Julie_Nguyen_Thesis.docx

49 

Full text

(1)

Julie Nguyen Senior Honors Thesis

Department of Health Policy and Management Gillings School of Global Public Health University of North Carolina at Chapel Hill

May 1, 2020

Approved:

(2)

Table of Contents

Abstract...4

Introduction...5

Good Bowls...6

Research Questions...7

Literature review...8

Chronic Disease and Nutrition...8

Food Insecurity...9

Rural Health and Food Deserts...11

Racial Historical Context of the Rural South...12

Current Approaches and Solutions...13

Methods...17

Corner Store Intercept Survey...17

Measures...17

Sample...18

Procedure...18

Data Analysis...19

Ethical Considerations...19

Good Bowls Taste Test Survey...20

Measures...20

Sample...20

(3)

Data Analysis...21

Results...21

Corner Store Intercept Survey Results...21

Demographic Information...21

Access to Healthy Foods...22

Barriers to Maintaining Healthy Diets...23

Food Shopping and Consumption Habits...24

Acceptability of Good Bowls...26

Good Bowls Taste Test Survey Results...26

Discussion...28

Limitations...30

Conclusion...31

Acknowledgements...32

Funding Sources...33

Works Cited...34

Appendix...45

Appendix A – Corner Store Intercept Survey...45

(4)

Abstract

Background: To sustainably resolve health disparities in low-income communities by

addressing food insecurity and promoting economic opportunities, Good Bowls, LLC has developed frozen meals produced through partnerships with small businesses. Good Bowls are sold using a cost-offset model in which products are sold at a higher price at higher-end stores and at a lower price at corner stores. We assessed the early acceptability of Good Bowls among corner store customers in a rural North Carolina county to tailor Good Bowls’ entry into this market and ensure that Good Bowls can achieve its intervention goals.

Methods: A cross-sectional study design was used. Two surveys were administered at four

corner stores a rural North Carolina county: 1) a corner store intercept survey designed to learn more about the perceived availability of healthy food, the barriers that customers experience when maintaining healthy diets, the food shopping and consumption patterns of customers, and the acceptability of Good Bowls; and 2) a taste test survey designed to test the reception of Good Bowls flavors.

Findings: We found that a substantial proportion of survey respondents faced significant barriers

(5)

Conclusions: The findings confirmed the existence of barriers to obtaining healthy foods that

Good Bowls seeks to address, the validity of corner stores as a point of intervention, and the positive reception of Good Bowls among corner store customers.

Introduction

Proper nutrition is central to the prevention and management of numerous diseases, particularly chronic diseases [1] [2] [3]. However, healthy foods can be expensive and

inaccessible, particularly for individuals of lower socioeconomic status [4]. Poor diet, poverty, unemployment, ethnic minority status, rural residence, and food insecurity have been found to be strong predictors of poor health [5]. These social determinants of health are often inextricably linked and can have a cyclical relationship in which one factor leads to the other. For example, food insecurity may result in poor diet, which can lead to poor health. Poor health can make it difficult to find and keep a job, which can in turn make it difficult to access healthy food [6] [7]. Similarly, inadequate housing and lack of transportation can make it difficult to purchase and prepare healthy food.

(6)

[12]. Not only are poverty and lower socioeconomic status contributors to chronic disease, but the reverse is also true: chronic disease can cause or reinforce poverty and lower socioeconomic status [5] [6] [13]. Addressing food insecurity and developing economic opportunities are necessary to resolving health disparities in rural low-income communities [14] [15].

Increasing access to healthy foods is a promising strategy to combat these health disparities [16] [17]. Corner stores are a significant source of ready-to-eat meals and limited groceries for those living in rural communities, and programs to address food insecurity in rural areas can involve stocking fresh foods in corner stores [14] [16] [18]. However, fresh produce and meats have a short shelf-life, making them expensive for corner stores to keep in stock and an unsustainable model for rural communities [19].

Good Bowls

(7)

to small Value-Added Processing Facilities (VAPFs) that will produce Good Bowls and sell them to both higher- and lower-cost food retailers.

Good Bowls can help reduce food waste and promotes economic opportunities for local farmers by using grade B produce when possible, and traditional, lower-cost southern vegetables in its products. Good Bowls recipes, which were developed to promote a healthy, evidence-based dietary pattern, combine the Mediterranean diet with Southern tastes and ingredients, such as sweet potatoes, collard greens, and peppers, to provide healthy meals with a Southern twist, also known as the Med-South diet [20] [21]. These Good Bowls recipes were well-received in a small pilot study of both high- and low-income consumers.

While there is a documented need for healthy, affordable food in lower income, rural areas, a better understanding of the acceptability of Good Bowls and impact on food insecurity and nutrition among low income communities is needed to tailor Good Bowls’ entry into these markets so that Good Bowls can achieve its goals to sustainably address food insecurity and provide economic opportunities in rural areas [22] [23].

Research Questions

The overall goal of this study is to assess the early stage acceptability and potential impact of Good Bowls on food insecurity and nutrition among corner store customers. This study seeks to answer the following:

(8)

 Research Question 2 – What barriers do corner store customers experience with regards to maintaining healthy diets?

 Research Question 3 – What are the food shopping and consumption habits of corner store customers?

 Research Question 4 – What is the early acceptability of Good Bowls as a healthy meal option among corner store customers?

Literature review

Chronic Disease and Nutrition

Chronic conditions, defined as “a physical or mental health condition that lasts more than one year and causes functional restrictions or requires ongoing monitoring or treatment,” are among the most prevalent and expensive health conditions in the United States [24].

Approximately 45 percent of Americans (133 million people) have at least one chronic disease, which includes cancer, diabetes, hypertension, stroke, heart disease, respiratory diseases, and obesity [24]. The Centers for Disease Control and Prevention estimates that 90 percent of the United States’ $3.5 trillion annual healthcare expenditures are for the treatment of chronic and mental health conditions [25]. Not only do these diseases carry healthcare-specific monetary costs, such as hospitalization, doctor appointments, specialist care, and medication, they can also cause long-term disability, reduced productivity, lost earnings, reduced quality of life, and death [24].

(9)

American Heart Association (AHA) currently recommends a dietary pattern that emphasizes fruits, vegetables, and whole grains while limiting saturated fat, trans fat, and sodium to prevent and manage cardiovascular disease [27]. Moderate to significant changes in diet, including the AHA’s recommended decreased calorie intake, lower sodium consumption, and decreased saturated fat consumption, can improve health outcomes and reduce national healthcare expenditures by an estimated $60 billion to $120 billion [28].

The Mediterranean diet is an extensively-studied, evidence-based dietary pattern that incorporates the AHA’s recommendations and promotes consumption of fish, monounsaturated fats from olive oil, fruits, vegetables, whole grains, legumes, and nuts [29]. Research indicates that the Mediterranean diet can reduce the severity and prevent the development of a number of chronic conditions, including cardiovascular disease, breast cancer, diabetes, obesity, and cognitive decline [30] [31]. The Mediterranean diet has also been shown to improve primary cardiovascular disease outcomes, such as death and cardiac events, and surrogates of

cardiovascular disease, such as lipid levels and markers of inflammation [29]. This dietary pattern has been studied through both observational and randomized controlled trial study settings, and the cardioprotective effect of the Mediterranean diet makes it a promising method to prevent and treat chronic disease [29] [30] [31] [32]. In the context of rising chronic disease burden and associated expenditures, evidence-based dietary patterns like the Mediterranean diet are an important prevention tool to combat chronic disease and its costs [25] [31] [33] [34].

Food Insecurity

Despite the empirical evidence demonstrating the importance of proper nutrition in disease prevention and treatment, numerous at-risk patients do not receive adequate or

(10)

defined by the United States Department of Agriculture (USDA) as “the limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways” [35]. As defined by the literature, “nutritionally adequate and safe foods” include a sufficient quantity, quality, and diversity of available foods [36]. Lack of these foods and limited ability to obtain food in a socially accepted manner can lead to negative physical and mental health outcomes, including feelings of deprivation and anxiety. According to data collected by the USDA in collaboration with the Census Bureau, an estimated 50 million people in the United States are food insecure [37]. Food insecurity is considered a social determinant of health, influenced by numerous interconnected factors, including household income, ethnic minority status, neighborhood, and rural residence status [7] [36] [38] [39] [40]. The conceptual framework of food insecurity and health developed by Weiser et al. spans three levels of determinants (community, household, and individual) and explains the relationship between food insecurity and health through nutritional, mental health, and behavioral pathways (Figure 1) [36]. As demonstrated by the conceptual framework of Weiser et al., food insecurity is part of a vicious cycle that involves nutritional, mental health, and behavioral factors, poor clinical outcomes, and increased morbidity and mortality (Figure 1) [36].

(11)

burden” of malnutrition and obesity [22] [40] [42] [43]. Given food insecurity’s relationship to numerous other health-related factors, addressing this critical social determinant of health is necessary to improve health disparities and health outcomes [7] [38].

Figure 1: Conceptual framework of food insecurity and health developed by Weiser et al. [36]

Rural Health and Food Deserts

(12)

nonmetropolitan areas and metropolitan areas [8]. Rural residence is consistently linked with higher risk of morbidity and mortality compared to urban residence [8] [10] [12]. The health disparities between urban and rural areas are influenced by numerous factors, including

differences in modifiable risk factors, such as smoking, opioid use, obesity, and inactivity, which are more prevalent among rural residents [8] [44]. Additionally, socioeconomic factors,

including health insurance status, employment status, and education attainment, are strongly related to these health disparities and vary greatly between rural and urban areas, with rural areas reporting fewer economic resources [8]. Rural areas are more likely to have a higher prevalence of food insecurity and decreased availability of affordable, healthy foods [45].

In addition to rural residence, living in an area with decreased access to a variety of healthy and affordable food, or a food desert, can be a predictor of food insecurity [46]. In 2008, Congress tasked the USDA with documenting the location and extent of food deserts in the United States with the signing of the Food, Conservation and Energy Act (commonly known as the “2008 Farm Act”) [47]. Using census data and the location of supermarkets and large grocery stores as a proxy for “healthy-food retailers,” the USDA assigned low access characterizations to areas of “500 people and/or 33 percent of the tract population residing more than 1 mile from a supermarket or large grocery in urban areas, and more than 10 miles in rural areas” [47]. According to the USDA’s findings, areas identified as food deserts also commonly included “large proportions of households with low incomes, inadequate access to transportation, and a limited number of food retailers providing fresh produce and healthy groceries for affordable price,” further demonstrating the interwoven relationships between health and negative social determinants of health, including socioeconomic status, rural residence, and lack of

(13)

Racial Historical Context of the Rural South

Demographic factors have also been shown to influence health, and individuals of

minority ethnic status report experiencing more negative social determinants of health and poorer health outcomes [48]. An exploratory study found that African American individuals living in the rural South have a higher prevalence of negative social determinants of health at each of the five levels of the socio-ecologic model [11]. At the individual level, members of these

communities are less likely to be engaged in personal health and health promotion activities. At the relational level, lack of social capital was identified as an important negative social

determinant of health. At the environmental level, deficiencies in the built environment, including decreased access to healthy foods and lack of safe areas for physical activity, were found to be prominent social determinants of health. At the structural level, lack of economic opportunity, cronyism, nepotism, and lack of support from the education system were identified as impediments to improved health. Finally, at the superstructural level, poverty and racism were recurring barriers to health, influencing multiple other social determinants of health [11].

Stemming from a long history of disenfranchisement and mistreatment, disparities in education, economic opportunity, and health among African American communities persist to this day [49].

(14)

South, food production-based programs are a potential method to generate economic opportunities for these farmers and promote health [52].

Current Approaches and Solutions

Recognizing the interconnectedness of health, nutrition, food insecurity, and economic opportunity, multiple approaches exist to address food insecurity and improve overall

community health. These approaches range from government-sponsored assistance to hunger relief initiatives led by not-for-profit organizations to private social ventures [53].

Government-sponsored assistance programs, including the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), are designed to provide benefits that supplement the food budget of eligible low-income individuals and families. SNAP and WIC income-eligible are more likely to be food insecure largely due to their low-income status [54]. Some research suggests that SNAP

(15)

In addition to government nutrition assistance programs, food banks and food pantries operated by charitable organizations are an important part of the food safety net that addresses food insecurity. Despite the nearly ubiquitous presence of food banks in communities across the United States, some research suggests that food banks fail to improve food security and meet the nutritional needs of their clients [60]. Research indicates that food banks and food pantries often have a limited variety and quantity of perishable food, and the food provided is often of lower nutritional content [60]. Although food banks play an important role in reducing the severity of food insecurity and providing emergency food aid, capacity building is required to increase the impact of food banks on food insecurity [60].

Grocery store-based interventions offer another approach to addressing food insecurity and increasing food access. Research and interventions have focused on food deserts, or underserved communities that have limited food access and fewer food retailers that stock affordable, healthy food [61]. Interventions designed to increase geographic access to food include increasing the amount and variety of fresh fruits and vegetables in existing stores and opening grocery stores in food deserts. Both of these interventions have mixed results [61].

Initiatives to increase the amount and variety of fresh fruits and vegetables in existing stores in food deserts have resulted in increased consumption of fruits and vegetables by

community members [14] [61] [62]. Despite the potential success in increasing food access, cost remains a barrier to converting corner store inventories [19]. Both corner store operators and customers have identified the high price of fresh fruits and vegetables as a barrier to this

(16)

and appliances needed to prepare meals using fresh produce, resulting in continued access issues to healthy food.

In addition to improving corner store inventories, another approach to increasing food access is opening larger grocery stores in food deserts [61]. Despite studies reporting that individuals living in food deserts would be willing to buy food at supermarkets and larger grocery stores, research indicates that opening grocery stores in food deserts does not result in increased overall access and consumption of healthy food [61] [63]. While this intervention may make healthy food geographically accessible, healthy foods remain financially inaccessible to some community members. Cost and limited financial resources are barriers to the success of these interventions, despite increasing geographic access. This suggests that food access interventions must include an economic strategy to make food financially accessible [61].

(17)

difficult for members, which can prompt members to cancel their CSA membership [65]. Although research suggests that these community food programs may successfully address financial and geographic food access issues, continued research is required [61]. Additionally, community food programs often encounter an issue of reach – many of these programs only have the capacity to serve a finite number of people located within a certain radius of the program [61].

Among these programs designed to address food insecurity, food production-based programs like CSAs have the potential to combine improved food access with increased

economic opportunity. Given the systemic factors influencing food access and the relationships between food insecurity, poverty and health, Good Bowls seeks to address food insecurity while developing economic opportunities and promoting overall health.

Methods

To assess the early stage acceptability and potential impact of Good Bowls on food insecurity and nutrition among corner store customers, a cross-sectional study design was used. Two surveys were administered – a corner store intercept survey designed to answer Research Questions 1-4 and a taste test survey designed to answer Research Question 4 by testing the reception of Good Bowls flavors among corner store customers. Data collection occurred at four corner stores located in a rural, a non-metropolitan area in North Carolina that has been

identified as a food desert [46]. The results of this approach help us better understand the

(18)

Corner Store Intercept Survey

Measures

Cross-sectional data collected through an intercept survey of corner store shoppers was used to answer Research Question 1, Research Question 2, Research Question 3, and Research Question 4 (1 – How do corner store customers perceive the availability of healthy foods options, including frozen, in convenience or corner stores and more broadly in their

communities?; 2 – What are the barriers do corner store customers experience with regards to

maintaining healthy diets?; 3 – What are the food shopping and consumption habits of corner

store customers?; 4 – what is the early acceptability of Good Bowls as a healthy meal option

among corner store customers?) (see Appendix A – Intercept Survey). The survey was used to collect information regarding the respondent’s perception of the availability of fruits and vegetables in the community, the respondent’s food shopping habits, and barriers to healthy eating. The survey was also used to collect preliminary data on the perceived acceptability of Good Bowls as a healthy meal that customers would be willing to purchase.

(19)

Sample

Survey respondents were identified using convenience sampling while shopping at one of four corner stores located in a rural North Carolina county. At each store location, researchers attempted to collect 12 customer surveys.

Procedure

Investigators conducted data collection at four corner stores after receiving permission from store managers. During the data collection period, research assistants were stationed at one of the four corner stores and asked each customer in the corner store to complete an intercept survey until 12 responses were collected. To avoid literacy challenges, participants were given the option to complete the survey on their own or receive assistance from investigators who could read the survey aloud. Investigators offered respondents $5 as a thank you for completing the intercept survey.

Data Analysis

Data analysis was conducted to analyze the frequency of responses and identify any trends in responses. Prevalence of food insecurity and perceived availability of healthy foods was determined. Overall perceived acceptability of Good Bowls was assessed through the frequency of positive responses to Good Bowls-related questions. Applicable questions were scored in accordance with NEMS guidelines.

Ethical Considerations

(20)

income background [46]. To protect participants, all surveys included a short, written paragraph with informed consent information, and participants were told that they could skip questions or stop the survey at any time. The study was determined to be exempt by the University of North Carolina at Chapel Hill Institutional Review Board.

Good Bowls Taste Test Survey

Measures

Cross-sectional data collected through a taste test survey administered after participants sampled one or more Good Bowls flavors was used to answer Research Question 4 (what is the early acceptability of Good Bowls as a healthy meal option among corner store customers?) (see Appendix B). The survey was used to collect information regarding the respondent’s opinion on Good Bowls’ taste and perceived healthiness. Respondents were also asked if they would eat Good Bowls again, if they would recommend it to a friend, and how much they would be willing to pay for a 12-ounce Good Bowl.

Sample

Survey respondents were identified by a convenience sampling method while shopping at one of four corner stores located in a rural North Carolina county. At each store location,

researchers attempted to collect as many customer surveys as possible. Some taste test survey participants also responded to the intercept survey.

Procedure

(21)

of the four corner stores and asked each customer if they were willing to sample one or more Good Bowls flavors and fill out the short taste test survey.

Data Analysis

Data analysis was conducted to analyze the frequency of responses and identify any trends in responses. Overall perceived acceptability of Good Bowls was assessed through the frequency of positive responses to Good Bowls-related questions.

Results

Corner Store Intercept Survey Results

A total of 50 individuals completed surveys at 4 small corner stores in rural North Carolina, with 13 surveys conducted at Store A, 21 surveys conducted at Store B, 3 surveys conducted at Store C, and 13 surveys conducted at Store D. On the day of data collection, the owner of Store C was closing the store early. Therefore, the minimum of 12 surveys were not collected at Store C. Surveys were primarily self-administered, but some were completed by interview upon the participant’s request. Out of the 50 surveys, 40 complete surveys responses were recorded. Because incomplete survey responses were not excluded from data collection, the total number of respondents (n) is reported for all measures, with n varying within question blocks in some cases. When applicable for survey questions that accepted more than one response per participant, the total number of answer selection is also reported.

Demographic Information

(22)

majority of participants reported worked full or part time (29, 63.04%, n=46). Fourteen respondents (n=46, 30.43%) reported that a member of their household was receiving Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or Supplemental Nutrition Assistance Program (SNAP) benefits. Of those 14 respondents reporting that a member of their household was receiving WIC of SNAP benefits, 7 of the respondents (50.00%) were identified as food insecure by the two-question food insecurity screener. Respondents most frequently (22, 47.83%, n=46) reported that their households spent $100-$200 per month on food.

Table 1: Demographic information of respondents

Demographic Count (%)

Gender (n=46) Male Female Non-binary 32 (69.57) 14 (30.43) 0 (0.00) Age (years) (n=45)

18 to 34 35 to 50 51 to 69 70 and older

9 (20.00) 15 (33.33) 20 (44.44) 1 (2.22) Ethnicity (n=46) Hispanic Non-Hispanic 0 (0.00) 46 (100.00) Race (n=46) African American

American Indian/Alaska Native White Asian/Pacific Islander Other 37 (80.43) 5 (10.87) 4 (8.70) 0 (0.00) 0 (0.00) Education Level (n=45)

No high school Some high school High school Some college College

Graduate school/professional degree

(23)

Access to Healthy Foods

Survey responses indicate that participants were almost evenly split between “never” or “sometimes” eating as healthy as they would like (25, 54.35%) and “often” or “always” eating as healthy as they would like (21, 45.65%). Similarly, nearly half of participants thought they ate “a little less” or “a lot less” vegetables than their peers (25, 54.35%), and nearly half of participants thought they ate “a little more” or “a lot more” vegetables (21, 45.65%).

Twenty-four participants (n=49, 48.98%) thought fresh fruits and vegetables were “never” or “sometimes” affordable and available near where they lived, and 22 participants (n=41, 53.66%) indicated that there were foods they would like to buy but cannot due to price or availability. When asked if there were items respondents would like to buy but could not due to availability or price, “more nutritious food” as well as meat products, including steaks and ox tails, were frequently listed.

Table 2: Frequency of responses to "How often did you eat as healthy as you would like?" (n=46)

Response option Count (%)

Never 3 (6.25)

Sometimes 22 (47.83)

Often 14 (30.43)

Always 7 (15.22)

Table 3: Frequency of responses to "Please indicate how often meals or snacks with fruits or vegetables were available and affordable at the following places"

Response option Never

(count (%)) Sometimes (count (%)) Often (count (%)) Always (count (%)) The store where you buy

most of your food (n=49) 1 (2.04) 12 (24.49) 15 (30.61) 21 (42.86) Near where you live

(n=49) 1 (2.04) 23 (46.94) 12 (24.49) 13 (26.53)

Small convenience stores (n=49)

7 (14.29) 24 (48.98) 13 (26.53) 5 (10.20) The restaurant you go to

most often (n=50)

(24)

Barriers to Maintaining Healthy Diets

Availability of food, convenience, and cost were most frequently reported to be barriers to healthy eating. While a majority of respondents (34, 85.00%, n=40) reported having a working microwave oven, 15.00% (6 respondents) did not have a working microwave oven. Overall, 17 of the respondents (41.46%, n=41) were identified as food insecure, as measured by the two-question screener in the intercept survey. The majority of respondents (34, 82.93%) reported often buying food that was less nutritious or lower in quality because they needed the money for something else.

Table 4: Responses to “What were the main things that made it hard to eat healthy?” (n=46)

Response option Count (%)

Not convenient 14 (18.67)

Availability 13 (17.33)

Family preferences 13.33 (10)

Time 13 (17.33)

Cost 12 (16.00)

Taste 7 (9.33)

Don’t know how to cook 3 (4.00)

Other 2 (2.67)

Don’t like to cook 1 (1.33)

*Total answer selections 75

* Respondents were asked to check all that apply Food Shopping and Consumption Habits

Nearly 1 in 5 participants (9, 18.00%, n=50) reported buying most of their food from corner stores or convenience stores. On average, participants shopped at corner stores 4.04 times per week (n=49, range 1 to 20), and participants reported buying a variety of foods at corner stores, from snacks, like chips, to staples, like chicken and bread. Respondents commonly reported that taste, nutrition, cost, and convenience were important when shopping for food.

(25)

Lion. Of the 18 respondents who had a preferred meal away from home (n=45, 40.00%), 7 reported that their preferred meal was a burger. Among the respondents who worked full or part time (29, 63.04%), 7 respondents reported eating meals from a nearby restaurant while at work, and 7 reported eating meals from a vending machine while at work. Only 2 respondents reported eating frozen meals for lunch while at work.

Table 5: Where respondents buy most of their food. (n=50)

Store Count (%)

Supermarket 21 (31.34)

Supercenter (ex. Walmart or Costco) 17 (25.37)

Small Grocery Store 14 (20.90)

Corner/Convenience Store 9 (13.43)

Restaurant 4 (5.97)

Other 2 (2.99)

*Total answer selections 67

* Respondents were asked to check all that apply

Table 6: Length of time it takes respondents to travel from their home to the place where they buy most of their food. (n=50)

Length of time Count (%)

10 minutes or less 22 (44.00)

11 to 20 minutes 11 (22.00)

21 to 30 minutes 9 (18.00)

More than 30 minutes 8 (16.00)

Table 7: Level of importance of selected criteria to customers when shopping for food.

Criteria Not important

(count (%))

Somewhat important (count (%))

Very important (count (%))

Taste (n=45) 3 (6.67) 6 (13.33) 36 (80.00)

Nutrition (n=46) 0 (0.00) 12 (26.09) 34 (73.91)

Cost (n=45) 3 (6.67) 14 (31.11) 28 (62.22)

Convenience (n=43) 2 (4.65) 13 (30.23) 28 (65.12)

Weight control (n=46) 11 (30.56) 14 (30.43) 21 (45.65)

Table 8: Number of made meals consumed per week from various locations that sell pre-made meals. (n=50)

Location Mean (range)

Regular grocery store like Food Lion or Piggly Wiggly

(26)

Smaller store with some groceries like Dollar

General 1.12 (0.00-5.00)

Convenience store 1.08 (0.00-7.00)

Frozen meals or frozen pizza 0.97 (0.00-5.00)

Vending machine 0.53 (0.00-6.00)

Other 0.08 (0.00-2.00)

Table 9: Frequency of responses to "What do you do for most meals when you are at work?" among 29 participants who reported working full or part time.

Meal option Count (%)

Other meal from home 15 (41.67)

Vending machine at work 7 (19.44)

Nearby restaurant 7 (19.44)

Frozen meal from home 2 (5.56)

Cafeteria or snack bar at work 2 (5.56)

I do not eat at work 2 (5.56)

Other 1 (2.78)

*Total answer selections 36

* Respondents were asked to check all that apply Acceptability of Good Bowls

Participants reported a willingness to pay an average of $3.28 for a Good Bowl (range $0.00-$8.99), and 73.17% of participants (n=41) indicated that they would be willing to buy a Good Bowl one or more times a week. The majority of participants (31, 75.61%) agreed that having access to an affordable, good tasting, healthy frozen meal, like Good Bowls, would increase their ability to eat a healthier diet. In an open-ended question asking participants what they thought of Good Bowls, “a 12-ounce healthy and good tasting frozen meal that [can be microwaved] in 4 minutes,” 25 of the 29 respondents (86.21%) reacted positively to the idea.

Good Bowls Taste Test Survey Results

(27)

Overall, Good Bowls were well-received by corner store customers with all respondents agreeing Good Bowls tasted good and seemed healthy. All respondents also agreed that they would eat the meal again and that they would recommend the meal to their friends, and none of the flavors received negative responses on the surveys. The Sausage, Peppers & Grits flavor Good Bowl was the most taste tested flavor with 14 individuals completing a taste test survey for the flavor. However, the taste test results do not indicate a flavor preference among taste testers, as all flavors were well-received. While most respondents did not leave comments or suggestions for improvement, two respondents mentioned that Good Bowls should have more pepper. Taste test respondents reported that they would pay an average of $4.40 for a Good Bowl (range $1.99-$4.99).

Table 1: Count and percentage of responses to taste test survey for the Chicken Burrito flavor Good Bowl. Statement Strongly Disagree (count (%)) Disagree (count (%)) Agree (count (%)) Strongly Agree (count (%)) It tastes good

(n=7)

0 (0.00) 0 (0.00) 6 (85.71) 1 (14.29)

It seems healthy (n=8)

0 (0.00) 0 (0.00) 6 (75.00) 2 (25.00)

I would eat it

again (n=7) 0 (0.00) 0 (0.00) 6 (85.71) 1 (14.29)

I’d recommend it

to a friend (n=8) 0 (0.00) 0 (0.00) 6 (75.00) 2 (25.00)

Table 2: Count and percentage of responses to taste test survey for the Sausage, Peppers & Grits flavor Good Bowl.

Statement Strongly

Disagree (count (%))

Disagree

(count (%)) (count (%))Agree Strongly Agree(count (%)) It tastes good

(n=14)

0 (0.00) 0 (0.00) 8 (57.14) 6 (42.86)

It seems healthy

(n=13) 0 (0.00) 0 (0.00) 9 (69.23) 4 (30.77)

I would eat it

(28)

I’d recommend it

to a friend (n=12) 0 (0.00) 0 (0.00) 9 (75.00) 3 (25.00)

Table 3: Count and percentage of responses to taste test survey for Asian Style Veggie flavor Good Bowl. (n=7)

Statement Strongly Disagree (count (%)) Disagree (count (%)) Agree (count (%)) Strongly Agree (count (%))

It tastes good 0 (0.00) 0 (0.00) 4 (57.14) 3 (42.86)

It seems healthy 0 (0.00) 0 (0.00) 4 (57.14) 3 (42.86)

I would eat it

again 0 (0.00) 0 (0.00) 4 (57.14) 3 (42.86)

I’d recommend it to a friend

0 (0.00) 0 (0.00) 4 (57.14) 3 (42.86)

Table 4: Count and percentage of responses to taste test survey for NC BBQ Veggie flavor Good Bowl. (n=8)

Statement Strongly

Disagree (count (%))

Disagree

(count (%)) (count (%))Agree Strongly Agree(count (%))

It tastes good 0 (0.00) 0 (0.00) 3 (37.50) 5 (62.50)

It seems healthy 0 (0.00) 0 (0.00) 5 (62.50) 3 (37.50)

I would eat it again

0 (0.00) 0 (0.00) 5 (62.50) 3 (37.50)

I’d recommend it

to a friend 0 (0.00) 0 (0.00) 5 (62.50) 3 (37.50)

Discussion

(29)

county’s residents are food insecure, nearly 42 percent of intercept survey respondents identified as food insecure based on the two-question screener [70]. Survey results suggest that corner store customers face significant barriers in maintaining healthy diets and accessing affordable healthy food, making corner stores an appropriate point of intervention for Good Bowls.

Results from survey measures designed to determine the perceived availability of healthy food options indicate that roughly half of respondents thought fresh fruits and vegetables were “never” or “sometimes” affordable and available near where they lived, and that participants face price and availability barriers to purchasing healthy food. With nearly 1 in 2 respondents facing availability and affordability challenges in obtaining healthy food, we can conclude that corner store customers in this area face significant obstacles in achieving healthier diets in this “Tier 1”, or “most economically distressed,” county [71]. These survey findings are consistent with data indicating that this rural county is also classified as a food desert, compounding the effects of economic depression of the area and posing health maintenance challenges to its residents [46].

In addition to geographic barriers in accessing healthy food, survey respondents also faced the challenge of convenience when attempting to achieve healthier diets. With 15 percent of respondents reporting that they did not have a working microwave oven, further development must be done to tailor Good Bowls’ entry into this market. Although Good Bowls’ frozen format make them convenient to prepare using a microwave, 15 percent of surveyed corner store customers would not be able to prepare Good Bowls in their home. Therefore, development instructions for stovetop preparation of Good Bowls is needed to mitigate this barrier.

(30)

pre-made meals that customers are already eating. Given the positive feedback to Good Bowls and overall high acceptability among corner store customers, we can expect Good Bowls to perform well as a product. As an intervention, we can expect that Good Bowls can reach the target population of food insecure individuals. Because most pre-made meals were bought at grocery store, roll out of Good Bowls into these communities should focus on both corner stores and grocery stores like Food Lion. Although respondents ate an average of nearly one pre-made meal per day, only two respondents reported eating frozen meals at work, and overall,

respondents ate an average of one frozen pre-made meal per week. To support the product launch and encourage customers to try Good Bowls, promotional discounts, point-of-sale advertising, and point-of-sale product taste sampling can be used.

(31)

Limitations

This study had a few limitations. A number of surveys were incomplete since participants were told to skip any question they would like and the surveys were administered via double-sided paper packets. During survey completion, some respondents failed to fill out entire pages of the survey, likely because they did not flip the page and did not know that the survey was double-sided. Additionally, data collection occurred with uneven sampling since Store C closed early on the day of data collection, and we were not able to collect the minimum of 12 survey at that location. Finally, sampling limited by funding, and our team had enough funding for 50 intercept surveys.

Conclusion

(32)

Acknowledgements

I would like to thank my mentors and fellow researchers for their support and guidance. I could not have completed this project without the help and mentorship of the following people:

Alice Ammerman, DrPH, the director of the UNC Center for Health Promotion and Disease Prevention and a Mildred Kaufman Distinguished Professor in the Department of Nutrition at the Gillings School of Global Public Health, served as the primary research advisor for this project. Learning with Dr. Ammerman has been an incredible experience, and I am grateful for her wisdom, powerful leadership, and dedication to transformative interventions in our community.

Karl Umble, PhD, MPH, an assistant professor in the Department of Health Policy and Management at the Gillings School of Global Public Health and the former director of the Department of Health Policy and Management’s Bachelor of Science in Public Health Program, served as the undergraduate Health Policy and Management thesis instructor and first reader for this project. Dr. Umble’s careful research approach, positivity, and mentorship were central to this project’s success, and I thank Dr. Umble for his invaluable guidance.

(33)

Business Technology Transfer grant. Her feedback and leadership helped drive this project forward, and I am grateful to have had the opportunity to learn from her.

Sebastian Elie-York, a fellow member of the Department of Health Policy and Management’s Bachelor of Science in Public Health, served as a research assistant. He has worked with me since the start of my time at the UNC Center to Health Promotion and Disease Prevention and has helped me tremendously throughout this research journey. I thank Sebastian for his energy, friendship, and support.

Thank you to Mia Fishkin and Chiragji Odedra for helping me organize and conduct data collection.

Finally, I thank the individuals who completed the surveys for their time and honesty. Hopefully this effort and participation will bring us one step closer to the implementation of sustainable, effective solutions to food insecurity and promote food justice in our communities.

Funding Sources

(34)

Works Cited

[1] W. A. Krehl, "The role of nutrition in maintaining health and preventing disease," Health Values, vol. 7, no. 2, pp. 9-13, 1983.

[2] World Health Organization, "Healthy diet," 23 October 2018. [Online]. Available: https://www.who.int/news-room/fact-sheets/detail/healthy-diet. [Accessed 21 November 2019].

[3] S. D. Ohlhorst, R. Russell, D. Bier, D. M. Klurfeld, Z. Li, J. R. Mein, J. Milner, A. C. Ross, P. Stover and E. Konopka, "Nutrition research to affect food and a healthy life span," J Nutr, vol. 143, no. 8, p. 1349–1354, 2013.

[4] P. Ohri-Vachaspati, R. S. DeWeese, F. Acciai, D. DeLia, D. Tulloch, D. Tong, C. Lorts and M. J. Yedidia, "Healthy Food Access in Low-Income High-Minority Communities: A Longitudinal Assessment: 2009–2017," Int J Environ Res Public Health, vol. 16, no. 13, p. 2354, July 2019.

[5] WHO Commission on Social Determinants of Health, "Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the

(35)

States," American Journal of Public Health, vol. 99, no. 7, pp. 1203-1211, 2009.

[7] R. L. Thornton, C. M. Glover, C. W. Cené, D. C. Glik, J. A. Henderson and D. R. Williams, "Evaluating Strategies For Reducing Health Disparities By Addressing The Social

Determinants Of Health," Health Affairs, vol. 35, no. 8, p. 1416–1423, August 2016. [8] M. Meit, A. Knudson, T. Gilbert, A. Tzy-Chyi Yu, E. Tanenbaum, E. Ormson, S.

TenBroeck, A. Bayne and S. Popat, "The 2014 Update of the Rural-Urban Chartbook," Rural Health Reform Policy Research Center, Bethesda, MD, 2014.

[9] G. K. Singh, G. P. Daus, M. Allender, C. T. Ramey, E. K. Martin Jr., C. Perry, A. A. De Los Reyes and I. P. Vedamuthu, "Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016," Int J MCH AIDS,

vol. 6, no. 2, pp. 139-164, 2017.

[10] M. S. Eberhardt and E. R. Pamuk, "The Importance of Place of Residence: Examining Health in Rural and Nonrural Areas," American Journal of Public Health, vol. 94, no. 10, pp. 1682-1686, 2004.

[11] A. J. Scott and R. F. Wilson, "Social determinants of health among African Americans in a rural community in the Deep South: an ecological exploration," Rural and Remote Health,

vol. 11, no. 1634, p. online, 2011.

[12] K. M. Shaw, K. A. Theis, S. Self-Brown, D. W. Roblin and L. Barker, "Chronic Disease Disparities by County Economic Status and Metropolitan Classification, Behavioral Risk Factor Surveillance System, 2013," Prev Chronic Dis, vol. 13, 2016.

(36)

Promoting Healthy Foods at Corner Stores in New York City," American Journal of Public Health, vol. 102, no. 10, pp. e27-e31, 2012.

[15] A. B. Dailey, A. Hess, C. Horton, E. Constantian, S. Monani, B. Wargo, K. Davidson and K. Gaskin, "Healthy Options: A Community-Based Program to Address Food Insecurity,"

Journal of Prevention & Intervention in the Community, vol. 43, no. 2, pp. 83-94, 2015. [16] B. A. Langellier, J. R. Garza, M. L. Prelip, D. Glik, R. Brookmeyer and A. N. Ortega,

"Corner Store Inventories, Purchases, and Strategies for Intervention: A Review of the Literature," Calif J Health Promot, vol. 11, no. 3, pp. 1-13, 2014.

[17] N. I. Larson, M. T. Story and M. C. Nelson, "Neighborhood environments: disparities in access to healthy foods in the U.S.," Am J Prev Med, vol. 36, no. 1, pp. 74-81, 2009. [18] K. S. Martin, E. Havens, K. E. Boyle, G. Matthews, E. A. Schilling, O. Harel and A. M.

Ferris, "If you stock it, will they buy it? Healthy food availability and customer purchasing behaviour within corner stores in Hartford, CT, USA," Public Health Nutrition, vol. 15, no. 10, p. 1973–1978, 2012.

[19] K. O’Malley, J. Gustat, J. Rice and C. C. Johnson, "Feasibility of Increasing Access to Healthy Foods in Neighborhood Corner Stores," Journal of Community Health, vol. 38, no. 4, p. 741–749, 2013.

[20] T. C. Keyserling, . D. Samuel-Hodge, . Jilcott-Pitts, B. A. Garcia, L. F. Johnston, . Gizlice, . L. Miller, . F. Braxton, . R. Evenson, . C. Smith, . B. Davis, . L. Quenum and Majette, "A community-based lifestyle and weight loss intervention promoting a

Mediterranean-style diet pattern evaluated in the stroke belt of North Carolina: the Heart Healthy Lenoir Project," BMC Public Health, vol. 16, no. 732, 2016.

(37)

Prevention, "Med-South Lifestyle Program," 2019. [Online]. Available: http://hpdp.unc.edu/research/medsouth/. [Accessed 22 November 2019].

[22] H. K. Seligman, B. A. Laraia and M. B. Kushel, "Food insecurity is associated with chronic disease among low-income NHANES participants.," J Nutr, vol. 140, no. 2, pp. 304-310, February 2010.

[23] D. S. Grigsby-Toussaint, S. N. Zenk, A. Odoms-Young, L. Ruggiero and I. Moise, "Availability of Commonly Consumed and Culturally Specific Fruits and Vegetables in African-American and Latino Neighborhoods," Journal of the American Dietetic Association, vol. 110, no. 5, pp. 746-752, 2010.

[24] W. Raghupathi and V. Raghupathi, "An Empirical Study of Chronic Diseases in the United States: A Visual Analytics Approach to Public Health," Int J Environ Res Public Health, 1 March 2018.

[25] National Center for Chronic Disease Prevention and Helath Promotion, "Health and Economic Costs of Chronic Diseases," 23 October 2019. [Online]. Available:

https://www.cdc.gov/chronicdisease/about/costs/index.htm#ref1. [Accessed 20 November 2019].

[26] R. Ronzio, Facts on File library of health and living: The encyclopedia of nutrition and good health, 3rd Edition ed., New York, New York: Facts On File, 2017, p. Introduction: The importance of nutrition..

[27] American Heart Association, "The American Heart Association Diet and Lifestyle Recommendations," 15 August 2017. [Online]. Available:

(38)

[28] T. Dall, V. Fulgoni, Y. Zhang, K. Reimers, P. Packard and J. Astwood, "Potential Health Benefits and Medical Cost Savings From Calorie, Sodium, and Saturated Fat Reductions in the American Diet," American Journal of Health Promotion, pp. 412-422, 2009.

[29] R. J. Widmer, A. Flammer, L. Lerman and A. Lerman, "The Mediterranean Diet, its

Components, and Cardiovascular Disease," American Journal of Medicine, pp. 229-238, 15 October 2014.

[30] M. de Lorgeril, P. Salen, J.-L. Martin, I. Monjaud, J. Delaye and N. Mamelle, "Mediterranean Diet, Traditional Risk Factors, and the Rate of Cardiovascular

Complications After Myocardial Infarction: Final Report of the Lyon Diet Heart Study,"

Circulation, no. 99, p. 779–785, 16 February 1999.

[31] R. Estruch, E. Ros, J. Salas-Salvadó, M.-I. Covas, D. Corella, F. Arós, E. Gómez-Gracia, V. Ruiz-Gutiérrez, M. Fiol, J. Lapetra, R. M. Lamuela-Raventos, L. Serra-Majem and e. a. P. Study, "Primary Prevention of Cardiovascular Disease with a Mediterranean Diet," N Engl J Med, no. 368, pp. 1279-1290, 4 April 2013.

[32] F. Sofi, R. Abbate, G. F. Gensini and A. Casini, "Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis," The American Journal of Clinical Nutrition, vol. 92, no. 5, p. 1189–1196, November 2010.

[33] J. M. Chapel, M. D. Ritchey, D. Zhang and G. Wang, "Prevalence and Medical Costs of Chronic Diseases Among Adult Medicaid Beneficiaries," American Journal of Preventive Medicine, vol. 53, no. 6, pp. S143-S154, December 2017.

(39)

2016.

[35] A. Coleman-Jensen, C. A. Gregory and M. P. Rabbitt, "Food Security in the U.S.: Measurement," United States Department of Agriculture: Economic Research Service, 4 September 2019. [Online]. Available: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/measurement/. [Accessed 21 November 2019].

[36] S. Weiser, K. Palar, A. Hatcher, S. Young, E. Frongillo and B. Laraia, "Chapter 2: Food Insecurity and Health: A Conceptual Framework," in Food Insecurity and Public Health, 1st Edition ed., CRC Press, 2015.

[37] A. Coleman-Jensen, C. Gregory and A. Singh, "Household food security in the United States in 2013," Department of Agriculture, Economic Research Service, p. Economic Research Report No. 173.

[38] J. Agyeman and J. McEntee, "Moving the Field of Food Justice Forward Through the Lens of Urban Political Ecology," Geography Compass, March 2014.

[39] L. Nowroozi, "Social Determinants Of Health Include Nutrition," Health Affairs, vol. 37, no. 8, August 2018.

[40] C. Gundersen and J. P. Ziliak, "Food Insecurity And Health Outcomes," Health Affairs, vol. 34, no. 11, pp. 1830-1839, November 2015.

[41] G. Coppin, "Appraising food insecurity," Behavioral and Brain Sciences, vol. 40, 2017. [42] World Health Organization, "Malnutrition double burden," Bulletin of the World Health

Organization, vol. 96, no. 2, p. 801, 2018.

(40)

Community Health, vol. 37, no. 1, pp. 253-264, 2011.

[44] M. Meit and A. Knudson, "Leveraging Interest to Decrease Rural Health Disparities in the United States," American Journal of Public Health, vol. 107, no. 10, pp. 1563-1564, 2017. [45] C. Huddleston-Casas, R. Charnigo and L. A. Simmons, "Food insecurity and maternal

depression in rural, low-income families: a longitudinal investigation," Public Health Nutrition, vol. 12, no. 8, p. 1133–1140, 2008.

[46] D. Bloom, "Food Access," North Carolina Cooperative Extension, 2019. [Online]. Available: https://localfood.ces.ncsu.edu/food-access-food-security/.

[47] P. Dutko, M. Ver Ploeg and T. Farrigan, "Economic Research Report Number 140: Characteristics and Influential Factors of Food Deserts," United States Department of Agriculture Economic Research Service, 2012.

[48] C. J. Mansfield, J. L. Wilson, E. J. Kobrinski and J. Mitchell, "Premature mortality in the United States: the roles of geographic area, socioeconomic status, household type, and availability of medical care," Am J Public Health, vol. 89, no. 6, pp. 893-898, 1999. [49] K. K. Thomas, Deluxe Jim Crow : Civil Rights and American Health Policy, 1935-1954,

University of Georgia Press, 2011.

[50] C. J. Havard, "African-American Farmers and Fair Lending: Racializing Rural Economic Space," Stanford Law & Policy Review, vol. 12, no. 2, pp. 333 - 360, 2001.

[51] T. A. Arcury, "Risk Perceptions of Occupational Hazards Among Black Farmers in the Southeastern United States," Journal of Rural Health, vol. 11, no. 4, pp. 240-250, 1995. [52] R. A. Russo, "Local Food Initiatives in Tobacco Transitions of the Southeastern United

States," Southeastern Geographer, vol. 52, no. 1, pp. 55-69, 2012.

(41)

International Journal of Environmental Research and Public Health, vol. Special Issue, pp. 1-4, 2019.

[54] B. T. Nguyen, K. Shuval, F. Bertmann and A. L. Yaroch, "The Supplemental Nutrition Assistance Program, Food Insecurity, Dietary Quality, and Obesity Among US Adults,"

American Journal of Public Health, vol. 105, no. 7, pp. 1453-1459, 2015.

[55] J. L. Pomeranz and J. F. Chriqui, "The Supplemental Nutrition Assistance Program: Analysis of Program Administration and Food Law Definitions," American Journal of Preventive Medicine, vol. 49, no. 3, pp. 428-436, 2015.

[56] Establishment of Program, 7 U.S.C. § 2013(a), 2008.

[57] A. S. Ammerman, T. Hartman and M. M. DeMarco, "Behavioral Economics and the

Supplemental Nutrition Assistance Program: Making the Healthy Choice the Easy Choice,"

American Journal of Preventive Medicine, vol. 52, no. 2S2, pp. S145-S150, 2017. [58] J. A. Kleman, S. Bartlett, P. Wilde and L. Olsho, "The short-run impact of the Healthy

Incentives Pilot program on fruit and vegetable intake," Am J Agric Econ, vol. 96, no. 5, pp. 1372-1382, 2017.

[59] L. Harnack, S. Valluri and S. A. French, "Importance of the Supplemental Nutrition Assistance Program in Rural America," American Journal of Public Health, vol. 109, no. 12, pp. 1641-1645, 2019.

[60] C. Bazerghi, F. H. McKay and M. Dunn, "The Role of Food Banks in Addressing Food Insecurity: A Systematic Review," J Community Health, vol. 41, pp. 732-740, 2016. [61] A. Evans, K. Banks, R. Jennings, E. Nehme, C. Nemec, S. Sharma, A. Hussaini and A.

(42)

Activity, vol. 12, no. Suppl 1, p. S5, 2015.

[62] K. S. Martin, E. Havens, K. E. Boyle, G. Matthews, E. A. Schilling, O. Harel and A. M. Ferris, "If you stock it, will they buy it? Healthy food availability and customer purchasing behaviour within corner stores in Hartford, CT, USA," Public Health Nutrition, vol. 15, no. 10, p. 1973–1978, 2011.

[63] M. Ghosh-Dastidar, G. Hunter, R. L. Collins, S. N. Zenk, S. Cummins, R. Beckman, A. K. Nugroho, J. C. Sloan, L. Wagner and T. Dubowitz, "Does Opening a Supermarket in a Food Desert Change the Food Environment?," Health Place, vol. 46, p. 249–256, 2017. [64] R. Loopstra, "Interventions to address household food insecurity in high-income countries,"

Proceedings of the Nutrition Society, vol. 77, pp. 270-281, 2018.

[65] M. J. White, S. Jilcott Pitts, J. T. McGuirt, K. L. Hanson, E. H. Morgan, J. Kolodinsky, W. Wang, M. Sitaker, A. S. Ammerman and R. A. Seguin, "The perceived influence of cost-offset community-supported agriculture on food access among low-income families,"

Public Health Nutrition, vol. 21, no. 15, pp. 2866-2874, 2018.

[66] D. A. Dillman, J. D. Smith and L. M. Christian, Internet, Phone, Mail, and Mixed-Mode Surveys: The Tailored Design Method, Wiley, 2008.

[67] Nutritional Environment Measures Survey, "The Perceived Nutrition Environment," 2015. [Online]. Available:

http://nems-upenn.org/wp-content/uploads/2018/10/NEMS-P-Survey.pdf.

[68] L. O’Keefe, "Identifying food insecurity: Two-question screening tool has 97% sensitivity,"

AAP News, pp. E151023-1, October 2015.

(43)

Available: https://www.feedingamerica.org/research/map-the-meal-gap/by-county. [Accessed 19 April 2020].

[71] North Carolina Department of Commerce, "County Distress Rankings (Tiers)," 2019. [Online]. Available: https://www.nccommerce.com/grants-incentives/county-distress-rankings-tiers.

[72] A. A. Gustafson, J. Sharkey, C. D. Samuel-Hodge, J. C. Jones-Smith, J. Cai and A. S. Ammerman, "Food store environment modifies intervention effect on fruit and vegetable intake among low-income women in North Carolina," J Nutr Metab, 2012.

[73] J. R. Halladay, K. E. Donahue, A. L. Hinderliter, D. M. Cummings, C. W. Cene, C. L. Miller, B. A. Garcia, J. Tillman and D. DeWalt, "The heart healthy lenoir project-an intervention to reduce disparities in hypertension control: study protocol," BMC Health Serv Res, vol. 13, no. 441, 2013.

[74] National Health and Nutrition Examination Survey, "Dietary Screener Questionnaire Questionnaires (DSQ) in the NHANES 2009-10: DSQ," 2009. [Online]. Available: https://epi.grants.cancer.gov/nhanes/dietscreen/dsq_english.pdf. [Accessed 29 November 2019].

[75] I. V. Ermakov, M. Ermakova, M. Sharifzadeh, A. Gorusupudi, K. Farnsworth, P. S.

Bernstein, J. Stookey, J. Evans, T. Arana, L. Tao-Lew, C. Isman, A. Clayton, A. Obana, L. Whigham, A. H. Redelfs and L. Jahns, "Optical assessment of skin carotenoid status as a biomarker of vegetable and fruit intake," Arch Biochem Biophys, vol. 656, pp. 46-54, 2018. [76] J. A. Kleman, S. Bartlett, P. Wilde and L. Olsho, "The short-run impact of the Healthy

(44)
(45)

Appendix

Appendix A – Corner Store Intercept Survey

We are interested in learning more about what foods people eat and where they buy them. Your information will help us work toward making good-tasting healthy foods more available and affordable for everyone. As a thank you for your

participation we would like to give you a $5 gift card. Would you be willing to complete this brief survey? Feel free to skip any question or stop at any time. Please answer the following questions as best you can about your household or yourself if you live alone. Please check the box or write in your answer.

In answering the following questions, please think about roughly the last 12 months

1. Where do you buy most of your food?

☐ Corner/convenience store ☐ Small grocery store ☐ Supercenter (ex. Walmart, Costco)

☐ Supermarket ☐ Restaurants ☐ Other (please specify): ___________

2. How long does it take you to get from your home to the store where you buy most of your food?

☐ 10 minutes or less ☐ 11 to 20 minutes ☐ 21 to 30 minutes ☐ More than 30 minutes

3. How many times a week do you shop at a convenience store? ________times/week

4. What type of foods do you usually buy at a convenience store? _____________ ________________________________________________________________

5. Please indicate how often meals or snacks with fruits or vegetables were available and affordable at the following places:

Never Sometimes Often Always

Near where you live ☐ ☐ ☐ ☐

The store where you buy most of your food

☐ ☐ ☐ ☐

Small convenience stores

☐ ☐ ☐ ☐

The restaurant you go to most often

(46)

6. When you shop for food, how important to you are the following:

Not important Somewhat important

Very important

Taste ☐ ☐ ☐

Nutrition ☐ ☐ ☐

Cost ☐ ☐ ☐

Convenience ☐ ☐ ☐

Weight control ☐ ☐ ☐

7. Do you work full or part time? ☐ Yes ☐ No

If yes, what do you do for most meals when you are at work? (check all that apply)

☐ Frozen meal from home ☐ Other meal from home ☐ Vending

machines at work ☐ Cafeteria or snack bar at work ☐ Nearby restaurant ☐ I do not eat at work ☐ Other: ___________________

8. During a typical week, how many pre-made meals (canned, fresh, or frozen) do you eat that are:

from a restaurant, fast food restaurant or food stand? _______

from a regular grocery store like Food Lion or Piggly Wiggly? _______ from a smaller store with some groceries like Dollar General? _______ from a convenience store? _______

from a vending machine? _______ frozen meals or frozen pizzas? _______ Other ________________

9. Do you have a preferred away from home meal, such as a burger, pizza, salad, etc.?

☐ Yes (please tell us what it is):______________________________________ ☐ No

10.Compared to other people like you, do you think you eat more vegetables or less?

☐ a lot less ☐ a little less ☐ a little more ☐ a lot more

11.How often did you eat as healthy as you would like? ☐Never ☐Sometimes☐Often ☐Always

12.What were the main things that made it hard to eat healthy? (check all that apply)

(47)

13.Are there some kinds of foods that you would like to buy but cannot very often due to price or availability?

☐ No ☐ Yes (please list the foods):___________________________________________

14.Would you say that you worried whether your food would run out before you got money to buy more?

☐ Yes ☐ No

15.Would you say that the food that you bought just didn’t last, and you didn’t have money to buy more?

☐ Yes ☐ No

16.How often did you buy food that was less nutritious or lower in quality than you wanted because you needed the money for something else (medicines, bills, mortgage/rent, etc.)?

☐ Never ☐ Sometimes ☐ Often ☐ Always

17.Please indicate how much you agree with the following statement: Having access to an affordable, good tasting, healthy frozen meal would increase your ability to eat a healthier diet. 

☐ Strongly disagree ☐ Disagree ☐ Agree ☐ Strongly Agree

18.Do you have a working microwave oven? ☐ Yes ☐ No

19.How much would you be willing to pay for a healthy and good tasting frozen meal that you can microwave in 4 minutes and is 30% larger than most other brands

☐ Less than $1.99 ☐ $1.99 ☐ $2.99 ☐ $3.99 ☐ $4.99 ☐ $5.99 ☐ $6.99 ☐$7.99 ☐$8.99 ☐Other: _______

20.How often would you be willing to buy a meal like this? (i.e. affordable, healthy, and good tasting)

☐ Never ☐ 1-2 times a month ☐ 1-2 times a week ☐ 3-4 times a week ☐ 5 or more times a week

21.What would make you choose this meal? ____________________________________________

_____________________________________________________________________________

22.We are testing a new idea for a 12 oz. healthy and good tasting frozen meal, called Good Bowls, that you can microwave in 4 minutes. What do you think of that idea? ____________________

(48)

Now a little more information about you…

1. Number of individuals in your household: _______ Adults _______ Kids (under 18)

2. Do you or someone in your household currently receive WIC or SNAP benefits? ☐ Yes ☐ No

3. Generally, how much does your household spend on food each month?

☐ Less than $100 ☐ $100-200 ☐ $200-300 ☐ $300-400 ☐ $400+

4. Age group: ☐ 18 to 34 ☐ 35 to 50 ☐ 51 to 69 ☐ 70 and older

5. Gender:

☐ Male ☐ Female ☐ Non-binary

6. Are you Hispanic/Latino? ☐ Yes ☐ No

7. Race/ethnicity (choose all that apply):

☐ White ☐ African American ☐ Asian/Pacific Islander ☐ American Indian/Alaska Native ☐ Other_______________________

8. Education level:

☐ No high school ☐ Some high school ☐ High school

☐ Some college ☐ College ☐ Graduate school/Professional degree

(49)

Appendix B – Good Bowls Taste Test Survey

We are conducting a research study at UNC among people 18 or over to understand more about how to get healthy food to people and hope you’d be willing to taste a few options and tell us what you think. This should take about 5 minutes. This is completely voluntary. We will not record your name, so no one will ever know you participated. If you have any food allergies, we ask that you not try the foods for your safety. Please check the box that indicates your opinion.

 Chicken Burrito  Grits and Sausage  Asian Style Veggie  NC BBQ Veggie

Str ongly Disagree

Disagree Agree Strongly

Agree

Suggestions for Improvement It tastes good

It seems healthy I would eat it again

I’d recommend it to a friend  Chicken Burrito  Grits and Sausage  Asian Style Veggie  NC BBQ Veggie

Str ongly Disagree

Disagree Agree Strongly

Agree

Suggestions for Improvement It tastes good

It seems healthy I would eat it again

I’d recommend it to a friend  Chicken Burrito  Grits and Sausage  Asian Style Veggie  NC BBQ Veggie

Str ongly Disagree

Disagree Agree Strongly

Agree

Suggestions for Improvement It tastes good

It seems healthy I would eat it again

I’d recommend it to a friend  Chicken Burrito  Grits and Sausage  Asian Style Veggie  NC BBQ Veggie

Str ongly Disagree Disagree Agree Str ongly Agree Suggestions for Improvement It tastes good

It seems healthy I would eat it again

I’d recommend it to a friend

What’s the most you would you pay/use EBT for a 12 oz bowl? (Most frozen meals are 8-9 oz) $1.99 $2.50 $3.99 $4.50 $4.99

Figure

Updating...

References

Updating...

Related subjects :