Characterizing Saskatoon's food environment: a neighbourhood-level analysis of in-store fruit and vegetable access.

del Canto, Sugandhi ; Engler-Stringer, Rachel ; Muhajarine, Nazeem 等

Abstract

This paper evaluates the relationship between in-store food offerings and neighbourhood level socio-economic and demographic characteristics in Saskatoon, Saskatchewan, as well as to assess differences in fruit and vegetable access among grocery stores in neighbourhoods of varying socioeconomic status. This study compares measures of the food environment using data based on structured observations, self-reported data and measured data. A census of 116 food stores were measured in Saskatoon's residential neighbourhoods (n=60), of which 24 were grocery stores. Neighbourhoods were assigned to categories of high, mid and low socioeconomic status (SES) based on the Material and Social Deprivation Index. Proportion of Aboriginal ancestry by neighbourhood was also incorporated into the analysis. High SES neighbourhoods had a higher proportion of grocery stores, of all store types, than mid or low SES neighbourhoods, while low SES neighbourhoods had a much higher proportion of convenience stores compared to mid and high SES neighbourhoods. Overall in-store grocery measures did not vary significantly across neighbourhood-level SES, but did vary by proportion of Aboriginal ancestry. Price and availability of fruits and vegetables varied in low SES neighbourhoods and those with a higher proportion of Aboriginal ancestry. This study uncovers a disproportionately high distribution of convenience stores in lower SES neighbourhoods, suggesting that food swamps are prevalent in Saskatoon and confirms previous research findings of inequities experienced by Aboriginal people in the city. Further research, including more qualitatively-driven data, is necessary to elucidate the complexities of Saskatoon's food environment.

Keywords: food environment, food desert, food swamp, neighbourhoods, health, socio-economic status, Aboriginal, Saskatoon, Canada

Resume

Cet article evaluer la relation entre l'offre de nourriture dans les magasins et les caracteristiques socio-economiques et demographiques des quartiers differents de Saskatoon, Saskatchewan; ainsi qu'une evaluation les differences d'acces des fruits et legumes dans les epiceries de quartiers de statut socioeconomique differents. Cette etude compare les mesures de l'environnement alimentaire en utilisant des donnees basees sur des observations structurees, les donnees auto-declarees et les donnees mesurees. Un recensement de 116 magasins d'aliments a ete mesures dans les quartiers residentiels de Saskatoon (n = 60), dont 24 etaient des epiceries. Les quartiers ont ete assignes a des categories de statut socio-economique (SSE) eleve, moyen et defavorise base sur l'indice de defavorisation materielle et sociale. Proportion d'ascendance autochtone par quartier a egalement ete integrees dans l'analyse. Les quartiers ou le SSE est eleve ont une proportion eleve des epiceries que les quartiers moyens ou defavorises. Les quartiers ou le SSE est defavorises ont une proportion eleve de depanneurs que les quartiers moyens ou eleve. Les scores composites des epiceries ne varient pas beaucoup selon le niveau SSE du quartier, mais varient cependant selon la proportion d'ascendance autochtone. Le prix et la disponibilite des fruits et legumes se sont distinguees parmi des quartiers defavorises et avec la proportion d'ascendance autochtone. Cette etude demontre une repartition disproportionnee des depanneurs dans les quartiers a faible SSE, les qualifiant de marecages alimentaires et confirme les conclusions d'etudes anterieures des inegalites vecues par la population autochtone de la ville. Les recherches plus poussees, y compris plus de donnees qualitatives, est necessaire pour elucider les complexites de l'environnement alimentaire de Saskatoon.

Mots cles: environnement alimentaire, desert alimentaires, marecages alimentaires, quartiers, sante, statut socio-economique, Autochtone, Saskatoon, Canada

Introduction

A healthy diet, one that is high in fresh fruit and vegetables (Paquette 2005) and low in processed, energy-dense food, offers protection against the onset of many chronic illnesses (Townshend and Lake 2009). Low intake of fruits and vegetables is one of the leading risk factors for death, related to many conditions worldwide (Egger and Swinburn 1997). It is evident, however, that there is little benefit in encouraging people to eat more fruits and vegetables if the food stores and restaurants accessible to them do not offer these choices at affordable prices (Kamphius et al. 2006), and studies suggest that low income individuals and families may be more affected by their neighbourhood environment, resulting from more constrained transportation options (Lytle 2009).

Previous research has shown that the cost of food plays a significant role in accessibility and is a barrier to healthy eating for people with low incomes (Paquette 2005). Nutritious food is often more expensive than highly processed, fat- or sugar-laden food, putting a balanced diet out of reach for people with limited finances (Inglis, Ball, and Crawford 2009) healthier foods may be overlooked in favour of more energy-dense lower-cost options. The aim of this study was to investigate whether modifications to the available household food budget led to changes in the healthfulness of food purchasing choices among women of low and high income. A quasi-experimental design was used which included a sample of 74 women (37 low-income women and 37 high-income women. A common measure for fresh produce access--itself a distal marker of a healthy diet--is residential proximity to a grocery store (Feng et al. 2010). A grocery store or supermarket format is the most likely to carry the widest range of healthy food, at more affordable prices compared to other store types, such as convenience stores (Powell et al. 2007). While grocery stores also carry unhealthy foods such as candy, chips and soft drinks, these items are more abundant at convenience stores (Farley et al. 2009; Wrigley 2002), making grocery stores the more desirable food outlet to have in a neighbourhood.

When people have trouble accessing healthy foods because of where they live and because of financial difficulty, they are said to live in a food desert (Wrigley 2002; Kershaw et al. 2010). Food deserts are the subject of great debate, as researchers attempt to define and delineate the extent of urban food deserts, and establish if they exist at all. In studies across Western, English-speaking nations, the findings are mixed: a number of food deserts have been uncovered in American cities (Morland et al. 2002; Morland and Filomena 2007), while findings in cities across Britain and Scotland suggest that they may not exist or may not be important indicators of healthy food access (Wrigley 2002).

Turning to Canada's growing food environment literature, researchers in London, ON, found that food deserts do exist, yet their findings indicate that areas of lower SES have better access to grocery stores, compared to higher SES areas, when public transit is taken into account (Larsen and Gilliland 2008). Researchers in both Edmonton, AB, and Montreal, QC, did not find evidence of food deserts, suggesting instead that interventions aimed at improving dietary outcomes should focus on issues broader than the geographic distribution of food stores (Smoyer-Tomic, Spence, and Amrhein 2006; Spence et al. 2009; Apparicio, Cloutier, and Shearmur 2007). Curiously, researchers in both London and Edmonton found that access to grocery stores was greater in neighbourhoods of lower SES (Larsen and Gilliland 2008; Smoyer-Tomic, Spence, and Amrhein 2006). These findings point to the complexity of Canadian food environment research and underscore the need to better understand the regional and demographic differences that may exist across cities of varying size and urbanity.

Food environment research in Saskatoon is relatively new. The Saskatoon Health Region, the University of Saskatchewan and the Smart Cities, Healthy Kids research initiatives have begun the process of enumerating this mid-sized city's built food environment, assessing the distribution of grocery and convenience stores, as well as fast food restaurants (Peters and McCreary 2008; Kershaw et al. 2010; Engler-Stringer, R. Muhajarine et al. 2014). Given its geographic similarity to Edmonton, also a Prairie city, it could be hypothesized that Saskatoon's built food environment would be similar. However, the size and urban development trajectory of Saskatoon (Engler-Stringer, R. Muhajarine et al. 2014) more closely parallels that of London (Larsen and Gilliland 2008), indicating that food deserts may have developed over time as large supermarket chains moved their increasingly-larger stores towards the outskirts of the city (Miller, Reardon, and Mccorkle 2012). Evidence exists to illustrate the growing dearth of grocery store access in the Saskatoon's poorest neighbourhoods (Engler-Stringer, R. Muhajarine et al. 2014). A great deal of the Canadian literature shows associations between the built food environment and residents' diet-related outcomes (Office of Nutrition Policy and Promotion 2013). There is increasing evidence of food swamps--areas of low socioeconomic status with high geographic access to nonnutritive food sources--which may prove to be more important than food deserts in influencing residents' diets (Office of Nutrition Policy and Promotion 2013).

American research findings indicate that residents of wealthier, white neighbourhoods tend to have better access to cheaper and more nutritious foods than those living in less affluent neighbourhoods. This disparity widens when obesogenic (obesity-promoting) built environments are factored in (Elinder and Jansson 2009). For example, a 2007 study by Morland and Filomena found that in wealthier, predominantly-white neighbourhoods in the US, the ratio of grocery stores to residents was 1:3816. In neighbourhoods of lower SES, where there was a greater proportion of black residents, the ratio was a disturbing 1:23,582 (Morland and Filomena 2007). While the body of Canadian food environment research has not explicitly documented race-based differences, there is extensive evidence of disparities in nutrition-related health outcomes (Office of Nutrition Policy and Promotion 2013). For instance, the prevalence of obesity and diabetes is considerably higher among First Nations communities (Loppie Reading and Wien 2009) and can be linked to, among other factors, the quality of an affordable diet (Office of Nutrition Policy and Promotion 2013). There is ample evidence to suggest that access to affordable, healthy food can be a challenge for Aboriginal people living on reserve or in remote, rural areas (Willows, Hanley, and Delormier 2012). Colonization, the Residential School Legacy, marginalization and ongoing systemic barriers contribute to disproportionately poor health outcomes among First Nations, Metis and, increasingly, Inuit, when compared to other Canadian populations (Loppie Reading and Wien 2009). Differences in neighbourhood-level SES and demographic indicators are linked to differences in health outcomes (Morland and Filomena 2007). Indicators such as income or race have been shown to possibly account for variations in grocery and convenience store distribution across neighbourhoods within the same city (Morland and Filomena 2007; Larson, Story, and Nelson 2009). A health disparities study by the Saskatoon Health Region (SHR) in 2007 contrasted the health status of residents within Saskatoon's six lowest income neighbourhoods--which have proportionally higher numbers of residents reporting Aboriginal ancestry--with the rest of the city, and found substantial disparities in chronic disease outcomes (Lemstra, Neudorf, and Beaudin 2007). Although inequities in health outcomes related to SES are not surprising, the magnitude of the disparity was enormous. After statistically controlling for variables of SES, cultural status, disease intermediaries, other health disorders, behaviours and healthcare utilization, the researchers found that low-income residents in Saskatoon are 50% more likely to report low self-reported health, 118% more likely to have heart disease and 196% more likely to have diabetes (Lemstra, Neudorf, and Beaudin 2007). A food access study by SHR found that food stores are not equally distributed throughout the city: Neighbourhoods with the poorest access to grocery stores lie along the river, particularly on the west side, and on the edges of the city to the north, west and south, corresponding to some of the lower SES neighbourhoods within the city (Figure 1). Fewer than half of Saskatoon's residents (46%) have any grocery stores within a walking distance of 1 km and only 17% have more than one grocery store within walking distance. Previous research has uncovered several food deserts in Saskatoon, such as those in Figure 1 (Peters and McCreary 2008; Kershaw et al. 2010). Conversely, convenience stores are much greater in number throughout the city (Figure 2), indicating relatively easier access to unhealthier food choices. These initial findings point to the presence of both food deserts and swamps across the city. This present study aims to further an understanding of Saskatoon's built food environment through an analysis of in-store food offerings across neighbourhoods of varying SES and varying proportions of Aboriginal ancestry.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Methodology

In-store measures of ten food categories were collected using the Nutrition Environment Measurement Survey for Stores (NEMS-S) (Glanz et al. 2007).The findings addressed in this article focuses on measures of fruit and vegetable access (price and availability) within grocery stores in relation to the SES-level of the neighbourhoods in which the store is located. Further assessed were correlations of fruit and vegetable access with Aboriginal ancestry at the neighbourhood level.

Measurement of food stores

Based on a geo-coded list of stores in residential neighbourhoods obtained from the City of Saskatoon and updated through observation, food stores were delineated by store type. Grocery stores included all large grocery stores and supermarkets--stores stocking fresh meat, wheat-based Western style bread, fruits, vegetables, and dairy milk, and requiring no membership (Smoyer-Tomic, Spence, and Amrhein 2006). Convenience stores were classified as those carrying a limited range of foods (compared to a grocery store). These included stores attached to gas stations, pharmacies carrying a range of food products and free-standing convenience stores. Consistent with other studies (Smoyer-Tomic, Spence, and Amrhein 2006; Apparicio, Cloutier, and Shearmur 2007), excluded were stores not open to the public or those requiring membership (such as Costco). "Big box" style department stores that sell a limited range of food, such as some Giant Tiger or Shoppers Drug Mart locations, were categorized as convenience stores. Food stores located in non-residential neighbourhoods were excluded in this analysis. The in-store survey instrument was administered in a census of 116 food stores (24 grocery and 92 convenience stores) across a total of 60 residential neighbourhoods between January and February 2011. As the purpose of this analysis was fresh and frozen fruit and vegetable access, only grocery stores are included. This inclusion criteria was based on the observation that, while canned fruits and vegetables may be available through convenience stores, fresh and frozen produce is available in the widest variety at grocery stores. It is posited that variations across grocery stores serve as a more meaningful analysis of the built food environment than variations across grocery and convenience stores combined.

Data Collection

The Nutrition Environment Measurement Survey for Stores (NEMS-S) was originally developed to measure healthy food options in grocery and convenience stores in neighbourhoods differing by income and community design. The tool has been tested extensively for reliability (test-retest and inter-rater) and validity (face and construct validity) (Glanz et al. 2007).The in-store survey is completed by a trained rater, for each food store, based on structured observations of price, availability and quality for ten indicator food categories: milk, bread, fruit and vegetables (fresh, frozen and canned), ground beef, hot dogs, frozen dinners, baked goods, beverages, chips, and cereal (Glanz et al. 2007). A composite score from each food category was used to assess the overall "healthiness" of a store, with higher score indicating a wider variety of healthy options at prices either equal to, or lower than, less healthy options within a comparable category. The in-store survey has been adapted for the Canadian context by researchers at the University of Alberta, including a wider list of fruits and vegetables for assessment, as well as additional sections for canned and frozen produce (Susan Buhler, personal communication, January 7, 2011).

Neighbourhoods were characterized as high, mid and low SES using the Material and Social Deprivation Index, a tool developed by the Institut national de sante publique (INSPQ) in Quebec (Pampalon et al. 2009) and which has been frequently adapted to characterize neighbourhood-level SES (Apparicio, Cloutier, and Shearmur 2007; Smoyer-Tomic et al. 2008; Pouliot and Hamelin 2009). The Material and Social Deprivation Index is based on material indicators of income, employment and education, and social indicators of marital status, lone parent status and living alone status (Pampalon et al. 2009). A material and social deprivation index was developed for Quebec and Canada. Data used for this index were derived from Statistics Canada's 2006 Census and projected data from the City of Saskatoon, up to 2010. Z-scores were calculated for each variable for each neighbourhood, and the sum of these values was used to divide neighbourhoods into categories of high, mid and low SES, (n=20 neighbourhoods of each type). Data on proportion of Aboriginal ancestry, by neighbourhood, was gathered from Statistics Canada's 2011 Census.

The decision to undertake a neighbourhood-level analysis, rather than a census tract-level analysis--as has been done in some Canadian studies (Apparicio, Cloutier, and Shearmur 2007; Black et al. 2011)--was based on several considerations. Previous studies of Saskatoon's food environment (Kershaw et al. 2010) and other pivotal health-related studies in the city (Lemstra, Neudorf, and Beaudin 2007) are neighbourhood-based. It was felt that keeping this present study at the neighbourhood-level would facilitate intra-city comparability of this study's findings.

Data Analysis

Mean in-store scores were calculated for the 18 neighbourhoods in which grocery stores are located. Fruit and vegetable access measures were based on the price and availability of 16 fruit and 16 vegetable varieties (fresh and frozen) available within grocery stores. While the original in-store measurement survey collected three dimensions of accessibility--price, availability and quality--the latter has not been included in the present analysis due to its greater degree of subjectivity. To measure price, the displayed cost of an item within a store is recorded and, to measure availability, the presence or absence of an item within a store is recorded by the rater. However, an assessment of quality is subject to the perception of the rater, where an item is recorded as being of acceptable or unacceptable quality (Glanz et al. 2007). Among the in-store raters of this study, there were several instances of non-consensus regarding the quality of an item within a store, such as the acceptability of a display of apples. Though quality (and, by extension, the desirability) of an item is an important metric, the researchers felt that the way in which this dimension was captured in the measurement tool had a high degree of subjectivity.

Using SPSS 21.0, t-tests assessed differences in the geographic distribution of grocery and convenience stores across neighbourhood types. Data gathered during store audits were used to calculate mean availability and price of fruits and vegetables in each grocery store. Data were also collected on the price per kilogram, or the price per item, for 32 individually-priced produce items within each store. Associations between price and availability measures and SES were assessed using ANOVAs (F-tests) and correlation ([r.sup.2]). Significance was set at [alpha]=0.05.

Results

Table 1 indicates the distribution of food stores by neighbourhood type. Low SES neighbourhoods were found to have significantly more convenience stores than high and mid SES neighbourhoods (p=0.052), while high SES neighbourhoods had a higher proportion of grocery stores than low or mid SES neighbourhoods (p=0.007). Table 2 indicates that in-store scores across grocery stores did not vary by neighbourhood-level SES, but did vary by Aboriginal ancestry (p=0.037). While the availability of fruits and vegetables did not vary, it did vary by price, with lower SES neighbourhoods experiencing higher prices (p=0.035). This finding of higher prices was also reflected in neighbourhoods with more Aboriginal-identifying residents (p=0.02).

Discussion

This study highlights the complex nature of food environments, and contributes to the growing body of literature specific to the Canadian context (Office of Nutrition Policy and Promotion 2013). These findings build upon the mapping and assessment of Saskatoons food environment begun by SHR, providing a further understanding of in-store healthy food offerings and produce access across the city (Kershaw et al. 2010). The identification and measurement of food deserts can be important, but there are limits in what it can reveal about healthy food access (Kamphius et al. 2006). The most prevalent nutritional problems in high-income countries (where the food desert metaphor has been applied) are related to over-consumption, particularly overweight and obesity, which are more prevalent among low-income populations (Ard 2007). If environment influences consumption, then the excess of unhealthy food found in convenience stores spread across low-income neighbourhoods is a potentially more pressing problem than the distribution of grocery stores (Farley et al. 2009). As discussed earlier in this paper, and supported by the findings of this study, a shift in focus towards identifying and understanding food swamps may be a more informative, and perhaps more comparable approach (Office of Nutrition Policy and Promotion 2013).

Food swamp is a term increasingly used to describe areas in which an abundance of energy-dense snack foods, such as those found in convenience stores or at fast food restaurants, inundate neighbourhoods and represent a disproportionately larger share of food options (Office of Nutrition Policy and Promotion 2013). The findings of the present study indicate that lower SES neighbourhoods in Saskatoon are more likely to be characterized as a food swamp, having significantly more convenience stores than mid or high SES neighbourhoods. This combination of ubiquitous convenience stores and economic marginalization indicate that the availability and affordability of healthy foods may be a challenge. Inequity is perhaps exacerbated by the fact that high SES neighbourhoods have a greater proportion of grocery stores, highlighting that healthy food access may be a function of a neighbourhood's level of SES.

No differences of in-store composite measures were found among grocery stores in neighbourhoods of varying SES and, due to the extremely small sample size of grocery store, results must be interpreted with great caution. While the correlation found between Aboriginal ancestry and in-store measures may be statistically weak, it is in keep with the extensive evidence of health inequity documented in other studies (Lemstra, Neudorf, and Beaudin 2007). Compounded by the finding of slightly significantly higher prices of fruits and vegetables, all of this is in keeping with the adverse health outcomes among marginalized communities reported in both SHR's Health Disparities Report (Lemstra, Neudorf, and Beaudin 2007) and Health Canada's Measuring the Food Environment in Canada (Office of Nutrition Policy and Promotion 2013).

These findings are troubling in that they support evidence of neighbourhood-level of this study suggest that, overall, food items within stores may not be consistently associated with low-income or other socioeconomic variables. However, given the complex nature of measuring in-store contents and the influence of a wide range of socioeconomic and demographic variables, it remains to be determined to what extent the consumer food environment affects the diet of a population. Objective measures alone can only provide a partial picture, and there is a need to better understand how people perceive and interact with their food environment in order to improve healthy food access among all neighbourhoods in Saskatoon. Identifying, developing and implementing solutions to address this inequity will require a multi-level response from leadership, businesses, urban planners, health care providers, researchers and the broader community.

Acknowledgements

This study was supported by grants from the Canadian Institute of Health Research and the Saskatchewan Health Research Foundation. The authors acknowledge the invaluable contribution of Ms. Tracy Ridalls, Research Coordinator at the Saskatchewan Population Health and Evaluation Research Unit (SPHERU), University of Saskatchewan.

Sugandhi del Canto

Rachel Engler-Stringer

Nazeem Muhajarine

Department of Community Health and Epidemiology

University of Saskatchewan

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Wrigley, Neil. 2002. 'Food Deserts' in British Cities: Policy Context and Research Priorities. Urban Studies 39 (11) (October 1): 2029-2040. doi: 10.1080/00420980 22000011344. http://usj.sagepub.com.cyber.usask.ca/content/39/11/2029. Table 1: Distribution of grocery and convenience stores by neighbourhood-level SES Neighbourhoods No. of food No. of grocery No. of convenience stores stores (% of stores (% of total ([dagger]) total food food stores) stores) All 131 24 (20.9) 92 (80) High SES 35 10 (28.6) * 21 (60.0) Mid SES 41 5 (12.19) 31 (75.6) Low SES 55 9 (16.4) 40 (72.7) ** ([dagger]) Includes all grocery, convenience and specialty food stores (such as bakeries and ethnic grocery stores), however, this analysis focuses solely on grocery and convenience stores. As such, percentages in the last two columns will not equal 100% * p=0.007 ** p=0.052 Table 2: Fruit and vegetable (F/V) access in Saskatoon's grocery stores Price (F/V) Availability Total NEMS-S (F/V) SES High F 1.225 2.681 2.762 [r.sup.2] 0.09 0.054 0.006 Mid F 0.345 5.673 1.554 [r.sup.2] 0.077 0.089 0.015 Low F 6.244 * 1.840 1.233 [r.sup.2] 0.343 ** 0.064 0.032 Aboriginal T 6.708 *** 4.002 3.785 ***** [r.sup.2] 0.201 **** 0.091 0.391 ([alpha]=0.05) * p=0.035 ** p=0.023 *** p=0.02 **** p=0.037