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Measuring Aspects of the Environment Related to Availability and
Accessibility of Healthy Foods

The survey of instruments was completed and the chapter written by Melissa Smiley and Ana Diez Roux. It was last revised in May, 2005.

Chapter Contents

1. Introduction
2. Key Elements in the Table
3. General Comments and Areas for Further Research

Introduction

The attached table summarizes articles demonstrating different ways to measure accessibility of grocery stores and availability of healthy foods. While people are often encouraged to improve their health by eating healthier foods, it is important to understand how access and availability of food impact dietary choicest in different communities and neighborhoods.

The overall goal of this table is to identify a range of ways to measure one environmental risk factor (accessibility and availability of food) for cardiovascular disease. The articles summarized in this table include measurement techniques to collect subjective and objective data. The articles themselves, however, generally do not specifically address cardiovascular disease. The table is focused exclusively on identifying and highlighting measurement techniques, and is not concerned with actual results calculated or correlations determined.

Key Elements in the Table

The following sections briefly describe the contents of each table column and the analysis criteria and definitions used in their creation.

Sources

Sources are arranged alphabetically by year, beginning with 2005. Only articles published more recently than 1990 are included in the table. We chose this year because significant research into the issues occurred throughout the 1990s. Multiple sources are grouped into one table row when they utilized substantially similar or identical data and measurement technique.

This table is not an exhaustive collection of articles. We consulted various databases, including PubMed, FirstSearch, the Avery Index to Architectural Periodicals, and Family and Society Studies Worldwide. We systematically reviewed citations in articles in the table and articles that were considered but ultimately not included. Once this process began to yield largely similar results, we were satisfied that we captured the majority of current work in this field.

Constructs

We identified two main constructs conveyed in the research. Readers are invited to scan the table using these constructs to find measurements of interest. The constructs are described below.

• Availability - These measurements focus on specific food items and determine whether they are sold, how much they cost, and what varieties and amounts are available.
• Accessibility - These measurements focus on counting numbers of food retailers (including stores and restaurants), determining where they are located, and calculating how they are distributed throughout geographic areas.

Note that slightly different definitions of availability and accessibility may be used by others.

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Strategies

• Focus Groups - Information on food access and shopping patterns are gathered by conducting focus groups in a neighborhood or community.
• Mapping - Locations of stores and/or restaurants are mapped for the purposes of identifying underserved areas.
• Observation (Single Item) - Observers visit stores for the purpose of measuring availability a particular product (usually milk).
• Observation (List) - Observers visit stores for the purpose of measuring availability of a collection of products, usually in the form of a shopping list.
• Statistical Analysis - New statistical measurements are created and calculated, using existing data sources and/or maps.
• Survey - Residents, shoppers, or grocery store managers are surveyed.

Measurement

This column contains a short summary of the actual steps taken to measure food access and/or availability. For surveys, the number and types of survey items are listed. For observations, the type of food and rationale for choosing it is included.

Validity/Reliability

Validity and/or reliability are noted with short descriptions, if applicable to the study. Wherever possible, coefficients and correlations are included. No mention is made if researchers merely noted that scales were previously tested or items had "face validity."

General Comments and Areas for Further Research

Overall, there are innovative steps being taken to research things in this field. This collection of articles and research strategies demonstrates ample room for more to be done. As small towns and cities combat declining downtowns with new residential development, access and availability of food will be important. It is also time to recognize the barriers to acquiring healthy food in neighborhoods where food access and availability has been consistently overlooked.

There are two main limitations of this collection of articles. Detailed examinations of physical access to stores rarely address whether residents have the economic means of purchasing food. Though some research includes cost considerations, much more can be done to examine disparities between the possibility of purchasing food and having the economic means to do it. A second limitation is that very few articles directly address how food availability and accessibility affect the dietary behavior of residents. Investigating this issue is especially complex because of the likelihood that reciprocal relationships are present.

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Sources	Constructs	Strategies	Measurements	Validity	Reliability
Abarca, J. & Ramachandran S. (2005). Using community indicators to assess nutrition in Arizona-Mexico border communities. Preventing Chronic Disease. 2(1), 1-11.	Availability	Survey	Gathered information about grocery store preferences and purchases from structured interviews with grocery store managers. Compared demand for certain healthy products with other products. Survey (in English and Spanish) included in the article. Researchers also gathered data on milk consumption from regional milk distributors.	None	Survey pilot-tested with 2 former grocery store managers.
Ayala, G. et al. (2005). Restaurant and food shopping selections among Latino women in Southern California. Journal of the American Dietetic Association. 105(1), 38-45.	Accessibility	Survey	Conducted a home-based interview with 357 Latino women in San Diego County, CA. Several questions address restaurant choice, including location, reason for selecting it and frequency of meals outside the home. Food shopping questions address where they shop, whether nutrition information is available, and reasons for selecting a store. Restaurants and food stores were then categorized by type of food and service.	None	None
Lewis, L. B. et al. (2005) African Americans' access to healthy food options in South Los Angeles restaurants. American Journal of Public Health. 95(4) 668-673.	Availability	Observation (list)	Visited random samples of different restaurant types (fast-food, fast-casual, sit-down) in less affluent and more affluent areas of Los Angeles. Used a 62-item instrument to assess availability, quality and preparation of food based on restaurant menus. Surveyors included students and local community members.	None	None
Zenk, S.N. et al. (2005) Neighborhood racial composition, neighborhood poverty, and the spatial accessibility of supermarkets in metropolitan Detroit. American Journal of Public Health. 95 (4), 660-667.	Accessibility	Mapping Spatial Analysis	Utilized a geographic information system (GIS) to measure distances between census tracts and chain supermarkets in Detroit. Supermarkets were identified with a government list and with online and printed directories. Analyzed relationship between store location and neighborhood socio-economic characteristics with s spatial regression model.	None	None
Patterson, P.K. & Chapman N. J. (2004). Urban form and older residents service use, walking, driving, quality of life, and neighborhood satisfaction. American Journal of Health Promotion. 19(1), 45-52.	Accessibility	Survey Statistical Analysis	Compared people with similar SES characteristics living in census tracts with different urban forms. Calculated distances to various neighborhood services (including grocery stores) and compared them to rates of walking and service use.	Validity of survey previously tested	None
Sloane, D. C. et al. (2003). Improving the nutritional resource environment for health living through community-based participatory research. Journal of General Internal Medicine. 18, 568-575.	Availability	Observation (list)	Assessed healthy food availability with store visits by trained community members. Created a one-page shopping list of services and healthy items. Adapted a previously validated twelve-page healthy food assessment of availability.	None	None
Clarke, G., Eyre, H., & Guy, C. (2002). Deriving indicators of access to food retail provision in British cities: Studies of Cardiff, Leeds, and Bradford. Urban Studies. 39(11), 2041-2060.	Accessibility	Mapping	Utilized complex mapping and modeling approaches to quantify city-wide food access based on actual shopping flows (instead of crude distance to stores) and identify so-called "food deserts." Defined food deserts as areas with high disadvantage scores, no local shops, and further than 500m from a large store.	None	None
Cummins, S., & Macintyre, S. (2002). A systematic study of an urban foodscape: The price and availability of food in greater Glasgow. Urban Studies. 39(11), 2115-2130.	Availability	Observation (list)	Visited 325 food retailers and collected data on 57 standard food items comprising of 100% of recommended daily nutrient intake. Information was collected on cheapest prices, branded price, and general food availability. Food retailers were categorized by type.	None	None
Morland, K., Wing, S., Diez Roux, A., & Poole, C. (2002). Neighborhood characteristics associated with the location of food stores and food service places. American Journal of Preventive Medicine. 22(1), 23-29.	Accessibility	Mapping Statistical Analysis	Collected names and locations of food retailers (including restaurants) from local and state government sources. Classified each retailer according to type and purpose of food provided using an established system. Geocoded addresses to census tracts for analysis of SES characteristics.	None	None
Whelan, A. et al. (2002). Life in a "food desert." Urban Studies. 39(11), 2083-2100.	Accessibility Availability	Focus Group	Focused on perceived economic and physical constraints on residents in an underserved area by conducting five focus groups prior to the opening of a large food retailer.	None	None
Edmonds, J. et al. (2001). Ecological and socioeconomic correlates of fruit, juice, and vegetable consumption among African-American boys. Preventive Medicine. 32, 476-481.	Availability	Observation (list)	Observed restaurants and food stores in census tract target areas. Measured different forms (fresh, frozen, dried, canned) of 10 types of fruit, 3 types of juice, and 12 vegetables commonly consumed by African-American youth. Measured presence on shelves or menu (Y/N) and width of shelf space. Recorded frequency and placement of items on restaurant menus.	Pretested check list	Test-retest of menu classification
Reidpath, D. D. et al. (2001) An ecological study of the relationship between social and environmental determinants of obesity. Health & Place. 8, 141-45.	Accessibility	Statistical Analysis	Calculated density of fast food outlets and compared it to SES characteristics of postal code districts in Melbourne, Australia. Fast food outlets were defined as retail outlets of one of the nations' five largest chains. Outlet location was determined online.	None	None
Donkin, A. et al. (2000). Mapping access to food in a deprived area: The development of price and availability indices. Public Health Nutrition. 3(1), 31-38. Donkin, A. et al. (1999). Mapping access to food at a local level. British Food Journal. 101(7), 554-564.	Accessibility Availability	Observation (list) Mapping Statistical Analysis	Selected one central point in two neighboring disadvantaged London wards and conducted a full census of all food shops within 2 km. Developed shopping lists (included in article) of healthy food quantities/types preferred by four local ethnic groups. Preferences were determined informally. Collected information availability, prices, location, subjective quality, cleanliness, bus stops, hours, and nearby shops. Devised sample indices of availability for mapping, including mean cost index per shop and a "green" (fresh fruit and vegetable) availability index. Included maps representing shops based on their index scores.	Pilot-tested shopping list	Reliability tested on a subset of food shops and also on price variation over months of data collection.
Ellaway, A., & Macintyre, S. (2000). Shopping for food in socially contrasting localities. British Food Journal. 102(1), 52-59.	Accessibility Availability	Survey	Surveyed approximately 700 forty- and sixty-year-olds from socially contrasting neighborhoods about food shopping practices, including whether they shopped locally and where/how certain items were purchased. Questions also rated the importance of certain factors when selecting food retailer including price, location, quality, service, and cleanliness.	None	None
Cummins, S., & Macintyre, S. (1999). The location of food stores in urban areas: A case study in Glasgow. British Food Journal. 101(7), 545.	Accessibility	Mapping Statistical Analysis	Studied a sample of 325 food stores in the Glasgow area, differentiating between chain and non-chain outlets. Assigned a deprivation score to each store based on the postal code district and municipality it is located in. Investigated of store distribution across areas with different deprivation levels.	None	None
Fisher, B. D., & Strogatz, D. S. (1999). Community measures of low-fat milk consumption: Comparing store shelves with households. American Journal of Public Health. 89(2), 235-237.	Availability	Observation (single item)	Visited a random sample of stores that sell milk and calculated the percentage of milk on the shelf with fat content of 1% or lower. Compared the results to telephone survey data targeting the type of milk generally found in respondent's homes and the places they generally purchase milk.	None	None
Skerratt, S. (1999). Food availability and choice in rural Scotland: The impact of "place." British Food Journal. 101(7), 537.	Accessibility Availability	Focus Group Survey	Combined several anthropological and qualitative techniques, including semi-structured interviews and focus groups, to gather data about rural food accessibility, availability, and healthy diets.	None	None
Barratt, J. (1997). The cost and availability of healthy food choices in southern Derbyshire. Journal of Human Nutrition and Dietetics. 10, 63-69.	Availability	Observation (list)	Priced 7-day purchases at 6-10 supermarkets in one region at two-year intervals from 1990-94. The shopping list (included in article appendix) came from an actual person and included both enough nutrients to be a healthy diet and also snack items. Observers noted the cheapest brand and most economical package.	None	None
Cheadle, A. et al. (1995). Evaluating community-based nutrition programs: Comparing grocery store and individual-level survey measures of program impact. Preventive Medicine. 24, 71-79. Cheadle, A. et al. (1993). Can measures of the grocery store environment be used to track community-level dietary changes? Preventive Medicine. 22, 361-372.	Availability	Observation (list) Survey	Visited grocery stores to record availability of low-fat and high-fiber foods (by proportion of shelf space) and health education information. Selected stores with 2 or more checkout aisles, with a phone book listing, and with meat and produce. Gathered self-reported dietary intake data by a phone survey of residents. Compared the two data sources to determine if grocery store surveys provide an accurate picture of community dietary practices.	Tested and discussed	Tested and discussed
Wechsler, H. et al. (1995). The availability of low-fat milk in an inner-city Latino community: Implication for nutrition education. American Journal of Public Health. 85(12), 1690-1692.	Availability	Observation (single item)	Observed and identified 257 bodegas (defined here as food stores that sell milk but have only one register) and 25 supermarkets in a low-income predominantly Latino neighborhood in New York City. Observers counted cartons of each milk type (fat content) and size (quarts, half gallons, gallons). Proportion of milk shelf space occupied by low-fat milk was calculated.	None	Inter-rater reliability r>.99 and P<.001. Test-retest reliability found availability and proportion of shelf space highly correlated (r=.92 and p<.001).
Sooman, A., Macintyre, S., & Anderson, A. (1993). Scotland's health - a more difficult challenge for some? The price and availability of healthy foods in socially contrasting localities in the west of Scotland. Health Bulletin. 51(5), 276-284.	Accessiblity Availability	Observation (list)	Selected a representative sample of shops based on type, SES characteristics, and geographical spread. Priced smallest available amounts of a list of healthy foods (consumption encouraged) and unhealthy foods (consumption discouraged). Lists included in article.	None	None
Mooney, C. (1990). Cost and availability of healthy food choices in a London health district. Journal of Human Nutrition and Dietetics. 3, 111-120.	Availability	Observation (list)	Visited the nine largest supermarkets (>2500 sq ft) in and adjacent to affluent and non-affluent parts of a London health district with 100,000 residents. Compared availability of a list of foods meeting health guidelines with a list less healthy foods to identify the cost of improving a diet. Different sizes and varieties were included.	None	None

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