Despite the geographic, ethnic and cultural differences in these two diverse urban cities, we saw a number of commonalities that reflect a need for continued attention to improving access to healthful food. Across both cities, supermarkets typically provided the best variety and quality of fruits and vegetables for a comparable or lower price, underscoring the importance of access to supermarkets for healthful foods. Convenience stores had the highest prices in both cities, and were more common in more deprived areas.
Honolulu census tracts included in the study tended to be higher income and more ethnically diverse than the Kansas City neighborhoods. Consistent with Kansas City and previous research, Honolulu store types varied by income, with more convenience and small grocery stores in the lowest income quartile.2,33
Incivilities such as trash and dirt on floors were more likely at these types of stores. In contrast to Kansas City, and previous research,2
the lower two income quartiles in Honolulu contained most of the supermarkets. Unlike Kansas City, Honolulu did not have a proliferation of liquor stores that sold food in lower income areas. In both Honolulu and Missouri, liquor can be sold in any commercial store with a liquor license; however, in Kansas, beer, wine, and spirits can only be sold at a retail liquor store, except for on Sundays, when no liquor is sold in stores.34,35
As might be expected from these policies, the majority (78%) of the liquor/convenience stores in the Kansas City study were on the Kansas side of the study area. A greater number of pharmacies were found in the higher income areas in both studies. Although they had a low availability of healthful food, their produce was reasonably priced in Honolulu. It is unclear why pharmacies had lower prices, a question for further inquiry. Farmer’s markets were more evenly distributed across income quartiles but had infrequent hours of operation, and may only provide limited access to fresh produce.
Only 25% of Kansas City’s ethnically dense HD neighborhoods had a supermarket, similar to what others have found.36
In contrast, Honolulu had the second highest number of supermarkets in the census tracts with the highest percentages of minority residents. At the same time, these areas also had the fewest convenience stores and pharmacies. Produce availability was higher at farmers’ markets, small grocery stores, and supermarkets than at conveniences stores and pharmacies in Honolulu. Supermarkets also had significantly higher availability than grocery stores. Previous research has shown similar high availability for supermarkets and low availability for pharmacies and grocery stores.18,19
Fewer than 20% of stores in both cities were open 24 hours. In Kansas City, these were all convenience stores, whereas in Honolulu, they also included supermarkets and pharmacies. This picture may have been different if all Honolulu convenience stores were assessed in all census tracts rather than a sample. Rather than simply indicating whether a store was open 24 hours as in the Kansas City Study, in Honolulu we assessed the opening and closing hours of each store both on weekdays and on weekends. We found that grocery stores were open significantly fewer hours than supermarkets, pharmacies, and convenience stores. Although residents might have access to healthful foods in a nearby grocery store in Honolulu, there were only limited hours within which to make purchases.
The availability of fruit was similar for both studies, but the availability of fresh vegetables was lower in Kansas City neighborhoods than Honolulu census tracts (25%–50% as compared to 81%). The quality of fruit in Kansas City was typically lower for HD neighborhoods. Although this result was not found for the lower income quartiles in Honolulu (i.e. most farmer’s markets and supermarkets had high quality produce),37
in both cities, produce ratings were highest at supermarkets and lowest at ethnic (Kansas City) or convenience (Honolulu) stores. Perhaps the lower quality of fruits and vegetables contributes to lower demand and a longer shelf life for the produce items. This might explain the slightly lower costs for fruits. It is impossible to know whether this reflects resident demand, although availability has been associated with greater consumption.38
The lack of availability in Kansas City may reflect more global issues such as perceived
lack of interest among residents that in turn contributes to lack of marketing to urban stores in low income areas. Perhaps merchants of small stores prefer to stock items that are accompanied by slotting fees or other promotional strategies. Ecologic remedies at multiple levels are needed to produce sustainable access to healthful foods. Taken together the current two studies and previous findings underscore the importance of supermarket access for high quality fruits and vegetables.
We found some direct support for the notion that residents in deprived, high ethnic concentration Kansas City neighborhoods may pay more for commonly eaten foods in that milk and eggs tended to cost about $.25 more on average in these areas compared to more affluent areas. On the other hand, sugary cereal was cheaper in the HD neighborhoods. Skinless chicken breasts and lean ground beef were only available at supermarkets in both cities. Access to low fat, skim and soy milk was much greater in Honolulu, possibly reflecting a statewide social marketing campaign to reduce the consumption of whole and 2% milk.39
Further, convenience stores, the most commonly seen store in both cities’ impoverished neighborhoods, consistently had the highest prices on produce. Consider that if one pound of the six fruits and vegetables measured were purchased every week for one year, then shopping at a convenience store in Honolulu would cost $575 as compared to $434 at a pharmacy or farmers’ market.
The direct cost of food may influence food preferences and purchase patterns.42,43
Lack of conveniently available high quality, healthful foods suggests that residents have to pay more indirectly
in terms of travel related costs, including time, especially costly if one has limited transportation opportunities. The indirect costs may be even greater barriers to affording a ready supply of healthful foods above and beyond measurable differences at the cash register. Taken together, the results from the two studies indicate the best produce scenarios are at farmers’ markets and supermarkets, although access to both places may be limited. Prices may be higher at supermarkets compared to farmers’ markets, particularly as fuel prices associated with transportation increase. The average supermarket vegetable travels many miles compared to farmers’ market produce that is typically locally grown and processed.
These studies used different sampling strategies that may have contributed to variability in the findings. However, many commonalities were found across the studies in terms of cost and availability suggesting that triangulation of methods is strength of this work. Broader geographic sampling would help determine whether these findings are generalizable to other locations, and longitudinal work is needed to determine the dynamic nature of the food environment. These studies only provide a cross-sectional picture of the food environment, and rely on census data to determine ethnicity and income. As census data are only collected once a decade, it is possible that migratory patterns may change the demography of neighborhoods. These studies were not able to assess these longitudinal factors. The Food Stores Assessment was developed for broad applicability while still providing a brief assessment suitable for a range of assessment needs; however, it did not access the full range of potential products and was only able to capture a relatively limited assessment of quality and price. Future efforts may compare how pricing per item, per pound or other quantity may impact consumer behavior. Further research might examine of culturally relevant factors that influence food preferences and available food options. Surveyors in both cities reported that grocery stores in more deprived areas with higher immigrant populations sold additional vegetables that were obviously popular items as shown by their quantity. Future research is needed to understand the relationship between available healthful foods and food purchasing habits.
These two studies tell two stories. The first is that of relatively poor access to fresh fruits and vegetables and other healthful foods in urban settings, regardless of the underlying mechanism of accessibility. The second is story of the development of an instrument and protocol. Despite a growing interest in research focusing on an obesogenic environment, there has been little attention to developing widely acceptable protocols for systematically assessing the food environment that can be used to compare across settings and document progress. This study demonstrates an assessment tool and protocol that have been adapted and tested in two unique urban settings, and thus may be more easily used in other settings as well. These findings suggest that an optimal food environment providing ready access to attractive, available and low cost fruits and vegetables was not found in either city, resulting from lack of stores selling products, lack of sufficient hours of operation, or higher costs in the available stores. Public health interventions and messages that emphasize eating a variety of foods, including 5 to 9 fruits and vegetables every day,1
will have little impact if there continue to be the same problem of limited access to these foods, even if the underlying cause is different. Increasing the availability of fresh fruits and vegetables might be enhanced by working directly with local Farm Bureaus and store merchants to enhance offerings. Given the complexities involved in availability, access and cost, a coordinated approach that capitalizes on regional strengths is important for sustained availability.