Global Societal Problem, Argument and Solution

Vol:.(1234567890)

J Community Health (2017) 42:1008–1019 DOI 10.1007/s10900-017-0348-1

1 3

ORIGINAL PAPER

Characterizing Rural Food Access in Remote Areas

Chris J. Bardenhagen1  · Courtney A. Pinard2 · Rich Pirog3 · Amy Lazarus Yaroch2 

Published online: 17 April 2017 © Springer Science+Business Media New York 2017

Keywords Rural grocery · Rural food access · Healthy food availability · Food environment · Outshopping

Introduction

Chronic disease is a leading cause of poor health, disabil- ity, and death in the United States, with low dietary quality viewed as a large contributor to this burden [1–3]. Limited access to more healthful foods (e.g., fruits and vegetables, whole grains, lean meat) and abundant access to energy- dense, nutrient-poor foods (i.e., junk foods) contributes to these poor health outcomes. The relationship between limited healthy food access and chronic disease has been well documented among urban populations [4–6], and evi- dence among rural populations is more recently emerging [7, 8]. Preliminary studies have demonstrated some of the unique issues that rural areas face in terms of barriers to access of more healthful food, such as a declining customer base, aging ownership, and a lack of available small busi- ness capital [9–12]. Generally, rural residents are located relatively far from any corner store or full-service grocery store [13]. This is compounded by a lack of public and/or individual transportation [13], spurring reliance on pre- packaged foods at the nearest food outlet, defined as retail establishments that sell some type of food, including the gas stations and convenience stores identified in the current study. These prepackaged, nonperishable foods are often higher in fat and/or sugar [14].

“Out-shopping” is a phenomenon where rural residents travel outside of their local area to shop [15, 16]. This allows these rural consumers to reach numerous large retail- ers during a trip, enabling them to access a greater variety of products and brands, and potentially at lower prices, for both grocery and non-grocery items [16]. Out-shopping can

Abstract Residents of rural areas may have limited access to healthy foods, leading to higher incidence of diet related health issues. Smaller grocers in rural areas expe- rience challenges in maintaining fresh produce and other healthy foods available for customers. This study assessed the rural food environment in northeast Lower Michigan in order to inform healthy food financing projects such as the Michigan Good Food Fund. The area’s retail food busi- nesses were categorized using secondary licensing, busi- ness, and nutrition program databases. Twenty of these stores were visited in person to verify the validity of the categories created, and to assess the availability of healthy foods in their aisles. In-depth interviews with key inform- ants were carried out with store owners, economic develop- ment personnel, and other food system stakeholders having knowledge about food access, in order to learn more about the specific challenges that the area faces. Out-shopping, seasonality, and economic challenges were found to affect healthy food availability. Mid-sized independent stores were generally found to have a larger selection of healthy foods, but smaller rural groceries also have potential to provide fresh produce and increase food access. Potential healthy food financing projects are described and areas in need of further research are identified.

* Chris J. Bardenhagen [email protected]

1 Department of Community Sustainability, Michigan State University, 480 Wilson Road, Room 131, East Lansing, MI 48824, USA

2 Gretchen Swanson Center for Nutrition, Omaha, NE, USA 3 Center for Regional Food Systems, Michigan State

University, East Lansing, MI, USA

1009J Community Health (2017) 42:1008–1019

1 3

negatively affect the local rural economy, as revenues shift from local to outside businesses, whereas money that is spent in the local area can provide an economic multiplier effect and help to sustain an area’s economy [16]. Strate- gies to retain rural customers by independent retailers have included focusing on customer service and involvement in the community, yet these strategies have not always proven effective [17]. When retailers lose customers or customers spend only a small percent of their purchases locally, job loss can result, leading to decreased overall spending in the rural area in question [18]. Out-shopping presents a nega- tive feedback loop for rural grocers, who are challenged with providing a wide enough assortment of food products and sufficiently low prices to continue to attract custom- ers. Out-shopping has been found to be a specific challenge among rural grocery storeowners [19].

Beyond the concern of the waning numbers of full-ser- vice rural food outlets, the options that do exist have been cited as containing poorly stocked shelves and an overall lack of healthful foods such as fruits and vegetables, having instead more energy dense, nutrient poor selections [20]. In addition, lower quality fruits and vegetables have been identified at rural food retail outlets that are furthest away from populous areas [21]. However, some research has shown that both rural grocers and urban corner store-own- ers have demonstrated a willingness to stock more health- ful options, but cite a lack of demand as the reason for not offering more fruits and vegetables [22–24]. Concurrently, studies demonstrate that there is a consumer demand for produce and lean meats in rural areas, with rural resi- dents citing lack of availability of fruits and vegetables in smaller, corner stores as the reason for not purchasing them [22, 24]. This demonstrates a lack of alignment between consumers and store-owners that needs to be addressed.

Issues related to more healthful food distribution in rural areas are at the root of challenges with rural resi- dent’s access to more healthful foods [23]. It has been hypothesized that limited infrastructure for food distribu- tion (e.g., roads, storage, frequency of delivery) in rural areas pose obstacles to maintaining high-quality produce at rural food outlets [21, 22]. This may be particularly true in the northeast of Michigan’s lower peninsula, a predomi- nantly rural area with limited food access and poor health outcomes [25]. The population density in this area ranges from 15.3 to 54.8 people per square mile with a large per- centage designated as state forest land [26]. There are large areas within this region that have a combination of stunted food sales, lower income, and high incidence of diet related deaths [27].

Current literature related to rural grocery and food access is scant [23] and those studies conducted in rural areas took place where a majority of the environment con- sists of actively farmed land [28, 29]. These studies may not

generalize to areas, such as northeast Michigan, which are differentiated by having a mix of dynamic farmland, low- productive farm or rangeland, and large swaths of lightly developed state forestland. The purpose of this study was to conduct a formative evaluation to help guide the direction of Michigan Good Food Fund investments. The Michigan Good Food Fund was created and launched in 2015 in order to address food access issues across the state of Michigan. The Good Food Fund is a public–private loan fund created to finance healthy food production, distribution, processing, and retail business projects that will benefit underserved communities across Michigan. The Good Food Fund is the healthy food financing arm of the Michigan Good Food Charter, which was created in 2010. The Charter contains a set of six goals and 25 priority actions to improve access of food that is healthy, affordable, fair and green for all Michi- ganders [30]. This study specifically sought to characterize rural food retail and healthy food access in the rural north- east region of Michigan in order to provide more informa- tion on the healthy food access needs of the region that could potentially be addressed by the Good Food Fund.

Methods

This study was conducted in rural Northeast Michigan, across a 15-county region. Institutional Review Board (IRB) approval for all components of this data collec- tion was obtained from the University of Nebraska Medi- cal Center IRB. The overarching strategy for this mixed- methods study utilized a combination of data sources to help determine the characteristics of the rural food retail environment.

Store Categorization

In order to identify grocers in the area, we combined and cross-referenced three secondary data sources to yield a list of over 800 retail food businesses. First, a list of retail food establishments was obtained from the Michigan Depart- ment of Agriculture and Rural Development. Grocers in Michigan must register with this state department for a retail food establishment license on an annual basis. This list provided us with owner’s addresses (e.g., sometimes this is the owner’s home address or the corporate office address), business addresses, and telephone numbers for each of the named businesses. Second, revenue informa- tion was collected from the Reference USA database, using North American Industry Classification System (NAICS) codes by county. Third, the Supplemental Nutrition Assis- tance Program (SNAP) database was used to determine which businesses participated in SNAP. Businesses found

1010 J Community Health (2017) 42:1008–1019

1 3

on one database but not the others were added to our master list.

Store categories were developed based on a combination of sources; key definitions and categories were grounded in information from the Rudd Center [31] with modifications and additions described by others [32–36]. These were fur- ther modified to match the rural food environment of the current study based on preliminary explorations in North- east Michigan. Using Internet searches, Google Earth data, and well known corporate names, food establishments on the list were placed into one of the 15 categories we devel- oped. Businesses were called when the methods described above did not yield sufficient data to confidently catego- rize them. For more details on the categorization process, please refer to the full report available online.

Rural Food Environment Scan Tool

In order to assess the availability of healthy foods at stores in the study area, items from the Bridging the Gap Com- munity Obesity Measures Project (BTG-COMP) Food Store Observation Form [37] and the Food Retail Outlet Survey Tool (FROST) [38] were combined and modified to create a rural food environment scan tool, which is avail- able upon request from the authors. We utilized the store types defined in categories described above, and combined specific items relevant to the rural study area. We simpli- fied items for ease of data collection and relevancy for the current study; for example, there was an interest in under- standing which types of healthy and non-healthy foods were available, yet measuring price and quality was less important and not included in the final version of the scan tool administered. We included items about availability of alcoholic products, signage and advertisement, availabil- ity of WIC and SNAP, and availability of food items in the following categories: fast food or other ready-to-eat items, beverages, dairy/eggs/meat, snacks, vegetables, fruits, bread, rice, pasta, beans, cereal. In addition, there was one item to describe the variety of fruits and vegetables and one item each to assess overall quality of both fruits and veg- etables [scale 1–4; 1 = All or most fruit is of poor quality (brown, bruised, overripe, wilted)—4 = All or most fruit is of good quality (very fresh, no soft spots, excellent color)].

Store Selection for Environmental Scan

Within the 15-county region of interest, we selected stores located in areas of low-food access, with representation across counties. We identified areas of low-food access uti- lizing the USDA’s Food Access Research Atlas [39]. The sample included 20 stores and selection was purposive, with an emphasis on low-income, low-food access areas

and store type (i.e., small- mid-sized retailers that could offer a selection of healthy foods).

Key Informant Interviews

A small number of telephone interviews (n = 10) were con- ducted in order to elaborate on and help contextualize find- ings from the in-person observations, to describe the com- munity and role of the store, and to understand food access issues. Store-owners, food bank representatives and other local stakeholders were identified for interviews. Interviews were audio-recorded with participants’ verbal consent, and detailed notes generated from audio files. Emergent themes were identified and statements in transcripts were classified into the themes.

Results

Store Categorization

Based on our categorization of the list of over 800 retail food establishments, 6% were considered large chain super- markets or larger independent supermarkets, 3% were mid- sized independent grocers, 15% were small grocers/con- venience without gas, 6% were small or mid-sized grocers with gas, and 22% were limited assortment food marts/gas stations. The remaining businesses included food pantries, dollar stores, drug stores, farm retailers, farmer’s markets, campground stores, specialized grocers (e.g., meat mar- kets), and other assorted establishments, such as candy stores. For a full list of the 15 store categories, see the full report online. For the purposes of this study, we focused on four main types of stores for observations, shown in Table 1.

Food Environment Scan Observations

Of the 20 stores that were assessed, there were small gro- cers/convenience stores without gas (n = 7), small or mid- sized grocers with gas (n = 6), mid-sized independent gro- cers (n = 5), and limited assortment/food mart/gas stations (n = 2). In terms of food assistance program participation, 75% of the stores had a SNAP Electronic Benefit Transfer (EBT) terminal on-site, 60% accepted SNAP, 20% accepted SNAP and WIC, and 20% did not accept any form of food assistance.

Table  2 shows the availability of foods by store type. Ready-to-eat items were available across all store types; the most common item available was sandwiches (90% across all stores), but this category also included many energy- dense, nutrient poor items such as pizza, hot dogs, and fried foods. Small or mid-sized grocers with gas typically

1011J Community Health (2017) 42:1008–1019

1 3

had slightly more availability of snack foods (e.g., potato chips, cookies, candy). Full fat versions of dairy were more widely available than low fat versions (e.g., whole milk in 90% of stores, 1% or skim in 69% of stores). The only dif- ference in lean meat availability by store type was extra- lean ground beef only being available in some of the mid- sized independent grocers (in 20% of mid-sized stores). In the whole grain category, higher sugar breakfast cereals were more likely to be available than lower sugar options (100%; those with more than 7 g of sugar per serving), with fewer whole-grain cereal versions (62%) available. Mid- sized independent grocers tended to have a greater variety and more types of whole grains and beans (similar to other healthy food categories). Across all store types, canned fruits (89%) and vegetables (100%) were more widely avail- able than fresh fruits (89%) and vegetables (80%) or frozen fruits (23%) or vegetables (60%). Mid-sized independent grocers provided a greater selection of fruits and vegetables than the smaller store types. Fresh fruit and vegetable qual- ity and variety (data not shown in table) compared by store type demonstrated that mid-sized independent grocers had a higher variety (M = 3.2) and quality rating (M = 3.5) than small or mid-sized grocers with gas (variety, M = 2.7; qual- ity, M = 3.4) or small grocers/convenience stores without gas (variety, M = 1.9; quality, M = 2.6).

Key Informant Interviews

Telephone interviews were conducted with a diverse set of stakeholders who were familiar with the geographic area and had knowledge regarding food access in their commu- nities. The resultant sample (n = 10) included two execu- tive directors of local councils of government, a Michigan State University Extension field educator, a president of a food bank, two store-owners, an economic development representative, and three food system stakeholders (food hub stakeholder, producer, restaurant owner). Key themes and example quotes are described in Table  3, with high- lights including the challenges that these rural communi- ties face in terms of healthy food access, such as the diver- sion of revenues to large supercenters and related economic challenges that limit buying power and ability of smaller food retailers to stock fresh, healthy foods. Many of these stakeholders reported that these communities were facing an aging and dwindling population, and the challenge of the duality of providing foods for local residents as well as meeting the needs of tourists traveling through these com- munities, mostly in the summer months. In addition, the challenge of offering fresh fruits and vegetables in these more remote communities was expressed: “Even if there is fresh produce available, it’s so expensive or past its prime, that is not attractive to people walking into the shops.” The interviewees also described an interest in supporting Ta

bl e

1 C

la ss

ifi ca

tio n

of st

or e

ty pe

s v is

ite d

Sm al

l g ro

ce rs

/c on

ve ni

en ce

st or

es w

ith ou

t g as

Sm al

l o r m

id -s

iz ed

g ro

ce rs

w ith

g as

M id

-s iz

ed in

de pe

nd en

t g ro

ce rs

Li m

ite d

as so

rtm en

t f oo

d m

ar ts

/g as

st at

io ns

N on

-c ha

in st

or es

th at

se ll

fo od

it em

s, bu

t h av

e a

lim ite

d se

le ct

io n

an d

va rie

ty Ty

pi ca

lly h

av e

co nv

en ie

nc e

fo od

s, sh

el f s

ta bl

e gr

oc er

y ite

m s,

an d

al co

ho l

In cl

ud es

sm al

l, co

rn er

, a nd

c on

ve ni

en ce

“m

om a

nd p

op ”

sto re

s

In de

pe nd

en t s

to re

s s el

lin g

br oa

de r l

in e

of

gr oc

er ie

s t ha

n sm

al l g

ro ce

rs a

nd fo

od m

ar ts

/ ga

s s ta

tio ns

G as

ol in

e sa

le s b

rin g

in /h

el p

re ta

in c

us to

m er

s Fo

cu s o

n gr

oc er

y ve

rs us

c on

ve ni

en ce

, a nd

us

ua lly

h av

e a

sm al

l b ut

a ttr

ac tiv

e di

sp la

y of

fr

es h

pr od

uc e

H av

e le

ss th

an $

5  m

ill io

n in

sa le

s Ty

pi ca

lly a

re ‘M

ai n

St re

et ’ g

ro ce

ry st

or es

in

sm al

l t ow

ns W

id e

se le

ct io

n of

fr es

h pr

od uc

e an

d m

ea t,

bu t

ca n

be li

m ite

d in

o th

er c

at eg

or ie

s

Es se

nt ia

lly g

as st

at io

n co

nv en

ie nc

e sto

re s s

el l-

in g

sn ac

k fo

od s,

sh el

f s ta

bl e

gr oc

er y

ite m

s, an

d al

co ho

l G

en er

al ly

d o

no t s

el l f

re sh

p ro

du ce

, w ith

th e

ex ce

pt io

n of

q ui

ck -g

ra b

ba na

na s a

nd a

pp le

s i n

so m

e sto

re s

1012 J Community Health (2017) 42:1008–1019

1 3

Ta bl

e 2

A va

ila bi

lit y

of fo

od it

em s b

y sto

re -ty

pe

St or

e ty

pe Pe

rc en

t o f s

to re

s w ith

it em

Re ad

y to

e at

it em

s

Sa la

d Sa

nd w

ic h

Pi zz

a H

ot d

og /h

am bu

rg er

M ex

ic an

Fr en

ch fr

ie s

A ll

sto re

s v is

ite d

(n =

20 )

14 90

37 38

32 12

M id

-s iz

ed in

de -

pe nd

en t (

n = 5)

20 80

40 20

20 20

Sm al

l g ro

ce r w

ith

ga s (

n = 6)

0 10

0 50

50 33

17

C on

ve ni

en ce

w ith

- ou

t g as

(n =

7) 22

89 22

44 44

0

D ai

ry , e

gg s,

m ea

t

M ilk

, w ho

le M

ilk , 2

% M

ilk , 1

% G

ro un

d be

ef

(> 10

% fa

t) G

ro un

d be

ef ,

ex tra

le an

Fr es

h eg

gs Tu

na c

an (i

n w

at er

) Fr

es h

or fr

oz en

fi sh

A ll

sto re

s v is

ite d

(n =

20 )

93 93

69 69

7 94

96 28

M id

-s iz

ed in

de pe

nd en

t ( n =

5) 80

80 80

80 20

10 0

10 0

40 Sm

al l g

ro ce

r w ith

g as

(n =

6) 10

0 10

0 83

83 0

83 10

0 33

C on

ve ni

en ce

w ith

ou t g

as

(n =

7) 10

0 10

0 44

44 0

10 0

89 11

Sn ac

k fo

od s

Po ta

to

ch ip

s, re

gu la

r

Sn ac

k ca

ke s

or d

ou gh

nu ts

C oo

ki es

C an

dy C

ho co

la te

b ar

s B

ak ed

o r

lo w

-fa t p

ot at

o ch

ip s

C ra

ck er

s Ic

e cr

ea m

A ll

sto re

s v is

ite d

(n =

20 )

10 0

86 10

0 10

0 10

0 66

10 0

90 M

id -s

iz ed

in de

pe nd

en t (

n = 5)

10 0

80 10

0 10

0 10

0 60

10 0

80 Sm

al l g

ro ce

r w ith

g as

(n =

6) 10

0 10

0 10

0 10

0 10

0 83

10 0

10 0

C on

ve ni

en ce

w ith

ou t g

as

(n =

7) 10

0 78

10 0

10 0

10 0

56 10

0 89

Fr ui

ts a

nd v

eg et

ab le

s

A ny

k in

d of

ve

ge ta

bl es

Fr es

h ve

g- et

ab le

s C

an ne

d ve

ge ta

- bl

es

Fr oz

en v

eg et

a- bl

es A

ny k

in d

of

fr ui

t Fr

es h

fr ui

ts C

an ne

d fr

ui ts

Fr oz

en fr

ui ts

A ll

sto re

s v is

ite d

(n =

20 )

10 0

80 10

0 60

95 89

91 23

M id

-s iz

ed in

de pe

nd en

t ( n =

5) 10

0 80

10 0

80 10

0 10

0 10

0 40

Sm al

l g ro

ce r w

ith g

as (n

= 6)

10 0

83 10

0 67

10 0

10 0

83 17

1013J Community Health (2017) 42:1008–1019

1 3

Ta bl

e 2

(c on

tin ue

d)

Fr ui

ts a

nd v

eg et

ab le

s

A ny

k in

d of

ve

ge ta

bl es

Fr es

h ve

g- et

ab le

s C

an ne

d ve

ge ta

- bl

es

Fr oz

en v

eg et

a- bl

es A

ny k

in d

of

fr ui

t Fr

es h

fr ui

ts C

an ne

d fr

ui ts

Fr oz

en fr

ui ts

C on

ve ni

en ce

w ith

ou t g

as

(n =

7) 10

0 78

10 0

33 89

67 89

11

W ho

le g

ra in

s

A ny

k in

d of

b re

ad H

ig h

fib er

b re

ad A

ny k

in d

of ri

ce B

ro w

n ric

e (p

la in

) A

ny k

in d

of p

as ta

H ig

h fib

er p

as ta

A ll

sto re

s v is

ite d

(n =

20 )

93 68

83 64

10 0

24

M id

-s iz

ed in

de -

pe nd

en t (

n = 5)

80 80

10 0

60 10

0 40

Sm al

l g ro

ce r w

ith

ga s (

n = 6)

10 0

67 83

33 10

0 0

C on

ve ni

en ce

w ith

- ou

t g as

(n =

7) 10

0 56

67 10

0 10

0 33

W ho

le g

ra in

s c on

tin ue

d

A ny

k in

d of

b ea

ns A

ny k

in d

of c

er ea

l O

at m

ea l (

pl ai

n) W

ho le

g ra

in c

er ea

l <

7  g

su ga

r Su

ga ry

c er

ea l

(> 7 

g su

ga r)

A ll

sto re

s v is

ite d

(n =

20 )

94 97

71 62

10 0

M id

-s iz

ed in

de -

pe nd

en t (

n = 5)

10 0

10 0

80 80

10 0

Sm al

l g ro

ce r w

ith

ga s (

n = 6)

83 10

0 67

50 10

0

C on

ve ni

en ce

w ith

- ou

t g as

(n =

7) 10

0 90

67 56

10 0

1014 J Community Health (2017) 42:1008–1019

1 3

Ta bl

e 3

T he

m es

a nd

e xa

m pl

e qu

ot es

fr om

k ey

in fo

rm an

t i nt

er vi

ew s

Th em

e D

es cr

ip tio

n Ex

am pl

e qu

ot e

D ra

in o

f t he

su pe

rc en

te r

Ru ra

l c on

su m

er s i

n no

rth ea

st M

I a re

d riv

in g

lo ng

d ist

an ce

s t o

sh op

a t s

up er

- ce

nt er

s ( e.

g. , W

al m

ar t)

“P eo

pl e

w ill

d riv

e to

sh op

a t W

al m

ar t t

hi nk

in g

th ey

a re

sa vi

ng m

on ey

. Y ou

kn

ow , t

he y

w ill

sa ve

a d

ol la

r o n

a pr

od uc

t, bu

t i t w

ill c

os t t

he m

$ 15

.0 0

in g

as

to g

et th

er e

an d

ba ck

” Li

m ite

d av

ai la

bi lit

y of

sm al

l, lo

ca l s

to re

s a nd

p an

tri es

Lo ca

lly o

w ne

d sto

re s a

re c

lo si

ng “A

lo t o

f t he

p ro

bl em

is b

ec au

se th

e bi

g gr

oc er

y ch

ai ns

h av

e go

ne aw

ay a

nd

so m

e of

th e

lo ca

lly o

w ne

d gr

oc er

s t ha

t h av

e a

hi sto

ry o

f b ei

ng in

a c

om -

m un

ity h

av e

... b

ee n

bo ug

ht o

ut b

y na

tio na

l c ha

in s a

nd th

en la

te r c

lo se

d. W

e ha

ve lo

st a

lo t o

f o ur

fa m

ily -o

w ne

d gr

oc er

s t ha

t u se

d to

d o

a re

al ly

g oo

d jo

b at

h av

in g

va rie

ty a

nd c

on si

ste nc

y in

a n

ei gh

bo rh

oo d”

D em

an d

fo r c

on ve

ni en

ce it

em s

Pe op

le w

an t f

as t a

nd c

he ap

“I t’s

g oi

ng to

c os

t y ou

$ 10

fo r a

p ou

nd o

f h am

bu rg

er , a

nd it

’s g

oi ng

to c

os t

yo u

$1 to

g o

to M

cD on

al d’

s. W

he re

a re

y ou

g oi

ng to

g o?

T he

n it

be co

m es

an

a cc

el er

at ed

p at

te rn

, b ec

au se

y ou

h av

e th

e he

al th

p ro

bl em

s a ss

oc ia

te d

w ith

th

at ”

Tr an

sp or

ta tio

n ch

al le

ng es

D ist

an ce

a nd

c os

t i s a

la rg

e ba

rr ie

r t o

ac ce

ss in

g he

al th

y fo

od s

Tr an

sp or

ta tio

n is

o ne

o f t

he la

rg es

t b ar

rie rs

to a

cc es

si ng

h ea

lth y

fo od

s A

re as

in n

or th

ea st

M I e

xp er

ie nc

e gr

ea te

r d iffi

cu lti

es w

ith fo

od a

cc es

s a nd

pe

op le

h av

e to

d riv

e to

g et

to g

ro ce

ry st

or es

“O ne

o f t

he b

ig ge

st ch

al le

ng es

is tr

an sp

or ta

tio n.

Y ou

c an

h av

e ev

er yt

hi ng

, 2 0

m ile

s a w

ay , b

ut p

eo pl

e ca

n’ t g

et to

it ”

Ec on

om ic

c ha

lle ng

es Ec

on om

ic al

ly d

ep riv

ed a

re a;

re si

de nt

s a re

u nd

er em

pl oy

ed a

nd st

ru gg

lin g

to

m ak

e en

ds m

ee t

Pe op

le a

re n

ot g

et tin

g th

e jo

bs to

su st

ai n

th em

se lv

es , i

m pr

ov e

th ei

r l iv

in g

si tu

at io

n

“T he

re is

n’ t a

si ng

le p

er so

n th

at I

kn ow

th at

d oe

sn ’t

kn ow

so m

eo ne

o r h

av e

ha d

th em

se lv

es c

om pl

et el

y lo

se th

ei r j

ob s,

lo se

th ei

r h om

e, lo

se e

ve ry

th in

g.

Li ve

w ith

fo ur

k id

s i n

a on

e- be

dr oo

m a

pa rtm

en t,

to tr

y to

g et

b y.

It ’s

h ap

- pe

ne d

he re

re pe

at ed

ly ”

“I n

so m

e of

th e

re al

ly ru

ra l a

re as

w he

re a

lo t o

f j ob

s d on

’t ge

t r ep

la ce

d, it

be

co m

es a

li ttl

e m

or e

ch ro

ni c.

T ha

t f am

ili es

a re

n’ t a

bl e

to g

et e

m pl

oy m

en t,

or th

ey a

re d

is ab

le d

an d

ca nn

ot w

or k”

C os

t o f h

ea lth

y ea

tin g

M os

t i m

po rta

nt fa

ct or

d riv

in g

fo od

p ur

ch as

in g

am on

g ru

ra l n

or th

ea st

M I

co ns

um er

s i s p

ric e

H ig

he r c

os t o

f h ea

lth y

fo od

s, an

d al

l f oo

ds o

ve ra

ll, in

ru ra

l M I

SN A

P is

le ss

av ai

la bl

e in

st or

es in

sm al

l c om

m un

iti es

St or

es h

av e

to k

ee p

th ei

r p ric

es d

ow n

in o

rd er

to re

m ai

n co

m pe

tit iv

e

“D ow

nt ow

n, li

ttl e

IG A

, t ha

t’s w

ha t y

ou w

ou ld

p ro

ba bl

y fin

d in

li ttl

e sm

al l

co m

m un

iti es

. T he

re ’s

n o

w ig

gl e

ro om

fo r m

uc h

ex tra

, i m

pa ct

in g

co st”

“E ve

ry th

in g

is m

or e

ex pe

ns iv

e he

re . I

t’s v

er y

m uc

h a

th ird

-w or

ld m

en ta

lit y.

Ev

er yb

od y

is so

d es

pe ra

te fo

r j ob

s, fo

r m on

ey , f

or fo

od , t

he y

w ill

se ll

th ei

r so

ul ju

st fo

r t ha

t l itt

le b

it. S

o, th

er e

is n

ot a

lo t o

f t ho

ug ht

p ro

ce ss

th at

g oe

s in

to a

ny th

in g.

E ve

ry th

in g

co m

es d

ow n

to su

rv iv

al is

m ”

A gi

ng a

nd d

w in

dl in

g po

pu la

tio n

Yo un

ge r p

eo pl

e m

ov in

g aw

ay fr

om sm

al le

r t ow

ns Tr

an sp

or ta

tio n

is su

es a

re h

ei gh

te ne

d in

th e

el de

rly p

op ul

at io

n Sm

al l c

hu rc

h pa

nt rie

s d o

no t h

av e

th e

vo lu

nt ee

rs to

m ai

nt ai

n; a

gi ng

v ol

un -

te er

s

“A lo

t o f o

ur y

ou ng

p eo

pl e

ar e

m ov

in g

aw ay

fr om

th e

sm al

l t ow

ns to

m or

e ur

ba n

ar ea

s. Th

is le

av es

b eh

in d

a lo

t o f e

ld er

ly fo

lk s w

ho h

av e

tro ub

le g

et -

tin g

to th

e sto

re ”

In te

re st

in M

ic hi

ga n-

gr ow

n fo

od s

D es

pi te

a la

ck o

f w ill

in gn

es s t

o pa

y hi

gh er

p ric

es , r

ur al

n or

th ea

st M

I r es

i- de

nt s a

re in

te re

ste d

in lo

ca lly

p ro

du ce

d fo

od s

Fa rm

er s m

ar ke

ts a

re p

op ul

ar (e

sp ec

ia lly

a m

on g

se ni

or s)

, b ut

p eo

pl e

ar e

of te

n un

w ill

in g

to p

ay h

ig he

r p ric

es Su

pp or

tin g

ne ig

hb or

s Pr

id e

in th

e re

gi on

“M or

e an

d m

or e

pe op

le in

th e

re gi

on w

an t t

o kn

ow w

he re

th ei

r f oo

d su

pp ly

is

co m

in g

fro m

, b ut

lo w

-in co

m e

pe op

le c

an ’t

al w

ay s p

ay th

e pr

ic e”

1015J Community Health (2017) 42:1008–1019

1 3

Ta bl

e 3

(c on

tin ue

d)

Th em

e D

es cr

ip tio

n Ex

am pl

e qu

ot e

Ev ol

vi ng

a gr

ic ul

tu ra

l s ys

te m

M ix

o f t

ra di

tio na

l/c on

ve nt

io na

l f ar

m in

g (s

oy be

an s,

co rn

, d ai

ry , b

ee f)

a nd

sl

ow ly

in cr

ea si

ng sm

al le

r, m

or e

di ve

rs ifi

ed fa

rm s

N ot

c ur

re nt

ly su

ffi ci

en t p

ro du

ct io

n in

n or

th ea

st M

ic hi

ga n

to su

pp or

t a lo

ca l

fo od

h ub

“I t’s

m os

tly tr

ad iti

on al

fa rm

in g,

9 9%

tr ad

iti on

al fa

rm in

g— so

yb ea

ns , c

or n,

da

iry , b

ee f.

W e

do h

av e

a co

up le

o f h

ig h-

en d

co m

m od

ity —

ki dn

ey b

ea n

an d

po ta

to es

. F ar

m in

g is

a b

ig p

ar t o

f t he

se c

om m

un iti

es . T

he re

a re

so m

e co

un tie

s l ik

e M

on tm

or en

cy a

nd A

lc on

a co

un tie

s, ju

st to

th e

so ut

he as

t o f u

s he

re in

th e

no rth

ea st,

th at

h av

e ex

te ns

iv e

fe de

ra l a

nd st

at e

la nd

s t ha

t r ea

lly

su ffe

r. Th

os e

ar e

th e

co m

m un

iti es

th at

re al

ly su

ffe r f

ro m

fo od

a nd

e ve

ry th

in g

be ca

us e

th ey

d on

’t ha

ve th

e ta

x ba

se b

ec au

se o

f t he

fe de

ra l a

nd st

at e

la nd

s th

at a

re th

er e”

“I th

in k

it’ s t

he p

ro bl

em w

e ha

ve h

er e

is w

e do

n’ t h

av e

an y

m or

e la

nd . I

t’s

pr im

e no

w to

g et

a ny

ty pe

o f a

gr ic

ul tu

ra l f

ar m

la nd

ri gh

t n ow

, a t $

10 ,0

00 a

n ac

re p

lu s”

N ee

d fo

r e du

ca tio

n N

ee d

fo r n

ut rit

io n

ed uc

at io

n fo

r c on

su m

er s,

ag ric

ul tu

ra l e

du ca

tio n

fo r m

ul ti-

pl e

se ct

or s

N ee

d to

b ui

ld d

em an

d fo

r h ea

lth ie

r f oo

ds Pe

op le

n o

lo ng

er k

no w

h ow

to c

oo k

Lo w

-in co

m e

pe op

le u

si ng

S N

A P

to p

ur ch

as e

un he

al th

y fo

od s

“S o

m an

y ot

he r t

hi ng

s s ta

ck ed

a ga

in st

w ha

t w ou

ld b

e he

al th

ie r c

ho ic

es , i

t’s

ha rd

fo r t

he h

ea lth

ie r c

ho ic

es to

e ve

r w in

. E ve

n w

he n

th ey

a re

th er

e, I

do n’

t th

in k

th ey

g et

p ic

ke d

w he

n yo

u ha

ve p

iz za

s a nd

h ot

d og

s a nd

d iff

er en

t t hi

ng s

on se

rv ic

e lin

es th

er e.

L ow

-c os

t p ro

du ce

in a

ny k

in d

of m

ar ke

t i s n

ot g

oi ng

to

h el

p, e

ith er

, i f y

ou st

ill h

av e

al l t

he o

th er

c ho

ic es

th er

e. It

’s re

al ly

th e

ed uc

at io

n of

w ha

t t o

do w

ith fr

es h

pr od

uc e,

w hy

it ’s

a b

et te

r o pt

io n,

g et

tin g

it in

co rp

or at

ed in

to th

e ho

m e

an d

th e

fa m

ily . E

du ca

tin g

pe op

le o

n w

ha t t

o do

w

ith a

z uc

ch in

i i s r

ea lly

m or

e cr

iti ca

l t ha

n pu

tti ng

m or

e op

tio ns

e ve

ry w

he re

, be

ca us

e pe

op le

st ill

a re

n’ t g

oi ng

to c

ho os

e it”

“E B

T— so

m e

us e

it fo

r w ha

t i t i

s m ea

nt , b

ut o

th er

s b uy

in ste

ad th

in gs

li ke

p op

, ch

ip s,

sn ac

ks , j

un k,

n on

-n ut

rit io

na l f

oo ds

. T hi

s s tu

ff w

as ta

ke n

ou t o

f s ch

oo l

bu t t

he y

w ill

c om

e in

a fte

r s ch

oo l a

nd b

uy it

w ith

th ei

r E B

T ca

rd s.

Pa re

nt s

w ill

b rin

g th

em in

a nd

th at

’s a

ll th

ey w

ill p

ur ch

as e”

A re

as o

f o pp

or tu

ni ty

In ve

sti ng

in e

xi sti

ng st

or es

N ut

rit io

n ed

uc at

io n

(c oo

ki ng

sk ill

s) In

no va

tiv e

di str

ib ut

io n

Ex pa

nd u

til iz

at io

n of

D ou

bl e

U p

Fo od

B uc

ks

“S ta

rti ng

a g

ro ce

ry st

or e,

y ou

h av

e to

h av

e a

bu si

ne ss

p la

n, y

ou h

av e

to k

no w

yo

ur c

om m

ut in

g pa

tte rn

s a nd

d em

an d—

it is

a fo

rm id

ab le

ta sk

, e ve

n if

yo u

ar e

a pr

et ty

d ec

en t b

us in

es sm

an . I

t w ou

ld b

e ni

ce if

so m

e of

th e

ex ist

in g

sm al

le r g

ro ce

ry st

or es

c ou

ld a

cc es

s f un

di ng

to e

xp an

d, o

r s om

et hi

ng li

ke

th at

. B ut

to st

ar t f

ro m

sc ra

tc h

is a

b ig

, b ig

jo b”

“W e

ar e

ta lk

in g

se m

i l oa

ds o

f f re

sh p

ro du

ce . I

f y ou

h av

e si

x tru

ck lo

ad s f

ul l o

f pe

pp er

s, th

er e

ar e

on ly

so m

an y

ag en

ci es

y ou

c an

c al

l i n

a da

y or

tw o’

s t im

e an

d ha

ve th

em g

et th

e pe

pp er

s o ut

. B ut

if w

e co

ul d

dr iv

e up

fi ve

c ou

nt ie

s, an

d ha

ve a

su pe

r-a ge

nc y

or h

ub th

at a

ct ua

lly h

as a

c oo

le r a

nd h

as c

ap ac

ity

to st

or e

a se

m i l

oa d

of p

ro du

ce , t

he n

al l t

he lo

ca l a

ge nc

ie s f

ro m

th at

c ou

nt y

co ul

d m

ay be

c om

e an

d pi

ck it

u p

fro m

th em

” “M

ob ile

fo od

p an

try , u

pw ar

ds o

f 6 30

o f t

ho se

a y

ea r,

th at

g o

ou t t

o ru

ra l

co un

tie s w

ith fo

od d

ist rib

ut io

n as

w el

l. So

m et

im es

th e

ag en

cy is

fu rth

er

aw ay

th an

a ny

o ne

fa m

ily m

ig ht

b e

ab le

to tr

av el

. A lo

t o f a

ge nc

ie s p

ar tn

er ed

to

ge th

er to

h os

t m ob

ile p

an tri

es in

u nd

er se

rv ed

a re

as o

f t he

c ou

nt y”

To ur

ist s v

er su

s l oc

al p

op ul

at io

n N

ee d

to d

iff er

en tia

te b

et w

ee n

to ur

ist s v

is iti

ng n

or th

ea st

M I a

nd lo

ca ls

In m

an y

ca se

s, th

e to

ur ist

s a re

m or

e op

en to

lo ca

lly so

ur ce

d fo

od s,

hi gh

er

pr ic

es

“W e

ha ve

le ss

th an

2 0%

c us

to m

er a

nd su

pp or

t f ro

m lo

ca l p

eo pl

e; 8

0% o

f o ur

bu

si ne

ss o

r m or

e co

m es

fr om

o ut

si de

, f ro

m p

eo pl

e ...

tr av

el in

g th

ro ug

h”

1016 J Community Health (2017) 42:1008–1019

1 3

locally grown foods as well as healthier items, but often this may be cost prohibitive for families: “…more people in the region want to know where their food supply is coming from, but low-income people can’t always pay the price.” Some other key themes included the need for further nutri- tion and health education in rural and remote communities, and allowing for stakeholders and communities members alike to come up with innovative solutions to address chal- lenges and food access needs. Store owners also reported the increasing demand for convenience items: “People come in often for our ready-made items. It’s been going well since we started our new sandwiches that are made here with our homemade buns.”

Discussion

Our research aligns with findings of other studies on the availability of healthy food and store-owner challenges in rural areas [16, 23, 24, 40]. We found that store-owners were willing to provide more healthful options, but per- ceived a lack of demand from their customers as one of the main barriers to executing this. They also experienced out- shopping as a significant challenge. Poverty and other eco- nomic issues in the area were noted by key informants as important factors relating to the complex food environment in northeast Michigan.

In addition, store type (e.g., supermarket, grocery store, or convenience store) has been found to influence the avail- ability of healthy foods [40]. Overall, we found that the larger stores had a greater variety and quality of produce. Existing literature suggests that one way to attract the rural consumer to small stores in their communities is through an abundant meat selection [19, 29]. We also found evidence that meat can be a potential source of attraction for custom- ers, as several stores in our study had numerous selections of frozen meats, sometimes including local meats and fish, even where other more healthful grocery offerings may have been fairly limited.

Several studies we referenced each had slightly differing categories of food retail outlets with diverging definitions [32–36, 41]. In addition, available secondary databases often contained incorrectly assigned food retail categories [42, 43]. Therefore, we created categories of food retail outlets relevant for rural communities. The Food Environ- ment Scan and in-person observations of the 20 stores sup- ported the four key categories of food retail environments in rural communities including (1) mid-sized independent Grocers, (2) small or mid-sized grocers with gas, (3) small grocers/convenience without gas, and (4) limited assort- ment food marts/gas stations. Further work in exploring these and other types of food retail outlet categories, and the relevance to particular geographies (rural, urban, etc.),

is needed to advance our understanding of food shopping behaviors and related health outcomes among different populations.

The results indicate that the best availability of more healthful foods and higher quality and variety of produce is found in the mid-sized independent grocer class of stores, followed by the small or mid-sized grocers with gas. The stores in these categories appear to have the largest poten- tial for increasing food access in rural areas. Mid-sized independent grocers generally have at least one open cooler (approximately 6 or 8 feet long) dedicated to highly perish- able fresh produce. A fair number of the small or mid-sized grocers with gas tend to have fresh perishable produce stocked in their stand-up coolers near beverages. Many of these stores could benefit from increased open cooler space that could enable a wider variety of offerings and a more attractive display. Further, most of these food retail outlets offer SNAP EBT redemption, with some redeeming WIC. Added cooler space in these outlets could therefore help provide increased healthy food access to low-income rural residents.

The results of this research and related studies sug- gest several ideas for healthy food financing and related projects. First, strategies geared towards “meeting people where they are at” may be successful in small rural grocer- ies. Presenting people with healthy versions of conveni- ence foods, such as pre-made salads, pre-cut fruit and veg- etable packs, and more healthful sandwiches (e.g., whole grain bread and low-fat, low-sodium, lean meats) and soups could provide people the convenience they seek while sur- rounding them with more healthful options to choose from. A second strategy that could be applied would be to create attractive displays of fresh produce and other healthy foods in rural grocery stores, potentially in partnership with a dis- tributor. It is possible that there may be a “critical mass” of produce needed to be displayed throughout a store in order to create a viable offering in a small grocery outlet; suffi- cient variety, quantity, and quality to be attractive enough to stimulate ongoing sales. In fact, the lack of such a criti- cal mass could help explain the conflicting data regarding store-owners who cite a lack of demand for fresh produce on the one hand, and consumers who express a desire to shop for produce in smaller rural stores on the other [17, 19, 24]. Strategies could include a marketing campaign and food placement/shelf layout plans that would increase the visibility of more healthful foods at small stores, fol- lowing the concept of “choice architecture” [44]. Addition- ally, healthy frozen options, including locally or regionally procured frozen fruits, vegetables, and meats, may have the potential to help provide continuity for healthy food mar- keting programs in rural grocery stores by utilizing exist- ing stand-up freezer capacity. There is also potential for rural grocers to operate a food hub for local products using

1017J Community Health (2017) 42:1008–1019

1 3

their store’s extra storage capacity; an advising group has recently developed a toolkit to help grocers determine if a food hub would benefit their business.

The current study indicates that willingness and capacity to increase healthy options in rural food outlets exists. The Good Food Fund can assist in Michigan by providing low interest loans for capital improvements such as increased cooler space. Support from university extension, NGOs, and public entities may also be needed to help design and implement pilot projects aimed at working with distributors and food businesses in order to help provide and distribute produce and more healthful ready-to-eat convenience foods. Once developed and implemented, these types of projects could become self-sustaining. However, our experience during this study illustrates that there is a need to develop a method for distinguishing between small/mid-scale gro- cers and simple convenience stores. For example, it may be helpful to find a way to determine which small stores with- out gas have a focus on grocery, and which stores with gas are focused on convenience. Finding approaches to make these distinctions based on available secondary data and/ or short telephone calls could be valuable to rural grocery and healthy food initiative assessment work, and may have wider application to work in urban or peri-urban areas.

In addition, there are general gaps of knowledge in this field that are important to pursue. Much is unknown about the shopping behavior of rural residents. For example, the concept of out-shopping needs expanded research in order to understand the factors used to make decisions about whether and when to shop in the immediate area versus to travel to an area with multiple larger retailers [45]. There is also a gap in knowledge with regard to the requirements that distributors place on store-owners, and how those requirements affect store-owners’ decisions about what to stock. Consequently, more research is warranted to better understand the amount, variety, and quality—the “critical mass”—of fresh produce offerings needed to attract and satisfy consumers who demonstrate willingness to buy more produce locally. Finally, future studies can help deter- mine best practices and methods to help stimulate consum- ers to buy healthy food at rural grocery stores.

This study has several limitations. First, due to funding constraints, we could not visit each of the 800 plus estab- lishments in person to confirm whether our initial cat- egorization was correct. However, we have gained insight which could be useful in devising methods that would help to confirm categorizations without the need for visitation. Next, we were only able to collect data on food availability using the scan tool at one point in time; offerings may dif- fer based on the time of year, especially in winter, due to lack of fresh local produce and fewer tourists or sportsmen and women. In addition, reaching store-owners and having them complete interviews by phone following the in-person

data collection was a challenge. This was due to various reasons, including the impracticability of stepping away from their duties and an increasing volume of business occurring during the spring and summer seasons. We were not able to extend our interviews to distributors or to con- sumers, which would have helped to more fully illustrate the rural food environment in the area. Studies involving these stakeholders would be logical next steps for research.

Despite these limitations, this study provides an impor- tant preliminary step in understanding the food retail environment in a remote area in Michigan. The methods described in this study can be replicated in other areas, starting with the culmination of secondary data sources, identifying food retail outlet categories relevant to a par- ticular local context, and ground truthing the location and category of these outlets. The observational tool was modi- fied from previous tools to assess the core components of healthy food availability in rural food retail outlets, and may be relevant for use in other communities. We found several strengths and opportunities for future investment by the Good Food Fund, as well as challenges experienced in these communities in accessing healthy foods.

Acknowledgements This research was supported by the Center for Regional Food Systems (CRFS) at Michigan State University. We would like to acknowledge the Gretchen Swanson Center for Nutrition for its partnership in this study, and Shane Solar Doherty, 2015 Sum- mer Intern for CRFS for his contributions.

Funding Funding in part for this research is from the W. K. Kellogg Foundation, Battle Creek, MI.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflicts of interest.

References

1. Bauer, U. E., Briss, P. A., Goodman, R. A., & Bowman, B. A. (2014). Prevention of chronic disease in the 21st century: Elimi- nation of the leading preventable causes of premature death and disability in the USA. The Lancet, 384(9937), 45–52.

2. Ley, S. H., Hamdy, O., Mohan, V., & Hu, F. B. (2014). Preven- tion and management of type 2 diabetes: Dietary components and nutritional strategies. The Lancet, 383(9933), 1999–2007.

3. Reedy, J., Krebs-Smith, S. M., Miller, P. E., et al. (2014). Higher diet quality is associated with decreased risk of all-cause, cardio- vascular disease, and cancer mortality among older adults. The Journal of Nutrition, 144(6), 881–889.

4. Kirkup, M., Kervenoael, R. D., Hallsworth, A., Clarke, I., Jack- son, P., & del Aguila, R. P. (2004). Inequalities in retail choice: Exploring consumer experiences in suburban neighbourhoods. International Journal of Retail & Distribution Management, 32(11), 511–522.

5. Lake, A., & Townshend, T. (2006). Obesogenic environments: Exploring the built and food environments. The Journal of the

1018 J Community Health (2017) 42:1008–1019

1 3

Royal Society for the Promotion of Health, 126(6), 262–267. doi:10.1177/1466424006070487.

6. Laska, M. N., Borradaile, K. E., Tester, J., Foster, G. D., & Git- telsohn, J. (2010). Healthy food availability in small urban food stores: A comparison of four US cities. Public Health Nutri- tion, 13(7), 1031–1035. doi:10.1017/S1368980009992771.

7. Smith, C., & Morton, L. W. (2009). Rural food deserts: Low- income perspectives on food access in minnesota and iowa. Journal of Nutrition Education and Behavior, 41(3), 176–187. doi:10.1016/j.jneb.2008.06.008.

8. Smith, D. M., Cummins, S., Taylor, M., et al. (2010). Neigh- bourhood food environment and area deprivation: Spatial accessibility to grocery stores selling fresh fruit and vegetables in urban and rural settings. International Journal of Epidemi- ology, 39(1), 277–284. doi:10.1093/ije/dyp221.

9. Bailey, J. (2010). Rural grocery stores: Importance and chal- lenges. Lyons: Center for Rural Affairs. Retrieved from http:// files.cfra.org/pdf/rural-grocery-stores.pdf.

10. Bustillos, B., Sharkey, J. R., Anding, J., & McIntosh, A. (2009). Availability of more healthful food alternatives in tra- ditional, convenience, and nontraditional types of food stores in two rural texas counties. Journal of the American Dietetic Association, 109(5), 883–889.

11. Kaufman, P. R., MacDonald, J. M., Lutz, S. M., & Smallwood, D. M. (1997). Do the poor pay more for food? Item selec- tion and price differences affect low-income household food costs (Agricultural Economics Reports No. 34065). Washing- ton, DC: United States Department of Agriculture, Economic Research Service. Retrieved from http://econpapers.repec.org/ paper/agsuerser/34065.htm.

12. Liese, A. D., Weis, K. E., Pluto, D., Smith, E., & Lawson, A. (2007). Food store types, availability, and cost of foods in a rural environment. Journal of the American Dietetic Associa- tion, 107(11), 1916–1923. doi:10.1016/j.jada.2007.08.012.

13. Sharkey, J. R., & Horel, S. (2008). Neighborhood socioeco- nomic deprivation and minority composition are associated with better potential spatial access to the ground-truthed food environment in a large rural area. The Journal of Nutrition, 138(3), 620–627.

14. Moore, L. V., Roux, A. V. D., & Franco, M. (2012). Measuring availability of healthy foods: Agreement between directly meas- ured and self-reported data. American Journal of Epidemiology, 175(10), 1037–1044. doi:10.1093/aje/kwr445.

15. Hawes, J. M., & Lumpkin, J. R. (1984). Understanding the out- shopper. Journal of the Academy of Marketing Science, 12(4), 200–217.

16. Mullis, K., & Kim, M. (2011). Factors determining inshopping in rural US communities: Consumers’ and retailers’ perceptions. International Journal of Retail & Distribution Management, 39(5), 326–345.

17. Lee, S.-E., Johnson, K. K., & Gahring, S. A. (2008). Small-town consumers’ disconfirmation of expectations and satisfaction with local independent retailers. International Journal of Retail & Distribution Management, 36(2), 143–157.

18. Goetz, S. J., & Swaminathan, H. (2006). Wal-mart and county- wide poverty. Social Science Quarterly, 87(2), 211–226.

19. Pinard, C., Fricke, H., Smith, T., Carpenter, L., & Yaroch, A. (2016). The future of the small rural grocery store: A qualita- tive exploration. American Journal of Health Behavior, 40(6), 749–760.

20. Walker, R. E., Keane, C. R., & Burke, J. G. (2010). Disparities and access to healthy food in the united states: A review of food deserts literature. Health & Place, 16(5), 876–884.

21. Shanks, C. B., Ahmed, S., Smith, T., et al. (2015). Availability, price, and quality of fruits and vegetables in 12 rural montana counties, 2014. Preventing Chronic Disease, 12, E128.

22. O’Malley, K., Gustat, J., Rice, J., & Johnson, C. C. (2013). Fea- sibility of increasing access to healthy foods in neighborhood corner stores. Journal of Community Health, 38(4), 741–749. doi:10.1007/s10900-013-9673-1.

23. Pinard, C., Shanks, C. B., Harden, S., & Yaroch, A. L. (2016). An integrative literature review of small food store research across urban and rural communities in the US. Preventive Medi- cine Reports, 3, 324–332.

24. Pitts, S. B. J., Bringolf, K. R., Lloyd, C. L., McGuirt, J. T., Lawton, K. K., & Morgan, J. (2013). Formative evaluation for a healthy corner store initiative in Pitt County, North Carolina: Engaging stakeholders for a healthy corner store initiative, part 2. Preventing Chronic Disease, 10, E120.

25. Citizen’s Research Council of Michigan. (2014). Address- ing Michigan’s obesity problem (No. 387). Lansing: Citizen’s Research Council of Michigan

26. United States Department of Agriculture. (2014). 2007 cen- sus publications. Retrieved January 12, 2015 from http://www. agcensus.usda.gov/Publications/2007/.

27. Manon, M. & Church, D. (2015) Food for every child: The need for healthy food financing in Michigan. Philadelphia: The Food Trust.

28. Hendrickson, D., Smith, C., & Eikenberry, N. (2006). Fruit and vegetable access in four low-income food deserts communities in minnesota. Agriculture and Human Values, 23(3), 371–383. doi:10.1007/s10460-006-9002-8.

29. Jilcott, S. B., Hurwitz, J., Moore, J. B., & Blake, C. (2010). Qualitative perspectives on the use of traditional and nontradi- tional food venues among middle-and low-income women in eastern north carolina. Ecology of Food and Nutrition, 49(5), 373–389.

30. Colasanti, K., Cantrell, P., Cocciarelli, S., et  al. (2010). Michi- gan good food charter. East Lansing: C.S. Mott Group for Sus- tainable Food Systems at Michigan State University, Food Bank Council of Michigan, Michigan Food Policy Council. Available from http://www.michiganfood.org.

31. Andreyeva, T., Blumenthal, D. M., Schwartz, M. B., Long, M. W., & Brownell, K. D. (2008). Availability and prices of foods across stores and neighborhoods: The case of new haven, con- necticut. Health Affairs, 27(5), 1381–1388. doi:10.1377/ hlthaff.27.5.1381.

32. Block, D., & Kouba, J. (2006). A comparison of the availabil- ity and affordability of a market basket in two communities in the Chicago area. Public Health Nutrition, 9(07), 837–845. doi:10.1017/PHN2005924.

33. Hoehner, C. M., & Schootman, M. (2010). Concordance of com- mercial data sources for neighborhood-effects studies. Journal of Urban Health, 87(4), 713–725. doi:10.1007/s11524-010-9458-0.

34. Larson, N. I., Story, M. T., & Nelson, M. C. (2009). Neighbor- hood environments: Disparities in access to healthy foods in the U.S. American Journal of Preventive Medicine, 36(1), 74–81. doi:10.1016/j.amepre.2008.09.025.

35. Moore, L. V., & Diez Roux, A. V. (2006). Associations of neighborhood characteristics with the location and type of food stores. American Journal of Public Health, 96(2), 325–331. doi:10.2105/AJPH.2004.058040.

36. Wang, M. C., Gonzalez, A. A., Ritchie, L. D., & Winkleby, M. A. (2006). The neighborhood food environment: Sources of his- torical data on retail food stores. International Journal of Behav- ioral Nutrition and Physical Activity, 3(1), 15.

37. Rimkus, L., Powell, L. M., Zenk, S. N., et al. (2013). Develop- ment and reliability testing of a food store observation form. Journal of Nutrition Education and Behavior, 45(6), 540–548. doi:10.1016/j.jneb.2013.02.005.

38. Hosler, A. S., & Dharssi, A. (2011). Reliability of a survey tool for measuring consumer nutrition environment in urban food

1019J Community Health (2017) 42:1008–1019

1 3

stores. Journal of Public Health Management and Practice, 17(5), E1–E8. doi:10.1097/PHH.0b013e3182053d00.

39. United States Department of Agriculture (USDA), Economic Research Service (ERS). (2014). Food Access Research Atlas. Retrieved from http://www.ers.usda.gov/data-products/food- access-research-atlas/go-to-the-atlas.aspx.

40. Leone, A. F., Rigby, S., Betterley, C., et  al. (2011). Store type and demographic influence on the availability and price of healthful foods, leon county, florida, 2008. Preventing Chronic Disease, 8(6), A140.

41. Powell, L. M., Slater, S., Mirtcheva, D., Bao, Y., & Chaloupka, F. J. (2007). Food store availability and neighborhood character- istics in the United States. Preventive Medicine, 44(3), 189–195.

42. Liese, A. D., Barnes, T. L., Lamichhane, A. P., Hibbert, J. D., Colabianchi, N., & Lawson, A. B. (2013). Characterizing the

food retail environment: Impact of count, type, and geospatial error in 2 secondary data sources. Journal of Nutrition Educa- tion and Behavior, 45(5), 435–442.

43. Liese, A. D., Colabianchi, N., Lamichhane, A. P., et al. (2010). Validation of 3 food outlet databases: Completeness and geospa- tial accuracy in rural and urban food environments. American Journal of Epidemiology, 172(11), 1324–1333.

44. Leonard, T. C. (2008). Richard H. Thaler, Cass R. Sunstein, Nudge: Improving decisions about health, wealth, and happiness. Constitutional Political Economy, 19(4), 356–360.

45. Addis, R. A., & Grünhagen, M. (2014). The influence of social identity on rural consumers’ intent to shop locally. New England Journal of Entrepreneurship, 17(1), 7.

Journal of Community Health is a copyright of Springer, 2017. All Rights Reserved.