Capstone report (need help)

School of Public Health

LM Ho

June 31, 2016

In the U.S., food access and food security is a challenge. The lack of convenient access to affordable and healthy food is a considered a national challenge. Socio-economic status of the country’s population affects the consumption and access of health food. Low-income areas usually lack access to adequate food and high-income areas have a challenge of access to health food. Therefore, for the two areas with different socio-economic population statuses, they all have challenges to food access. Lack of healthy foods often lead to poor diet and higher levels of risk to obesity. Due to the persistent food access and food insecurity challenges, the aim of this study is to discuss the link between food access and food consumption among the American population. The paper will also focus on the exploring the variation between food access and food consumption among the American population. A two-stage sampling cross-sectional survey will be used to sample participants from 48 states of the U.S. A self-administered questionnaire will be used as quantitative data collection instrument. The target population will be sampled adult U.S. citizens who have families to feed. Grown-ups with families are likely to demonstrate their understanding of access to health foods because they have families to feed. Descriptive statistics and Analysis of Variance will be used to analyze data using the SPSS software version 22. Food access in the U.S. remains a challenge even in the modern society. Food security is also a challenge and this challenge is a risk factor to the health outcome of the consumer.

Table of Contents Abstract 2 CHAPTER 1 5 Introduction 5 CHAPTER TWO 8 Systematic reviews 8 Food accessibility versus dietary intakes 8 Food accessibility and prevalence of obesity 9 Role of food pricing in food accessibility 1110 Formulation of products 11 Role of different policies in ensuring accessibility of food 1211 The role of Geographic distribution, food access and food security 13 Research question 14 Hypothesis 14 CHAPTER THREE 15 METHODOLOGY 15 Study location 15 Research design 15 Target population 1615 Variables 16 Sampling Procedure 16 Sample size determination 16 Inclusion criteria 1716 Exclusion criteria 1716 Research instrumentation for data collection procedure 17 Methods of Data Collection 17 Quality control 1817 Pre-test 18 Validity 18 Reliability 18 Methods of Data analysis 1918 Ethical consideration 19 Limitations of the study methodology 19 CHAPTER FOUR 20 WORK SCHEDULE 20 Expected results and Implications of results 2120 TENTATIVE THESIS CHAPTER OUTLINE 22 Reference 23

Most of Americans live in places characterized as low income areas with limited access to supermarkets and grocery stores. Individuals in such areas find themselves seeking food from fast food restaurants that offer limited varieties of food. Inability to access healthy foods is the leading cause for poor dietary decisions. This is because limited access to healthy food contributes to difficulties in adhering to nutritious diet for the low income families (Inagami, et al., 2006). However, for communities with better accessibility to supermarkets with limited access to stores, they have better and healthier diets and lower chances of diseases such as obesity. Consumer accessibility to supermarkets, grocery stores and appropriate markets allows consumers to choose from a variety of fruits and vegetables. Research has demonstrated that diets rich in fruits and vegetables offer several health benefits to the consumers which imply lower levels of obesity and increased weight loss. It is studied that Americans living in low income areas consumes fewer fruits and vegetables than what is recommended by dietary guidance. It is also suggested that availability of a number of retail stores corresponds to healthier eating, (Galvez et al., (2007). There are a number of factors that contribute to a person’s body weight and risks associated with diet related diseases such as diabetes and other chronic diseases. It is hypothesized that lack of access to fully equipped groceries with easier accessibility of fast foods contributes to poor diets accelerating the rate of chronic diseases that are termed as food related diseases.

In US, the issue of public health has over years been an increasing concern due to increases in health care costs and economic constraints. Most of diet related diseases are constantly increasing in both rural and poorer urban centers. Relationship between poverty and poor health outcomes are increasing which poses complexity in understanding the issue despite solutions being suggested (Michimi and Michael, 2010). Most work that has been studied focuses on food access by poorer urban dwellers without concentration on rural poverty to unhealthy diets. This forms the basis as to why there is difficulties in identifying the key reasons as to why the rural citizens are not able to access healthier diets despite the fact that they are at a position of consuming healthier diets due to availability of land where they can grow their fruits and vegetables, and in case they are to buy from those growing them they can access at a cheaper price other than those from urban centers.

Observations on the changes that occur in the food environment, utilization patterns and diet-related diseases are the basic reasons behind more researches being conducted in determining possible association of the issues (Morland, 2015). The field of food access is the common source of information that elaborates the effects of food access on consumption and health outcomes that has different perception by different researchers. It is identified that food access is piled into food availability, accessibility, affordability, acceptance and accommodation which are aspects of importance to an individual and health outcomes. The problem of one being unable to access healthy food in US was initially dealt with by the food conservation and energy act of 2008. Later, the act delegated most of its duties such as the assessment ofthe extent of limited access, the identification of characteristics and causes of the problem together with effects associated with the problem to US department of agriculture (USDA), which is the body that handles all food problems within US. A number of methods have been used in identifying the extent of limited availability and nutritious food which are individual and area based measures of food accessibility (Pearson, 2005). Attention has concentrated on studying the relationship between food access and increase on chronic diseases so as to understand the factors behind food accessibility and individual behavior in establishment of appropriate health and outcomes. This work will give a synthesis of skills and core competencies in the public health at the verge of accessing food accessibility and health outcomes in America.

[1. You will a short para describing the structure of systematic reviews.

2. More importantly, you should highlight what has been known and what has not been known, so that you can formulate your research questions]

Most researches examine the effects of food access on outcomes [what kinds of outcomes?] such as food retailing behavior and consumption in regard to specific fruits and vegetables, whole grains and milk products. There are those studies that have focused on outcomes on the basis of BMI, heart diseases and obesity. The reasons for different outcomes are to specifically identify the outcome that accounts for rates of food inaccessibility. Majority of studies explains the relationship between food accessibility [consistent use of Access vs Accessibility] and dietary intake from large stores in showing that there people who are likely to source their foods from such stores consumes healthier diets (Larson et al., 2009). Relationship between availability of fast food from restaurants and the intake of such food is studied to informing citizens that even if the consumers access the food at cheaper prices, the content of the food is poor in terms of nutrition. There is less information on how changes in food accessibility affect diet changes. For instance, from a study by Cummins et al. (2005), it was demonstrated that shopping behavior is influenced by establishment of new stores. Probably because the more stores are there in a location, the more dwellers are able to consume a variety of the foods and source the food stuff from various stores. Additionally, the owners are likely to source a variety of fresh fruits and vegetables more often as a strategy of offering quality products to the customers, which will be result into appropriate health among the consumers.

Some localities have also implemented programs that are geared to improvement on what is offered by the residential stores. This is a cost effective strategy instead of building new stores that would somehow be expensive for rural dwellers. The idea is to cause [an in?] improvement by [offering healthier options with less healthier options what do you mean?]. This also improves sales within a store as consumers are able to access a variety of foods. For instance a study by Galvez et al. (2009) in which consumption of fruits and vegetables was evaluated to determine the number of customers who preferred [purchasing their products when packaged ?meaning?] or to consume it at the store showed that most consumers preferred packaged product due to convenience in consuming it at work place or at home. The study was testing whether [improvement on a product ?meaning?] has repercussion on consumer’s preference. This implies that [small store interventions are a promising strategy to having consumers take the product. ?meaning?]

A Study by Larson et al., (2009) has explained the relationship between accessibility of food from a store or restaurant with cause ofand obesity by measuring the BMI of a person. The study explains that individuals who have an appropriate access to supermarkets for their foods experience less risks of obesity, unlike and those who have better access to convenience stores who experience increased risks of obesity. In a study by Chung and Myers (1999), there is a relationship between accessibility of fast food from supermarkets and restaurants, andto BMI offrom Indiana citizens. The study shows that proximity of fast foods from supermarkets has a small [positive implication ??meaning??] on BMI which is a contrast to many studies that shows negative implications on BMI on food sourced from grocery stores. The occurrence of obesity based on BMI calculations is also dependent on neighborhood environment that one lives at. This is because according to a study done by Chauet al. (2013), the neighborhood that had a wider access to fresh commodities had a lower susceptibility to obesity than those neighborhoods that lacks stores for fresh nutritious commodities.

It is hypothesized that food rich in fiber content, fruits and vegetables and whole grains increases satiety, making consumers to consume less. This is an indicator that those consumers who much of the time access foods that are rich in fats [do you mean that these consumers tend to consume more?] are likely to be obesity victims. This is because stronger evidence exists in suggesting that consumption of sweetened beverages [do you mean that fat food is sweet, as you use “This is because” ?] is associated with increases in BMI and obesity. However, there is less evidence to proving that consumption of healthy foods such as fruits and vegetables leads to lower BMI, meaning that one has a reduced risk of obesity [?are you sure that there is “less evidence” on this point?.

The assessment of nearest food environment to an individual

The geographical regions on the basis of socioeconomic, demographic and local food surroundings are the determinants of a person’s behavior into choosing which food are to be consumed (Cummins and Sally, 2005). The nearest store to an individual determines the buying pattern since most of the consumers are concerned with convenience into accessing the food. For instance, a nearest store may be offering fast foods that are poor in nutrition quality but there are consumers who prefer it other than walking to a longer distance in search of nutritious products. in a region where there are many stores for accessing food, consumers are likely to have better and improved nutrition due to varieties unlike in rural areas where there may be few limiting alternatives. The economic capacities of individuals also influence the likelihood of individual to access nutritious products. Health conscious individuals with higher levels of income are able to access nutritious product which is a strategy to stay healthier live and refraining from diet-based diseases. On the other hand, for consumers who have less income, they are likely to look for convenience by consuming fast foods with no nutritional components which lead to obesity and other diet related complications.

Prices of food have an impact on consumer choices (Jetter and Cassady, 2006). As food prices declines, the energy dense food becomes a convenient food for consumption. The technological advancement has contributed to food being cheap due to available means that can be employed into availing food to consumers. Research indicates that as the rice of fruits and vegetables increases at the expense of less healthier foods, most of the consumers are still passionate in consuming fruits and vegetables. Some studies indicate that energy-dense foods such as refined grains and fats are still the lowest kinds of foods that are consumed by most consumers, probably due to increased health concerns that consumers have in fighting diet-based diseases. Research also indicates that healthier foods are purchased out of reduced prices which to some extent is difficult to maintain due to increased costs of raw materials and payment of taxes by the processing companies.

The accessibility of food stuff at the supermarkets and grocery stores requires equitable product formulation that is geared at offering the consumers healthier products, (Jetter and Cassady, 2006). Processers much of the times have to meet the demands of the consumers in ensuring compliance to acts that require human food to be safe. When doing this, consumers are sensitized on strategies that will lead them to consuming healthier products. It is at this point when some of the consumers will not inquire of the various products at the shelf by only preferring a certain product from a particular company without preferring it. This limits the accessibility of healthier products from certain companies lowering the efforts of certain companies which may lead to deterioration of products out of minimizing the cost incurred during productions.

In America, agricultural policies have tried to ensuring stability of crop prices, availability, affordability and consistent food supply. The state calls for researchers to hold studies that can mitigate unhealthy conditions brought by the above issues. Subsidized prices are offered by the state in encouraging citizens to consume healthier food options as an initiative of limiting poor nutrition. A study on effects of price incentives in regard to healthy food intake shows that 10% subsidy of fruits and vegetables increased vegetable and fruits intake from 1.26-1.33 cups per day (Galvez et al. 2007). The increase is an indicator that most individuals are closer to what is recommended.

Based on the above reviews, it is important to develop new strategies that would make American have an easy access to nutritious and healthy foods so as to reduce the rate of diet based diseases. First, there is need to increase the availability of fruits and vegetables in most of food supply chains. For instance, food supply chains should be encouraged to have a variety of raw fresh fruits instead of processed fruit juices which have preservatives and chemicals that are likely to accelerate prevalence of diseases. Food supply chains are to follow the guidelines of the dietary bodies so as to support consumption of fruits and vegetables. The processing industries need to be educated on ways of being creative and utilizing the available resources in developing healthier foods for citizens. For instance, food should be produced without adding calories, fats, soils and sugars but should be nutritious. All restaurants need to expand their capability in being actively involved at production of healthier foods with attention being placed on the quality of food and not on quantity. Improved policies and practices may be adopted in ensuring ready accessibility of nutritious food to citizens through programs that are demonstrative in encouraging consumers to stay healthier. For instance, the feeding programs for school going children needs to be monitored and revised so as to engage healthier food so as to eliminate calorific and energized foods. This can only be effective by imposing and laying down rules that school feeding programs needs to adhere to. In addition to assisting communities that are under their own authority into eating whatever they want, communities can be assisted by helping them eat healthier foods. Knowledge on potential steps that can be used to promote healthier eating can be given the citizens. Information can be made available to citizens via communication networks which are tools that recently been considered as advertisement tools that reaches a wide scope of individuals. In regard to this, all stakeholders need to work as a single unit in assessing the progress of shifting from unhealthier food to increased intake of healthier foods.

Researchers have often indicated that the geographic access to adequate food is one of the most important dimensions of food insecurity. Geographic distribution affects the cost of food among the socio-economic status classes of which the low-income consumers have limited variety of food to choose from. Researchers have tried to develop new techniques for characterizing the food environment as an effort to develop specific food security income. The central concepts of domestic food security have constantly been searching for a long term food security answer with no vain, (Rose, 2010). Every time in history comes with its own challenges of food security. The common variables that are used in food security studies include food availability, food access, food utilization and dietary health outcome.

Rose, (2010), indicates that the process of food insecurity must be defined. Active food policies must demonstrate their relationship with geographic food distribution as well as relationship with future food access and food security challenges. In broad terms, adequate food security has been defined in terms of consuming adequate nutritious food. The process of ensuring adequate and healthy food availability in the U.S. is continuous. However, even with enough resources and adequate policies, the challenges of food security remain persistent because of natural and inevitable environmental changes. Given that America is high developed, but there is food access and food security challenges, researchers should invest on innovating new food security strategies, (Rose, 2010). Often healthy food items do not exist because of lack of alternative, but because the modern populations are relying more on fast foods as compared to natural foods.

1. What is the link between food access and health outcome of American population.

2. What is the variation [?meaning? do you mean “relationship”?] between food access and food consumption among American population?

3. What is the classification of healthy and unhealthy foods?

1. There is no link between food access and health outcome of American population.

2. There is no variation between food access and food consumption among American population?

3. There is no classification of healthy and unhealthy foods.

IT SEEMS THAT YOU ARE WRITING A PROPOSAL.

Of THE 4 COMPETENCIES, WHICH 2 ARE YOU AIMING AT?

This chapter deals with the research design and methodology employed in the study. It also outlines the location of the study, target population, sample size and sample selection, sampling technique, data collection and analysis methods.

This study will be conducted in 48 States of the United States. The rationale for choosing the 48 States is that food security instruments cater for all Americans and not just a section of the American. Even though America tends to be divided into two parts: the Northerners and Southerners, with different socio-economic population statuses, food security resources and recommendations are distributed equally. The Northerners are considered being a population of a higher socio-economic class as compared to the Southerners and the researcher believes that food access and food security might be different in these two classes.

The study design for this research is a cross sectional survey that involve a onetime interaction with the target population of the study. The study will be quantitative in nature, which will utilize a structured questionnaire as the main data collection instrument. The purpose of the choice of a cross-sectional survey is that there will be a large target population for this study. Also, the information needed for this research will evaluate the current food access situation in the country.

This study will be carried out in 50 states of the U.S. and will target a sample population from high, middle and low socio-economic income. The study participants will comprise of adults who are informed about food security, food access and who have knowledge of healthy foods in the U.S. Sample units for this study are likely to be family homes in the select study locations. The sample size will be determined using a standardized formula for determining the sample size of cross sectional surveys. The target participants in the sampled units have equal chances of participating in the study. However, the sampling frame utilized for this study will determine the limit number of study participants who will provide data for survey.

The independent variables for this study will be availability of health foods, socio-economic status, food security resources, and food consumption status. The dependent variable will be indicators for food access among the U.S. population.

Two-stage sampling procedure will be used to identify and register the study population in the study location. The two-stage cluster sample will be obtaining by selecting cluster samples in the first stage and the selecting samples of elements from a sampled cluster. Simple random sample is used in the second stage. The two-stage sampling is quicker and more reliable and is therefore used to sampling in this study.

The sample size for the study population will be calculated using the Fisher's et al., (1999) formula. The margin of error to be allowed in the estimate is 5% which means a 95% confidence level, (Mugenda, 2008).

n= sample size for the study

p= percentage estimate picking a choice (50%) expressed in decimal (0.5)

z=statistical constant representing a 95% confidence interval which is 1.96

d= sampling error representing 5% expressed in decimal.

Inclusion criteria for participating in this study will be adults who have families. Adults with families are likely to understand the required health foods for their families and are likely to give information on their status of food assess.

Exclusion criteria for participating in this study will be those adults who do not have their own families and those who are likely to not understand the purpose of health maintaining healthy foods.

The study survey instruments that will be used to collect data for food access and health outcome based on the identified variables will be a structured questionnaire. This questionnaire will be self administered. The questionnaire is a quantitative data collection tool significant with social science surveys where researchers use descriptive statistics and concepts of hypothesis testing with the data collected using these instruments.

The range of expected values in the data collected using the questionnaire depends on the variables used. Since demographic variables are general and the value trends are known in the home science sector, they will provide a rough map of the expected qualitative variables that will be used to estimate the expected values in the present. Since the variables for the present study test seeks to identify various food access and health outcome for the American population among participants, a higher number of the healthy participants are likely to report that there are significant food access resources. This means that the general distribution graph will be skewed towards healthy participants who will be expected to give concrete data.

A structured self-administered questionnaire will be used to collect data for this study. Through stratified random sampling, the researcher through their assistants will identify the presumed eligible participants will be approached for face to interview before allowing them to fill in the self-administered questionnaire. At a select sample unit, researchers will approach identified study participants, introduce themselves and explain the basic study intentions. The study participants will be asked to provide their consent and will sign the consent form. The research assistants will guide the study participants on how to fill the questionnaire and request them to consider providing as much data as possible within their capacity. Section one of the questionnaire will be used to collect data on demographic information of the study participants. Section two and three will involve the variables for this study.

Quality control will be a continuous process throughout the study to maximize validity and reliability of the findings of the study.

Pre-testing for this questionnaire will be done in select non-study states. One state in the Northern and one state in the Southern parts of the U.S. The states that will be used for pre-test will be excluded from the main study. Pre-test activity is done to ensure clarity and for gaining preliminary insight into the questionnaire construct. Sample size for pre-testing will be 30% respondent of the target sample population for the study.

According to Mugenda (2008), validity is the degree to which an instrument measures what it purports to measure. The validity of the study will be ascertained by ensuring that the data collection instruments reflect the objectives of the study. The research will concentrate on content validity by performing a pre-test so as to adjust the research tool to meet the required standards. The questionnaire will be presented to the University for Validation by the supervisors and research panelists before data collection.

This is a measure of the degree to which a research instrument would yield the same results after repeated trials, (Mugenda, 2008). The reliability of the questionnaire will be established through a test and re-test technique whereby the instrument will be administered twice to the same group of subjects during the pilot study. There will be a time lapse between the first test and the second test. Cronbach's alpha coefficient will be used to test reliability of data collected. An alpha (α) score of 0.70 or higher will be considered satisfactory and ascertains reliability.

Descriptive and Analysis of Variance (ANOVA) statistics will be used for analyzing results for this study. Data of the scores from the measurable variables in the questionnaire will be coded into SPSS Version 12. The data will be tabulated and analyzed to generate graphs and charts that will be used to make inference on hypotheses presented.

Permission to conduct research will be sought from the relevant authorities. Respondents will give their consent to participate. The respondents will be informed that their participation is voluntary and will also be informed of their rights to accept or withdraw or refuse to participate in the study. The researcher will give full information about what the research entails and ensure participants are competent to give consent. Full consent and explanation will be contained in the questionnaire. The questionnaires will be administered with duly obtaining the consent of the participant. Participants’ privacy will be highly maintained by ensuring that they will not be exposed to public when filling questionnaires. The researcher will ensure the anonymity of respondents by concealing their identity and keep research data confidential for research purposes only. All concerns causing any sort of discomfort to respondents will be resolved immediately and mitigation strategies put in place.

Based on the cross-sectional nature of the study, foreseen limitations include limited target respondent. The investigator only assumes positive response for completing the comprehensive questionnaire with no influence to have the questionnaire completed in full. Missing responses are common in long and comprehensive questionnaires that affect the general data analysis. Furthermore, this is a field study. Field studies are associated with unpredictable challenges that will often compromise on scope of time to finish collecting data. Extended time will not only constrain the research study schedule but is also associated with increased miscellaneous cost.

In this study, the expected results include determining food access for the American population within the 48 study states of the U.S. The study will also determine the classification of food in the U.S. and the link between food access and health outcome of American population. The study will also determine the food access and food consumption among and the classification of healthy and unhealthy foods. The implications of the study will be inform and recommend to stakeholders on how they will change the food access and food insecurity challenges among the study population. The study will identify stakeholders and inform them on the strategies that are appropriate in changing the organization’s needs.

Abstract

The abstract contain information aiming at summarizing the project study. This section briefly presents an overview of all the sections of the research.

CHAPTER 1

This section contains the introduction to the topic as well as to the study. Americans are considered having limited food choices hence the phenomenon of food insecurity. This study will aim at documenting the link between food insecurity and health among the U.S. populations.

CHAPTER TWO

Systematic reviews

This section aims at evaluating literature and past researches about the topic. Recent literatures are evaluated to try and identify gaps existing about food access, food insecurity and health outcome among the American citizens.

CHAPTER THREE

METHODOLOGY

This chapter deals with the research design and methodology employed in the study. It also outlines the location of the study, target population, sample size and sample selection, sampling technique, data collection and analysis methods.

CHAPTER FOUR

WORK SCHEDULE

The project schedule information will be contained in this section. The project will run from April through November 2016. This section will also contain the expected results and implications of the study.

Chau, C., Jamie, Z. and Jennie, H. (2013). Availability of healthy food: Does block group

race and income matter? Journal of Hunger and Environmental Nutrition.8:22-38.

Chung, C., and Myers, J. (1999). Do the poor pay more for food? An analysis of grocery

store availability and food price disparities.Journalof Consumer Affairs 33:276-296.

Cummins, S and Sally, M. (2005). Food environments and obesity neighborhood or

nation?International Journal of Epidemiology. 35:100-104.

Galvez, M., Morland, K., Raines, C. (2007). Race and food store availability in an inner

city neighborhood. PublicHealth Nutrition 11: 624-631.

Inagami, S., Cohen, D., Finch K. B., and Asch, S. (2006). You are where you shop:

Grocery store locations, weight, and Neighborhoods.American Journalof Preventive Medicine.31(1): 10-17.

Jetter, K., and Cassady, D. (2006). The Availability and cost of healthier food

alternatives. AmericanJournal of Preventive Medicine 30:38-44.

Larson, N., Mary, S and Melissa, N. (2009). Neighborhood environments disparities in

access to healthy foods in the US. American Journal of Preventative Medicine36(1):74-81.

Morland, K. (2015).Local food environment food access in America.Boca Raton.

Michimi, A. and Michael W. (2010). Associations of supermarket accessibility with

obesity and fruit and vegetable consumption in the conterminous United States. International Journal of Health Geographic’s.9(1):49-63.

Mugenda, A. G. (2008). Social science research conception. Nairobi: Applied Research and Training Services.

Pearson, T., Jean, R., Michael C. and Margo B. (2005). Do food deserts' influence fruit

and vegetable consumption? A cross sectional study.Appetite.45:195-197.

Rose, D. (2010). Access to Healthy Food: A Key Focus for Research on Domestic Food Insecurity. The Journal of Nutrition. 140(6):1167-1169.

4