Research ArticleFood Shopping Perceptions, Behaviors, and Abilityto Purchase Healthful Food Items in the LowerMississippi DeltaBernestine B. McGee, PhD1; Glenda S. Johnson, PhD1; M. Kathleen Yadrick, PhD2;Valerie Richardson, MPA1; Pippa M. Simpson, PhD3; Jeffrey M. Gossett, MS4;Alma Thornton, PhD1; Crystal Johnson, BS1; Margaret L. Bogle, PhD5

1Human NRouge, LA2Departmeburg, MS3Arkansas C4Children’s5Delta NuAgriculturCorresponSouthern UE-mail: Be�2011 SOdoi:10.1016

Journal of

ABSTRACT

Objective: To examine the agreement between perceptions, behaviors, and ability to purchase healthfulfood in the Lower Mississippi Delta (LMD).Design: A regional food store survey of healthful food options in supermarkets, small/medium stores, andconvenience stores. Focus group discussions were conducted on shopping perceptions and behaviors.Setting: Counties in Arkansas, Louisiana, and Mississippi.Participants: Eighty-one LMD residents, 18-60þ years of age.Main Outcome Measure: Perceptions of healthful food and ability to acquire these food items acrossstore types.Analysis: Focus group data were analyzed using thematic coding. Summary food store statistics wereweighted, and estimates were constructed using SUDAAN 9. Data triangulation was achieved by compar-ing focus group findings with food availability data.Results: A majority (> 85%) of supermarkets had selected vegetables, breads, and cereals perceived ashealthful, whereas availability was limited in small to medium grocery stores and convenience stores.Skim milk, perceived as healthful, was limited in all store types.Conclusions and Implications: Limited availability and perceived costs of healthful food in the LMDinfluenced purchasing behaviors. Attitudes and perceptions should be incorporated into interventiondevelopment to improve food choices in conjunction with increasing the availability of healthful foodin the LMD.Key Words: shopping perceptions, food supply, rural, attitudes (J Nutr Educ Behav. 2011;43:339-348.)

INTRODUCTION

Following the healthful diet recom-mendations of the Dietary Guidelinesfor Americans could help lower theincidence or severity of chronicdiseases.1 The Dietary Guidelines forAmericans recommends consuminga healthful diet that emphasizes fruit,vegetables, whole grains, and fat-free

utrition and Food Program, South

nt of Nutrition and Food Systems, U

hildren’s Hospital Research InstitutResearch Institute, Medical Collegetrition Intervention Research Inial Research Service, SPA, Little Rocding Author: Bernestine B. McGee, Pniversity and A&M College, Batonrnestine_mcgee@subr.eduCIETY FOR NUTRITION EDUC/j.jneb.2010.10.007

Nutrition Education and Behav

or low-fat milk and milk products;that includes lean meats, poultry,fish, beans, eggs, and nuts; and thatis low in saturated fats, trans fats, cho-lesterol, salt (sodium), and addedsugars.1 Few Americans follow thedietary guidelines, and low-incomeindividuals are less likely to followthem.1-3 Several studies haveidentified barriers associated with

ern University and A&M College, Baton

niversity of Southern Mississippi, Hatties-

e, Little Rock, ARof Milwaukee, Milwaukee, WI

tiative, US Department of Agriculture,k, ARhD, Human Nutrition and Food Program,Rouge, LA 70813; Phone: (225) 771-4660;

ATION

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eating healthful food.4-6 Barriersidentified by low-income individualsthat prevented them from eatingmore healthful food include highprices and difficulty in accessinghealthful food.4-6

Environmental, social, and indi-vidual factors influence food intake,which in turn affects the risk ofmany chronic diseases. Influences onfood choices include knowledge ofthe relationship between diet andhealth; educational attainment andaffordability; and availability andaccessibility of food.7-11 Availabilityand affordability of healthful food inthe local food environment mayinfluence food choices. Foodrecommended by health authoritiesis sometimes more expensive andless available in poor areas. Emergingresearch has shown a link betweenthe local food environment andhealthful food choices.12-17 Difficultyin changing dietary behavior may

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340 McGee et al Journal of Nutrition Education and Behavior � Volume 43, Number 5, 2011

stem from characteristics of the localenvironment that either reducepeople’s motivation to adopta healthful diet or make changesdifficult or impossible to achieve.7

Nutrition-related attitudes and behav-iors can be influenced by cultural, psy-chosocial, and socioeconomicfactors.18 Social Cognitive Theory(SCT) has been used extensively toexplain beliefs and motivations ofindividuals for adopting preventivehealth behaviors.19-21 Social CognitiveTheory conceptualizes behavior interms of a 3-way dynamic and reci-procal interaction between personalfactors, environmental influences, andbehavior.

Approximately 5.3 million peoplein Arkansas, Louisiana, and Missis-sippi live in the Lower MississippiDelta (LMD) region.22 Similar to otherrural areas, adults living in theLMDaremore likely to experience higher ratesof chronic diseases, such as type 2 dia-betes, cancer, hypertension, and car-diovascular disorders.23-25 Mortalityrates from these diseases are muchhigher in the LMD states thannationally.26,27 High rates of foodinsecurity, poverty, unemployment,and lack of educational attainmentfurther complicate efforts to improvehealth in this high-risk, predomi-nantly minority population.26 Foodaccess is limited in rural areas, particu-larly in the LMD.26 Adults in theregion consume 20% fewer servingsof fruits and vegetables comparedwith national intakes and have higherintakes of fats and lower intakes of sev-eral micronutrients.28 Children in theLMD generally have lower intakes ofcalcium, iron, and vitamins A, C, ribo-flavin, and B-6 compared with chil-dren nationally.28 Low-incomeresidents have limited access to super-markets.29

Research conducted by the Consor-tium involved several components,Foods of Our Delta Study (FOODS2000),30 a focus group study (FGS),31

and a food store survey (FSS).29 Thisarticle reflects the analyses of a subsetof data from 2 components ofresearch, the FGS and the FSS, focus-ing on factors influencing nutrition-related health issues in the LMD. Theauthors’ purpose was to examine the2 data sets to compare food acquisi-tion perceptions of Delta residentswith actual availability of food within

the Delta Nutrition Intervention Re-search Initiative (NIRI) core food bas-ket. Examining the 2 data setstogether may provide insight relativeto dietary quality in the LMD as re-flected by Healthy Eating Indexscores,3 which can then informcommunity-based participatory re-search intervention efforts. This studyinvestigated whether LMD residents’perceptions and knowledge of health-ful food contradict the actual avail-ability of healthful food in this region.

The SCT served as the frameworkfor understanding the determinantsof a change in healthful food acquisi-tion. The reciprocal nature of thedeterminants of nutrition behaviorin SCT makes it possible for nutritionintervention efforts to be directed atpersonal, external, or behavioralfactors. Food choices are influencedby personal and environmentalfactors. In this study, linking thesefactors provides information for plan-ning sustainable nutrition interven-tions in the LMD.

METHODSDevelopment of DataCollection Instruments

The FGS collected information fromDelta residents on their perceptionsof the problems associated with theacquisition and consumption ofhealthful food, food security, groceryshopping, and factors that influencebehavioral changes in the consump-tion of healthful food.31 The FSSevaluated the availability of food in18 counties representing a larger36-county region of the LMD ofArkansas, Louisiana, and Missis-sippi.29 The 9 focus group countieswere included within the 18-countystudy area. The methodology for FGSand the FSS was determined by theDelta NIRI Consortium researchteam. The Delta NIRI is a multistate,multi-institution consortium whosemission is to improve the nutrition-related health of LMD residentsthrough community-based participa-tory research.26

Focus group study. Nine focus groupscentering on the topic of food acquisi-tion were conducted, 1 in each of 9counties in Arkansas, Louisiana, andMississippi, as part of a larger focus

group study on factors affecting con-sumption of healthful food.33 The 9counties were chosen randomly from18 counties selected as interventioncounties for the FOODS 2000 study.30

Focus groups were conducted be-tween July and September 2001 onvarying days of the week at localchurches, community centers, andthe Louisiana Cooperative ExtensionService offices.

A minimum of 8 to 10 people wererecruited for each session throughava-riety of means, which included word-of-mouth contacts by communityagency representatives and postingflyers in grocery stores, local busi-nesses, and churches. The investiga-tors used a participant applicationform to screen volunteers and collectdemographic data. Participants wererequired to be: 18 years of age or older,a resident of the selected community,and the primary person responsiblefor preparing meals and purchasingfood for the household. Participantswere served light refreshments andgiven a $50.00 gift certificate as an in-centive to offset any inconveniencethatmighthave resulted from involve-ment in the study. Participants signedan informed consent form before eachsession. Institutional ReviewBoard ap-proval was obtained from SouthernUniversity and A&M College, Pen-nington Biomedical Research Center,University of Southern Mississippi,Alcorn State University, University ofArkansas at Pine Bluff, and ArkansasChildren's Research Institute.

The research team designed discus-sion questions to identify the food ac-quisition perceptions of residents.Questions were informed by the con-structs and reciprocal interactions pos-ited in SCT and provided informationon factors supporting or interferingwith healthful food acquisition(Table 1). The research teamdeveloped12 open-ended questions, arrangedfrom general to specific.32 Universityfaculty and staff at 4 of the project in-stitutions reviewed the questions forcontent and clarity; modificationswere made based on their suggestions.Pilot focus group sessions wereconducted in the 3 states to pretestthe focus group questions and meth-odology. Only logistic adjustmentswere made in recruiting participantsas a result of pilot-testing. Focusgroups were conducted according to

Table 1. Healthful Food Acquisition Focus Group Discussion Questions

1. Tell us your name and where you live.2. Where do people shop for groceries in your community?3. How do people get to the grocery stores in your community? How far do

you travel to get to the grocery stores?4. Are there places in your community that you will not go to shop? Why?5. How often do you shop for: a) fruits and vegetables? b) other healthful

food?6. Think back to the last time you were shopping for food for your family.

What types of healthful food were in your shopping cart? What types offruits or vegetables were in your shopping cart?

7. What influenced your decision about purchasing healthful food includingfruits or vegetables?

8. As you make shopping decisions, what’s your opinion of fresh, frozen,and canned vegetables and fruits? Which do you prefer and why?What’s your opinion of healthful food? Which do you prefer and why?

9. If you could make changes in the grocery store where you shop, whatchanges would you make? Probe: variety, what do you mean? Lowerprices, how?

10. What are some ideas that might get people to purchase more healthfulfood including fruits and vegetables while at the grocery store? Whichof these would work for you? Probe: What do you mean? How wouldthis work?

11. We have talked about things that affect you purchasing healthful foodincluding fruits and vegetables. What would it take for you to eat morehealthful food including fruits or vegetables?

12. The goal of our discussion is to discover how to get people to eat morehealthful food including fruits and vegetables in order to stay healthy.Have we missed anything?

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standard procedures.32 The focusgroup team, consisting of a teamleader, moderator, and recorder, wastrained by a nationally recognized ex-pert in focus group methodology andevaluation.32 The team leader super-vised and assisted with the overallflow of the sessions, including settingup, greeting participants, helpingwith snacks, and distributing partici-pant incentives. The moderator ledthe discussion and was assisted by therecorder, who taped the discussionsand took field notes. During the ses-sions, participants were encouragedto speak until all views were expressedfollowed by additional probing andclarification. The same focus groupteam conducted all 9 sessions. Theduration of each focus group sessionwas 50-65 minutes. A quality controlmonitor attended all sessions andobserved the structure of each sessionrelative to delivery of questions bythe moderator and to taping and de-briefing procedures. The quality con-trol monitor was also available toaddress all field operation problems.

Using the transcripts, field notes,and moderator/recorder reports, thefocus group team reviewed the datafor the purpose of identifying recur-ring trends and patterns among thefocus group sessions.32 These datawere coded and sorted using the or-ganizing framework of the discussionguide. The focus group team, includ-ing members of the writing group,identified emerging themes froma list of most frequent responses by3 or more focus groups and catego-rized themes according to SCT con-structs. Each writing group memberreviewed the summary of emergingthemes as part of a process ofreaching consensus for thefinal summarization. Representativequotes were included with theemerging themes. A descriptive sum-mary of findings, which highlightedthe most frequent and dominant re-sponses, was then compiled. Finally,an independent consultant skilledin focus group analysis revieweddata, transcripts, field notes, andsummary reports prior to preparation

of the final report by the focus groupteam.

Food store survey. A regional surveywas conducted of food stores of 3types (supermarkets, small/mediumgrocery stores, and conveniencestores) to determine availability andquality of 102 food items. The DeltaNIRI FSS food basket was a representa-tive list of food items that, if chosen,would supply a healthful diet withculturally appropriate food choices.Survey sampling and data collectionmethodology have been described indetail elsewhere.29 Briefly, 225 stores(62 supermarket stores, 77 small/medium stores, and 86 conveniencestores), drawn from a sampling frameof 557 stores stratified by county andstore type, were surveyed to deter-mine availability of 102 discrete fooditems. Supermarket stores weredefined as large grocery stores withshopping carts and more than 1checkout station; availability of allfood sections to be surveyed on theFSS instrument; and extensive varietyin produce and frozen food. Small/medium stores were classified byexclusion from the convenience andsupermarket categories. They weresmaller than supermarkets, but largerthan convenience stores; had a limitednumber of the food sections to besurveyed with very limited variety,especially seasonal produce, and theywere often locally owned. Food storeswere surveyed by 2 pairs of trainedsurveyors. Food item lists were derivedfrom the Thrifty Food Plan foodlists,33 the Authorized Food Retailers’Characteristics and Access Survey,34

and food commonly consumed inthe LMD region as determined fromthe Delta NIRI FOODS validationstudy and development of the DeltaNIRI food frequency questionnaire.35

The Delta NIRI core food basket wasderived from the Delta NIRI FSS foodbasket and included 38 regionallyimportant items. The items weredivided into 5 broad food categorieswith subcategories based on the formof food. These categories were: (1)fruits and vegetables, subdivided byfresh, canned, and frozen; (2) breadsand grains; (3) meat, fish, and poultry;(4) dairy; and (5) baking products,fats, and sweets. Availability wasdefined as the presence in food stores

Table 2. Demographic Profile ofParticipants in the Healthful FoodAcquisition Groups (n¼ 81)

Healthful Food

342 McGee et al Journal of Nutrition Education and Behavior � Volume 43, Number 5, 2011

of food items making up each foodbasket. Each item was recorded asavailable or not available. For theDelta NIRI core food basket, availabil-ity was calculated as the percentage offood basket items available in a store.

Acquisition n (%)Age (y)18-44 36 (44)45þ 45 (56)SexMale 4 (5)Female 77 (95)RaceAfrican American 56 (69)Caucasian 22 (27)Hispanic 2 (2)Asian 1 (1)Educationa

< High school 6 (7)High school 35 (43)> High school 35 (43)StateArkansas 23 (28)Louisiana 32 (40)Mississippi 26 (32)

Note: Percentages may not total100 because of rounding.aFive individuals did not provideinformation on education level.

Data Analysis

The frequency counts of the emergingthemes were determined across focusgroups (counties). Food store surveydata were stored in a Microsoft Accessdatabase. SAS (version 9.1, SASInstitute, Inc., Cary, NC, 2002-2005)was used for FSS data management.A stratified sampling plan was used,with stores selected by store typewithin county. Five stores of eachtype were targeted from each county.Sample weights were constructed toaccount for differential probabilitiesof selection within county and storetype. All available stores were sampledin counties with 5 or fewer supermar-kets. A finite sample correction wasmade to account for large samplingfraction in some strata. All summarystatistics (eg, means, medians, 25thand 75th percentiles) were weighted,and estimates were constructed usingSUDAAN 9 (RTI International, Re-search Triangle Park, NC, 2009). Dotplots were constructed using Stata 10(Stata, College Station, TX, 2007).

RESULTS

A demographic profile of the food ac-quisition focus group participants issummarized in Table 2. Of the 81participants, 44% were 18-44 years ofage and 56% were over 45 years ofage. The majority were female (95%)and African American (69%); 43%had a high school education, and43% had more than a high schooleducation.

The food acquisition perceptionsof focus group participants are sum-marized in Table 3. Environmentaland personal factors may motivate orinterfere with food acquisition behav-ior change.

Perceptions of FoodAccessibility

Participants reported purchasing foodfrom a large retailer as well as fromsmall/medium grocery stores. Al-

though most participants reportedtraveling 8-15 miles to the nearestacceptable retail outlet, some traveledapproximately 60 miles. Use of per-sonal cars for shopping was reportedmost often, but arranging to sharea ride was also frequently reported.Most participants reported shoppingfor fruits and vegetables 2 times perweek.

Participants seemed to prefer freshfruits and vegetables over other forms.Many obtained fresh vegetables fromhome gardens rather than purchasingthem from the grocery store. Con-cerns were raised as to the qualityand availability of fresh fruits and veg-etables in local markets. Participantquotes: ‘‘I just love fresh fruits andvegetables’’; ‘‘My father has a garden’’;‘‘I have neighbors with gardens’’; ‘‘Iraise my own garden’’; ‘‘They shouldsell better products. Fresher’’; ‘‘Betterfresh fruits and vegetables-betterquality.’’

Desired changes in the shoppingoutlet indicated by participants werelower prices, better variety, betterquality, and more fresh food items.

Healthful Food Perceptions

Participants were asked, ‘‘What is youropinion of healthful food?’’ Partici-pants stated eating 3 meals a day;eating a balanced diet from the foodgroups; eating fruits and vegetables;eating food items that are low insugar, fat free, low in fat, or low calo-rie; consuming chicken, turkey, orskinless chicken; and using cookingmethods such as baking, broiling,and grilling. Personal and familyhealth motivated participants to pur-chase healthful food. Participantquotes: ‘‘For my health, I like vegeta-bles for my health’’; ‘‘My husband’sstroke was a wake-up call.’’

Although personal preferencesinfluenced food purchases, the major-ity of participants were influenced byfamily members. Participant quotes:‘‘Taste for me, I buy vegetables be-cause I like them’’; ‘‘My husband isa vegetable eater . . . so I buy andprepare vegetables that I wouldn’tordinarily’’; ‘‘My children. My boys,because my boys like to eat.’’

Participants associated healthfuleating with higher food prices andstated that healthful food was not af-fordable. Participants reported thatlower prices, risks/benefits of health-ful versus unhealthful food choices,and food preparation would motivatethem to purchase more healthfulfood. Participant quotes: ‘‘The bottomline is price. If you can’t afford it,you’re not going to buy it’’; ‘‘Healthyfood is very expensive, so it goesback with bringing the prices down’’;‘‘Money makes it hard, because whenyou go to the grocery store, pricesshoot up on all the fruits and vegeta-bles’’; ‘‘What I’m saying is I’m ona budget and I have to get what I canget to make it last as long as it can.That means I can’t really get what Ishould and ought to have. I buy likechicken, flour, and meal, somethinglike that. And I can’t get the fruitsthat I should have.’’

Healthful Food PurchasingMotivators

Education on the risks of unhealthfuleating and benefits of healthful foodchoices and food preparation wouldmotivate participants to purchasemore healthful food. Most suggested

Table 3. Food Acquisition Perceptions and Behaviors of Focus Group Participants

Question/ResponseNumber of Groups

Making Responses (n)Social CognitiveTheory Construct

Where do people shop for groceries in your community?

Large grocery retailer 9Small/medium grocery store 9

How do people get to the grocery stores in your community?

Personal vehicles 9Friend/family 6Pay someone to transport 6

How far do you travel to get to the grocery stores?

Average distance 8-15 miles 6Are there places in your community that you will not go to shop? Why?Stores with high prices 7

What influenced your decision about purchasing healthful food includingfruits or vegetables?Personal and family health 7 Personal

As you make shopping decisions, what’s your opinion of fresh, frozen,and canned vegetables and fruits? Which do you prefer and why?What’s your opinion of healthful food? Which do you prefer and why?

Prefer fresh 7 PersonalAcquire vegetables from home garden 7 Environmental

If you could make changes in the grocery store where you shop, whatchanges would you make? Probe: variety, what do you mean? Lower

prices, how?Lower prices 9 EnvironmentalBetter variety 8 EnvironmentalBetter quality 8 EnvironmentalFresh food items 8 Environmental

What are some ideas that might get people to purchase more healthful

food including fruits and vegetables while at the grocery store?Lower prices 6 EnvironmentalCooking demonstrations 6 Personal

(knowledge/skills)Education on the risk of unhealthful eating and benefits of healthful eating 9 Personal

(knowledge/skills)We have talked about things that affect you purchasing healthful food

including fruits and vegetables? What would it take for you to eat morehealthful food including fruits or vegetables?Teach new ways to prepare meals 9 Personal

(knowledge/skills)Providing healthful recipes and cookbooks 6 Environmental

Journal of Nutrition Education and Behavior � Volume 43, Number 5, 2011 McGee et al 343

that teaching food preparation skillsand providing healthful recipes andcookbooks would provide motivationfor consumption of more healthfulfood. Participant quotes: ‘‘You reallyhave to be taught to eat it’’; ‘‘Cook it an-other way’’; ‘‘My biggest problem is fig-uringoutwhat tofix for ameal’’; ‘‘Iwantsomebody to showme how to do it.’’

Healthful Food Purchased

When asked about the types ofhealthful food and fruits and vege-

tables purchased, chicken, beef,pork, fish, whole-wheat bread, ce-real, milk, and Jello were named,in addition to several fruits andvegetables (Table 4). Jello was per-ceived as a healthful food item incomparison to desserts such ascakes and pastries. This observationwould suggest a substitution ofJello for cakes and pastries as des-sert as a tradeoff, thus contributingto the perception that Jello is lowerin sugar and calories and morehealthful.

Food Availability by Store Type

Data on availability of the core foodbasket items (38 items) by store typeare illustrated in Figure 1. Small/me-dium stores had fewer of these itemsavailable than supermarkets, andmore items than convenience stores.Most items in the core food basketwere found in more than 94% ofLMD supermarkets. On average, 25%of the stores had less than 95% (36items) of the 38 items. Over 50% ofthe supermarkets stocked 100% of

Table 4. Healthful Food Acquisition Practices of Focus Group Participants

Food Group ItemGroup

Frequency (n)Fruit Banana 5

Peach 4Watermelon 4Grapes 4

Vegetables Carrots 5Greens 5Potatoes 5Broccoli 4Cabbage 4Field/dried peas 4Tomatoes 4

Meat, Fish, Poultry Chicken 7Pork 6Ground meat, beef 4

Dairy Milk 6Breads and Grains Whole-wheat bread 4

Cereal 4High-fiber cereals 3

Baking products, fats, and sweets Gelatin dessert 4

344 McGee et al Journal of Nutrition Education and Behavior � Volume 43, Number 5, 2011

the items. Approximately 48% of thecore items, including some meatsand most fresh produce, were stockedby fewer than 50% of the small/me-dium stores (Table 5). Only 32% ofthe food basket was available inconvenience stores; these items werelimited primarily to nonperishableitems such as stick margarine, cannedtuna, canned peaches, fresh andcanned green beans, whole milk,eggs, dry spaghetti, rice, corn flakes,oatmeal, crackers, bread, enrichedflour, and sugar.

Food items perceived as healthfuland their availability by store typeare presented in Figure 2. Vegetablesincluded green beans, broccoli,greens, potatoes, and canned vegeta-bles. Although 81%-93% of supermar-kets had these vegetables, the fooditems were available in less than 20%of small/medium stores except forcanned vegetables and in less than4% of convenience stores. Bread wasalso perceived as healthful, however,whole-wheat bread was available infewer than 85%, 23%, and 6% ofsupermarkets, small/medium stores,and convenience stores, respectively.Cereal and high-fiber cereals andoatmeal were perceived as healthfuland were available in 97%-100% ofsupermarkets, 39%-75% of small/medium stores, and 18%-36% of con-venience stores.

Whole milk, another food itembelieved to be healthful, was availablein over 85% of supermarkets, small/medium, and convenience stores.Low-fat milk was available in 93%-100% of supermarkets and fewerthan 50% of small/medium and con-venience stores, and there was limitedavailability of skim milk.

DISCUSSION

This study extends the understandingof the challenges to nutritional healthfaced by LMD residents. This study isone of the first to link qualitativedata on food acquisition perceptionsand behaviors with quantitative dataon food availability in the region.Increasingly, researchers are turningto mixed-method techniques to pro-vide expanded analysis and greaterdetail, providing new insight and con-firming findings from each other.36,37

Barriers to Purchasing HealthfulFood

Focus group discussion with LMD res-idents identified factors that supportor interfere with healthful food pur-chasing. The FGS findings supportthe theoretical tenets of the SCT.Additionally, knowledge gained fromthe FGS provides an understanding

of the complex personal and externaldeterminants of behavior change.The study demonstrated that health-ful food acquisition is influencedby individual and environmentalfactors.

Environmental factors. For some in-dividuals, the local food environmentis associated with meeting dietary rec-ommendations.38 Because populationdensities are low and stores are widelyscattered in rural areas, distance tomarket is a significant barrier for low-income, elderly, and rural residents.Residents of the LMD have difficultyaccessing fresh, nutritious food.Transportation was problematic forparticipants. Studies have shownthat lack of transportation in ruralareas is a barrier to food access andpotentially to a healthful diet.39,40

Personal factors. Personal factorsemerging from data analysis includedindividualor familyhealth,preferences,and lack of food preparation skills.Health status, either for themselves orfamilymembers,wasastrongmotivatorfor purchasing healthful food. Consis-tent with other research, the findingsdemonstrated that the presence of cer-tain health conditions influenced pur-chasing decisions, and the influence ofpersonal and family preferences,including taste of food, influenced pur-chasing decisions.41,42 Consequently,focus group participants purchasedfood based on family preferences andexpressed a preference for fresh fruitsand vegetables.

Meaning of healthful eating. Partici-pants had some knowledge of themeaning of healthful eating. Thisfinding is consistent with otherresearch identifying perceptions ofa healthful diet.43 However, knowl-edge of healthful eating may nottranslate to healthful food acquisitionor eating behavior. Similarly, partici-pants had some misconceptionsabout healthful food. This findingmay explain the listing of Jello asa healthful food. Although Jello pro-vides little nutritional value, it canbe a sweet treat to replace desserts forsome individuals. Data from NationalHealth and Nutrition ExaminationSurvey (NHANES) III and NHANES1999-200044 and FOODS 200045

Figure 1. Availability of Delta Nutrition Intervention Research Initiative core food basketitems by food store type. Note: Foods are ranked by overall availability. Numbers em-bedded in labels refer to type of product: [1] fresh, [2] frozen, [3] canned, and [4] dried.

Table 5. Percentile Estimates of Delta NIRI Food Basket Items (38 items)Available by Store Type

Store Type 25th Percentile 50th Percentile (median) 75th PercentileSupermarket 95.3% (36.2 items) 100% (38 items) 100% (38 items)Small/medium 35.3% (13.4 items) 47.6% (18.1 items) 62.6% (23.8 items)Convenience 15.3% (5.8 items) 21.8% (8.3 items) 32.4% (12.3 items)

Journal of Nutrition Education and Behavior � Volume 43, Number 5, 2011 McGee et al 345

indicated that fats and sweets aremore available than fruits and vegeta-bles in the LMD. An assessment of di-etary quality in the LMD based onHealthy Eating Index scores indicateda lower overall diet quality, particu-larly concerning grains, vegetables,fruit, dairy products, meats, and die-tary variety.3 Inadequate food and nu-trient intake of Delta residents wasmore pronounced in African Ameri-cans than Caucasians, in adults thanin children, and in lower-incomehouseholds.28 This is a concern be-cause of the chronic disease burdenin this LMD population.24 Residentsof the LMD perceived knowledge of‘‘healthful eating’’ contradicts theLMD’s high incidence of nutrition-related chronic diseases.

Determinants of FoodAcquisition Behaviors

Healthful eating behaviors may beinfluenced by biological determinants(hunger, appetite, taste); economicdeterminants (cost, income, availabil-ity); physical determinants (access,education, skills, time); social deter-minants (culture, family, peers, meal

patterns); psychological determinants(mood, stress, guilt); and attitudes,beliefs, and knowledge about food.46

Although individuals may have someknowledge of healthful food, unlessthere are sources of affordable, accessi-ble healthful food it will be difficult toacquire those healthful food items toeither initiate or maintain healthfuleating. The research findings demon-strated that food availability, variety,quality, and affordability influencedpurchasing behaviors. These barriershave an impact on the LMD residents’ability to achieve a healthful diet. Aprevious study on fruit and vegetableaccess in low-income communitieshas also reported participants’ con-cerns that healthful food choiceswere not affordable within their com-munities.39 The absence of qualityand affordability of food for low-income residents prevents or dimin-ishes their ability to choose food itemsthat help maintain a healthful life-style.39,47 Persons with low incomesand members of ethnic minoritygroups spend less money on foodthan their counterparts do, buta higher proportion of their incomeis spent on food.38,41,48

Reconciling Food PurchasingPerceptions and FoodAvailability

Previous research has demonstratedthat environmental factors, such asaccess and affordability, are onlya small part of the problem surround-ing low fruit and vegetable consump-tion, and greater recognition shouldbe given to how the importance ofmotivation to eat fruit and vegetablesinfluences consumption.49 Limitedtime for food shopping, cooking, andfamily activities and transportationchallenges are factors that must becaptured in measures of physical andeconomic access and availability offood.50

Figure 2. Foods perceived as healthy and their availability by store type. Note: Num-bers embedded in labels refer to type of product: [1] fresh, [2] frozen, [3] canned, and[4] dried.

346 McGee et al Journal of Nutrition Education and Behavior � Volume 43, Number 5, 2011

Limited availability and perceivedcosts of healthful food in the LMDinfluenced purchasing behaviors andability to achieve a healthful diet. Asa result, LMD residents are limited bythe cost of food and availability andaccess to supermarkets. Food choicespeople make are influenced by foodavailability. Participants indicatedthat convincing families to eat health-ful food can be achieved by changingpersonal and family behaviors relatedto meal planning, food purchasing,and food preparation. The averagenumber of daily servings of greenvegetables and breads and grains con-sumed by LMD residents was 0.14 �0.02 and 5.9 � 0.09, respectively.27

Low consumption of these food itemshighlights the importance of chang-ing behaviors and food environment.

Limitations of the Research

The focus group sample was not ran-domly selected and only 1 group wasconducted in each county, limitinggeneralizeability. However, the sam-ple design included participants from9 counties representing the predomi-nant ethnic groups in the LMD regionand a range of ages and educationlevels. A limitation of focus group re-search was the somewhat subjectivenature of qualitative data analysis.

However, an independent consultantskilled in focus group analysis re-viewed data, transcripts, field notes,and summary reports prior to prepara-tion of the final report by the focusgroup team. A trained facilitator lim-ited focus group-related interactiveproblems such as 1 participant domi-nating others, normative discoursetendencies, within-group conflicts,and arguments. Another limitationcommon to focus group methodologywas that discussion responses reflectthe perceptions and opinions of theparticipants and that the responsesof participants may have biased theresponses of other participants. How-ever, data analysis bias may havebeen minimized because participantsresponded to open-ended questions,which allowed the participants togive detailed reactions to questions.Further, the sampling frame for theFSS included the 9 counties in whichfocus groups were conducted.

CONCLUSIONS

TheLMDhas reported challengeswhenit comes to availability, accessibility,and adequacy of health servicesand healthful food.23-29 This articleexamined agreement betweenperceptions, behaviors, and ability topurchase healthful food in the LMD.

The findings show that changesin healthful food access andconsumption will happen onlythrough understanding and addressingthe experiences, knowledge, and needsof the residents. Knowledge alone doesnot result in healthful eating behavior.Personal, external, and behavioralfactors may affect the ability to makedietary changes. Sources of affordableand accessible food are needed toinitiate and make healthful foodchoices. Physical access to food, as wellas affordability, time to prepare food,and cultural traditions are importantin determining whether people willpurchase and consume more healthfulfood. Thus, greater attention must befocused on developing interventionsthat include strategies to increaseknowledge of nutritious food, assistlow-income adults in making healthfulfood acquisitions, and promote envi-ronmental and public policies toimprove availability and accessibilityof healthful food.

IMPLICATIONS FORRESEARCH ANDPRACTICE

Development of nutrition interven-tions targeting food purchases is oflimited value without changing avail-ability within local stores in the LMD.Attitudes and perceptions of LMD res-idents should be incorporated intointervention development to improvefood choices in conjunction with in-creasing the availability of healthfulfood in the LMD. Greater understand-ing and incorporation of attitudes andperceptions of LMD residents are crit-ical for effectively increasing availabil-ity of healthful food. Availability andaccess to supermarkets that offer a va-riety of food at lower cost suggest thatchanges in the food environment arenecessary to achieve a healthful,affordable diet. United States policiesand programs aimed at improvingaccess, availability, and diet qualityshould consider the social context offood preparation and purchasing andthe residential environment.

Research is needed to obtaina broader understanding of foodaccess issues in the LMD, includingstudies that identify the barriers andfacilitators to healthful food choices.Research is needed to access the

Journal of Nutrition Education and Behavior � Volume 43, Number 5, 2011 McGee et al 347

cultural appropriateness of emergingand nontraditional approaches to im-proving availability and accessibilityto lower-cost, nutritious food. Forexample, little research is availableon the viability of communal gardensfor this population. What types offood should be available at farmers’markets that would increase the likeli-hood of increased use by the targetpopulation? Little is known aboutthe extent of influence of cultureand class on acceptability and foodchoices among this population.Although it is known that there areregional differences in food habits,what are the common factors acrossall cultures that should be examinedto develop a universal model promot-ing achievement of a healthful andnutritious diet? Supermarkets or otherfood sources that offer a variety offood at lower cost appear to be essen-tial to achieve a healthful and afford-able diet. The need for nutritionintervention is indicated for adults inthe LMD. A multimodal, longitudinalapproach is needed to address themany challenges that thwart health-ful food choices. Most importantly,this approach must be taken in part-nership with the community andinvolving a broad diversity of people.

ACKNOWLEDGMENTS

This research was funded by theAgricultural Research Service, UnitedStates Department of Agriculture,Project No. 6251-53000-002-00D.

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