Redefining Rural Food Deserts by Transportation Networks

2017Hyung Jin Kim, Kansas State UniversityGregory Newmark, Kansas State University

Collaborators: David Procter, Nancy Knopp Daniels (Kansas State University); Glen Muske (North Dakota State University) and Lori Capouch (North Dakota Association of Rural Electric Cooperatives)

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NCRCRD Staff:Mark Skidmore, DirectorRosa Soliz-McKelvey, Communications & Logistics Assoc.Annabel Ispen, Post Doctoral Fellow, NCRCRDPao Xiong, Hmong Language Media Resources

Board of Directors:Doug Buhler, Michigan State University AgBioResearchBrent Elrod, USDA/NIFA LiaisonPatrick Cudney, Michigan State University ExtensionChris Caldwell, College of Menominee NationSarah A. Low, USDA/ERS LiaisonKarl Martin, University of Wisconsin CY Wang, South Dakota State UniversityRichard Todd, Federal Reserve Bank of Minneapolis

The North Central Regional Center for RuralDevelopment (NCRCRD) is one of four regional centers in the United States that work to improve the quality of life in rural communities. With funding from the USDA National Institute of Food and Agriculture and the land-grant universities in our 12-state region, the NCRCRD helps Extension professionals, researchers and other partners address issues that affect rural areas across the region. The center provides leadership in rural development by linking research with education and community outreach to facilitate, integrate, link and coordinate research and action for rural America.

This material is based on work supported byannual base funding through the National Institute of Food and Agriculture, U.S. Department of Agriculture. Any opinions, findings, conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the U.S. Department of Agriculture or other funders.

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Executive Summary

A critical concern for the sustainability of rural communities is access to food. Food access promotes the health of rural residents as well as the stability of rural areas. These concerns are particularly pressing for weaker social groups with limited means to travel, such as older adults, disabled persons, and low-income households. Effective public policy to en-hance rural food access needs to be based on a rigorous understanding of the actual travel and activity behaviors of rural residents. To date, these patterns have been unexplored with the result that policymaking continues to rely on simple, distance-based models of food deserts imported from urban environments – models which may not translate fully to the very different rural context where longer, chained-trips are common. This research seeks to explore the food access pat-terns of rural residents to better inform public policy. Specifically, this study aims (a) to reframe rural food access within the context of rural travel behavior that considers the distribution of food outlets using GIS-based spatial network analyses; and (b) to understand rural food access barriers and disparities based on focus group studies focus groups conducted through community extension programs in Kansas and North Dakota. This study also examines the grocery-related travel of rural residents in the NCRCRD regions by combining the highly-detailed, geocoded information on trip and activity be-havior from the National Household Travel Survey (NHTS) with a GIS mapping of food outlet location data.

Redefining Rural Food Deserts by Transportation NetworksBackground

A critical concern for the sustainability of rural communities is access to food. Better food access is associated with healthier diets and lower obesity rates (Larson, Story, & Nelson, 2009; Ver Ploeg et al., 2012). Rural residents make less frequent major grocery-shopping trips, often only once monthly to supercenters, than urban residents, due to a lack of proximate food stores, longer travel distances, and more common severe-weather events (Lucan, Gustafson, & Jilcott Pitts, 2012; Powell, Slater, Mirtcheva, Bao, & Chaloupka, 2007). Unreliable or nonexistent public transportation is a critical barrier to food access, especially for low-income, disabled, and older adult households in rural communities (Lucan et al., 2012; Sharkey, 2009). Larger food stores, such as supermarkets or large grocery stores, offer more affordable food prices than the small grocery or convenience stores on which many rural communities have to rely (Ver Ploeg et al., 2012). Stud-ies have identified food deserts and inequalities serving as barriers for healthy food-access for rural population using both spatial and non-spatial dimensions, which includes food store locations and its service areas, home-to-store distances, neighborhood characteristics and policies and programs (Clifton, 2004; Connors, Bisogni, Sobal, & Devine, 2001; Mela, 1999; Popkin, Duffey, & Gordon-Larsen, 2005; Zenk et al., 2005), however, these studies have not examined actual travel behaviors.

Food desert measurements:Since better access yields an array of public health and community resilience benefits, public policy has focused on how to improve food access in rural areas. These policies tend to be based on concepts imported from research on urban food deserts – concepts that do not readily translate to the rural context (http://www.ers.usda.gov/). For example, urban food deserts are typically defined as a lack of food outlets within a one-mile buffer of a household to the nearest food store. Based on the population-weighted centroid of the census tracts, a “one-mile” mark represents the outer bound of a walkable access distance and is reasonable for an urban context where relatively short, single purpose trips are common. However, this idea is typically translated to the rural context by simply extending the buffer to “10-miles”. Since this exten-sion inherently implies some sort of access to motorized transportation, it is not clear why a 10-mile buffer is appropriate (Ver Ploeg et al., 2012). Rural trip-making is characterized by relatively long, chained trips through which multiple activities are linked together on a single tour.

Transportation and spatial networks:Some studies have employed methods using a Geographic Information System (GIS)-based street buffer and network distance for assessing food access. However, they have mainly focused on urban areas, with lack of consideration of rural residents and their distinct travel activities and destinations, including multi-purpose trips and multi-type food stores (Gordon et al., 2011; Laska, Graham, Moe, & Van Riper, 2010; Van der Horst et al., 2008). As it is still unclear whether dis-tance is relatively a greater barrier to food access in rural areas, rigorous and dynamic measures about rural food-access should be employed to consider the interplay between street network-based distance, travel patterns, and retail service areas of multi-type food stores (see Figure 1).

The specific aims of this study are: (A1) to frame and examine rural food deserts within the context of rural travel patterns at a regional level with relation to the actual distribution of retail food outlets using GIS-based spatial network analyses; and (A2) to investigate rural food access barriers and opportunities at local level within identified food desert areas using focus group studies. The NCRCRD grants provided supports for data collection and analyses in the report.

Study Targets

The study setting includes rural residents throughout the twelve NCRCRD states with additional focus on communities in Kansas and North Dakota. For the purposes of this study, rural areas are defined using the current USDA threshold for housing assistance. In 2010, 25.8 % and 40.1% of population are living in rural areas in Kansas (total population: 2,853,132) and North Dakota (total population: 674,499), respectively, while the national rural population proportion is 25.5% in 2010 (US Census, 2010). And, rural population densities (people per square mile) are 9.1 in Kansas and 3.9 in North Dakota. This research will also consider different types of rural communities, for example those with populations under 2,500 residents as defined by USDA.

Focus groups were recruited among the residents living within the identified rural food deserts in Kansas and North Da-kota. To maximize the support and potential benefits, we have partnered with researchers and practitioners of community extension organizations in these regions, including the Kansas Rural Grocery Initiative at the Center for Engagement and Community Development (CECD) at Kansas State University, Center for Community Vitality at North Dakota State Uni-versity and North Dakota Association of Rural Electric Cooperatives Rural Electric and Telecommunications Development Center (NDAREC).

Study Approaches

Aim 1: To frame and examine rural food deserts within the context of rural travel patterns at a regional level with relation to the actual distribution of retail food outlets using a GIS-based spatial network model

This cross-sectional study examines rural food environments at multiple levels, including household, community and regional contexts. The first aim focuses on understanding the bigger picture of rural grocery trip-making using GIS-based network analysis models in order to identify and compare rural food access networks between ‘conventional food desert model’ and ‘network-based food desert model (proposed)’ (Figure 1).

A. Conventiion food desert model B. Proposed model of this study

Figure 1. Conceptual illustrations of food desert study models

Literature ReviewFood desert definitions The term ‘food desert’ was coined in the 1990s to describe the lack of food choices in Scottish housing projects (Hallett IV & McDermott, 2011). This expression, which evokes a powerful image of privation, has been embraced by researchers and policy makers alike. The definitions of food deserts vary substantially. These differences have very practical consequences as an area that may be considered a food desert under one definition may not under another (Apparicio, Cloutier, & Shearmur, 2007). To date, there have been no comprehensive reviews of food desert definitions. As a result, researchers and policy-makers lack structured guidance for setting thresholds to determine food insecurity.

Food desert definitions qualify acceptable food resources in two distinct ways: direct measures or proxy, both heavily influ-enced by data availability. Direct measures focus fundamentally on the availability of food and secondarily on the appro-priateness of that food for a low-income consumer base. Such qualification can be as simple as all stores that sell food, without any additional qualification, even if this includes convenience stores or gas stations that vend food items (Sharkey, 2009). More restrictive definitions focus on the availability of specific types of food, such as fruits or vegetables (Sharkey, Horel, & Dean, 2010), or other definitions of healthy options, even if a fast food outlet (Sharkey, Johnson, Dean, & Horel, 2011). Some direct measures qualify food based on appropriateness by income or culture preference. These definitions include stores that accept public food assistance programs (McDermot, Igoe, & Stahre, 2017), meet cost criteria (Beau-lac et al., 2009; Coveney & O’Dwyer, 2009; Jiao, Moudon, Ulmer, Hurvitz, & Drewnowski, 2012), or offer ethnic offerings (Raja, Ma, & Yadav, 2008).

Proxy measures use a secondary attribute as a proxy for the underlying benefits of the food resource, including gross floor area (Hallett IV & McDermott, 2011 require 30,000 sq ft), status as a national supermarket chain (Apparicio et al., 2007), or shelf space devoted to grocery items (Beaulac et al., 2009). Van Hoesen et al (2012) characterize stores into nine cat-egories: Grocery Stores, Supermarket, Big Box Stores, General Store, Gas Station, Farmers’ Market, Co-op, Farm Stand, and CSA. They emphasize that consideration of the smaller venues is particularly important for an assessment of rural areas and that such inclusion often reduces the likelihood of rural food deserts. They also a prior associated a nutritional ordinal rank to each store type on two attributes: diversity of food items and the level of processing of those food items.

Food desert measures: The food resource threshold has a significant impact on what is considered a food desert. Re-search in rural Texas, for example, found that the average household distance to a supermarket (9.9 miles) (Sharkey et al., 2010). Food desert definitions qualify acceptable access to food resources in terms of the ease of traveling to the resource. The measure of ease (or impedance) is usually travel distance or time often varying by the travel mode. While the food resource definition is often affected by data availability, the food access definition is affected by computational availability – specifically the sophistication of geographic information system (GIS) analysis.

Many food desert definitions determine the access threshold through simply buffering the food resource (Block & Kouba, 2006). This approach, a basic GIS feature, is indifferent to the realities of the transportation network which may make a straight-line distance to the food resource an impossibility. For example, in an urban area, even with a robust road network, a pedestrian may face impassable elements, such as an interstate highway, separating him or her from a food resource. In suburban and rural areas, circuitous or limited road networks may require many more road miles to access a relatively short straight-line distance.

Among studies that consider the reality of the transportation network, different distance thresholds have been used. A one mile distance is common for pedestrians (McDermot et al., 2017; Sharkey et al., 2010) although some studies also include quarter and half mile distances (Russell & Heidkamp, 2011), while driving distances have ranged from three (Sharkey et al., 2010) to five (Sharkey et al., 2010) to, particularly for rural areas, ten miles (Hubley, 2011; McEntee & Agyeman, 2010; Sharkey et al., 2010). Although there is some recognition that driving distance does not perfectly accord with the experi-ence of making the trip which can vary with weather, topography, and road conditions (Hubley, 2011).

This mixed approach is very reasonable since pedestrian speeds are much less variable and most planning studies assume a three miles-per-hour walking pace, which perfectly equates a one-mile walk with a twenty-minute drive. Note criticism of the 10-mile rural standard that does not account for different travel times in mountainous areas like Colorado or Vermont in comparison to Iowa (Van Hoesen et al., 2012). Also, Van Hoesen et al (2012) used network distances to identify the nearest store based on every household and then aggregate those to a township score.

Data Collection and AnalysisMulti-type food store data were obtained through ArcGIS ESRI Business Analyst. These GIS point-based data include geocoded locations, types and other business information related to multi-type food stores were selected using the Stan-dard Industrial Classification (SIC) code 541. The food store data were geocoded into a GIS-based spatial dataset, then the research team has attempted to link these data to the household travel data, collected from the 2009 National House-hold Travel Survey (NHTS) in order to understand the rural grocery trips within a broader context of household travel activities; for example, our team wanted to explore how households link trips into larger chains so that a grocery trip might be connected to a commuting trip home from a work location.

Data availability and limitation: The research team couldn’t compile the basic NHTS data products as well as the add-on NHTS data sets for Kansas and North Dakota but other NCRCRD states such as Wisconsin. The basic products, which are openly available, offer a robust data, but lack geographic specificity. The add-on data, which require signing specific research agreements with the relevant state departments of transportation (DOTs), offer fewer records but are geocoded at the necessary level to support the more detailed GIS analysis of this project. Gathering the critical add-on data was a time-consuming effort requiring much contact with each DOT.

Due to the data availability, the research team conducted limited research on the NHTS-food store analyses for Kansas and North Dakota. However, we extended the scope of this research procedure using NHTS to another NCRCRD state, Wisconsin (Table 1).

Table 1. Food stores and NHTS data and analysis

Data and Analysis Source and Description Proposed ExtendedKansas North Dakota Wisconsin

Food stores GIS-based food store (SIC 54) data collected from ESRI Business Analyst

O O O

Household informa-tion

State-level 2009 National House-hold Travel Survey (NHTS) add-on data

O

Basic food desert analysis

GIS-based simple buffers from food stores (10-mile radius) O O O

GIS-based network buffer (10-mile network service area)

NHTS-food access analysis

GIS-based shortest routes from home to grocery store O

O: The data is avail-able.

1 The Standard Industrial Classification (SIC) is four-digit numerical codes assigned by the U.S. government to business establishments to identify the primary business of the establishment. The research team used the SIC Code 54 (“food store) for capturing all the food retail stores within the study areas. Under the SIC code 54, seven sub-categories are included, such as Grocery Stores (541), Meat and Fish (Seafood) Markets, including Freezer Provisioners (542), Fruit Stores and Vegetable Markets (543), Candy, Nut, and Confectionery Stores (544), Dairy Products Stores (545), Retail Bakeries (546), and Miscellaneous Food Stores (549).

Results and Discussion

After collecting and geo-coding the multi-type food store location data for Kansas and North Dakota using the ESRI Busi-ness Analysts software, the research team conducted the preliminary GIS-based network analyses for identifying the food store service areas and potential rural food deserts for the following specific tasks:

A. Conducting network buffer analyses for identifying service area of rural food stores and identifying differences between network-based and conventional measures of rural food service area.

Conventional model (10-mile simple buffers) Network model (10-mile network buffers)

Figure 2. Food Store Service Area Buffer Comparisons (Kansas)

Conventional model (10-mile simple buffers) Network model (10-mile network buffers)

Figure 3. Food Store Service Area Buffer Comparisons (North Dakota)

Previous studies used street connectivity measures and network distance or network buffer analyses because the actual street network patterns can be different from environmental patterns measured based on the direct point-to-point (as the crow flies) aerial distance or simple buffer measures. Likewise, the above maps show the differences of food service area between conventional model (10-mile simple buffer, highlighted in blue in the map) and network model (10-mile network based buffer, highlighted in purple in the map) (Figure 2 and Figure 3).

Scale: 1: 250,000

Figure 4. Food Store Service Area Buffer Examples (North Dakota)

Figure 4 shows different catchment area patterns of different buffer measures (10-mile simple buffers are blue; and 10-mile network buffers are purple). The images also visualize how the street networks can affect creating network buffers which are different from simple buffer measures in size and in form (Figure 4).

In North Dakota, network buffers are normally smaller than simple buffers in the size of the area as the grocery store ser-vice area (Table 2). And, the results imply that the food deserts (or food service areas) captured by using the conventional simple buffer measures can miss significant parts of rural areas where streets are fewer or scattered.

Table 2. Food Store Service Area Buffer Comparisons

The Size of the AreaFood Store service Area

Simple Buffer Network BufferTotal (N) 405 405Minimum (mile 2) 314.1 83.4Maximum (mile 2) 314.1 220.5Sum (mile 2) 127,210.5 75,648.5Mean (mile 2) 314.1 186.8

Also, using the GIS-based network analyses (shortest route analyses) from NHTS households to the nearest grocery store, our team explored a typical travel distance distribution which can imply food accessibility and food desert in rural areas. Figure 5 shows the distribution of distances from NHTS households in the Wisconsin add-on sample to the nearest grocery outlet using the road network. The vertical lines demonstrate breakpoints at the second and third quartile to show that roughly half of the rural households are roughly 10 miles from the nearest store and more than a quarter are more than 18 miles from the nearest store.

Figure 5. distance to Nearest Grocery Store (Wisconsin)

B. Using the NHTS data, demonstrating the relevance of rural grocery travel, and presenting descriptive statistics on travel differences between rural and urban grocery shopping travel behavior in rural areas.

The best multi-state source of information on travel behaviors in the United States is the National Household Travel Survey (Federal Highway Administration 2009). The most recent NHTS for which data are available was conducted in 2009 and contains data considered complete for 150,147 households across the nation (Federal Highway Administration 2011). These data provide information on all travel by sampled household members for a single day. The survey provides weights at the household, person, and trip level to expand the findings from the sample to the general population.

Since travel patterns are affected by topography and development history, it is often advisable to focus on smaller regions than the nation as a whole. This project only considers data from the Midwest Region established by the U.S. Census Bureau. That region includes the Plain States of North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Wisconsin, Illinois, Indiana, Ohio, and Michigan. The NHTS includes 13,271 complete households from these states.

The NHTS identifies households as either ‘urban’ or ‘rural’ based on their location. Households coded as ‘urban’ are located in urbanized areas, urban clusters, or are surrounded by urbanized areas as defined by the data from the 2000 decennial census. All other households are considered ‘rural’ (McGuckin 2011). 4,371 NHTS households in the Midwest Region, or 32 percent of the total, are coded as rural. This share is substantially larger than for the NHTS as a whole for which 23% of the sample is rural (McGuckin 2011). The NHTS identifies the purposes of travel. This research on food ac-cess considers the NHTS trip purpose category of “Buy goods: groceries/clothing/hardware store” as the activity marker for grocery shopping. The NHTS category is broader but is the closest analogue to the current research purpose.

The analysis of the NHTS Midwest Region sample, as shown below, finds that the probability of making a shopping trip and the duration of an average shopping stay are comparable among urban and rural households. Rural households are 4.5 percentage points less likely to make a shopping trip and tend to spend about a minute longer on any given trip. The more significant variation occurs in the travel necessary to go shopping in the first place. The distance from home to shopping venues for rural households were about 10 miles, roughly twice the 4.9 mile distance reported by urban house-holds. Given the faster traffic speeds in rural environments, the travel times associated with these trips was less diverse with rural households driving 18 minutes to the 15 minutes of urban households. For shopping trips, neither originating at a home or other shopping location, rural households still covered longer distances than urban households (7.4 vs 5.7 miles), but actually spent less time traveling (13.9 vs. 14.5 minutes).

Table 3. Grocery Shopping Trip Pattern Comparisons: Urban and RuralVariable Urban Rural N WeightsProbability that a Household Shops on a Given Day 0.485 0.439 13,721 HouseholdAverage Duration of Shopping Activity in Minutes 34.6 35.6 12,957 TripMinutes from Home to Shopping 15.4 18.2 4,864 TripMiles from Home to Shopping 4.9 10.1 4,864 TripMinutes from Non-Home, Non-Shopping Venues to 14.5 13.9 4,006 TripShopping TripMiles from Non-Home, Non-Shopping Venues to Shopping 5.7 7.4 4,006 Trip

Another area of distinction is the mode used to arrive at the shopping location. Rural households are much more likely to drive; By contrast, urban households report higher shares of walking and transit travel to grocery shopping destinations.

Access Mode Urban Share Rural ShareCar or Truck 89.2% 97.6%Walk 7.3% 1.2%Public Transit 2.1% 0.0%Bike 1.1% 0.3%Other 0.2% 0.2%Motorcycle 0.1% 0.4%Charter Bus 0.0% 0.2%

This variation in acceptable distances and modes used challenges the current conception of rural food deserts. These findings suggest that far from being the definition of a food desert, a ten-mile trip to a store is the norm in rural areas. These high distances are supported by almost universal (98.5 percent) use of private vehicles for grocery shopping pur-poses.

Aim 2: To investigate rural food access barriers and opportunities at local level within identified food desert ar-eas using focus group studies.

Focus Groups:Seven focus groups were held from June 2017 to July 2017 ranging in size from 2 – 10 participants with a total of 49 par-ticipants after the IRB approval. Focus groups took place in several different settings ranging from an elementary school classroom, a meeting room at a county extension office and a city hall conference room. In all settings, chairs were set up in a circle to be more conducive for the flow of conversation. All focus group discussions were recorded and transcribed. Each focus group lasted about one hour. A $20 gift card was offered to each participant in appreciation for their participa-tion.

Study Design:Focus group questions and scripts were designed for exploring the shopping patterns that emerged from focus group participants and the adaptations that participants commonly mentioned. The questions include their grocery shopping pat-terns, frequency of shopping, choice of store, challenges and barriers to grocery shopping while living in rural areas, and family dynamics of who does the shopping, and so on.

Also, our team used travel diaries during the focus group sessions for framing participants’ rural food access and transpor-tation which was specific to the individual’s most recent trip to the grocery store. Each participant was given time to fill out a travel diary. The appendices to this report provide more details about focus group questions and travel diaries (Appendix A).

Focus Group Communities:• Kansas: 19 participants of three focus groups

- Kansas focus group participants were recruited from Lyon County, Kansas (Emporia, Americus, Cottonwood Falls, Hartford and Reading) via Kansas State University Research and Extension.

Figure 6: Kansas Focus Broup Communities

• North Dakota: 30 participants from four focus groups- North Dakota focus group participants were recruited from rural towns surrounding the City of Bismarck (Hazel-ton, Bowdon and Elgin) via North Dakota Association of Rural Electric Cooperatives.

Figure 7: North Dakota Focus Group Communities

Results and Discussion (More details are in Appendix A, Focus Group Results)

Focus groups in Kansas and North Dakota showed that rural residents have habits, patterns and preferences determined by their identity as rural residents. Patterns emerged based on household roles related to grocery shopping, store choice, and shopping frequency. Linking trips was a common strategy for rural residents. Adaptations emerged based around reducing trips to the grocery store and increasing resilience at home. These adaptions included gardening, buying in bulk and storing food. In some ways, these adaptations bond rural residents to the idyllic lifestyle of living off the land that many participants’ parents and grandparents experienced and taught them. Additionally, rural residents detailed specific adaptations derived from the realities of living a rural lifestyle.

From the travel diary results about the most recent grocery shopping trip, 9 Kansas respondents (81.8%) and 17 North Dakota respondents (60.7%) reported the grocery shopping trips were part of their multiple destination trips. Other des-tinations included gym, library, laundry, school, daycare, pharmacy, church, store, hardware shop, hospital or clinic, post office, beauty shop, park, bank, café, other’s home and work place: It should be noted that, among those 26 respondents reporting their multiple destination trips for grocery shopping, 3 respondents visited more than two different grocery stores, even in a distance; and 8 respondents reported that they traveled to grocery stores on their way to (or from) work.

ReferencesApparicio, P., Cloutier, M.-S., & Shearmur, R. (2007). The case of Montreal’s missing food deserts: evaluation of accessi-bility to food supermarkets. International Journal of Health Geographics, 6(1), 1.

Beaulac, J., Kristjansson, E., & Cummins, S. (2009). A systematic review of food deserts, 1966-2007. Preventing Chronic Disease: Public Health Research, Practice, and Policy, 6(3), A105.

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Clifton, K. J. (2004). Mobility Strategies and Food Shopping for Low-Income Families: A Case Study. Journal of Planning Education and Research, 23(4), 402–413.

Coveney, J., & O’Dwyer, L. A. (2009). Effects of mobility and location on food access. Health & Place, 15(1), 45–55.

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McDermot, D., Igoe, B., & Stahre, M. (2017). Assessment of Healthy Food Availability in Washington State—Question-ing the Food Desert Paradigm. Journal of Nutrition Education and Behavior, 49(2), 130–136.e1. https://doi.org/10.1016/j.jneb.2016.10.012

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APPENDIX A: Focus Group Results

Rural Food Access Adaptations: Learning from Focus Group Participants(Manuscript in Progress)

1. IntroductionA critical concern for the sustainability of rural communities is access to food. Food access promotes the health of rural residents as well as the stability of rural areas. These concerns are particularly pressing for weaker social groups with limited means to travel, such as older adults, disabled persons, and low-income households. Effective public policy to enhance rural food access needs to be based on a rigorous understanding of the actual travel and activity behaviors of rural residents. To date, these patterns have been unexplored with the result that policymaking continues to rely on simple, distance-based models of food deserts imported from urban environments – models which may not translate fully to the very different rural context where longer, chained-trips are common. This research seeks to explore the food access patterns of rural residents to better inform public policy. Specifically, this study aims to understand rural food access barri-ers and disparities. This study examines the grocery-related travel of rural residents in Kansas and North Dakota through focus groups.

Walker et al. (2010) conducted a systematic review of studies focusing on 31 food access and food desert studies in the U.S., and summarized four major research categories from the studies, such as access to supermarkets, racial/ethnic dis-parities in food deserts, income/socio economic status in food deserts, and differences in chain versus non-chain stores; however, among 11 articles on access to stores, none focuses on multiple destination travels involving grocery shopping. Also, according to Walker et al. (2010), the focus groups and interviews were ones of the common measures to explore food access. In food desert research, focus group discussions were used to assess specific phenomena and intervention, such as assessing the primary food store or changes in travel behavior post intervention (Walker et al., 2010; Hendrick-son, et al., 2006; Smith and Morton, 2009). Smith and Morton (2009) identified three determinant themes of rural food deserts, including personal and household determinants of food; social and cultural environment; and structure of place or the external environment by investigating seven focus groups in rural Minnesota and Iowa.

This paper explores the shopping patterns that emerged from focus group participants and the adaptations that partici-pants commonly mentioned. The shopping patterns included frequency of shopping, choice of store, and family dynam-

ics of who does the shopping. Two families of adaptations emerged from the focus group conversations; adaptations for resilience and adaptations as necessity.

2. Methodology

This research uses the qualitative focus group methodology to characterize the challenges to accessing food in rural areas and the attendant adaptions. The authors conducted eight focus groups at four venues in Kansas and North Dakota to gather the opinions of 49 participants.

Focus group questions were developed as open-ended questions with prompts for classic content analysis procedures: Focus groups were questioned about their general grocery shopping behaviors and patterns, the challenges they face to go grocery shopping while living in a rural area, and their thoughts and suggestions for improving their accesses to healthy foods. In addition to these transcript-based questions, we included some guiding questions in order to capture the consensus views on key concepts and issues under each open-ended question as noted by Onwuegbuzie et al., (2009) and Crabtree et al. (1993). The detailed guiding questions included the frequency, trip mode, chain trips and other travel behaviors of grocery shopping, and differences and options in choosing grocery stores and healthy foods, and were de-signed for analyses with respect to the conformity of opinion using micro-interlocutor analysis approaches (Onwuegbuzie et al., 2009). (see Appendix A). Also, the travel diary method was employed to capture the trip chaining activities related to the grocery shopping. Studies used a one-day and a multiple-day (i.e., a 6-week or a 7-day) travel diary methods to observe the typical trip patterns and multi-purpose trip routines (Chen et al., 2010; Susilo and Kitamura, 2005; Schlich and Axhausen, 2003; Crane and Crepeau, 1998), but this study employed a one-day travel diary about the most recent grocery shopping in order to reduce recall bias. The questions included all the trip destinations during the grocery shop-ping trip, trip time and mode for each trip, trip day of the week and grocery shopping items. All focus group study protocols were approved by the Kansas State University Institutional Review Board (IRB) in May, 2017.

The focus groups were facilitated and led by a same trained moderator for a consistency in assessment. Total seven focus groups were held during the months of June and July 2017 ranging in size from 2 to 10 participants with a total of 49 participants. Each participant was given time to fill out a travel diary form after the focus group discussion session. The travel diary was specific to the individual’s most recent trip to the grocery store. The travel diary provided an activity for participants while waiting for all participants to arrive and the focus group to begin. It also set the tone of the focus group and helped frame participants’ minds around the topic of rural food access and transportation. Focus groups took place in several different settings ranging from an elementary school classroom, a meeting room at a county extension office and a city hall conference room. In all settings, chairs were set up in a circle to be more conducive for the flow of conversa-tion. All focus group discussions were recorded and transcribed. Transcripts were coded for themes and subthemes, and travel diaries were coded separately for analysis in Microsoft Excel. Each focus group session lasted between 60 and 90 minutes. A $20 gift card was offered to each participant in appreciation for their participation.

Kansas: All three Kansas focus groups took place in Emporia, Kansas located in Lyon County, Kansas. Emporia, Kansas is a city of nearly 25,000 (2015 ACS), surrounded on all sides by rural areas (“Food Access Research Atlas Documen-tation,” 2017) Two of the three Lyon County census tracts are also considered low access. This means that at least 33 percent of the census tract lives more than 10 miles from the nearest supermarket.

The research team partnered with a Lyon County extension agent to recruit participants from rural areas in Lyon County. A recruitment flyer, shown in Appendix 2, was created and posted by the extension office. Additionally, the focus groups were advertised at a Lyon County community health meeting. Table 1 and Figure 2 detail the communities where focus group participants resided.

North Dakota: A total of four focus groups were conducted in North Dakota in three different localities. These three lo-calities were Bowdon, Elgin and Hazelton, ND, located 100, 175, and 50 miles away from Bismarck, ND, respectively. All three towns are considered to be rural (“Food Access Research Atlas Documentation,” 2017). Each town had a rural grocery store. All three towns are located within census tracts with Low Access, as described above, to grocery stores. Hazelton is also considered low income meaning that the poverty rate of the census tract is at least 20 percent or that the median family income for those in the census tract is less than 80 percent of the state’s median income (“Food Access Research Atlas Documentation,” 2017).

The research team partnered with the North Dakota Association of Rural Electric Cooperatives (NDAREC) to locate com-munities within 1-2 hours of Bismarck, North Dakota. NDAREC works with rural communities in North Dakota and con-nected the research team to community members in each town. Each North Dakota town had a community liaison that secured a location for the focus group(s) and invited community members personally.

In total 19 people participated in the three Kansas focus groups and 30 people participated in the four North Dakota focus groups. Participants were mostly female. Focus group participants represented a range of households and life stages. Most participants lived with at least one other adult. In Kansas, a majority of participants had children in their household, while in North Dakota, only one quarter of participants had children living in their home. Differing recruitment strate-gies and focus group locations may contribute to this discrepancy. Reported household sizes ranged from one to eleven people.

3. Analysis

Coding of transcripts was systematically conducted by the same research team members, and themes were identified considering commonalities and differences between states and communities. Mixed methods were used to analyze the qualitative data. For discussion related to trip patterns and behaviors, the Micro-Interlocutor Analysis approach was used. This approach aims to identify the sentiment of focus group participants as it emerges during a discussion. For the con-versations related to challenges, the classic content analysis approach was used. The classic content analysis approach applies coding schemes to transcriptions in order to identify themes. (Onwuegbuzie, Dickinson, Leech, & Zoran, 2009). These two analysis strategies were useful in sorting the vast amount of information gleaned from the focus group conver-sations.

4. Findings

Challenges

Focus group participants identified several challenges of access food while living in rural areas. The most prominent chal-lenge was, unsurprisingly, the relatively large distances to traverse between home locations and grocery stores. These long distances exacerbate the traditional trade-offs between cost, convenience, and variety. For example, many focus group participants did not live in a town with a local grocery store forcing residents to travel for purchasing food. Even when towns did have a local grocery store or convenience market, these outlets were not able to carry all the products they desired, forcing residents to travel for as, one resident described, “the exotic stuff that nobody else wants.” Partici-pants cited such “weird things” (to use the phrase of another participant) as artichokes, sugar-free and gluten-free prod-ucts, chicken breasts, etc. These distances also increase the risk of weather disrupting food access. For example, partici-pants reported not purchasing certain frozen items, such as ice cream, in the summer for fear of them melting on the long trip home. Conversely, participants noted that winter snow might make roads to grocery stores impassable for periods of time.

Adaptations

Focus group participants reported a mix of adaptation to address the challenges inherent in accessing food from a rural area:

Store-Spreading Rural residents spread their shopping across multiple stores. On average, participants mentioned shop-ping at three different venues. Many respondents reported frequenting convenience marts tied to local gas stations, such as the Casey’s chain, or to using local, rural grocery stores when available. For some participants, these venues were suf-ficient to serve their entire needs. For one North Dakota resident, the time spent travelling to Bismarck to get better prices was not worth it. She declared, “I’d sooner pay more than have to do that[drive in to Bismarck for groceries shopping.]” For many others, these local venues were insufficient and were complemented by trips to more distant larger venues.

It’s just the chicken breasts. You can get a great big pack [at Target], I eat chicken for every single meal, so, for me, it’s just more convenient and easier. You can get chicken breasts here[Elgin] once in a blue moon or you’ll get like thighs or stuff like that. I only like the breasts, I don’t like any skin on it. And if you get it here, you only get 1 or 2 in a pack, so I can get like 9 or 10 in a pack and that lasts me 2 weeks.

Shopping at multiple venues also allowed for more price discrimination. One participant described how every week she would receive a newspaper that listed the specials at the different stores in her region and she would use that information to determine where to shop.

Participants with access to local grocery stores do value that availability regardless of their shopping elsewhere. These venues were often seen as critical back stops to food security. One mother with four kids at home described using the local grocery as a back up. She explained, “A lot of times, I’ll miscalculate how much milk we need, how much vegetables[when shopping in Bismarck] and then I’ll go [to the Bowdon Community Grocery].”

North Dakota participants acknowledged the importance of having their rural grocery store in town open during the winter months. Times when inclement weather means it would have been difficult to drive out of town for groceries, one mother said, “ Thank goodness for the grocery store, we would’ve starved, my children would have been eating like cereal and potato chips, I guess, for weeks on end.”

Characterized as independently run, sometimes community-run stores, rural grocery stores clearly provide an important grocery option. Several rural groceries stores offered store credit to their customers. This helped store owners to minimize credit card fees and also allowed customers to pay for groceries on a more flexible schedule. Unfortunately, rural grocer-ies are not able to provide everything. Rural grocery stores are typically smaller than grocery stores in larger cities. Par-ticipants noted that specialty items like gluten-free and sugar-free options tended to not be available at their rural grocery stores. Quality of produce was often mentioned as a needed improvement. On the other hand, participants appreciated the smaller layout because they knew exactly where everything in the store is located and were able to be in and out of the store quickly.

I have found that there was something I wanted when I was in Bismarck, couldn’t find it, couldn’t find it, couldn’t find it, come down here, and there it was.

When considering potential for expansion of product mix in rural grocery stores, focus group participants cited concern with the grocery store being able to make money off new items. There’s also concern for stepping on toes within the community. For example, one participant suggested the rural grocery store sell coffee and cookies, but others in the focus group felt this might hurt the restaurant down the road that, similar to the grocery store, is, “just trying to make it.” In general participants seemed to agree that it was not realistic to expect the rural grocery store to supply everything for everyone in the community.

One North Dakota participant described her thought process when travelling into Bismarck for work:

If I have the energy, I will probably stop at one of the grocery stores and bring a few things home just because I don’t have to come to town to go home. I have a shortcut and if I needed groceries, I’d just pick them up on the way home, but it’s not a habit, I really try to do my business in town[Elgin] because it’s really important to me to have that store [Jude’s Prairie Mart in Elgin].

For older populations, focus group participants relayed that they prefer visiting store closer to their home so as to mini-mize driving. Older adult participants also acknowledged that their appetites are smaller than they used to be. Thus, their grocery shopping needs are also smaller, making it harder to justify the trip into a big city for food. One older participant said this:

Well I am single, so that means no matter where I go to purchase [groceries], I don’t purchase a lot of food because I’ll probably end up throwing it out. But I try to do most of mine here[at the local grocery store], but if there’s something that [the local grocery store] does not have, then it would be Linton or maybe I’ll go into Bis-marck for a medical appointment or something like that, then I’ll probably stop in at Cash Wise or SuperValue, whichever one is closest to where I’m at.

When seniors do drive into the larger city of Emporia or Bismarck, these shoppers preferred stores with smaller footprints, like Aldi, as opposed to supercenters like Walmart. One focus group participant described her mother’s feelings related to grocery shopping at supermarkets, “I think of my mom who says, ‘I can’t go shopping in those stores. It’s too big, it’s too much parking, it’s too busy in Bismarck to navigate.’”

Trip-Chaining Most of the focus group participants reported that they always linked their grocery shopping trip to other trip purposes. In the parlance of transportation planning, people make tours away from and returning to a given anchor, typically a home location. A simple tour consists of a trip from the anchor to a destination and back again. A complex tour consists of additional destinations linked together to create a ‘trip chain.’ Focus group participants living in rural areas without a local grocery store almost always reported incorporating their shopping trips within complex tours. Two tour pat-terns emerged: chaining a grocery shopping trip to a tour made for another primary purpose, such as work or a medical appointment, and chaining other trips to a tour made for the primary purpose of grocery shopping.

The first type, a more common adaptation, was typically made during weekdays. These grocery shoppers shopped more frequently during the week, purchased fewer items per trip, and tended to visit the store closest to their home or work-place. The permutations of these chains varied. Some participants shopped during their lunch break and took advantage of the availability of refrigeration at their work place to temporarily store perishables before going home. Other participants mentioned more traditional shopping after work on their way home. For example, one participant mentioned always shop-

ping after going to the gym as a mechanism for maintaining her and her family’s healthy diet. Parents with responsibilities for picking up school age children reported shopping either before or after pick-up. This pattern was not limited to tours whose primary purpose was work. One retiree mentioned that whenever she comes to town, for example to see her doc-tor or visit a friend, she always tacks on a grocery trip.

The second type, chaining additional trips to a grocery shopping tour, was typically made during weekends. These gro-cery shoppers tended to make fewer shopping trips, purchase more items per trip, and travel farther to places with more grocery stores, and shop and multiple venues on the same trip. These trips were almost always linked with other needs like shopping (clothes, office supplies), family visits, medical appointments, and recreation or entertainment activities. One participant stated, “I don’t ever make a trip just to the grocery store in Bismarck. When I go to Bismarck, I got other things to do.” For families with kids, the weekend shopping trip tended to be pared with some sort of recreational activity like the library, the zoo or a meal out. For these participants, shopping was the activity that framed a family excursion.

Trip chaining was typically a strategy used to access more distant, more expansive grocery outlets. Rural residents economize on their travel by ensuring that the time and money cost of driving a longer distance optimizes its benefit. For residents with access to a local, rural grocery store, trip chaining to a distant shopping venue was still a common strat-egy to access more specialty items. One participant described these items as,” the exotic stuff that nobody else wants.” Another called them the “weird things” like artichokes. This reliance on multiple shopping venues represents another com-mon adaptation.

Keeping a Cooler in the Car Weather impacts what people purchase at the grocery store. Many focus group participants keep a cooler in the car to use during shopping trips. Several participants mentioned that purchasing ice cream in warmer months, even with a cooler, is difficult. Another mentioned that they will not buy chicken when they have an hour drive back from the store because an appropriate temperature can’t be guaranteed. Even with the coolers, there’s a limit to how much cold storage products one can buy on each grocery store trip and participants were aware of this.

Bulk-Purchasing One solution to the high cost of traveling to grocery stores for rural residents is to buy food in bulk. This adaption was alluded too earlier in the section on store choice, but it extends beyond direct grocery store purchases. One-third of focus group participants indicated that they purchase meat in bulk. This included beef, pork, chicken and lamb that they purchased about once a year then stored in a freezer. Opportunity to purchase meat in bulk was readily available in these communities due to their rural nature. In some cases, participants or their family members raised animals that they could pay to have processed.

“We also own cattle so we can go get a half a, you know we don’t have to pay for meat, so which is your main expense and we have a freezer full of meet every quarter or whatever it is, twice a year maybe. You know, it works for us.”

The benefit to purchasing in bulk is the decreased cost per pound, however, the units of purchase are quite large. One participant mentioned that her family of 4 purchased half a cow for $2.50 per lb. Weighing in at more than 650 lbs, this family spent more than $1600 on beef at one time.

Participants discussed the seasonality of buying meat in bulk, “Usually in the fall, I buy it[meat] and it’s enough for winter and usually in the summertime you can buy brats and hamburger.”

Garden Growing Another adaptation is to maintain a vegetable garden. About half of participants maintained a vegetable garden. Vegetable gardens supplement fresh produce in the household. Half of those with a vegetable garden also indi-cated canning and/or freezing garden items to use later in the year. One participant mentioned that the garden has a posi-tive economic impact on her household’s grocery bill, it helps “on the back end if you have some of the [garden] spaghetti sauce in the freezer that you can make spaghetti with in January and you may only have to buy noodles.” The garden also acted as a stopgap for times when the pantry is running low and the next grocery trip is still a few days away. Those that didn’t freeze or can their garden excess indicated that they donate or share with neighbors.

Food Warehousing Participants indicated needing to have additional storage space to accommodate preserving and freezing food. Additional appliances, mostly freezers, were used to accommodate large quantity of bulk meat and frozen garden excess. One single person admitted to having 3 freezers for just herself, but was in the process of emptying one freezer. Considering rural food access on a low income, one participant reflected, “If your electricity might get cut off on a regular basis because you can’t pay the bill, then what good is your refrigerator or freezer?”

Also need to have space to store canned and jarred items.

A food desert isn’t so difficult if you have enough money to buy in bulk, I mean not bulk, but in quantity, I should say, and you have transportation and you have storage.

All three of these adaptations require advance planning, know-how, and financial resources.

Non-Adaptations

The researchers thought that rural residents might take advantage of additional adaptions, namely coordinating food pur-chases and online shopping. However, neither were much used.

Online shopping for groceries was not common in this participant group, however, online shopping for other items was more common. The convenience of having items delivered directly to your front door was listed as a benefit for online shopping. Participants mistrusted the ability for online grocery items to be delivered and handling safely and properly. One participant in North Dakota mentioned that a new contract for Amazon deliveries to be delivered through United States Postal Service (USPS) instead of United Parcel Service (UPS) presented challenges to her community. The USPS ve-hicles are unable to haul all of the packages on their regular route, so instead, USPS is leaving messages for residents to pick up their package(s) at the Post Office in town. For those residents, having to drive into town to pick up their package defeats the point of shopping online and having the items shipped directly.

One adaptation that we anticipated hearing frequently was that of rural residents sharing the burden of shopping in the bigger city by offering to shop for each other and trade off the task of driving to Bismarck or Emporia. Participants did not mention this, however, one participant mentioned that on weeks when her daughter comes to visit from a bigger city, her daughter will call ahead to ask if any grocery items are needed.

Grocery shopping trip pattern: Results from the travel diary

Using a one-day travel diary for the most recent grocery shopping, travel mode (from and to the grocery store), travel des-tination (including multi-destinations), travel time, and shopping item data were captured. 11 Kansas and 28 North Dakota focus group participants responded to the follow-up travel diary investigations.

9 Kansas respondents (81.8%) and 17 North Dakota respondents (60.7%) reported the grocery shopping trips were part of their multiple destination trips. Other destinations included gym, library, laundry, school, daycare, pharmacy, church, store, hardware shop, hospital or clinic, post office, beauty shop, park, bank, café, other’s home and work place: It should be noted that, among those 26 respondents reporting their multiple destination trips for grocery shopping, 3 respondents visited more than two different grocery stores, even in a distance; and 8 respondents reported that they traveled to gro-cery stores on their way to (or from) work.

The maximum total travel time of grocery shopping (round-trip) was 140 minutes and the minimum travel time was 2 min-utes. 14 respondents spent more than 30 minutes for their grocery shopping trips; 5 respondents traveled more than one hour, including a longer trips to the closest large city like Kansas City, KS and Bismarck, ND. The median total travel time for grocery shopping (round-trip) was 20.0 minutes including multiple destination trips (mean: 29.6 minutes). However, the grocery shopping travels without multiple destinations took median 15.1 minutes (mean: 10 minutes). The total travel times of the respondents visited more than two grocery stores were ranged from 25 minutes to 80 minutes.

From their recent grocery shopping, the most purchased item was fruits (30 responses) and the least purchased was meat and bean (18 responses). Participants also reported purchasing grain (25 responses), vegetables (25 responses) and milk (23 responses).

Discussions

One limitation of this research was in the recruitment of rural participants. The mechanisms used to target rural residents were effective in attracting rural residents to the focus groups, but were not exclusive to urban residents. While all adver-tising include reference to “rural food access,” this supports evidence of confusion related to the definition of “rural.” The USDA Food Environment Atlas follows the “Census Bureau’s urbanized area definitions, where rural areas are sparsely populated areas with fewer than 2,500 people, and urban areas are areas with more than 2,500 people” (“Food Desert Locator Documentation,” 2013). This research focused on access to food without a focus on income level. Many of the adaptations identified in this study required a steady income. Future research could focus on the transportation and shop-ping patterns specifically of low-income, rural individuals.

ConclusionFocus groups in Kansas and North Dakota showed that rural residents have habits, patterns and preferences determined by their identity as rural residents. Patterns emerged based on household roles related to grocery shopping, store choice, and shopping frequency. Linking trips was a common strategy for rural residents. Adaptations emerged based around reducing trips to the grocery store and increasing resilience at home. These adaptions included gardening, buying in bulk and storing food. In some ways, these adaptations bond rural residents to the idyllic lifestyle of living off the land that many participants’ parents and grandparents experienced and taught them. Additionally, rural residents detailed specific adaptations derived from the realities of living a rural lifestyle. These realities include transporting groceries in heat and cold. It also means that rural grocery stores are an opportunity to support a local economy, while accepting that the store is not going to have every item needed.

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APPENDIX B

FOCUS GROUP PROTOCOL

Introduction and Background

Hi. My name is [moderator’s name]. We are a research team from Kansas State University and doing research about rural food access.

Food access is important because better food access is associated with healthier diets and lower obesity rates. We think unreliable or nonexistent public transportation is a barrier to food access, especially for rural communities. The purpose of our study is to understand rural food access barriers and disparities within the context of rural travel behavior. For this research, we are working together with the K-State Center for Engagement and Community Development, K-State Research and Extension, North Dakota State University Exten-sion and North Dakota Association of Rural Electric Cooperatives.

Participant Consent Form [both written form and verbal instructions by the moderator]

This focus group study will be conducted for understanding your general grocery shopping behaviors and barriers to healthy food ac-cess. Several questions will be asked to each of you during the interview in a round table manner, and you will fill out the grocery shop-ping diary after the interview. Each participant has an opportunity to answer each question. It will take approximately less than an hour, and your responses will be audio recorded.

Your names or any personal information will not be identified with any information collected during this study without your written per-mission. All the information gathered from this study will be kept confidentially and used only for research purposes. Your participation will be crucial to the success of this research. This study is completely voluntary and you may withdraw your participation at any time without any explanation, penalty, loss of benefit or academic standing to which I may otherwise be entitled. Please feel free to contact our research team with any question or concern.

Thank you so much for your participation.Elena Aronson Hyung Jin Kim, Ph.D Gregory Newmark, Ph.D. Project Coordinator Assistant Professor Assistant ProfessorKinesiology Landscape Architecture and Landscape Architecture andKansas State University Regional & Community Planning Regional & Community Planningaronson@ksu.edu Kansas State University Kansas State University 773-726-4310 hyungjin@ksu.edu gnewmark@ksu.edu 979-739-1405 510-282-8413

Terms of Participation

I verify that my signature below indicates that I understand this consent form, and willingly agree to participate in this study under the terms described, and that my signature acknowledges that I have received signed and dated copy of this consent form.

Participant Name: _________________________________Participant Signature:_________________________________ Date:______________Witness to Signature (Project Staff):_____________________ Date:______________

Questions

We are interested in understanding how households in rural areas make trips for grocery shopping. Before we begin, please take a minute to think about how your household acquires groceries – including the different places your household shops, which household members do the shopping, how often shopping trips are made, if those trips are part of other activities (e.g. shopping after work) or stand-alone trips, if you shop for certain things at only certain places, etc. It might be helpful to make a list of all grocery shopping trips, if any, your household made over the last week. Please take a minute to think over it or note your experiences on the paper.

Now, please tell us about your grocery shopping patterns? How would you describe your household grocery shopping?

[Prompts]

1. How often do household members go grocery shopping?a. Frequency? [Daily, Weekly, Bi-Weekly]b. Variations? [e.g. Drive to Costco seasonally, but Dillons daily]

2. How many different venues do they frequent?a. Could you describe these different places [supermarket, local store, convenient mart, drugstore, farmer’s market]

3. How do you choose which place to buy groceries?4. How far away are these different places from your house?5. How do you get to these places?

a. Do you chain your grocery trip with other trip purposes (e.g. church or work)?b. Do you ever take transit or catch a ride with someone from another household?

6. Who does the shopping for your household?a. Does anyone outside the household make grocery purchases for you?b. Do any social services provide access to groceries?

What are the challenges you face to go grocery shopping while living in a rural area? Could you describe any clear barriers?

1. Do you find the distances to shopping locations to be a burden?2. Are there local shopping options?

a. Do those options have healthy foods?b. Do those options charge more?c. Do you produce any of your own food? If so, please describe.d. Do you use any social media (e.g, Twitter, Facebook), blog or online website for your grocery shopping?

3. Do you feel like you generally have access to healthy foods? (1~5 points scale)4. Do you think your grocery market has sufficient food options?

a. If not, what items are not sufficient?

Now we would like you to think about policies that might improve your access to healthy foods. What would make the grocery shopping experience better for you?

Grocery Shopping Travel Diary

The following diary is to record your recent grocery shopping trips. Please answer each question on the diary. If you have any question, please let me know.

Recuritment flyer used for Kansas focus group

APPENDIX C: IRB Approval Letter

Appendix C: Demographic Data

Kansas

Community Name Americus Cottonwood Falls Hartford Reading

County Lyon Chase Lyon Lyon

Population* 841 939 384 298

Median Age 44.2 44.2 42.3 29.3

Average Household Size 2.27 2.9 2.28 3.27

Mediam Household

Income $40,455.00 $ $46,250.00 $38,393.00

Source: 2015 ACS

Kansas

Community Name Reading

County Lyon

Population* 298

Median Age 29.3

Average Household Size 3.27

Median Household

Income $38,393.00

North Dakota

Community Name Bowdon Elgin Hazelton Bismark

County Wells Grant Emmons Burleigh

Population* 123 600 223 66,980

Median Age 65 54.7 42.5 37

Average Household Size 1.68 1.85 2.03 2.19

Median Household

Income $33,750.00 $35,625.00 $29,615.00 $58,901.00

Source: 2015 ACS