small gardens, of poor quality and prices were lowered in order to but how much food the gardens contribute to the move them off the shelves. Only two urban stores had household diet is unclear and would be an interesting proper refrigeration and/or other means to keep the subject for future research.
380 Deja Hendrickson et al. The quantity as well as quality of food was limited in that healthy foods cost more in poorer areas than in the urban areas we studied. The small size of the stores as affluent ones (Morris et al., 1992; Kaufman, 1998; Rose well as the problem of theft in the urban areas severely and Richards, 2004). Additionally, our urban participants limited the amount of shelf space the owners could more strongly disagreed with the idea that the cost of commit to stocking food. Often, stores displayed one or healthy eating was higher in their communities than did two packages of a single brand of food, and there were their rural counterparts (Table 1). Such differences in only a small number of fruits and/or vegetables to choose opinion may be the consequence of a confusion over from. Lack of variety is not an uncommon occurrence in what exactly constitutes a healthy meal. They may also low-income neighborhoods, and focus group data as well be the result of healthy foods such as fresh fruits and as survey participants reported that the lack of variety vegetables becoming available to urban participants limited food choice options available in the urban areas. through food assistance programs such as soup kitchens, Issues surrounding food quantity were associated with which make healthy eating more affordable because they the urban communities in this study. By contrast, stores do not need to spend money to obtain these items. As in the rural areas generally offered at least one brand of mentioned earlier, a large proportion of urban residents generic food for each type of highly recognizable brand participated in food assistance programs and did not pay name offered. Fruits and vegetables were available in for the ‘‘healthy’’ food consumed. Therefore, cost may larger quantities and were restocked when supplies ran be less of an issue for them than it otherwise would be if low. they had to rely solely on neighborhood stores to pur- In addition to this data, Healthy People 2010 reported chase their foodstuffs. Additionally, nearly one fifth of that residents in low-income areas are more likely to be the urban survey respondents reported resorting to from minority populations and suffer from one of several dumpster diving in order to obtain enough food to eat diet-related ailments (i.e., obesity, diabetes, cancer, and (Eikenberry and Smith, 2005) and reported that fruits and heart disease) that may be ameliorated with a diet rich in vegetables were rarely found in dumpsters. Better access fruits and vegetables (USDHHS, 2003). The urban resi- to food assistance programs also may have led urban dents in our study were predominantly from minority dwellers to disagree with the statement ‘‘People in my populations, while our rural poor were white. Nonethe- community never go hungry.’’ A key benefit to less, individuals living in both areas suffered from participants of these programs is the reduction of hunger obesity and self-reported related chronic diseases. (Edward and Evers, 2001). Several studies have been conducted that identify a Retailers maintained that the location of the store link between a diet rich in fruits and vegetables and the necessitated the higher cost of their products. Crimes, prevention of diseases such as diabetes, cancer, and heart like theft, were very common occurrences in urban disease (Anderson and Hanna, 1999; Duff, 2001; Hu and neighborhoods where food items were the most expen- Willet, 2002; Marlett et al., 2002; Sadovsky, 2002). sive, and store-owners used them to justify increased Additionally, Lin and Morrison (2002) found that regular prices. This phenomenon is not isolated to these neigh- consumption of fruits was correlated with a lower Body borhoods. McCarthy and Hogan (1992) discussed the Mass Index (BMI). They did not come to the same link between poverty, hunger, and food theft and found conclusion about vegetables but speculated that the that hunger among youth is associated with increased practice of adding high fat sauces to many vegetables theft of food. They suggested that serious theft is the confounded the results. We understand that the mere result of a combination of lack of proper shelter and presence of healthy food within the community does not proper meals. Neighborhoods where many residents live necessarily mean that the food will be purchased and below the poverty level presumably have a larger per- consumed within the home. However, it is impossible to centage of people living with hunger and shelter issues. eat what is not available. We believe cheaper foods and Yet, an increase in food prices because of theft makes it greater variety of fresh fruits and vegetables should be even more difficult for residents to obtain food and can made available to all, especially low-income people who perpetuate the problem of crime. In focus groups some are at such a high risk for chronic disease. Discussions in participants reported having to steal food from small focus groups suggest that individuals living in these food stores as one strategy to cope with food insecurity and deserts are very interested in having more food choice hunger (Eikenberry and Smith, 2005). Furthermore, the and that, if fresh foods were affordable, they would residents living in both the urban and rural neighbor- make an effort to include them in their diet. hoods we studied reported that crime was a major barrier Survey participants in urban neighborhoods were more to procuring food. In the urban focus groups, the concern likely to disagree with the statement ‘‘Cost makes heal- over crime was very evident as one woman said, thy eating hard for me’’ than were residents living in rural counties. Other researchers have examined the price You know that’s when I keep my phone right there, I and availability of healthy foods and have also reported keep it right there Lord. Look, I heard bom, bom, bom,
Food access issues for low-income residents in Minnesota 381
bom. I just picked up my phone and dialed 911 and I While the urban dwellers in this study certainly had
said honey somebody got killed over here. I don’t know some transportation problems of their own, they were
why... generally within walking distance to several stores.
Responses to the consumer survey indicated that walking
Another man said, ‘‘That’s right. There was a guy that
was the most common means of getting to the urban
got killed from Park Plaza, right down the street. When I
grocery store. Sixty percent of the residents in one urban
came in, there he was laying in a body bag.’’
community reported that they walked to the store. While
Although residents in rural communities also felt
only 40% of the respondents in the other community
threatened by general crime, the price of food in these
reported that they walked to the store, an additional 30%
communities was generally lower than in urban areas,
responded that they took the bus, limiting their choice of
and store-owners did not feel that theft was a major
stores to those located within walking distance of a bus
problem. The lack of theft may contribute to store-
stop.
owners keeping food prices lower in these communities.
In their study of low-income women, Shankar and
In fact, the only foods outside the affordable range in
Klassen (2001) reported that 70% do their grocery
rural communities were low-fat milk, white rice, and
shopping within 10 blocks of their homes, and an equal
white sugar. While low-fat milk would offer a positive
number of people drive and don’t drive to the store. Even
alternative to whole milk in the diets of low-income
though large chain grocery stores are within driving
residents, it does not seem to be an item purchased on a
distance to all the neighborhoods we studied, we found
regular basis. Fischer and Strogatz (1999) and Jones
that a large proportion of urban subjects in this study
(1997) determined that, although national preferences of
reported that they often walked to the nearest store to buy
those with higher incomes have shifted towards low-fat
their food, limiting their choice to a store that is within
milk, residents in low-income areas still purchased three
walking distance and their purchases to that which could
times more whole milk than residents of higher-income
easily be carried home. In our focus groups, the main
areas. The former may be opting to purchase whole milk
reasons given for shopping in the community were
because of sensory issues (taste), lack of health infor-
convenience, transportation issues, and supporting local
mation, cost, or the presence of small children in the
businesses. Because none of the neighborhoods had large
household. White rice and white sugar, by contrast, are
chain grocery stores within walking distance, the resi-
highly processed foods that are not considered to be
dents who walked to the store were forced to pay more
staples of a healthy, well-balanced diet. In this regard,
for their groceries. However, some residents did report
low-income rural residents may have access to more
leaving the neighborhood in order to have more food
affordable and healthier food options than do their urban
choice or to obtain lower prices. They used private cars,
counterparts.
public buses; they created an informal taxi network, and
People living in the rural counties were more likely to
they car pooled. Additionally, urban residents appear to
agree with the statement, ‘‘Transportation problems make
have greater access to food programs. Altogether, these
healthy eating hard for me,’’ than were their urban
conditions may be the major contributors to a diet that is
counterparts. This comes as no surprise with the advent
higher in fruit and vegetables for our urban sample.
of retail consolidation in many rural communities due to
diminishing rural populations but does mean that rural
residents must travel greater distances to access the food Conclusion
system (e.g., stores, markets, and restaurants). Our par-
ticipants reported traveling further to shop for groceries This study found that low-income urban residents in two
but felt they had lots of food choice available to them Minneapolis neighborhoods shopped in grocery stores
once they reached their destination. However, a lack of where small selection and poor quality was coupled with
transportation in a rural county is a major barrier to food expensive prices, hindering their access to a wide variety
access and potentially to a healthy diet. For the rural of food choices. The lack of reliable transportation and
sample, lack of access to a car could mean walking for the proximity of neighborhood stores made walking a
miles, waiting for hours for a bus or other form of viable option. The residents of these neighborhoods
transport, borrowing a car, or arranging to share a ride shopped in more expensive neighborhood groceries
(Kaufman, 1998). Glasgow (2000) also reported that because they lacked reliable transportation, choosing
transportation was problematic for low-income house- instead to walk to the nearest store. Low-income resi-
holds, the elderly, and people without reliable personal dents in two rural communities appeared to have a wider
cars or with driving limitations. Furthermore, in our variety of foods to choose from but still were affected by
communities, food assistance programs were more lim- the high cost of food in their area. Additionally, they
ited in rural areas. They had shorter hours, and sites were suffered from transportation problems (longer distances)
located in the largest community in the county. and some spent extra money for gas. Many rural urban382 Deja Hendrickson et al.
participants have been exposed to years of excessive Anderson, J. W. and T. J. Hanna (1999). ‘‘Impact of nondi-
environmental and physical stress and this may contrib- gestible carbohydrates on serum lipoproteins and risk for
ute to the increased prevalence of chronic disease, such cardiovascular disease.’’ Journal of Nutrition 129: 1457S–
as heart disease, cancer, and diabetes. Better access to a 1466S.
Ary, D., L. C. Jacobs, and A. Razavieh (2002). Introduction to
variety of affordable and high quality fruits, vegetables,
Research Education 6th edition. Belmont, California:
whole grains, fresh dairy, and meat products within their
Wadsworth.
community would provide this population with a cost- Bazzano, L. A., J. He, L. G. Ogden, C. M. Loria, S. Vupputuri,
effective way to create a healthy diet, thus reducing their L. Myers, and P. K. Whelton (2002). ‘‘Fruit and vegetable
risk of chronic disease. As the food system continues to intake and risk of cardiovascular disease in US adults: The
consolidate in rural communities and as large stores first National Health and Examination survey epidemiologi-
continue to migrate out of inner cities it will be important cal follow-up study.’’ American Journal of Clinical Nutrition
for civic leaders to address the problems associated with 76(1): 93–99.
food access in these food desert communities. Better Chung, C. and S. L. Myers Jr. (1999). ‘‘Do the poor pay more
community planning and a strong community infra- for food? An analysis of grocery store availability and food
structure are needed so that these areas can secure better price disparities.’’ Journal of Consumer Affairs 33(12): 276.
Cummins, S. and M. Macintyre (2002). ‘‘‘Food deserts’ evi-
access to food stores with healthy food options of high
dence and assumption in health policy making.’’ British
quality, thus reducing the burden on the neediest.
Medical Journal 325: 436–438.
Duff, K. (2001). ‘‘Diet and cancer: Nature’s cancer fighting
foods.’’ Townsend Letter for Doctors and Patients August:
146.
Notes
Edward, H. G. and S. Evers (2001). ‘‘Benefits and barriers
associated with participation in food programs in three low-
1. The North American Industry Classification System (NA-
income Ontario communities.’’ Canadian Journal of Dietary
ICS) was developed as the standard for use by Federal
Practice and Research 62(2): 76–81.
Statistical agencies in classifying business establishments. It
Eikenberry, N. and C. Smith (2004). ‘‘Healthful eating: Per-
replaced the US Standard Industrial Classification (SIC)
ceptions, motivations, barriers, and promoters in low-income
system in 1997 (http://www.census.gov/epcd/www/drna-
Minnesota communities.’’ Journal of American Dietetic
ics.Htm#a1).
Association 104(7): 1158–1161.
2. The Economic Research Service (ERS) is the main source of
Eikenberry, N. and C. Smith (2005). ‘‘Attitudes, beliefs and
information and research from the US Department of
prevalence of dumpster diving as a means to obtain food by
Agriculture in Washington DC. The ERS has developed a
Midwestern, low-income, urban dwellers.’’ Agriculture and
set of categories at the county level known as urban influ-
Human Values 22(2): 187–202.
ence codes. These categories were based on the population
Fischer, B. D. and S. Strogatz (1999). ‘‘Community measures
size of the county and the proximity to an area of economic
of low-fat milk consumption: Comparing store shelves with
opportunity. It is believed that access to large-scale econo-
households.’’ American Journal of Public Health 89(2): 235–
mies enables smaller economies to connect to national and
237.
international marketplaces. The urban influence county
Friedrich, M. J. (2000). ‘‘Poor children subject to ‘environ-
codes categorize rurality based on population and com-
mental injustice.’’ Medical News and Perspectives 283(23):
muting patterns. The codes consist of nine categories: codes
3057–3058.
1 (large metro) and 2 (small metro) are grouped based on
Glasgow, N. (2000). ‘‘Older Americans patterns of driving and
size – greater than a million and less than a million
using other transportation.’’ Rural America 15(3): 26–31.
respectively; codes 3–9 designate non-metropolitan coun-
Hu, F. B. and W. C. Willet (2002). ‘‘Optimal diets for pre-
ties. This study used codes 1, 7, 8, and 9. Urban Influence
vention of coronary heart disease.’’ Journal of the American
Codes 7, 8, and 9 were used to identify rural counties non-
Medical Association 288(20): 2569–2578.
adjacent to a metro area. Specifically, Code 7 is a county
Jones, E. (1997). ‘‘An analysis of consumer food shopping
non-adjacent to a metro area and has a city of at least 10,000
behavior using supermarket scanner data: Differences by
residents; Code 8 is a county non-adjacent to a metro area
income and location.’’ American Journal of Agricultural
and has a town of 2,500–9,999 residents; and Code 9 in non-
Economics 79(5): 1437–1444.
adjacent to a metro area and does not contain a town greater
Jones, E. and B. W. Mustiful (1996). ‘‘Purchasing behavior of
that 2,500 residents.
higher and lower-income shoppers: A look at breakfast
cereals.’’ Applied Economics 28(1): 131–138.
Joshipura, K., F. Hu, J. Manson, M. Stampfer, E. Rimm, F.
References Speizer, G. Colditz, A. Ascherio, B. Rosner, D. Spiegelman,
and W. Willet (2001). ‘‘The effect of fruit and vegetable in-
Alaimo, K., C. M. Olson, and E. A. Frongillo (2001). ‘‘Low take in relation to risk of heart disease.’’ Annals of Internal
family income and food insufficiency in relation to over- Medicine 134(12): 1106–1114.
weight in US children: Is there a paradox?’’ Archives of Kant, A. K., G. Block, A. Scharzkin, R. Ziegler, and M. Nestle
Pediatrics & Adolescent Medicine 155(10): 11–27. (1991). ‘‘Dietary diversity in the US population, NHANES II,Food access issues for low-income residents in Minnesota 383 1976–1980.’’ Journal of the American Dietetic Association Olson, C. M. (1999). ‘‘Nutrition and healthy outcomes associ- 91: 1526–1537. ated with food insecurity and hunger.’’ Journal of Nutrition Kaufman, P. R. (1998). ‘‘Rural poor have less access to 129: 521–524. supermarkets, grocery stores.’’ Rural Development Perspec- Perez, A. and S. Pollack (2003). ‘‘Fruit and tree nuts outlook.’’ tives 13(3): 19–26. USDA Electronic report from the economic research service, Koh, E. T. and V. Caples (1979). ‘‘Frequency of selection of FTS-302. Accessed on May 19, 2003 at http://www.ers.us- food groups by low-income families in southwestern Mis- da.gov/Briefing/FruitAndTreeNuts/. sissippi.’’ Journal of the American Dietetics Association Putnam, R. D. (1993). Making Democracy Work. Princeton, 74(6): 660–664. New Jersey: University Press. Kratt, P., K. Reynolds, and R. Shewchuk (2000). ‘‘The role of Resnicow, K., R. Wang, W. Dudley, A. Jackson, J. Ahluwalia, availability as a moderator of family fruit and vegetable T. Baranowski, and R. Braithwaite (2001). ‘‘Risk factor consumption.’’ Health Education Behavior 27(4): 471–482. distribution among socioeconomically diverse African Lang, T. and G. Rayner (2002). ‘‘Why health is the key to the American adults.’’ Journal of Urban Health 78(1): 125– future of food and farming.’’ UK Public Health Association. 140. Accessed on March 29, 2002 at http:/www.ukpha.org.uk. Rose, D. and R. Richards (2004). ‘‘Food store access and Lin, B. H. and R. M. Morrison (2002). ‘‘Higher fruit con- household fruit and vegetable use among participants in the sumption linked with lower body mass index.’’ Food Review US Food Stamp Program.’’ Public Health Nutrition 7(8): 25(3): 28–32. 1081–1088. Lindstrom, M., B. S. Hanson, E. Wirfalt, and P. O. Ostergren Ross, C. E. (2000). ‘‘Walking, exercising, and smoking: Does (2001). ‘‘Socioeconomic differences in the consumption of neighborhood matter?’’ Social Science and Medicine 51(2): vegetables, fruit, and fruit juices: The influence of psycho- 265–274. social factors.’’ European Journal of Public Health 11(1): Sadovsky, R. (2002). ‘‘Eating fruit and vegetables affects cor- 51–59. onary heart disease risk.’’ American Family Physician 65(2): Lino, M. (2001). ‘‘The thrifty food plan, 1999: Revisions of the 285. market baskets.’’ Family Economics and Nutrition Review Shankar, S. and A. Klassen (2001). ‘‘Influences of fruit and 13(1): 50–64. vegetable procurement and consumption among urban Afri- Marlett, J. A., M. I. McBurney, and J. L. Slavin (2002). ‘‘Po- can-American public housing residents, and potential strate- sition of the American Dietetic Association Health implica- gies for intervention.’’ Family Economics and Nutrition tions of dietary fiber.’’ Journal of the American Dietetic Review 13(2): 34–46. Association 102(7): 993–1000. Townsend, M. S., J. Peerson, B. Love, C. Achterberg, and S. P. McCarthy, B. and J. Hogan (1992). ‘‘Mean streets: The theo- Murphy (2001). ‘‘Food insecurity is positively related to retical significance of situational delinquency among home- overweight in women.’’ Journal of Nutrition 131: 1738– less youths.’’ The American Journal of Sociology 98(3): 597– 1745. 564. US Census Bureau (2002). ‘‘Small area income and poverty McDowell, D. R., J. E. Allen-Smith, and P. E. Mclean-Mey- estimates.’’ Accessed on May 20, 2002 at http://www.cen- insse (1997). ‘‘Food expenditures and socioeconomic char- sus.gov/hhes/www/saipe/saipe.html. acteristics: Focus on income class (Income inequality: USDHHS (US Department of Health, Human Services) (2003). Implications for food consumption behavior).’’ American Healthy People 2010. Accessed on May 19, 2003 at http:// Journal of Agricultural Economics 79(5): 1444–1452. web.health.gov/healthypeople. Morgan, L. L. and R. A. Kruger (1998). The Focus Group Kit. Duyn, M. A. and E. Pivonka (2000). ‘‘Overview of the health Thousand Oaks, California: Sage Publications. benefits of fruit and vegetable consumption for the dietetics Morland, K., S. Wing, A. Diez Rioux, and C. Poole (2002). professional selected literature.’’ Journal of the American ‘‘Neighborhood characteristics associated with the location of Dietetic Association 100: 1511–1521. food stores and food service places.’’ American Journal of Veenema, T. G. (2001). ‘‘Children’s exposure to community Preventative Medicine 22(1): 23–29. violence [Review].’’ Journal of Nursing Scholarship 33(2): Morris, M. P., L. Neuhauser, and C. Cambell (1992). ‘‘Food 167–173. security in rural America: A study of the availability and costs of food.’’ Journal of Nutrition Education 24(1): 52S–25S. Ness, A. and J. Powles (1997). ‘‘Fruit and vegetables, and Address for correspondence: Dr. Chery Smith, Department of cardiovascular disease: A review.’’ International Journal of Food Science and Nutrition, University of Minnesota, FScN Epidemiology 26: 1–13. 225, 1334 Eckles Ave., St. Paul, Minnesota, 55108, USA NVIVO-QSR version 1.2. (2000). Australia: QSR International, Phone: +1-612-6242217; Fax: +1-612-6255272; Inc. E-mail: csmith@umn.edu
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