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Food deserts and perceptions of food access in urban low-income areas

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Food deserts and perceptions of food access in urban low-income areas

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Food Deserts and Perceptions of Food Access in Urban Low-Income Areas
by
Brittany Fetkin

Rossier School of Education

University of Southern California

A dissertation submitted to the faculty

in partial fulfillment of the requirements for the degree of

Doctor of Education

December 2021

© Copyright by Brittany Fetkin 2021
All Rights Reserved

The Committee for Brittany Fetkin certifies the approval of this Dissertation

Bryant Adibe
Alison Muraszewski
Kimberly Hirabayashi, Committee Chair

Rossier School of Education
University of Southern California
2021

iv
Abstract
The study looks at participants’ knowledge and perceptions about nutrition and healthy food
availability in urban low-income areas in Southern California by using Albert Bandura’s (1998)
social cognitive theory as it relates to health promotion. Exploratory analyses of this study
indicate that majority of participants presented to have knowledge of nutrition and its importance
to health and prevention of chronic illnesses. Majority of the participants’ perceptions of healthy
food access, regardless of income level, were that fresh produce and foods are costly and require
a time commitment to prepare. Individuals in the lower income brackets tend to purchase food
based on what they can afford, and which items are on sale. When it comes to effects of the
COVID-19 pandemic on food consumption, many participants’ included aspects of mental
health, changed eating habits from pandemic induced stress and less grocery trips resulting in
increased purchasing of nonperishable foods. This study highlights how food consumption may
be affected by the increasing socioeconomic gap and contributes to social equality through
nutrition.

v
Dedication
To my family, I would like to thank you for your positive words, open ears, and unfaltering
belief in me. To my father, I am grateful for the self-discipline and work ethic you instilled in me
at a young age. It was truly discipline and incremental progress that enabled me to finish this
dissertation. To my mother, I am thankful for your love and emotional support. Your compassion
for others inspires me to be a better person and to always see the good in this world.

vi
Acknowledgements
Throughout this dissertation journey I have received an overwhelming amount of support
and encouragement. I would like to express my intense gratitude to the mentor who took this
journey with me, my dissertation chair Kimberly Hirabayashi, Ph.D. Dr. H you are a brilliant
educator, mentor, and friend. I am truly grateful for the consistency, understanding, and
positivity you brought to all our meetings. You made conducting a study during a pandemic
achievable.
I would like to thank my wonderful dissertation committee Bryant Adibe, M.D., and
Alison Muraszewski Ed.D. I appreciate the time you put into reading my dissertation and the
invaluable feedback you provided. I am thankful for Evelyn Castillo, Ed.D. and her willingness
to read drafts during the weekend write workshops. The collaborative support I received from all
the professors during my coursework at USC contributed to this accomplishment.
I am humbled by the Chief Medical Officer at Vista Community Clinic, Sarah Fatland D.O., and
her willingness to help and graciously extend their organization to assist with data collection. I
am thankful for the organizations Vista Community Clinic, Catholic Charities, Orange County
Food Bank, Hunger Action LA, and various social media support groups for their contribution
and selfless work to improve the lives of others. I would like to thank the individuals who
participated in the survey. It is your answers that give me hope for change.

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ........................................................................................................................................v
Acknowledgements ........................................................................................................................ vi
List of Tables ................................................................................................................................. ix
List of Figures ..................................................................................................................................x
Chapter One: Overview of the Study ...............................................................................................1
Context and Background of the Problem ............................................................................ 3
Purpose of the Project and Research Questions .................................................................. 4
Importance of the Study ...................................................................................................... 5
Overview of Theoretical Framework and Methodology .................................................... 5
Definitions ........................................................................................................................... 7
Organization of the Dissertation ......................................................................................... 7
Chapter Two: Literature Review .....................................................................................................8
Challenges of Food Deserts ................................................................................................ 8
Personal Understanding of Nutrition ................................................................................ 12
Food-Related Behavior ..................................................................................................... 19
Environmental Influences ................................................................................................. 21
Conceptual Framework ..................................................................................................... 30
Summary ........................................................................................................................... 33
Chapter Three: Methodology .........................................................................................................34
Overview of Design .......................................................................................................... 34
Research Setting ................................................................................................................ 35
Data Sources ..................................................................................................................... 37
Data Collection Procedures ............................................................................................... 39
viii
Ethics ................................................................................................................................. 39
Data Analysis .................................................................................................................... 40
Validity and Reliability ..................................................................................................... 41
Chapter Four: Results ....................................................................................................................42
Research Question 1: What Are the Participants’ Knowledge of Nutrition and
Healthy Diets? ................................................................................................................... 47
Research Question 2: What Are the Participants’ Perceptions of Healthy Food
Access? ............................................................................................................................. 56
Research Question 3: How Has the COVID-19 Pandemic Affected Participants’
Perceptions of Healthy Food Access? ............................................................................... 61
Summary ........................................................................................................................... 66
Chapter Five: Recommendations ...................................................................................................68
Discussion ......................................................................................................................... 68
Recommendations for Practice ......................................................................................... 74
Limitations and Delimitations ........................................................................................... 78
Recommendations for Future Research ............................................................................ 80
Conclusion ........................................................................................................................ 81
References ......................................................................................................................................83
Appendix A: Survey Protocol ........................................................................................................95
ix
List of Tables
Table 1: Demographics by Income ............................................................................................... 44
Appendix A: Survey Protocol ....................................................................................................... 95

x
List of Figures
Figure 1: Conceptual Framework ..................................................................................................32
Figure 2: Responses to Q.19 (Good Nutrition Is Important to Overall Health) by
Education Level .............................................................................................................................48
Figure 3: Responses to Q.18 (Eating More Plants and Vegetables Can Reduce My Risk of
Cancer, Diabetes, Obesity and Heart Disease) by Annual Income ................................................49
Figure 4: Responses to Q.16 (I Prefer Fast Food Over Cooking at Home) ...................................50
Figure 5: Responses to Q.12 (I Eat at Least 5 Servings of Vegetables Every Week) by
Annual Income ...............................................................................................................................51
Figure 6 Responses to Q.20 (I Feed My Kids the Same Food That My Parent/Guardian
Fed Me) by Ethnicity .....................................................................................................................52
Figure 7: Responses to Q.13 (There Are Aspects of My Diet I Would Like to Change if I
Could) by Annual Income ..............................................................................................................53
Figure 8: Responses to Open-Ended Q.17 (Describe the Types of Food You Eat on a
Weekly Basis) ................................................................................................................................55
Figure 9: Responses to Q. 11 (Fresh Fruits and Vegetables Are Expensive) by Annual
Income ............................................................................................................................................57
Figure 10: Responses to Q.9 (I Have No Problem Getting to the Grocery Store and
Buying the Food I Want) by Annual Income .................................................................................58
Figure 11: Responses to Q.15 (I Buy Food Based on What I Can Afford) by Annual
Income ............................................................................................................................................59
Figure 12: Responses to Q.21 (My Food Options Have Changed Since the COVID-19
Pandemic) by Annual Income ........................................................................................................62
Figure 13: Responses to Q.23 (I Was Able to Buy the Recommended Two Weeks’ Worth
of Food at One Time, in Order to Follow COVID-19 Social Distancing Guidelines by
Health Officials) by Annual Income ..............................................................................................63
Figure 14: Responses to Q.22 (Getting Food Has Become More Difficult Since the
COVID-19 Pandemic) by Annual Income .....................................................................................64

1

Chapter One: Overview of the Study
The widening socioeconomic gap within the U.S. economy contributes to food insecurity
and obesity; hence, individuals are eating unhealthy food for survival, yet are unable to
contribute fully and inclusively within their communities (Elmes, 2018). According to
Vandevijvere and Swinburn (2014), food environments are constructed through the surrounding
physical, economic, sociocultural, and policy contexts, all of which combine to influence food
choices and consumption habits. Poverty is a risk factor for conditions like obesity,
cardiovascular disease, diabetes, and hypertension (Walker et al., 2016). Poverty, neighborhood
segregation, and deprivation results in less access to affordable healthy food and healthcare,
while increasing exposure to fast food and the marketing of unhealthy food (Walker et al., 2016).
Urban areas face unequal health outcomes, in part due to the lack of proper nutrition
(Hartman, 2013). Food distribution to low-income urban areas tends to be of low-quality and
lack nutritional value (Hartman, 2013). Marginalized communities have restricted access to
healthy, affordable, and nutritious food, which has a significant impact on their health and as a
result, low-income individuals and minorities are typically both overweight yet malnourished
(Hartman, 2013). Some account for these nutritional discrepancies by referring to the existence
of food deserts, which are defined as “areas with limited access to affordable and nutritious food,
particularly such an area composed of predominantly lower income neighborhoods and
communities” (Bastian et al., 2017, p. 87). Food deserts are attributable to an unjust industrial
food system that prioritizes profits over the well-being of consumers (Elmes, 2018). Food has
become increasingly processed, thereby multiplying its negative health effects on the population
(Vandevijvere & Swinburn, 2014).
2

Children from low socioeconomic households are already susceptible to lower health
outcomes and poor academic performance due to disadvantaged nutrition (Dunn et al., 2020).
According to Gurnani et al. (2015), Aboriginal, Hispanic, and South Asian ethnicities are more
prone to childhood obesity. They also assert that children from lower socioeconomic
backgrounds have higher rates of obesity than those from a higher socioeconomic status
(Gurnani et al., 2015). According to Dunn et al. (2020), the United States Department of
Agriculture (USDA) and other food-based programs serve daily meals to about 35 million kids.
Fatigue and weakened immune system responses are two important short-term health effects of
poor nutrition, and both can heighten the risk of communicable diseases (Dunn et al., 2020).
COVID-19 has caused additional strain on food systems, especially for vulnerable
populations who already faced food security issues before the pandemic (Patel et al., 2020).
Individuals from a low socioeconomic status and with poor health due to nutrition are
disproportionately affected by the current COVID-19 pandemic (Patel et al., 2020). Food
security and lack of access to proper nutrition impose constraints on low-income individuals in
typical life; however, during the current COVID-19 pandemic, the concepts of “panic buying”
and “shelter in place” put further stress on these individuals (Nicola et al., 2020). Without meals
provided by schools, kids remaining at home during the global COVID-19 crisis led to an
increased food-related financial burden for families, as well as increased food insecurity (Dunn
et al., 2020). Dunn et al. (2020) found that even small bouts of food insecurity can have long-
lasting developmental, physical, psychological, and emotional consequences.
The purpose of this dissertation is to look at participants’ knowledge and perceptions
about nutrition, food availability, and their impact on unequal health outcomes in low-income
urban areas. It is also important to look at how a global pandemic contributes to the problem of
3

food insecurity. The next section will describe the background and context of the research
problem and why this problem is important to address. It will also outline the research questions
for the study, as well as provide an overview of the theoretical framework and methodology used
within this research project.
Context and Background of the Problem
Obesity affects about 37% of the adult population in the United States and 16% of the
child population and is the second leading cause of preventable death (Bastian et al., 2017).
Lower socioeconomic class is linked to higher rates of obesity in children in the United States
(Gurnani, 2015). Minority neighborhoods have disproportionately high rates of obesity and
chronic disease due to the lack of availability and affordability of high-quality food, as well as
the unequal distribution of the U.S. food system (D’Angelo et al., 2011). According to Boris
(2011), the prevalence and exponential growth of industrially produced meat has cheapened the
cost for consumers and, in turn, allowed the average American to consume significantly more
meat than the recommended dietary allowance. Consequently, the transition from a majority
plant-based diet to a primarily animal-based diet has contributed to the rise in obesity, and
subsequently, increases in healthcare costs (Boris, 2011; Richards & Richards, 2011). Obesity
not only affects the individual; the societal and economic costs are plentiful, as an obese
individual’s healthcare is roughly $1,500 (approximately 42%) more per year than someone of
normal weight (Bastian et al., 2017). Estimates placed 2018 healthcare costs above $344 billion
per year, with taxpayers accounting for about half of all medical spending (Boris, 2011).
Marketing efforts and low-quality food within low-income areas have resulted in the
highest rates of poverty directly correlating with the highest rates of obesity in the United States
(Hartman, 2013). According to Gurnani et al. (2015), dietary factors contribute to higher rates of
4

obesity, including high caloric food consumption in infancy, a high intake of soda and juice, high
consumption of fast food, reduced family mealtimes, and lower consumption of milk, vegetables,
and fruit. Some of the factors that influence grocery purchasing in low-income areas include
resource constraints, the need for cost-effectiveness to provide for a household, the supermarket
environment, pricing, and perceived quality or healthiness (Zachary et al., 2013).
While there has not been a global pandemic in the last century, the social and economic
structural discrimination within low-income communities makes their health outcomes more
vulnerable in the face of a global pandemic (Patel et al., 2020). Food insecurity and its related
health inequalities have significantly increased during the unprecedented COVID-19 pandemic
(Wolfson & Leung, 2020). COVID-19 has amplified the existing health disparities and unequally
continues to affect low-income households that struggle to meet basic nutritional needs (Wolfson
& Leung, 2020).
Purpose of the Project and Research Questions
This study will focus on the problem of food deserts and perceptions of food access
within low-income areas. The purpose of this dissertation was to look at participants’ knowledge
and perceptions about nutrition and healthy food availability in urban low-income areas in
Southern California utilizing Bandura’s (1998) social cognitive theory.
As such, the research questions that guide this study are the following:
1. What are the participants’ knowledge of nutrition and healthy diets?
2. What are the participants’ perceptions of healthy food access?
3. How has the COVID-19 pandemic affected participants’ perceptions of healthy food
access?
5

Importance of the Study
Our current food system and the existence of food deserts has unequal health outcomes
for individuals in urban low-income areas (Béné et al., 2018). Growing economic inequality has
contributed to food insecurity, obesity, and other chronic diseases due to poor nutrition (Elmes,
2018). Nutritious sustenance, similar to education, is vital to help people perform their roles as
participants in society and the workplace (Elmes, 2018). The health-related consequences from a
poor diet affect more than the individual. Both the societal and economic costs are increasing
(Boris, 2011). There is a substantial economic burden on the healthcare system associated with
chronic illness, as well as the long-term management of other ailments (Schaffler et al., 2018).
By regularly consuming unhealthy food, which is often the only food available in food deserts,
individuals living in urban low-income areas, including a high percentage of ethnic minorities,
are unable to fully function within their community and within society (Elmes, 2018).
While the concept of food insecurity typically focuses on inadequate consumption,
obesity among the food insecure is a growing health problem amongst those living in poverty
(Bhattacharya et al., 2004). Although the connection between poor nutrition and health outcomes
is notable, this study also recognizes the contributing factors of food access, including logistics,
affordability, and government policies.
Overview of Theoretical Framework and Methodology
The theoretical framework used to address the problem of practice identified is Albert
Bandura’s (1998) social cognitive theory as it relates to health promotion. Social cognitive
theory posits that a collective interchange of the individual, the environment, and behavior
influences learning within a social context (LaMorte, 2019). However, when pointed toward
health outcomes, Bandura asserted a multifaceted view of socio-structural agents as well as
6

personal determinants. In terms of the way he connected social systems and the habits of the
individual, Bandura (1998) stated that “a comprehensive approach to health must provide people
with the knowledge, skills and sense of collective efficacy to mount social and political
initiatives that affect human health” (p. 646). Furthermore, health outcomes, including those
related to chronic disease prevention, are reliant on behavioral, environmental, and economic
factors (Bandura, 1998).
In terms of the methodology of this study, I frame knowledge through the pragmatist
view by considering how historical tradition has shaped nutritional knowledge and practice in
low-income urban areas. In the context of this study, the knowledge holders are identified as the
study participants, along with modern doctors and health administrators. As defined by Merriam
and Tisdell (2016), ontology is how one perceives the nature of reality. This study uses a realist
perspective to understand the perspectives of minorities in urban low-income areas in Southern
California on nutritional beliefs and food accessibility.
This study utilized a mixed methods methodology that combined both quantitative and
qualitative survey research data (Creswell & Creswell, 2018). The quantitative data collected
from various organizations will provide numerical information while the qualitative questions
will provide insight into how knowledge of nutrition by culture and access inequities contribute
to nutritional health concerns among the marginalized population. The research design addressed
questions of validity and credibility by looking at and speaking to a large enough database.
Additionally, the study methods are transparent and all notes along with standardization of
measurement were tracked and reviewed.
7

Definitions
This section provides brief definitions of key terms related to the study. The following
definitions are central to understanding the dissertation design and approach.
• Food deserts are defined as “areas with limited access to affordable and nutritious
food, particularly such an area composed of predominantly lower income
neighborhoods and communities” (Bastian et al., 2017, p. 2).
• Food insecurity is defined by the USDA as a “lack of consistent access to enough
health food for an active and healthy lifestyle” (Cutts & Cook, 2017, p. 1699).
• Health inequalities are defined by McCartney et al. (2013) as “systematic differences
in the health of people occupying unequal positions in society” (p. 221).
Organization of the Dissertation
The organization of this study follows a traditional five-chapter format. Chapter 1
introduces the context and background of the research, the purpose of the project, the research
questions, the theoretical framework, the methodology, and key definitions related to the
research project. Chapter 2 provides a review of the relevant literature and a discussion of the
social cognitive theory, which is the conceptual framework that guides this study. Outlined in
Chapter 3 is the research methodology for data collection, which is a mixed methods survey
design. Chapter 4 highlights the results of the quantitative and qualitative survey data as well as a
discussion of the findings. Chapter 5 outlines a discussion of the findings, as well as
recommendations for addressing the problem of practice.
8

Chapter Two: Literature Review
This review covers literature in which the following themes emerged: inequities in
nutrition-based health outcomes, misconceptions of nutrition, food behavior influences,
environmental barriers, and food access during a global crisis. Although the literature presented
here has been applied to a variety of contexts, this review focuses primarily on application of this
literature to the problem of food deserts, the inequitable health outcomes as a result of nutrition,
and perceptions of food availability in urban low-income areas within the United States. The
following literature review examines the problem through Albert Bandura’s (1998) social
cognitive theory as he related it to health promotion.
Challenges of Food Deserts
Food Justice
Food sustainability researchers define food justice as the meeting of basic human needs
and freedom from oppression and exploitation, as well as having access to opportunities and
participation (Hartman, 2013). Food scarcity is not the issue; rather, the food and resources
distributed to low-income regions are not of equal nutritional value to the food available in high-
income neighborhoods and it is inefficient (Hartman, 2013). Many large players in agribusiness
suggest that rising population numbers are the reason we need larger animal farms and greater
production; however, the toll this method takes on health outcomes is unsustainable (Hartman,
2013). In opposition to this belief is the belief that distribution and reduction of excess
consumption of grain-fed animals, rather than increased production, would contribute more
toward domestic hunger and nutritional deficits (Hartman, 2013). Hunger and malnutrition are a
controllable injustice and a form of human suffering that leaves those affected in vulnerable
9

health, including higher susceptibility to quiet forms of coercion (Hartman 2013). Food
purchasing and nutritional decision-making is dictated by socioeconomic status (Dixon, 2014).
A common misconception is that all Americans have the personal choice, ability, and
opportunity to change the way they eat and control their diet; however, this ideal does not
necessarily apply to those living under economic constraints (Dixon, 2014). Further, Dixon
(2014) offered the idea that, in popular opinion, everyone has equal access to nutritious food in
the proper context and circumstances; however, in many cases, individuals’ access to nutritious
food, and potentially food of their choice, is impeded. Dixon also emphasized that to properly
seek food justice for all we must set the narrative specific to person, place, and time to fully
understand the constraints and viable solutions. Moreover, to address the socioeconomic
disparities in health outcomes as a result of food deserts and their negative impact on what
individuals eat and drink, one must note the existence of a nutrition-income relationship (Allcott
et al., 2019). A study conducted by Lillard et al. (2015) found the likelihood of current poor
health in adults was linked to the experience of greater inequality in childhood. They also noted
that early life inequities played a role in the resources available for obtaining good health (Lillard
et at., 2015). The current food system has an inherent sense of “Whiteness” in which food
councils leave minorities only to be represented by pathological conditions like obesity and
diabetes (Cadieux & Slocum, 2015). Cadieux and Slocum (2015) provided an example of a food
council based in Birmingham, Alabama, in which the only African American representative was
allowed to speak about the aforementioned conditions rather than address how these deficiencies
are connected to a greater problem of White privilege and systemic racism. The lack of food
justice contributes to obesity and chronic health conditions in low-income communities.
10

Health Inequities
Low-income neighborhoods in the United States have a disproportionately high rate of
obesity and chronic disease due to the lack of available and affordable food, as well as the
unequal distribution of our food system in these areas (D’Angelo et al., 2011). Inexpensive and
low-quality food is marketed to and made more easily available in low-income areas, thus
leaving the highest rates of poverty to directly correlate with the highest rates of obesity in the
United States (Hartman, 2013). Food that is distributed to low-income areas tends to be of low
quality and lack nutritional value. As a result, childhood obesity has reached epidemic
proportions in the last 30 years, as rates have more than tripled and have caused a public health
crisis associated with poverty (Kaufman & Karpati, 2007). Adults and children alike from poor
neighborhoods have higher rates of obesity and other health-related issues than those from
upscale neighborhoods (Kaufman & Karpati, 2007). For women in particular, obesity rates
increase as income levels decrease (McCurdy et al., 2015). It is a paradox that is difficult to
understand; due to poverty, food insecurity, and a lack of sufficient resources, there are
numerous adults and children from this community that are overweight or obese (Kaufman &
Karpati, 2007). According to Bastian et al. (2017), obesity affects about 37% of the adult
population and 16% of the child population and is the second leading cause of preventable death
in the United States.
The role of socioeconomic status and location is significant to obesity due to the widely
available and cheap energy-dense but nutrient-poor food. The consumption of fast food, which is
high in calories and fats, tends to be vastly less expensive than healthier food options (Kaufman
& Karpati, 2007). Individuals from low-income areas are often overweight yet malnourished
because these areas tend to be crowded with fast food and processed food options, which are
11

constantly marketed as “cheap” food (Hartman, 2013). Animal-based products are a main
component in fast-food restaurants, which are a high source of saturated fats, both of which
contribute to cardiovascular disease as well as high cholesterol. The American Heart Association
recommends people eat 80 pounds less meat than the average American currently consumes
(Boris, 2011). Boris (2011) posited that heart disease, various cancers, diabetes, stroke, and
obesity are all significant results of a highly meat-based diet. Those who eat large amounts of
meat are at the highest risk for more than one of these ailments (Boris, 2011). The World Cancer
Research Fund and the American Institute for Cancer Research suggest completely avoiding
processed meat, and to vastly limit the intake of red meat to reduce colon cancer, prostate cancer,
breast cancer, and overall cancer risk (Boris, 2011).
Socioeconomic inequality has proven to be a strong predictor of obesity rates due to the
over-consumption of low-budget, high-caloric foods during times of food scarcity, as well as
heightened anxiety attributed to low social status (Bratanova et al., 2016). This is often a result
of supermarkets in urban areas predominantly displaying processed and sugar rich foods and
beverages (Hartman, 2013). The burden of inequality and a low position on the social hierarchy
can induce stress, rejection and psychosocial implications which can lead to overeating and other
unhealthy behaviors (Bratanova et al., 2016). Families that rely on food assistance programs, like
food stamps or food banks, typically have to stretch their resources each month, buy in bulk, use
coupons, and opt for nonperishable items that do not include fresh fruits and vegetables
(McCurdy et al., 2015). Cheap, calorie-dense food products that lack proper nutrition have
become rampant in low-income areas and have been a contributing factor to the decline in health
and increased healthcare costs (McCurdy et al., 2015).
12

Low-income areas suffer from a reduction in hospital services and physician departures
in the communities that tend to have the highest demand for care (Yearby, 2018). The U.S.
healthcare system is based on the ability to pay, thus widening the gap of inequality based on
income, nutrition, and healthcare (Yearby, 2018). White individuals, who are often those with
higher socioeconomic status, are able to obtain health insurance through their jobs or pay for
healthcare not provided by their insurance (Yearby, 2018). Minorities have limited access to
healthcare and are disproportionately serviced by Medicaid. Of the 45 million people in the
United States that did not have health insurance in 2008, more than half were minorities (Yearby,
2018). These individuals also significantly lacked access to preventative primary care services
and ultimately faced worse health outcomes (Yearby, 2018). While direct consumption of low-
quality food affects individuals, a person’s understanding of healthy nutrition also plays a role in
health outcomes.
Personal Understanding of Nutrition
Education
Due to the link between low socioeconomic status and limited access to educational
resources, many individuals from low-economic households may not acquire the knowledge
needed to guide their nutrition choices and health behaviors (Rustad & Smith, 2013). Rustad and
Smith’s (2013) study showed that experiential learning activities expanded nutritional knowledge
among low-income women and resulted in positive food behavioral changes. The Hierarchy of
Nutritional Knowledge indicates that having knowledge about particular healthy foods increases
an individual’s likelihood of consuming that food (Rustad & Smith, 2013). Numerous qualitative
studies have revealed confusion around eating a healthy diet and doubts regarding the impact of
nutrition on health among low-income African American women (Lynch et al., 2012). In their
13

2012 study, Lynch et al. provided an illustration of that confusion through the following quote
from a participant: “A steak it ain’t fattening you know and it ain’t starchy. It ain’t no starchy
food. I guess it’s good you know, good for your body, good to eat, and it’s not fattening” (p.
156). According to Lynch et al., the participants interviewed shared little knowledge about which
foods cause certain health effects. While participants did mention obesity and cardiovascular
issues as part of their culture, they did not acknowledge other health-related ailments like cancer
and diabetes, both of which are among the main five diseases for African Americans in the
United States (Lynch et al., 2012).
Pursuant to Guntzviller et al. (2017), one’s health literacy and ability to obtain and
comprehend health information positively influences their food behavior, while those who lack
health literacy tend to lack in preventative health measures. According to Cluss et al. (2013),
parental nutritional knowledge may play a role in childhood obesity; low-income parents need a
working knowledge of nutritional guidelines to inform their shopping habits and the food they
provide to their overweight children. About one third of children in the United States are
overweight or obese, and studies have shown that in high-income countries, the highest rates of
obesity occur in children with low socioeconomic class as opposed to their affluent
socioeconomic counterparts (Gurnani et al., 2015). Results from the General Nutrition
Knowledge Questionnaire for Adults from the Diet and Health Knowledge Survey indicated that
lower-income and minority adults had less knowledge about fat and cholesterol in foods (Cluss
et al., 2013). Moreover, low-income individuals, African Americans, and those with lower levels
of education correlated with high caloric intake, along with ‘misidentification’ of food (the belief
that food is healthier than it is; Cluss et al., 2013). The U.S. Census Bureau reported that 46.7
million people are touched by poverty and roughly 36% lack sufficient health literacy (Schaffler
14

et al., 2018). They concluded that a lower income coupled with a low health literacy was linked
to poor health outcomes and a higher occurrence of chronic diseases. Guntzviller et al. (2017)
found that a higher health literacy affirmed a prominent relationship with self-efficacy and better
health behaviors.
Health literacy is important to note because it incorporates one’s ability to follow
nutrition-related tasks such as reading food labels, following dietary instructions from health
providers, and making decisions while food shopping (Speirs et al., 2013). Further from Speirs et
al. (2013), race and parental status were associated with health literacy, with White participants
being more likely to have a higher health literacy than participants from other racial/ethnic
backgrounds. However, the results from this particular study did not find a significant
relationship between health literacy and healthy eating practices; rather, the importance of health
literacy as it relates to following dietary recommendations from health professionals should be
noted (Speirs et al., 2013). While education can be influential on nutrition, cultural identity also
plays a role in food decision-making.
Cultural Identity
Culture can influence nutrition misconceptions and contribute to obesity as it relates to
what is valued and not valued in a preferred body image (Caprio et al., 2008). For example,
perceived ideal body weight is sizably smaller in White women compared to African American
women, and African-American men are more likely to express preference for a larger body type
(Caprio et al., 2008). Similarly, “culture influences child-feeding practices in terms of beliefs,
values, and behaviors related to different foods” (Caprio et al., 2008, p. 2215). Food habits can
be formed in the early stages of life, which later affects self-regulation, food beliefs that are
focused on set times and certain portion sizes (Caprio et al., 2008). According to the Lovell’s
15

(2016) study, the majority of participants who were at or below the federal poverty line
expressed that a key influence on their beliefs about nutrition stemmed from their upbringing,
their cultural identity, and familial/friend connections. Lovell (2016) found that “deep personal
beliefs associated with upbringing and these values are intertwined with food, relationships and
cultural identity” (p. 141). Lovell’s findings also indicated that food and activity level were
products of cultural heritage as well as personal identity, and that socio-historical context,
individual development, environment, parental values and engagement were all predictors of
future health. Similarly, Fuster et al. (2019) noted that identities are developed by the social and
physical environment, and food practices are an important facet of these environments. From
their study of Latino food practices in the United States, family meals were impacted by the
mother’s food identity along with other cultural influences, such as eating together as a family,
consuming too much, and cooking traditional dishes (Fuster et al., 2019). Efforts to sustain
culture typically fall on the women of the family to form or maintain traditional norms, values,
and food patterns (Benavides-Vaello & Brown, 2016). According to Wright et al. (2016), there is
overwhelming evidence that our food choices derive from personal experience, culture, custom,
habit, and food traditions, with the assumption that health and price are universal influencers.
Nutritional marketing can be specifically targeted toward ethnic groups, Caprio et al.
(2008) found that African American children’s exposure to food television advertising was 60%
higher than other children, with fast food ranking the most frequent. Marketing can be
detrimental in adjusting desirability and belief systems for certain types of food that are high in
calories and low in nutritional value (Caprio et al., 2008). According to Stoll-Kleemann and
O’Riordan (2015), diets are a compilation of factors that include habits, social identity, and a
history of interpersonal relationships, as well as the influence of food marketing strategies.
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Furthermore, they emphasize that deep-seated habits and traditions are resistant to change,
namely when lobbyists and large industries are involved (Stoll-Kleemann & O’Riordan, 2015).
Wright et al. (2016) illustrated that the contemporary diet for some African Americans in certain
regions reflects past slave culture which revolved around leftovers and emerged into the soul
food diet. African Americans have expressed in past studies that to eat healthier would
compromise their culture and altering the flavors of their ancestors could be viewed as a form of
disrespect (Wright et al., 2016).
In current media, the concept and practice of veganism has an association with White
privilege and thus alienates minorities, creating stigmas that might compound health problems
specifically in marginalized communities (Greenebaum, 2018). Research has shown that meat
and other protein product purchases are more frequent among African Americans compared to
Whites (Dammann & Smith, 2010b). Culturally, minorities may resist plant-based diets because
of their link to White culture, affiliation with privilege, and contrasting of their soul food
traditions (Greenebaum, 2018). On the contrary, according to Greenebaum (2018), “veganism
can be a form of resistance to the industrial food complex that oppresses and disenfranchises
poor people of color who lack access to healthy, affordable food” (p. 682). In addition, according
to Danielle (2010), “collectively, we can embrace [veganism] as more than just a change in our
way of eating. It is a political statement, another weapon in our fight for economic, social and
political empowerment” (p. 48). Mainstream and mass media that promote White celebrities,
thinness, and affluency associated with eating plant-based diets also results in a perception that it
is unattainable (Greenebaum, 2018). Increased plant-based consumption is not accessible to all,
pointedly those living in food deserts that lack the ability to choose what they eat (Greenebaum,
2018).
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Food Insecurity
The fear of insufficient food, or food insecurity, is common in urban low-income areas
(Bhattacharya et al., 2004). While actual starvation in the United States is rare, hunger and the
inability to access nutritious food for proper nutrition are more common (Bhattacharya et al.,
2004). Moreover, Bhattacharya et al. (2004) pointed out that while food insecurity typically
focuses on inadequate consumption, obesity among the food insecure is a growing health
problem among those living in poverty. Bhattacharya et al. found that food insecurity was a
reliable predictor of health outcomes among adults and food insecure young adults, as self-
reported food insecurity is linked to obesity and less healthy diets. Economic instability and the
monthly food cycle, based on government support at the beginning of the month, also play a role
in eating habits (Kaufman & Karpati, 2007). Roughly 30% to 40% of food goes to waste while
food insecurity and food-related diseases have risen (Elmes, 2018). According to Elmes (2018),
the number of households that were food insecure between the years 2000 and 2014 rose nearly
33%, thus putting higher demands on food banks and other food assistance programs. As an
effect of the COVID-19 pandemic, food insecurity has rapidly increased from pre-epidemic
levels. For example, in 2018 household insecurity was around 11%, and by March 2020 it rose to
38%, and in April 2020 to 35% (Wolfson & Leung, 2020). Due to a lack of resources and ability
to comply with social distancing regulations, those already living with food insecurity have that
experience intensified by COVID-19 (Wolfson & Leung, 2020). Many studies have shown that
food insecurity and crisis create a higher likelihood of consuming high calorie but nutritionally
poor foods in order to address hunger, stress, and low income (Elmes, 2018).
According to Miesing (2019), there was a lack of food security among three out of four
urban community college students, which was more common than in U.S. households overall.
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Food insecurity creates a higher likelihood for students to experience academic difficulties and
anxiety (Miesing, 2019). Cook et al. (2013) concluded that low food security and food insecurity
had a positive correlation with the probability of a low-income caregiver experiencing depressive
symptoms and having higher chances of poor health in comparison to those from food secure
households. According to Rabbitt et al. (2017), food security can be categorized in terms of low
food security and very low security. During the U.S. recession from 2007–2009, both forms of
food insecurity rose and were tightly linked to income and households at or below the federal
poverty line (Rabbitt et al., 2017). Of great importance within the Cook et al. study was the
conclusion that even mild food insecurity led similar outcomes as those with great food
insecurity across categories like socio-demographics and psychosocial profiles, along with child
developmental status and health risks. Per Cutts and Cook (2017), food insecurity is linked to
negative physical and mental health outcomes. After 20 years of food insecurity research, Cutts
and Cook determined that it was a commonly hidden condition that lacked physical evidence and
could lead to adverse social stigma and personal shame. Moreover, in 2015 Children’s
Healthwatch estimated that the healthcare and education costs associated with food insecurity
among families with children was greater than $1.2 billion (Cutts & Cook, 2017).
Pursuant to Nikolaus et al. (2019), food insecurity related to low income is a result of
various factors such as lower financial management skills, less education, lack of physical assets
(owning a home), lack of savings or access to credit, composition of the household (single-
parents, grandparents, incarcerated parent, more children), or living in chaos. They continue to
acknowledge that personal grit may assist in warding off food insecurity by actions like
budgeting, using coupons, limiting food waste, and shopping at discount stores (Nikolaus et al.
(2019). Nevertheless, the structural barriers and inequities need to be considered in their context
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when examining behavior and psychological traits (Nikolaus et al., 2019). There are numerous
factors that play a role in our inadequate food system. Elmes (2018) attributed the pitfalls to an
industrial food system that is constructed for the producers and distributors to attain profits
through excess market concentration and unprincipled behavior at the cost of long-term interests
for consumers, food workers and the ecosystem. Food insecurity, which can be fueled by
perceived food availability and heightened during a global crisis, influences behavior.
Food-Related Behavior
Various factors like the cost of healthy food, the cheapness of fast food for feeding a
family, food cravings based on taste, and emotional reasons motivated food purchasing and
consumption in the Dressler and Smith’s (2013) study. Overweight or obese women who felt
depression, stress, boredom, or other emotional distress, at times used food as a coping
mechanism (Dressler & Smith, 2013). Guntzviller et al. (2017) posited that self-efficacy, as part
of social cognitive theory, drives healthy behavior. Wright et al. (2016) found a pattern of food
consumption motivators that consisted of familiarity, convenience, nutritional quality,
enjoyment, satiation, and cost. Relationships, trust and support were important drivers to the
receptivity of parents to take action when provided new health related information (Lovell,
2016). Similarly, Lovell (2016) labeled “‘relatedness’ as a part of self-determination theory,
which is a person’s desire to engage in behavior modeled by people they trust” (p. 143).
Moreover, Dammann and Smith (2010a) found that some low-income children were
“opportunistic eaters,” which led to overconsumption of food when it was available due to
perceived insecurity that there would be less or no food available in the future. Considering
impoverished individuals and families living in shelters, food attitudes centered around eating an
early dinner which led to wanting snacks later (mainly junk food available; Dammann & Smith,
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2010a). In relation to having limited access to refrigerated goods, one of the Dammann and
Smith (2010a) study participants stated, “So that’s why you can’t have no fruit” (p. 391).
When it comes to food consumption and purchasing, Anderson et al. (2007) claim self-
efficacy is the main factor that influences food behavior. Further indications from their research
insinuated that improving family attitudes, behaviors, and family social support can boost an
individual’s nutrition self-efficacy and rouse self-regulating behavior (Anderson et al., 2007). A
theme from the Eikenberry and Smith (2004) study was that the most offered definition of
healthy eating, regardless of race and income, revolved around fruits and vegetables; yet the
daily recommendations for these food groups were not met by many Americans. Numerous
participants in the study associated healthy eating with positive health outcomes and the most
commonly noted barriers to eating healthy were cost and time constraints (Eikenberry & Smith,
2004).
Emotional and stress-related eating are linked to obesity and research has correlated early
childhood food insecurity with future food emotional attachment (Wiig & Smith, 2008). Cyclical
in nature, the food stamp program can contribute to the obesity epidemic by creating feasts at the
beginning of the month for families, and famines at the end of the month when stamps are low.
In Wiig and Smith’s (2008) study, many families reported that their food stamps lasted 2 to 3
weeks. Most participants from their study affirmed meat products as their most important and
most expensive food purchase, some of whom spent about 50% of their food stamp allocation on
this product alone (Wiig & Smith, 2008). Subsequently, it was noted that the majority spent their
budget on cheaper types of meat with higher fat content, such as hot dogs and ground beef (Wiig
& Smith, 2008). Rationale cited for higher meat intake in low-income families included
upbringing, ethnicity, traditions, taste, and meat status within American culture, which
21

presumably contributes to familial self-esteem (Wiig & Smith, 2008). There was a disconnect
between high meat consumption and low-income participants. As meat products are strongly
responsible for various types of cancer, high blood pressure, obesity, and cardiovascular
problems, higher-income groups have cut back on their meat consumption, which is vital to the
unequal numbers of impoverished individuals affected by these ailments (Wiig & Smith, 2008).
Wiig and Smith also indicated that children motivated food purchasing while accompanying their
parents to the store by putting items in the cart and begging for certain foods. Lifestyle is
relevant to many of the issues surrounding nutritional health inequities; however, it is vital to
acknowledge the historical context and surrounding environment that molds these conditions.
Environmental Influences
Retail Redlining
The act of retail redlining, the removal of a supermarket within a community, has various
long-lasting negative effects that are both visible and invisible (Eisenhauer, 2001). While in 1984
the United States as a whole experienced more retail openings than closings, the 1980s inner
cities experienced a net loss of supermarkets due to an industry practice called redlining
(Eisenhauer, 2001). Retail redlining is described as “a spatially discriminatory practice among
retailers, of not serving certain areas, based on their ethnic minority composition, such as the
potential profitability of operating in those areas” (D’Rozario & Williams, 2005, p. 175).
According to Eisenhauer (2001), some of the decline came in the form of less access to healthy
food and the elimination of jobs; however, on a deeper level, it symbolizes the communities’
stress and failure to achieve inclusion in the rest of the country’s activities. One store’s decision
to disinvest in a community can create a ripple effect and encourage other stores to disinvest or
actively avoid a particular area, thus furthering the economic isolation (Eisenhauer, 2001).
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Conversely, Eisenhauer went on to explain that the incorporation of a grocery store within a
community can have many positive effects. The presence of more grocery stores can drastically
reduce neighborhood unemployment, and their presence encourages other retail stores to develop
around them because they serve as a strong anchor that draws traffic (Eisenhauer, 2001). In
addition, they offer low-income residents more opportunity to attain a healthy diet and food
security (Eisenhauer, 2001). While the practice of redlining in the financial industry was made
illegal by the Fair Housing Act of 1968, redlining from a retail standpoint was not blatantly
addressed (D’Rozario & Williams, 2005). D’Rozario and Williams (2005) claimed that urban
low-income habitants were a vulnerable population and at a higher risk for exploitation.
Exploitation emerges in the form of (a) having lower education levels or access to information to
influence shopping decisions, (b) lower incomes making it less likely to afford higher food
prices, and (c) lack of sufficient mobility to shop elsewhere (D’Rozario & Williams, 2005). As
organizations faced technological innovation and market and warehouse location decisions, the
private sector facing competitive demands of distribution channels and territory developments,
the options available in a capitalist market contributed to urban inequality (Deener, 2017).
Affordability
Food affordability has proven to be considerably skewed per calorie cost when obtained
from low-quality and energy-dense sources as opposed to healthy, less energy-dense foods
(Powell & Chaloupka, 2009). Numerous experiments have found that significantly lower prices
would result in sizable rises in healthy food purchasing (Powell & Chaloupka, 2009). As one
example, fruit sales quadrupled, and carrot sales doubled in a high school cafeteria after their
prices were cut by 50%; a university office building cafeteria reported fruit and salad sales
tripling (Powell & Chaloupka, 2009). According to Ghosh-Dastidar et al. (2014), there are mixed
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results amongst studies that have examined the relationship between food prices and weight.
They referenced studies that found high-priced, healthy food as a barrier for consumption for
low-income individuals, one study in particular found an increase in buying of healthy food by
lowering prices through a rebate program (Ghosh-Dastidar et al., 2014). Results from another
study by Zachary et al. (2013) found factors influencing grocery purchasing in low-income areas
to include resource constraints, the need for cost-effectiveness to provide for a household, as well
as supermarket environment, pricing and perceived quality or healthiness.
To keep up with the growing demand of fast-food chains for cheap products and the
concept of the “value meal,” Concentrated Animal Feeding Operations (CAFO) are constantly
looking for ways to produce more animal products at a lower cost (Richards & Richards, 2011).
Richards and Richards (2011) claimed that McDonald’s purchases the most beef in the United
States, with Taco Bell running a close second. These large fast-food retailers fail to mention that
their cheap meat products come with the cost of added hormones, chemicals, and byproducts that
have been linked to various health concerns (Richards & Richards, 2011). Richards and Richards
asserted that cattle raised for these operations are fed grain diets, opposed to a natural grass diet,
in order to promote larger growth; however, this adds fat content, the majority of which comes in
the form of saturated fat. Saturated fat, and lower beneficial nutrient contents are coupled with a
higher risk for nutrition-related health issues, which are then passed on to the consumer
(Richards & Richards, 2011). A participant from Zachary et al.’s (2013) study explained her
food choices as an analogy to McDonald’s. For the participant, it was not feasible to buy a salad
at McDonald’s that cost $4.99 when she had three children to feed because the purchase of a
Double Cheeseburger for $1.00 would at least address their hunger. Likewise, Fulkerson (2018)
pointed out that poor diet quality and fast-food consumption was more evident among lower-
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income youth. According to Stoll-Kleemann and O’Riordan (2015), diets that consist of a high
intake of meat, dairy, and eggs can lead to weight gain, obesity, hypertension, diabetes, heart
disease, cancer, and gout because they consist of high amounts of saturated fat, cholesterol, high-
density energy, and carcinogenic compounds in processed meats that result from cooking.
Research from Boris (2011) claimed that antibiotic resistant infections contribute $50 billion
more to the annual cost of American healthcare, in addition to the cost of food-borne illnesses.
Studies examined by Fulkerson (2018) indicated that the higher consumption of fast food is
notably associated with higher body fat, and the odds of being overweight or obese from
frequently eating fast food doubled in youth and more than doubled in adults. The COVID-19
pandemic has not only caused a loss or reduction in wages thus putting more into poverty, but it
has furthered the gap of economic access to healthy fresh fruits and vegetables (Zurayk, 2020).
Food shortages and hoarding left shelves empty, fresh food wasted, and increases in pricing
(Zurayk, 2020). Food access affects individuals unequally and it is important to look at the
governing policies that enable the disparity in nutritional health outcomes.
Policies
The U.S. agriculture business is a $125 billion industry that is largely run by powerful
corporations and interest groups that push the border between politics, private interests, and
public service (Stoll-Kleemann & O’Riordan, 2015). The Wrock (2016) literature approximates
that the government subsidizes $38 billion to the meat and dairy industries and only 17 million
(less than 1%) to fruit and vegetable producers, regardless of the Physicians Committee for
Responsible Medicine’s recommendation for consumers to limit meat and dairy and eat more
fruits and vegetables. In addition to the low cost of meat and dairy products in the United States,
government funds and contortion of the public’s knowledge of nutrition is exploited through
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control of the USDA (Wrenn, 2018). Researchers and agricultural organizations have postulated
that with the growing population and the demand for farmed meat consumption to double by
2050, current factory farming is unsustainable and detrimental to the ecosystems (Pluhar, 2010).
For example, the manipulation comes as an external cost of $1.75 to society for every $1 spent
on non-animal products by the consumer; these subsidies are backed by tax dollars, as well as the
passed through higher costs related to healthcare, environmental concerns, and food
inefficiencies (Wrenn, 2018). Furthermore, Wrenn (2018) suggested that the health of low-
income individuals would benefit from the elimination of meat within welfare programs and
would free up funds to put toward more productive programs. McCarthy (2016) noted a study
that concluded that the probability of obesity, high cholesterol, and risk for cardiovascular
disease was lower among those that consumed less federally subsidized foods. Agricultural
policies and agricultural markets that overproduce key ingredients to processed and energy-
dense foods contribute to poor health (Franck et al., 2013). The current food systems produce
3,900 calories per person every day, which equates to roughly twice the average person’s daily
requirement (Franck et al., 2013). The saturation of cheap, high-caloric options comes with a
variety of hidden costs for consumers, including taxes for agricultural subsidies and healthcare
expenses, along with the three main causes of death in the United States, which are associated
with poor dietary intake and being overweight (Franck et al, 2013). Subsidies for commodities
like grains and oilseeds also contribute to the weight epidemic as they are used as cattle feed to
increase growth quickly and thus lower the expenses for animal husbandry (Franck et al., 2013).
The utilization of subsidies has created a lack of agricultural diversity, specialty crops like fruits
and vegetables are typically penalized rather than incentivized (Franck et al., 2013). These
26

policies push smaller farms out of the market and put high profits and power into the hands of a
few industrialized corporations (Franck et al., 2013).
According to Béné et al. (2018), our current food system is failing because it is unable to
feed future world populations, does not deliver a healthy diet equally or produce equitable
benefits, and yields unsustainable consequences on the environment. Béné et al. argued that our
system now produces enough food to feed the population, yet nearly one billion still suffer from
hunger. Noting that this becomes a concern focused on food access inequality, the researcher
stated, “Essentially the concern here is that food systems, through self-organizing behavior
seeking economies of scale, a) are heading towards more socially unjust structures, and b) are
leaving the most vulnerable behind” (Béné et al., 2018, p. 119). Inefficiencies within the food
system also prevail when there is tension among federal policies regarding agricultural subsidies
and proposals to tighten food assistance programs, and local government efforts to support and
sustain their own food organization, thus impeding social food justice (Reece, 2018). This
problem can be attributed to the lack of regulations by the USDA on large agribusinesses and
their subsidies, thus large corporations monopolize farming and during food crises continue to
advance profits (Hartman, 2013). Governmental subsidies for large factory farms, as supported
through the Farm Bill in 2002, disproportionately supports large corporations and encourages
vertical integration (Richards & Richards, 2011). This places control of regulations, or lack
thereof, in the hands of large organizations, pushes smaller farms out of the market, and hampers
industry standard developments, which negatively affects economic equality (Richards &
Richards, 2011).
The U.S. food environment is designed to produce mass quantities of unhealthy food with
a quick short-term profit, thus compromising quality, fair access, and long-term health concerns
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among minorities (Elmes, 2018). According to Elmes (2018), it is important to note that the food
industry is competitive and similar to the tobacco industry, their primary goal is to sell as much
product as possible, not serve as a health or social service agency. Moreover, “the ultimate
challenge of sustainability science is to grapple with these ‘dark forces’ of interconnected self-
replicating power and influence by bringing their moral and ecological dangers into the day-to-
day public consciousness” (Stoll-Kleemann & O’Riordan, 2015, p. 47). The food industry reigns
as the most powerful industry in the world, it nonetheless yields an uninformed and controlled
food environment that is dominated by interest groups and exclusion of public health officials
(Franck et al., 2013). Politically driven structural barriers play a role in nutritional health
outcomes, as do environmental logistics.
Accessibility
Food accessibility within low-income urban areas is a pressing concern for the inflated
obesity rates and health disparities among the population. Pursuant to Walker et al. (2010), lack
of large grocery store access creates heightened procurement of nutrient-empty, yet high-calorie
foods typically found in corner markets and fast-food restaurants. Those residing in marginalized
neighborhoods that do not have access to a car to transport to supermarkets are at a disadvantage
because people with limited resources tend to rely on the food options within their immediate
area (Walker et al., 2010). A study conducted by D’Angelo et al. (2011) found that walking was
the most used form of transportation to food sources, particularly those who shopped at
convenience stores, with nearly 97% using walking as their main source of travel. Of the
individuals studied that did have access to their own car or a friend/relative that drove them,
almost 91% used supermarkets (D’Angelo et al., 2011). This is significant because their research
found that soda, potato chips, and other unhealthy options were more associated with the
28

convenience store shoppers, as well as those who walked, in comparison to supermarket
shoppers and those with access to a vehicle (D’Angelo et al., 2011). They also concluded that
transportation played a role in patterns of acquiring food, as walking was associated with shorter
transportation times (D’Angelo et al, 2011). Transportation remains a constant issue for those
who leave the city to shop. Eisenhauer (2001) noted that in the past couple of decades funding
and support for public transportation have been reduced. Transport lines between urban areas and
the suburban grocery centers are time consuming and can be costly. Eisenhauer claimed that
annual costs for cabs and use of public transportation for grocery needs can add between $400
and $1,000 extra per year.
The surrounding food environment has an impact on food consumption as well as the
distance to grocery stores, fast-food restaurants, and corner markets all play a role in dietary
intake of fruits and vegetables as well as the occurrence of obesity (Phillips and Rodriguez,
2019). Their study found that individuals with diabetes living in areas deemed as food swamps,
had a higher rate of hospitalization (Phillips & Rodriguez, 2019). Furthermore, “low-income and
racial-ethnic minorities are more likely than Whites to live near unhealthy food retailers, which
has been associated with a poor diet” (Cooksey-Stowers et al., 2017, section 1.1, para. 3). In their
review of fast-food research, Cooksey-Stowers et al. (2017) assert that of the studies examined,
10 out of 12 displayed evidence that fast-food restaurants were more inclined to locate in areas
with a higher density of minorities than Whites. To address the health equity gap, they further
imply that limiting access to unhealthy food access while providing incentives for healthy food
retailers in marginalized neighborhoods along with revising zoning laws must be addressed by
local governments and policies (Cooksey-Stowers et al., 2017).
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The current COVID-19 pandemic lockdown and transportation control has created more
food deserts, particularly in areas where public transit is the only way to acquire food (Zurayk,
2020). Shifts to more shelf-reliable, packaged foods and the triple burden of obesity,
undernutrition, and malnutrition will presumably increase due to restricted access, poor food
choices, and the reduction of exercise (Zurayk, 2020). Food accessibility is an existing issue for
the poor that will invariably be further obstructed during a global crisis.
COVID-19
The current COVID-19 pandemic not only emerged from the food system like many
other viral epidemics, but it also exposed systemic shortcomings that threaten the food security
of billions globally (Zurayk, 2020). Galanakis (2020) highlighted food system issues that must
be acknowledged in current and future pandemic crises. These issues include (a) adopting
healthier diets to protect consumers and their immune systems, (b) the critical availability of
bioactive ingredients of food, (c) increased food safety along the supply chain, (d) food security
issues during a lockdown, and (e) the sustainability of our current food system (Galanakis,
2020). Functional foods and foods rich in vitamins can boost the immune system and help defend
the body against viruses; for instance, foods rich in Vitamin C are citrus fruits, kiwifruits, and
broccoli, while foods rich in Vitamin A are vegetables like carrots, spinach, and sweet potato
(Galanakis, 2020). The U.S. government does intervene in food-related commerce; fresh food
supplies are either lost or wasted due to gaps in supply chain logistics (Galanakis, 2020). The
USDA has not mandated that schools continue to provide food service during quarantine closure,
leaving local education authorities to implement summer school feeding initiatives (Dunn et al.,
2020). According to Dunn et. al (2020), academic and daycare closures account for about $30 of
food per week per child and this loss of food service for families emphasizes their vulnerable
30

financial health. The COVID-19 transition from the National School Lunch Programs to the
Supplemental Nutrition Assistance Program (SNAP) could yield negative health effects because
school meals are forced to align with the most recent nutritional guidelines where SNAP puts
fewer restrictions on nutritional needs (Dunn et.al, 2020). Individuals with low socioeconomic
status that rely heavily on this program during COVID-19 may result in weight gain in racial
minorities and already overweight children (Dunn et. al, 2020). The added food-related stressors
can force families to ration food resulting in insufficient nutritional intake or force them to give
up other critical needs like healthcare, medication, rent and/or utilities (Dunn et al., 2020).
With the food system supply chain under pressure during COVID-19, Lal (2020)
suggested the importance to strengthen local food production and urban agriculture. Improved
urban agriculture strengthens many ecosystems such as human health, food security, food access,
and education around food production (Lal, 2020). During a crisis like COVID-19, the
conventional systems of bringing food into large cities is disrupted and requires large amounts of
energy, results in high food waste, and increased poor nutritional quality of food (Lal, 2020).
Localized food production can be more resilient during a crisis, reduce food insecurity and
improve human health (Lal, 2020). The COVID-19 pandemic escalated the pre-existing issues
surrounding nutritional food access.
Conceptual Framework
The following section explains the conceptual framework developed to guide the research
study of food deserts, unequal health outcomes from nutrition, and perceptions of food access
from the perspective of Bandura’s (1998) social cognitive theory as it relates to health
promotion. The broad social cognitive theory posits that a collective interchange of an
individual’s knowledge, behaviors, and their environment influences learning within a social
31

context (LaMorte, 2019). This concept applies to cultural aspects of dietary habits formed in the
early stages of life which later affect self-regulating behavior (Caprio et al., 2008). It also applied
to the lifestyle and social environment that indicates an individual’s nutritional knowledge and
self-regulating behavior as influenced by family attitudes toward accessibility, food security,
lifestyle, and family social support (Anderson et al., 2007).
When pointed toward health outcomes, Bandura (1998) asserted a multifaceted view of
sociostructural agents and personal determinants. Moreover, altering the practices of social
systems have expansive adverse effects on health, in addition to changing the habits of the
individual (Bandura, 1998). According to Bandura, health outcomes continue to be influenced by
one’s knowledge, learned behaviors, environment, and economic factors namely in extremely
poor areas as urbanization grows. Social sanctions and self-sanctions are the control processes
that influence and regulate action within social cognitive theory (Bandura, 1998). Healthy living
is not only a personal matter, but rather related to the lack of health resources and how health
systems are structured socially and economically (Bandura, 1998). This aspect of Bandura’s
social cognitive theory applies directly to environmental barriers in relation to retail redlining,
policies, affordability, and the current COVID-19 pandemic. The food environment has a direct
impact on food consumption as well as the distance to grocery stores, fast-food restaurants, and
corner markets (Phillips & Rodriguez, 2019).
The following core concepts in the study—education, cultural identity, healthcare, food
insecurity, lifestyle, accessibility, retail redlining, policies, affordability, and COVID-19—are
influenced by the person, their behavior, and the surrounding environment (see Figure 1). These
concepts ultimately contribute to health outcomes and perceptions of healthy food access in
urban low-income individuals. The aforementioned core concepts map out the social and
32

environmental barriers that leave minority neighborhoods with a disproportionately high rate of
obesity and chronic disease in the United States due to the lack of availability, affordability and
injustice of the U.S. food system (D’Angelo et al., 2011).

Figure 1:
Conceptual Framework

Note. Figure 1 depicts core concepts about knowledge of nutrition, perceptions of food access
and access as a result of COVID-19 for low-income individuals through social cognitive theory
applied to health promotion. Adapted from Social Foundations of Thought and Action: A Social
Cognitive Theory, by A. Bandura, 1986, Prentice Hall.
33

Summary
Nutritional retention and poor health outcomes are controllable injustices that are largely
dictated by socioeconomic status (Dixon, 2014). The increasing economic gap has contributed to
food insecurity, obesity, and other chronic diseases due to poor nutrition (Elmes, 2018). With
regular consumption of unhealthy food for survival, minorities and those living in low-income
urban areas are denied food justice and their ability to fully function within their communities
(Elmes, 2018). Those living in low-income cities have a high likelihood of being simultaneously
overweight and malnourished due to the food they can afford, the saturation of fast food within
their environment, and marketing efforts (Hartman, 2013). The societal and economic
consequences from poor nutrition are growing to unmanageable healthcare costs (Boris, 2011).
The long-term care required for a chronic illness and its ailments is an impeding strain on the
healthcare system (Schaffler et al., 2018). Galanakis (2020) acknowledged the necessity for
healthier diets to protect consumers and their immune systems, the critical availability of
bioactive ingredients of food, increased food safety along the supply chain, food security issues
during a lockdown, and the sustainability of our current food system, factors that have all been
amplified during the COVID-19 crisis. Food access and the surrounding environment have an
impact on consumption choices, in addition, the distance to grocery stores, fast-food restaurants,
and corner markets all play a role in the dietary intake of fruits and vegetables as well as the
occurrence of obesity (Phillips & Rodriguez, 2019). Agricultural policies that subsidize the mass
production of components to energy-dense foods like meat contribute to the poor health of low-
income Americans (Franck et al., 2013). Those who consume more federally subsidized foods
have a higher probability and risk for obesity, high cholesterol, and cardiovascular disease
(McCarthy, 2016).
34

Chapter Three: Methodology
The following chapter describes the methods used to conduct the current research
inquiry. The purpose of this study was to empirically look at participants’ knowledge and
perceptions about nutrition and food availability. The analysis utilizes social cognitive theory
(Bandura, 1998) to frame the challenges individuals face with attaining proper nutrition in urban
low-income areas. The organization of this chapter begins with an overview of the research
questions, design, setting, and my positionality. The next portion covers explanations of the data
sources. It then discusses the validity and reliability of the study and is summed up by the ethical
considerations involved within this research project. This study is guided by the following
research questions:
1. What are the participants’ knowledge of nutrition and a healthy diet?
2. What are the participants’ perceptions of healthy food access?
3. How has the COVID-19 pandemic affected participants’ perceptions of healthy
food access?
Overview of Design
The selected research design was a mixed methods survey methodology. This particular
study utilized primarily quantitative data and modified a convergent mixed methods survey
design by simultaneously collecting qualitative data through selected open-ended survey
questions (Creswell & Creswell, 2018). The survey was cross-sectional, which indicates that data
was collected between designated points of time (Creswell & Creswell, 2018). The supplemental
open-ended survey questions were chosen to provide insight into the knowledge, perceptions,
and beliefs of research participants about how the current pandemic affects food consumption.
The qualitative questions were designed to delve deeper into the impact that COVID-19 has had
35

on food accessibility. This research design addressed questions of validity/credibility by
examining a large database of 137 participants. The study methods conducted are transparent,
and all notes on qualitative survey answers were tracked and organized using the Atlas.ti
platform.
Research Setting
Participant Sample
The target population for this dissertation was racially and ethnically diverse participants
from primarily low-income urban areas in Southern California. This area was selected for its
racial and ethnic diversity, as well as the range of residential socioeconomic statuses of
participants. While other locations were considered for the study, they were eliminated due to
limited ability to travel during the COVID-19 pandemic. The quantitative and qualitative
portions of the study were retrieved through a mixed methods survey. The survey was
administered to the target population through various nonprofit community organizations within
Southern California, including Vista Community Clinic, Catholic Charities, Orange County Food
Bank, Hunger Action LA, and various social media support groups that influence urban low-
income areas within the selected counties. The organizations selected to assist with distribution
of the survey assist various demographic populations within these areas.
The sample criteria included that the individuals be of various ethnicities and racial
backgrounds. Southern California was the location of concentration and the criteria for
participants in this area was that they receive assistance from one or more of the above
organizations. The study focused on both genders, and the age group of focus was adults who are
head of household or are responsible for the grocery shopping.
36

The Researcher
This section will address my positionality and power by discussing the necessary steps
that were taken to avoid potential biases during the study. This section was intended to
encourage my reflexivity and to acknowledge the inherent biases that I may have from personal
experience. It will also acknowledge the positions of the research participants.
My positionality, which includes reflecting upon the characteristics that make up my
identity, is essential to understanding how my personal outlook on the world can affect my view
of the research participants. Reflexivity entails me, the researcher, reflecting on my own
experiences (such as my race, class, values) and acknowledging how these influence the
interpretation of the study results (Creswell & Creswell, 2018). Acknowledging my perception of
nutrition is important as to projecting my own biases onto my research participants. As a plant-
based consumer, I have preconceived notions of what I believe to be the healthiest and most
beneficial diet. In addition, awareness of my personal socioeconomic status is part of avoiding a
biased interpretation of the data. I also reflect upon my experience of being raised in an upper-
middle class family, which has led to a socioeconomic gap between myself and the current study
participants. As an outsider in the community under study, it is important to reflect on my
personal experience with familial and cultural food traditions, and how those influences have
shaped my food perceptions. According to Merriam and Tisdell (2016), the use of researcher
reflexivity is vital to mitigating insider/outsider issues that intersect with positionality.
A goal of the study is to analyze the power relationships that contribute to unequal health
outcomes from nutrition, so I took into account balanced power relationships (Merriam &
Tisdell, 2016). I maintained the balance of power by allowing the participant to feel empowered
37

through the open-ended portion of the survey. Peer review of the survey questions also helped to
reduce personal bias in the questions asked.
Data Sources
The study was based on a mixed methods survey methodology utilizing a combination of
both quantitative and qualitative survey research data (Creswell & Creswell, 2018). The survey
data was collected from various organizations and the quantitative portion provided numerical
information while the qualitative questions provided information on how knowledge of nutrition
contributes to nutritional health outcomes among marginalized populations. The qualitative
survey questions provided additional insight into the impacts of COVID-19 on perceptions of
food resources for the target population. The community organizations have access to the
participants intended for the study, which helped to build a mutually beneficial relationship
between the participants, the organizations, and myself which helped to alleviate potential
barriers. This reciprocal relationship assisted with challenges that arose within the current study.
In Chapter 5 recommendations will be provided to the participating community organizations.
Survey Method
The administered survey was partly adapted from a survey study published in the
American Journal of Lifestyle Medicine and was conducted by a medical doctor and their
colleague (Krause & Williams, 2017). Similar to their survey goal, the survey for this current
study was designed to assess the participants’ knowledge, behavior, and perceptions of their
surrounding environment as influences on their nutritional behaviors. Since Krause and
Williams’ (2017) target population were individuals within the medical field, the language from
their study was adapted to fit the target population in this current study. The survey design
selected provided “a quantitative description of trends, attitudes, and opinions of a population, or
38

tests for associations among variables of a population, by studying a sample of that population”
(Creswell & Creswell, 2018, p. 147). The majority of survey questions were measured using an
ordinal level of measurement because the answers had an inherent order and were not
randomized, and the survey placed categories on a continuum which assisted with the data
analysis process (Robinson & Leonard, 2019). Open-ended questions were added at the end to
provide additional insight. While education level, age, and gender were considered in the Krause
and Williams study, the ethnicity and socioeconomic background of the doctors were not. The
adapted survey for this study asked demographic questions pertaining to age, race, sex,
education, and income levels.
Participants
The criteria of the sample included individuals who were racially and ethnically diverse,
were individuals of both genders that are either head of the household or responsible for the
grocery shopping within a household, and at least 18 years of age. The intended participants
were residents in low-income areas within Southern California. Access to the participants was
gained through coordination with Vista Community Clinic, Catholic Charities, Orange County
Food Bank, Hunger Action LA, and various social media support groups.
Instrumentation
The survey instrument asked demographic questions regarding age, race, gender,
household size, education level, and the socioeconomic background of the participants. The
questions focused on perceptions of food availability before and after the current COVID-19
pandemic. All of the survey questions within the instrument were guided by Bandura’s (1998)
social cognitive theoretical framework. The majority of the survey instrument consisted of
questions with an ordinal level of measurement. The survey questions were designed to answer
39

one of the three research questions. Each of the questions within the instrument measured one or
more of the concepts from the emerging conceptual framework as it relates to the person,
behavior, and/or environment. Selected open-ended questions provided the opportunity for
deeper reflections, opinions, attitudes, and led to the discovery of unanticipated responses
(Robinson & Leonard, 2019).
Data Collection Procedures
The procedure for collecting the quantitative and qualitative data for the study took place
in nonprofit community organizations including Vista Community Clinic, Catholic Charities,
Orange County Food Bank, Hunger Action LA, and various social media support groups. These
organizations were selected because they have direct access to the target population and could
assist with overcoming access barriers. I contacted these organizations through networking with
colleagues that work in social service industries and through social media platforms like
LinkedIn and Facebook. Individuals in managerial or executive roles were the target contacts to
help disseminate the survey. Survey results and analysis was offered to participating
organizations to maintain a mutually beneficial relationship. The survey was available in both
English and Spanish. Translation support for creation and analysis was peer reviewed. Qualtrics
facilitated the data collection process and organization into spreadsheets for easier data analysis.
Ethics
Ethical concerns within this study included informed and voluntary consent, which was
obtained from all participants before they participated in the study. Confidentiality was explained
and granted to participants prior to survey distribution. There was no form of coercion or
compensation for study participation. All participants had the opportunity to participate in a
small raffle to win a gift card as a thank you for their participation within the study. At the end of
40

the study, five participants were chosen at random to receive the thank you gift cards. The five
survey winners were selected with peer review. The University of Southern California
Institutional Review Board (IRB) granted approval for data collection after successful defense of
proposal to the dissertation committee.
The underlying ethics of this study addressed all stakeholders. While this research will
initially help the health concerns of individuals in low-income areas in Southern California
specifically, the rest of the population of the United States can benefit due to increasing
healthcare costs throughout the country. Stakeholders will benefit from the more efficient and
equal health outcomes that can result from implementing this study’s recommendations about
nutritional food access and the reduction of food deserts. Community organizations will benefit
from learning how a global crisis like COVID-19 amplifies the current food structure
deficiencies and may be encouraged to improve the system. The results of the study will be
disseminated transparently to the public.
Data Analysis
The data analysis portion consisted of an exploratory analysis that examined the
relationships that emerged from the data as a whole. Descriptive statistical analysis was
conducted once all survey results were submitted to find meaningful information. Open-ended
survey questions included on the survey were intended to take a holistic account of the varying
factors contributing to participants’ nutritional decisions, and to ultimately to help form the
bigger picture of the participants’ data (Creswell & Creswell, 2018). The open-ended survey
questions from the Spanish-language survey were translated and combined with the English-
language answers. The answers were then coded and categorized into emerging themes. The
present themes were compared with and organized according to the quantitative data results.
41

Validity and Reliability
To ensure that external validity was achieved, the sample was large enough and
constituted a representative random sample (Merriam & Tisdell, 2016). The participant goal was
to get the survey in front of 1,000 people within the target demographic, with the assumption that
10% of people would complete the majority of the survey. In the end, 137 useable surveys were
collected. The potential of lacking construct validity was minimized through collaboration with
the local organizations, which helped to ensure a mutually beneficial research relationship and
that the survey answers would serve a purpose when put into practice (Creswell & Creswell,
2018).
To maximize internal reliability, I adapted standardized tools from an already established
instrument that provided survey administration instructions (Creswell & Creswell, 2018). To
further external reliability, there was transparency about the study, methods, sample, and location
(Creswell & Creswell, 2018). The intention of the study was to be reproducible so that other
researchers can collect similar data collection, interpretation, coding, and analysis.
According to Merriam and Tisdell (2016), survey questions are intended to be holistic,
multidimensional, changing, and not represent a fixed objective phenomenon. Moreover, validity
is relative and must be examined in relation to the purposes and contexts of the research
(Merriam & Tisdell, 2016). The chosen research design addressed questions of
validity/credibility by looking at and providing survey questions to a sufficient participant group.
In order to improve credibility, study methods were completely transparent, and all notes were
tracked and reviewed while coding the open-ended survey questions.

42

Chapter Four: Results
The intention of this chapter is to extract meaning from the data collected from the mixed
methods survey. The data analysis began with a descriptive look at the results of the survey and
how the responses apply to the research questions they were created to answer. After a thorough
explanation of the collected data, the secondary portion of the data analysis will display
conclusions derived from the exploratory analysis. A deep exploration of the findings will be
presented in which relationships are presented and analyzed. The concluding portion of this
chapter presents the qualitative analysis based on the findings from the open-ended survey
questions.
The survey was open for two and a half months, which was longer than intended due to
COVID vaccinations and the logistics of distributing the survey. At the close of the data
collection period, there were 137 usable surveys. Approximately 118 surveys were completed in
English, and 19 were completed in Spanish. The data were translated and combined to support
the analysis as a whole. The open-ended questions were translated and combined with the
English answers. There were three optional open-ended questions on the survey and
approximately 122 participants answered one to three of these questions. Question 14 had 120
responses, Question 17 had 120 responses, and Question 24 had 120 responses. Responses were
then coded for common themes and are presented at the end of each research question.
The reported gender identification of the participants was significantly skewed, with male
participants at 13 (9.5%) of the survey pool compared to 124 female participants (90.5%); no
other genders were identified by the participants. The majority of participants, 52 (38%), came
from the 37–50 age range. Thirty-nine (28.5 %) were in the age range of 26–36 years, eight
(5.8%) respondents were in the 61–70 age range, and six (4.4%) were in the over 70 category.
43

The majority of the participants were White, at 64 (46.7%), with Hispanic and Latin Americans
close behind with 59 (43.1%) participants. There were three (2.2%) Black or African American
participants.
The majority household size was three, with 38 (27.7%) of participants, and a close
runner up was four per household, with 33 (24.1%) respondents answering. Approximately, 17
(12.4%) had a household of five and seven (5.1%) of the participants had households of six or
more. Of the 136 participants that chose to answer the education level question, 41 (30.1%) went
to community college and the second highest response was a Bachelor’s degree, with 36 (26.5%)
respondents. Seventeen (12.5%) participants had earned a graduate degree. Approximately 31
(22.8%) graduated high school, and 11 (8.1%) did not graduate high school. The income levels
of respondents were also higher than expected for this study, but the number of respondents with
lower income levels provided opportunity for a comparison analysis. The majority of
participants, 53 (40%), made over $50,000 annually. The next highest was 43 (31.6%)
participants who reported earning less than $20,000 per year. Table 1 illustrates the number and
percentage of participant responses for all the demographic questions asked on the survey.

44
Table 1:
Demographics by Income
Characteristic < $20,000 $20,000–$34,999 $35,000–$49,000 > $50,000
n % n % n % n %
Gender
Male 3 7 3 10.3 1 9.1 6 11.3
Female 40 93 26 89.7 10 90.9 47 88.7
Trans 0 0 0 0 0 0 0 0
Non-binary 0 0 0 0 0 0 0 0
Prefer not to say 0 0 0 0 0 0 0 0
Age Range
18-25 9 12 5 17.2 0 54.6 1 1.9
26-36 10 23.3 11 37.9 6 27.3 12 22.6
37-50 17 39.5 9 31 3 9.1 22 41.5
51-60 3 7 2 6.9 1 0 11 20.8
61-70 3 7 2 6.9 0 9.1 3 5.7
Over 70 1 2.3 0 0 1 0 4 7.6
Ethnicity
American Indian or Alaska Native 0 0 0 0 0 0 0 0

45
Characteristic < $20,000 $20,000–$34,999 $35,000–$49,000 > $50,000
n % n % n % n %
Asian 2 4.7 0 0 1 9.1 1 1.9
Black or African American 2 4.7 1 3.5 0 0 0 0
Native Hawaii or Pacific Islander 0 0 1 3.5 0 0 0 0
White 11 25.6 9 31 3 27.3 41 77.4
Hispanic or Latin American 25 58.1 17 58.6 7 63.4 9 17
Other 3 7 1 3.5 0 0 2 3.8
Marital Status
Single 28 65.1 9 31. 3 27.3 3 5.7
Married 9 20.9 10 34.5 4 36.4 41 36.4
Divorced 2 4.7 6 21 2 18.2 6 18.2
Living with partner 4 9.3 4 13.8 2 18.2 3 18.2
Household Size
1 7 16.3 5 17.3 1 9.1 2 3.8
2 9 20.9 6 20.7 4 36.4 8 15.1
3 9 20.9 7 24.1 3 27.3 18 34
4 9 20.9 7 24.1 0 0 17 32.1
5 7 16.3 4 13.8 2 18.2 4 7.6
6 or more 2 4.7 0 0 1 9.1 4 7.6

46
Characteristic < $20,000 $20,000–$34,999 $35,000–$49,000 > $50,000
n % n % n % n %
Education Level
Did not finish high school 4 9.5 4 13.8 1 9.1 2 3.8
Graduated high school 16 38.1 9 31 1 9.1 4 7.6
Community college 14 33.3 11 37.9 3 27.3 13 24.5
Bachelor's degree 6 14.3 5 17.2 5 45.5 20 37.7
Graduate degree 2 4.8 0 0 1 9.1 14 26.4
47

The purpose of this study was to look at participants’ knowledge and perceptions about
nutrition and food availability. How the global COVID-19 pandemic contributed to the problem
was also examined. The analysis utilized Bandura’s (1998) social cognitive theory to frame the
challenges individuals face within urban low-income areas in Southern California. The data were
all collected to answer one of the following research questions:
1. What are the participants’ knowledge of nutrition and healthy diets?
2. What are the participants’ perceptions of healthy food access?
3. How has the COVID-19 pandemic affected participants’ perceptions of healthy food
access?
Research Question 1: What Are the Participants’ Knowledge of Nutrition and Healthy
Diets?
Quantitative Findings
The participants within the study all presented some knowledge of nutrition and its
importance to health and the prevention of chronic illnesses. The survey questions asked the
participants’ questions about their self-reported knowledge of nutrition and a healthy diet. To
look at the participants’ self-reported knowledge of nutrition and its effect on health, the survey
results were analyzed with the respondents’ answers in relation to their highest level of
education. The majority of answers regardless of education level, showed significant self-
reported knowledge of nutrition, with 134 (97.8%) participants strongly or somewhat agreeing
with the statement, “good nutrition is important to overall health.” While the other demographics
and their influence were examined, the majority of the figures were disaggregated by education
and income for this research question because they aligned with the literature and conceptual
48

framework. The demographic information was used to inform the data analysis. The percentages
and education levels are presented in Figure 2.

Figure 2:
Responses to Q.19 (Good Nutrition Is Important to Overall Health) by Education Level

49

The overall self- reported knowledge of nutrition and healthy food of participants also
came out to be relatively the same as the education category when the results were analyzed by
income. As displayed in Figure 3, the majority of participants at all income levels strongly
agreed with the statement that “eating more plants and vegetables can reduce my risk of cancer,
diabetes, obesity and heart disease.” The majority agreed that nutrition is important to overall
health, which was consistent across education and income levels.

Figure 3:
Responses to Q.18 (Eating More Plants and Vegetables Can Reduce My Risk of Cancer,
Diabetes, Obesity and Heart Disease) by Annual Income

50

A large majority of participants, 85 (62.04%), disagreed or strongly disagreed with the
statement that they “prefer fast food over cooking at home.” When it came to gender, all six of
the “strongly agree” responses were female and 11 somewhat agreed about preferring to eat fast
food over cooking at home. There were three males that somewhat agreed with this preference.
The majority at all age ranges strongly or somewhat disagreed with this statement. For the 18–25
year range, 10 (66.7%) strongly or somewhat disagreed, 20 (58.8%) of those 26–36 years old
strongly or somewhat disagreed, 33 (73.3%) of those ages 37–50 strongly or somewhat
disagreed, 12 (70.6%) of those 51–60 years strongly or somewhat disagreed, seven (87.5%) of
those 61–70 years strongly disagreed, and three (33.3%) in the over-70 age range strongly
disagreed. The overall response to this question is displayed in Figure 4.

Figure 4:
Responses to Q.16 (I Prefer Fast Food Over Cooking at Home)

51

The next question, “I eat at least 5 servings of vegetables every week,” was intended to
see if the participants’ self-reported knowledge played a role in their consumption behavior. This
question was looked at demographically by both ethnicity and annual income. The following
were the responses based off on participants’ ethnicity: three people (75%) who identified as
Asian strongly or somewhat agree and one (25%) neither agreed nor disagreed. Of Black or
African American respondents, one (33.3%) somewhat agreed and two (66.7%) somewhat
disagreed. One (100%) Native Hawaiian or Pacific Islander participant neither agreed nor
disagreed. Of White respondents, 50 (78.1%) strongly or somewhat agreed and 11 (17.19%)
somewhat or strongly disagreed. Of Hispanic or Latin American participants, 29 (49.1%)
strongly or somewhat agreed and 19 (32.3%) somewhat or strongly disagreed. Out of the “other”
ethnicity category, three (50%) strongly agreed and two (22.3%) somewhat or strongly
disagreed. Figure 5 represents this survey question by annual income.

Figure 5:
Responses to Q.12 (I Eat at Least 5 Servings of Vegetables Every Week) by Annual Income

52

To understand food consumption as it relates to culture, the survey answers to “I feed my
kids the same food that my parent/guardian fed me” were analyzed by ethnicity. The results to
that statement are depicted in Figure 6.

Figure 6
Responses to Q.20 (I Feed My Kids the Same Food That My Parent/Guardian Fed Me) by
Ethnicity

53

The final Likert scale formatted question to support Research Question 1 was the
statement that says, “There are aspects of my diet I would like to change if I could.” The answers
to this statement as they relate to income are shown in Figure 7.

Figure 7:
Responses to Q.13 (There Are Aspects of My Diet I Would Like to Change if I Could) by Annual
Income

54

Qualitative Findings
The open-ended survey question that corresponded with Research Question 1 was
Question 17, “Describe the types of food you eat on a daily basis.” The answers to Question 17
were coded into three main themes that emerged from the responses: Majority Plant-Based;
Meats, Dairy, and Simple Carbs; and Other. The coding category Majority Plant-Based depicted
participants that answered with plant-based foods as the majority type of food they consume on a
daily basis. Some of the answers consisted of “plant-based,” “vegan diet,” “Granos, frutas,
verduras” (“Grains, fruits, vegetables”), “Fresh fruits/vegetables, salads, soup, smoothies,”
“Mostly plant-based lots of soups,” “A lot of produce fruits and vegetables, I don’t make pasta,
rice or grains and we don’t eat breads. We do two vegetables and a meat of some sort,” and
“Orange juice, soy milk, almond milk, vegan ‘meat’; bread, beets, potatoes, water, etc.”
The code Meats, Dairy, Simple Carbs represented the vast majority of what participants
listed as their main sources of nutrition. A White female participant that graduated from high
school and earns less than $20,000 per year answered this question by writing “Pastas, rice, meat
on sale and whatever green veggies are on sale.” Some of the other responses that fall under this
code are, “If it doesn’t have meat in it somewhere I’m 0% interested,” “Mexican, spaghetti,
frozen family meals, mac and cheese,” “Chicken, beef, eggs, bread,” “Pan, jamón, queso,
naranjas, plátanos, agua, soda” (“Bread, ham, cheese, oranges, bananas, water, soda”), “Pollo
atún y poca carne roja” (“Chicken tuna and a little red meat”), “Meats, dairy, veggies, fruits,
protein supplement, eggs in abundance, whole grains (children), small amounts of natural sugar
products (children),” “Chicken, beef, milk, whole grains, juices,” “Chicken, cheeses, chips,
pasta, fruit,” “Chicken, canned veggies,” and “Carnes y frijoles” (“Meat and beans”).
55

The “Other” code category was created to represent all the responses that did not directly
answer the question. Some of these responses were as follows, “Anything quick to cook,”
“Anything fast,” “Healthy,” “Fast, quick, somewhat healthy,” “I purchase fast food when I do
not have the time to cook. I would like to buy fast food less,” “I eat all foods,” “Since I work all
the time I mostly eat fast food sometimes I can make some avocado toast or easy meals,”
“Balanced nutrients. Everything,” “Fatty foods,” “Italian,” and “Anything gluten free.” Figure 8
is a graphic depiction of the three main codes used to analyze the 120 participant responses.

Figure 8:
Responses to Open-Ended Q.17 (Describe the Types of Food You Eat on a Weekly Basis)

56

For Research Question 1, most participants within the study all presented with self-
reported knowledge of nutrition and its importance to health and the prevention of chronic
illnesses. This was a consistent result regardless of the various demographic categories. An
important finding that emerged through the qualitative survey answers was that while the
majority self-reported knowledge of healthy nutrition, environmental influences such as sale
items and time constraints impact their behavior.
Research Question 2: What Are the Participants’ Perceptions of Healthy Food Access?
Quantitative Findings
The majority of participant perceptions of healthy food access, regardless of income
level, was that fresh produce and healthy foods were costly and required a time commitment (see
Figure 9). The over-50,000 income bracket was the only one where most respondents at 32
(60.4%) strongly agreed with the statement from Question 12, indicating they eat at least five
servings of vegetables each week. The majority of the respondent from the second-to-lowest
income bracket of $20,000–$34,999 answered that they disagreed with this statement.

57

Figure 9:
Responses to Q. 11 (Fresh Fruits and Vegetables Are Expensive) by Annual Income

Examining Question 9, “I have no problem getting to the grocery store and buying the
food I want,” the following results show how answers relate to income. Figure 10 displays the
survey answers based on income levels. This question was intended to focus on transportation
and physical access to grocery stores. According to Walker et al. (2010), low-income individuals
are disadvantaged when they do not have access to car transportation to the grocery store
because they often depend on food options in proximity. Lack of time emerged from this
question as a barrier to eating healthy.

58

Figure 10:
Responses to Q.9 (I Have No Problem Getting to the Grocery Store and Buying the Food I Want)
by Annual Income

When purchasing food based on affordability, 17 (39.5%) out of the 26 responses in the
less-than-$20,000 annual income group somewhat or strongly disagreed with the Question 10
statement, “I can afford the food items that I would like to purchase.” Conversely, the other
income brackets somewhat or strongly agreed, including 20 (69%) out of 26 in the $20,000–
$34,999 bracket and eight (72.7%) of the $35,000–$49,000 bracket. Out of the respondents from
the highest income bracket, over $50,000, 47 (88.7%) out of 50 strongly or somewhat agreed that
they could purchase the food items of their choice. The variation in income levels and the
responses provided for Question 15 is represented in Figure 11.

59

Figure 11:
Responses to Q.15 (I Buy Food Based on What I Can Afford) by Annual Income

Qualitative Findings
The open-ended survey question that coincided with Research Question 2 was Question
14, “In your opinion what do you think would help you get closer to your ideal nutrition?” This
question was intended to understand participants’ perceived challenges to their ideal nutrition.
Four themes emerged from the 120 answers submitted. The emerging themes in the order of
highest occurrence are Money, Consume More Vegetables, Time, and Motivation, with sub-
codes of self-efficacy and Other.
The majority of responses to this question had to do with not having enough money to
consume the foods that participants deemed would bring them their ideal nutrition. Some of the
responses that fell under this code were, “Prices of the food that are healthier,” “Affordable
healthy food,” “Healthy food being cheaper,” “Lower cost for organic + healthy choices,” “More
60

funds cheaper healthy food,” “Affordable fresh fruit and vegetables,” “If healthy food was
cheaper and more healthier stores near,” “Increased access to vegan options and cheaper fruits
and veggies,” “Healthier food being priced better than unhealthy food,” “Having more affordable
options on fruits and veggies,” “Affordable produce,” “If fresh fruits and vegetables were as
cheap as their canned counterparts it’ll be easier,” “Cheaper or free food,” “$$$,” “Resources to
FRESH fruit and vegetables whenever I use commodities I have to use the food immediately or
else they go bad,” “More money,” “Cheaper price,” “Cheaper price on veggies & fruit,” “More
resources,” “Reduced cost of nutritional foods,” and “Being a senior with a fixed income it is
hard.” Additional responses included “Having more money,” “More amount of stamp food
money provided for low income,” “Cheap food,” “Fresh food should be cheaper than it is,”
“Cost,” “Poder comprar lo que me ayudaría con mi salud” (“To be able to buy what would help
me with my health”).
The next highest occurring theme from this question was Consume More Vegetables.
Some of the responses include “Comprar más verduras” (“Buy more vegetables”), “Eating
overall healthier meaning not eating out and eating less red meat,” “Eat healthy food & more
vegetables,” “Comer más vegetales” (“Eat more vegetables”), “Eat more vegetables and fruit.
Things that are nutritious for me and workout,” “Less fatty foods,” “More natural fruit,” and
“Fruit n veggies.”
Time was the next variable that respondents claimed affects their ability to eat based on
their ideal nutrition. Some responses include, “Convenience,” “I do not have a lot of time to
cook,” “More time in the day to prep,” “Prepared meals,” another respondent said,
“Convenience,” “Meal planning and advanced preparation,” “Having more time to prepare my
food,” “More time to meal plan and prep food,” “Meal prepping,” and “Food prep.”
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The final code for this open-ended survey question was Motivation, with the sub-code of
self-efficacy included. Responses include “The willpower to say no to unhealthy, addicting
foods,” “To not have as many accessible snacks in the household,” “Willpower,” another
“Willpower,” “Self-control,” “Less snacking,” “Discipline,” “Better nutritional education,” and
“More specific information on exactly what I should be eating.”
For Research Question 2, the majority of participants’ perceptions of healthy food access,
regardless of income level, was that fresh produce and foods are expensive and require a time
commitment. Those in the lower income brackets indicated that they tend to purchase food based
on what they can afford. The qualitative participant answers further confirmed that cost was
barrier to healthy food. A recurring finding in this part of the survey was that time and
convenience influenced the participants’ consumption habits.
Research Question 3: How Has the COVID-19 Pandemic Affected Participants’
Perceptions of Healthy Food Access?
Quantitative Findings
The information gathered for this research question varied based on income level but was
consistent among participants took fewer grocery trips and purchased more nonperishable foods.
There was also a common theme of pandemic fatigue and how mental health impacted food
consumption. The responses to the statement, “My food options have changed since the COVID-
19 pandemic” as they relate to income level are displayed in Figure 12 because the results show
that individuals experienced food options during the pandemic differently based on their income
level.

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Figure 12:
Responses to Q.21 (My Food Options Have Changed Since the COVID-19 Pandemic) by Annual
Income

When it comes to the statement, “I was able to buy the recommended two weeks’ worth
of food at one time, in order to follow COVID-19 social distancing guidelines by health
officials,” Figure 13 displays the responses.

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Figure 13:
Responses to Q.23 (I Was Able to Buy the Recommended Two Weeks’ Worth of Food at One
Time, in Order to Follow COVID-19 Social Distancing Guidelines by Health Officials) by
Annual Income

The final multiple choice survey question to support this research question was, “Getting
food has become more difficult since the COVID-19 pandemic.” Those results are displayed in
Figure 14.

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Figure 14:
Responses to Q.22 (Getting Food Has Become More Difficult Since the COVID-19 Pandemic) by
Annual Income

Qualitative Findings
The final open-ended survey question that correlated with Research Question 3 was
Question 24, “How has the COVID-19 pandemic changed your food consumption?” Three coded
themes stood out amongst the responses and were all fairly equal in their occurrence in answers.
The codes are, Reduced Income, Access, and Choices, with the sub-code of mental health. The
first theme for this survey question was Reduced Income, which included responses such as
“Had to buy cheaper foods,” “Less availability higher prices,” “No puedo comprar los alimentos
que quiero” (“I can't buy the food I want”), “I eat what is available and I can afford. If I go to the
store for something specific chances are it doesn’t work out because they are out so I will switch
what I buy,” “Lost job,” “Yes I eat out more since I cannot afford to cook (moneywise and
timewise),” “Less work equals less ability to purchase healthier options,” “Mucho no tuve
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trabajo por meses” (“A lot I didn't have a job for many months”), “A veces no encontramos los
productos o están muy caros” (“Sometimes we can't find the products or they are very
expensive”), “La comida está más cara y a veces no hay” (“The food is more expensive and
somethings there is none”), “Lost my job,” “Mucho porque no siempre se puede comprar lo
necesario” (“A lot because you can't always buy what you need”), “More cautious of what I buy
due to financial stress,” and “No puedo comprar los alimentos que quiero” (“I can't buy the food
I want”).
The second emerging theme was the effect COVID-19 had on access to food. The
responses included “Less fresh food,” “Consumimos más productos procesados” (“We consume
more processed products”),” “Yes, with allergies more concerned about availability,” “I didn’t
go to the store for fresh vegetables and fruits as often,” “I only shop once a month now,” “Less
shopping – less fresh fruit n veggies,” “A veces no encontramos los productos o están muy caros
(“Sometimes we can't find the products or they are very expensive”),” “I didn’t go to the store
for fresh vegetable and fruits as often,” and “Stocking pantry to avoid grocery shopping. Plan for
long-term food preparation, non-perishables in case of more infections.”
The final theme was Choices and included the sub-theme of mental health, as it had an
effect on food consumption during the COVID-19 pandemic. Responses included “Aislamiento”
(“Isolation”), “I’ve eaten more and in turn have gained weight. I’ve eaten more sweets as well,”
“More fast food less cooking, I’m too tired to cook for myself on the weekends and after work,”
“It has changed by mood because I choose comfort food,” “A lot of stress,” “I eat a lot more
food,” “Eating more because of stress,” “Not been able to buy as much food and have had to
change the way I eat,” “Eating more,” “It has made my eating habits poor,” “We snack more
now that we are home,” “More fast food and I’m definitely fatter,” “So much more sugar and
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processed carbs than normal and alcohol intake has gone way up. Trying to change all of that this
year but sometimes I’d be off it,” “Eat more comfort food,” and “Was snacking and eating
more.”
For Research Question 3, when it came to changes in food options and buying in bulk the
survey results varied based on income. Responses that were consistent among participants
included reduced grocery trips and increased purchasing of nonperishable foods. The qualitative
findings introduced how mental health influenced food behaviors. The concept of “pandemic
fatigue” and stress can affect the participants’ food choices and portions.
Summary
The purpose of this study was to look at participants’ knowledge and perceptions about
nutrition and healthy food availability in urban low-income areas. It was also important to look at
how a global pandemic contributed to this problem. The results obtained from the Likert scale
survey portion indicated that majority of question responses were impacted by the income level
of the participant. However, for Research Question 1, the majority of participants within the
study all presented with self-reported knowledge of nutrition and its importance to health and the
prevention of chronic illnesses. This was a consistent finding regardless of the various
demographic categories. The overall majority of participants’ perceptions of healthy food access
for Research Question 2, regardless of income level, was that fresh produce and foods were
costly and required a time commitment. Those in the lower income brackets tended to purchase
food based on what they were able to afford and depending on which items are on sale. When it
came to answering Research Question 3 regarding food and nutrition during the COVID-19
pandemic, some answers varied based on income, however, more answers across the participant
pool included aspects of mental health and eating habits. While results for this research question
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varied based on income level, responses that were consistent among participants included that
they took fewer grocery trips and they purchased more nonperishable foods due to the
restrictions in place during the pandemic. There was also a common theme of pandemic fatigue
and how stress during this time impacted participants’ food choices and portion sizes.

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Chapter Five: Recommendations
The final chapter of this dissertation study discusses the results as they connect back to
the literature reviewed in Chapter 2 and the conceptual framework, Bandura’s (1998) social
cognitive theory. This section also addresses how the results of the study answer the three
research questions and address the problem of practice. Following the discussion of the results
section, I present the recommendations and solutions for the problem of practice. This section
will outline four recommendations for practice that align with the results found within the study.
The next section discusses the limitations and delimitations of the study, with an additional
section containing recommendations for future research. This chapter ends with a final
conclusion encompassing the problem of practice, what the literature says about this problem,
the study methodology, the study conducted, and final thoughts on what the study results
indicate.
Discussion
The results from the survey were disaggregated primarily by income. They were also
categorized by education level for some of the research questions because those categories
aligned with the literature and conceptual framework as well as contained a large enough
distribution of answers. All the demographic questions were used as a lens to detect relevant
relationships in the survey results. Participants’ socioeconomic status connected to the problem
of practice of unequal health outcomes from nutrition in low-income urban areas. As previously
discussed, increasing economic inequality has contributed to food insecurity, obesity, and other
chronic diseases due to poor nutrition (Elmes, 2018). Previous research has shown a positive
correlation between income inequality and preventable deaths from obesity and cardiovascular
disease (Ronzio et al., 2004). This section will look at the results and findings that answer each
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research question and connect it back to the literature reviewed in Chapter 2 as well as the
conceptual framework. The study results, combined with the literature review and the conceptual
framework, will address the problem of practice.
To analyze the participants’ self-reported knowledge of nutrition and its effect on a
person’s overall health, the survey results were first analyzed with the respondents’ demographic
information about their highest level of education. Research Question 1 focused on knowledge,
so education level was used as the respondents’ key demographic identifier in order to see
response patterns. Most participants who responded to the survey knew that nutrition is
important to overall health; however, their answers indicated that their self-reported knowledge
can be insufficient when there are behavioral and environmental influences on food consumption
that restrict their food choices. A key finding from the study when looking at participants’
knowledge vs. behavior was the high perceived knowledge because it is based on self-reported
knowledge.
The participants’ perceptions of healthy food access were that fresh produce and healthy
foods were expensive and time consuming, and for those in lower-income brackets, food was
purchased based on affordability and on their understanding of its nutritional value. It was clear
that perceptions of healthy food access based on affordability influence how the participants in
this study purchase and consume food. This is more impactful among those with low
socioeconomic status in both the current study and in the literature reviewed in Chapter 2. For
Question 16, the majority of the respondents in the two lowest income-level brackets did not
prefer to eat fast food over cooking at home. The majority of participants strongly or somewhat
agreed that they purchased foods based on what they could afford. This was particularly apparent
in the two lowest income groups. Of the lowest income group of $20,000, 20.9% conveyed they
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had difficulty getting to the grocery store. Their perception that healthy food was not attainable
influenced their food purchasing habits. Other research has found that when fresh produce costs
significantly less, there are sizable rises in healthy food purchasing (Powell & Chaloupka, 2009).
Moreover, Ghosh-Dastidar et al. (2014) found that high-priced healthy food is a barrier to
consumption for low-income individuals.
While self-reported knowledge of nutrition and healthy eating was found from the survey
results, the participants’ behavioral responses in subsequent questions were not in line with what
they answered based on their self-reported knowledge. Based on the conceptual framework of
social cognitive theory (Bandura, 1998) established in Chapter 2, traditions, lifestyles, and
preferences influence an individuals’ behavior. While the quantitative results showed that most
people believe they know what constitutes a healthy diet and that a healthy diet is important to
overall health, the answers obtained from the open-response question showed that many did not
actually purchase food or eat food according to what they knew or perceived to be a healthy diet.
The most offered definition of healthy eating from another study, regardless of race and income,
was focused on fruits and vegetables; conversely, the daily recommendations for these food
groups are not met by Americans (Eikenberry & Smith, 2004). From the literature review in
Chapter 2, the types of foods individuals eat on a regular basis play a role in heart disease,
various cancers, diabetes, stroke, and obesity; these ailments are all significant results of a highly
meat-based diet, so those who eat large amounts of meat are at the highest risk for more than one
of these ailments (Boris, 2011). Additionally, the World Cancer Research Fund and the
American Institute for Cancer Research suggest completely avoiding processed meat, and vastly
limiting intake of red meat to reduce colon cancer, prostate cancer, breast cancer, and overall
cancer risk (Boris, 2011). Diets that consist of a high intake of meat, dairy, and eggs can lead to
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weight gain, obesity, hypertension, diabetes, heart disease, cancer, and gout because they consist
of high amounts of saturated fat, cholesterol, high-energy density, and carcinogenic compounds
(Stoll-Kleemann & O’Riordan, 2015).
The environment and its influence on behavior was prominent in the final category for
this research question, and it reflects all the answers that referenced fast food and quick at-home
preparation. The qualitative survey question revealed that a majority of participants felt that
healthy, fresh, organic foods were not affordable. Money—either having more money or having
access to lower-priced healthy food—was expressed as the main reason they were not consuming
based on their ideal nutrition. The second most common theme that emerged from this open-
ended question was the lack of time, including eating for convenience and needing more time to
prepare healthy foods. While a small number of participants said they had difficulties with
accessibility in the form of reaching the grocery store, more participants viewed accessibility as
an issue of time constraints. According to Guntzviller et al. (2017), self-efficacy as part of social
cognitive theory drives healthy behavior. Another study found a pattern of food consumption
motivators that consisted of familiarity, convenience, nutritional quality, enjoyment, satiation,
and cost (Wright et al., 2016).
Regardless of income, in response to Question 21 (food consumption) and Question 22
(getting food), participants consistently affirmed that accessing healthy food has become more
difficult since COVID-19 due to the increased purchasing of nonperishable foods and fewer
outings to the store. There was also a common theme of pandemic fatigue and how mental health
impacted food consumption. These findings indicate that most participants, regardless of their
income level, were able to buy food to prepare during the typical 2-week purchasing cycle during
the beginning of the COVID-19 pandemic. What is unknown is the types of food that were
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purchased in preparation for this 2-week period. As previously mentioned in Chapter 2,
participants knew that cheap high-calorie food products that lack proper nutrition are common in
low-income areas and have been a contributing factor to the decline in health, as well as
increased healthcare costs (McCurdy et al., 2015). Families that rely on food assistance
programs, like food stamps or food banks, typically must stretch their resources each month, buy
in bulk, use coupons, and opt for nonperishable items that do not consist of fresh fruits and
vegetables (McCurdy et al., 2015).
The qualitative portion of the survey that helped to answer Research Question 3 lent
insight into how the COVID-19 pandemic changed eating habits, as the following themes
emerged: Reduced Income, Access, and Choices. When it comes to reduced income, many
participants indicated they lost their job completely, had less work or no work for months, had to
buy cheaper food, and/or that food prices went up as availability went down. Access was also a
barrier because people shopped less, which meant they purchased more nonperishable and
packaged foods, stocked pantries, and bought conservatively due to uncertainty surrounding jobs
and the pandemic. Since nutrition is important to health and fatigue, a weakened immune system
response is one of the short-term health effects of poor nutrition and can heighten the risk of
communicable diseases (Dunn et al., 2020). The current food system faces the following
challenges: barriers to adopting healthier diets, which protect consumers and their immune
systems; availability of bioactive ingredients of food, food safety along the supply chain, food
security issues during a lockdown, and the sustainability of our current food system (Galanakis,
2020). Furthermore, practical foods and foods rich in vitamins can boost the immune system and
can help defend the body against viruses; for instance, foods rich in Vitamin C are citrus fruits,
kiwifruits, and broccoli, while foods rich in Vitamin A are vegetables like carrots, spinach, and
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sweet potatoes (Galanakis, 2020). Consuming more of these items can lead to a marked
improvement in individuals’ health, while the shift to pre-packaged foods and challenges with
obesity, undernutrition, and malnutrition increase due to restricted access, poor food choices, and
the reduction of exercise during the pandemic (Zurayk, 2020). During a crisis, when nutrition
and health are extremely important, individuals with reduced income had less access to healthy
food and consumed less of the foods that are central to health and well-being.
The final theme from the results was mental health and its relationship to food
consumption. Stress-related eating, food insecurity, isolation, eating more comfort food,
increased snacking from being home, increased sugar and alcohol intake, and increased fast-food
consumption all came as a result of changes in environment during the COVID-19 pandemic.
According to Dunn et. al (2020), the closures of schools and daycares account for about $30 of
food per week per child, and the loss of food service for families negatively impacted their
already vulnerable financial health. Added food-related stressors can force families to ration
food, resulting in insufficient nutritional intake or force them to give up other critical needs like
healthcare, medication, rent and/or utilities to prioritize food in their budget (Dunn et. al, 2020).
The COVID-19 pandemic has not only caused a loss or reduction in wages, thus putting more
into poverty; it has also furthered the economic gap of those who have access to healthful fresh
fruits and vegetables (Zurayk, 2020). Food shortages and hoarding have left shelves empty, fresh
food wasted, and has led to increases in pricing (Zurayk, 2020). Emotional and stress-related
eating is linked to obesity; research has correlated early childhood food insecurity with future
emotional attachment to food (Wiig & Smith, 2008). As an effect of the COVID-19 pandemic,
food insecurity has rapidly increased from pre-epidemic levels, from 11% in 2018 to 38% in
March 2020 (Wolfson & Leung, 2020). Due to a lack of resources and the ability to comply with
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social distancing regulations, those already living with food insecurity have experienced
intensified food security because of COVID-19 (Wolfson & Leung, 2020). Many studies have
shown that food insecurity and crisis create a higher likelihood of consuming high calorie but
nutritionally poor foods in order to address hunger, stress, and low-income (Elmes, 2018).
Dressler and Smith (2013) noted that overweight or obese women who felt depression, stress,
boredom, or other emotional distress at times used food as a coping mechanism.
Recommendations for Practice
Recommendation 1: Increase Fresh Fruit and Vegetables in Locally Sourced Food
Distribution
The first recommendation for food distribution service organizations is to increase the
number of fresh fruits and vegetables offered to their clients. Two major barriers, access and the
perceived high cost of fresh produce, emerged and generally agreed with the scholarly literature
reviewed. The studies described in Chapter 2 found high-priced healthy food to be a barrier for
consumption for low-income individuals, and one particular study found an increase in the
buying of healthy food when prices were lower (Ghosh-Dastidar et al., 2014).
Since barriers to access nutritious foods increase during a global crisis, a plan or gradual
switch to locally sourced food should be made. As reviewed in the literature, the COVID-19
pandemic furthered the gap between those with and without economic access to fresh fruits and
vegetables (Zurayk, 2020). By creating relationships with local famers and residential gardens,
the logistical challenges created by a crisis can be overcome and access to fresh produce can
increase. The use of technology can help connect low-income servicing organizations with
sustainable food organizations like: Seeds of Hope, FEAST, Food Finders, Garden School
Foundation among others to collaborate services and to eliminate waste. Localized food
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production can be more resilient during a crisis, reduce food insecurity, and improve human
health (Lal, 2020). Organizations would benefit from nutritional plans and guidelines to aid their
food distribution, as well as from evaluating their current ratios of produce to packaged food. By
reinforcing the quality of the food over quantity, general health can improve for food aid
recipients over time.
Recommendation 2: COVID-19 or Crisis Long-Term Comprehensive Social Support
Services
The second recommendation for organizations servicing low-income individuals during
and after a pandemic is to incorporate a holistic social services support approach. When it comes
to food, stress, mental health, and the need for other resources, a multifaceted social support
approach would be valuable. Organizations should not only provide physical resources but
should also provide other services or resources to proactively address the emotional and
psychological repercussions that come because of heightened stress during a crisis. According to
Ebrahim (2021), the importance of direct and indirect psychological interventions was
discovered by mental health psychologists. Person-centered care plans yielded benefits that
helped develop skills in emotional resilience and helped individuals understand the triggering
and maintenance factors for their mental health (Ebrahim, 2021). The participants from
Ebrahim’s study indicated that increased resources for psychological care could positively affect
direct patient care by increased access to psychological assessments, formulation, and brief
interventions. The recommendation is to adopt a proactive instead of a reactive social service
approach.
The concept of “self-care” in the form of education and coping mechanisms should be
developed on an organizational level and utilized during and after a pandemic. Since the long-
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term effects of COVID-19 remain unknown, developing a long-term self-care plan for
individuals is suggested. As the findings indicated, increased stress-related eating, snacking, and
comfort food consumption are a common behavioral response to stress in the environment. The
literature pointed to links between emotional and stress-related eating and obesity; research has
correlated early childhood food insecurity with future emotional attachment to food (Wiig &
Smith, 2008). The literature also positively indicated a correlation between poor nutrition and
chronic conditions. Furthermore, the literature showed that overweight individuals and those
with chronic conditions are at higher risk for mortality and long-lasting symptoms of COVID-19.
Ongoing self-care plans can include the following: nutrition and meal-planning
education/tips; exercise; mental health awareness, including signs and symptoms for those with
and without previously diagnosed conditions and telehealth therapy for individuals and families
as a proactive rather than a reactive measure. Crisis and coping therapy should be encouraged for
everyone during times of unforeseen circumstances, and mental health should be emphasized as
much as physical health. The results and findings from this study indicate that both need to be
addressed. The research cited in Chapter 2 shows that improving family attitudes, behaviors, and
family social support can boost an individual’s nutritional self-efficacy and promote self-
regulating behavior (Anderson et al., 2007).
Recommendation 3: Meal Planning and Time Management
The third recommendation that would assist organizations servicing low-income
individuals is to incorporate meal planning, preparation, and cooking time management into food
and health programs. A Canadian study found that meal preparation is associated with higher
consumption of fruits, vegetables, and a higher diet quality in children (Chu et al., 2014). Their
findings suggested that the positive correlation of meal preparation and dietary outcomes lends
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support for inclusion of meal preparation in health promotion programs (Chu et al., 2014). A
common theme that emerged from the study was poor food choices based on time constraints
and convenience. By providing education surrounding recipes for the week that are healthy and
quick to prepare, more options will be available to those with busy schedules. Preparing healthy
meals that can last for a couple days to a full week can also assist with preventing episodes of
impulsive eating and snacking. It can also help reduce the stress of daily food decision-making.
The recommendation to encourage more weekly meal preparation can expand
participants’ food knowledge. Engaging in nutritional learning activities can expand knowledge
and result in positive food behavior changes (Rustad & Smith, 2013). By planning out meals and
creating a grocery list and budget for a week or weeks, individuals can gain more control of their
eating habits. This kind of planning can encourage collaboration among family members and
begin to positively influence food knowledge at a younger age.
Recommendation 4: Advocate for Policy Change
The last recommendation is aimed toward the broader problem of inequitable access to
nutritious food in low-income urban areas and advocates for policy changes from the federal
government. The first recommended policy change comes in the form of increased produce
subsidies and a reduction in subsidies to the meat and dairy industries. The majority of the study
participants, regardless of their income status, indicated they believe fresh fruits and vegetables
are expensive; access to organic and healthy foods seems out of reach for many. The underlying
issue is that the government subsidizes approximately $38 billion to the meat and dairy industry,
versus $17 million to the fruit and vegetable industries (Wrock, 2016). The Physicians
Committee for Responsible Medicine recommends that consumers limit meat and dairy and eat
more fruits and vegetables (Wrock, 2016). By making healthy foods cheaper and more accessible
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to low-income populations, agricultural policies, and agricultural markets (Franck et al., 2013)
can improve Americans’ health. The government should analyze the health impact of the
industries they subsidize and allot funds based on objective health information. By increasing
produce subsidies, the U.S. food environment, which is currently designed to produce large
quantities of unhealthy food for a quick profit (Elmes, 2018), can become more equitable for
those of all socioeconomic statuses. The federal government needs to regulate the powerful meat
and dairy industries and change their current subsidy programs (Franck et al., 2013).
Limitations and Delimitations
This section discusses how my choices about the study methods and the conceptual
framework chosen had both anticipated and unanticipated limitations and delimitations.
Limitations are defined as, “the systematic bias that the researcher did not or could not control
and which could inappropriately affect the study results” (Price & Murnan, 2004, p. 66). A
delimitation, in contrast, is an intentional systematic bias brought into the study by the researcher
(Price & Murnan, 2004). The first limitation was the uncontrollable factor of participants’
truthfulness when answering the survey questions. Another limitation was the inability to
disseminate the survey in person to ensure that the target demographic were the participants.
With COVID-19 as a major limitation to access of participants, I was unable to distribute as
many surveys as possible, as well as ensure that the target demographic were the ones filling out
the survey. As seen from the results, some of the participants that submitted surveys were in a
higher socioeconomic demographic and had higher education levels than I intended to recruit.
This study is not as generalizable because the lack of diversity in the demographics did not
provide a representative sample.
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The University of Southern California IRB had strict regulations of not having any
person-to-person contact during data collection, and this hindered my ability to reach individuals
with low socioeconomic status that did not have access to the needed technology to complete the
survey. The requirement to complete the survey via smartphone or computer made it difficult for
the elderly and poor to access the survey. Prior to COVID-19, the intention was to also have a
paper version that could be passed out at food distribution events and collected and recorded.
This barrier to access individuals in person due to the pandemic excluded many from the
opportunity to submit a survey. Working with organizations during this time was difficult
because priorities and needs were focused elsewhere. A lot of the organizations were short
staffed and focusing on vaccines or other COVID-19 matters, such that it was difficult to speak
with and work with the necessary people to assist in survey distribution. An unanticipated
limitation was the length of time it took to get the completed surveys. Working with the
organizations, gaining the necessary approvals, and then explaining the distribution goals and
needs electronically made things progress slower than intended and naturally left more room for
error and miscommunication.
There were natural delimitations from the study method choices that were more apparent
during the data analysis, when it became clear that more exploratory open-ended questions or
possibly interviews with participants could have yielded more in-depth data. A delimitation by
choice was including the option of not using “Neither agree nor disagree” as part of the survey.
While including this option could have helped participants to complete the survey quickly, it also
minimizes participants’ need to give more thought to their answers. While the goal of receiving
over 100 complete surveys was achieved, it was a limitation to not have the survey distributed on
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a larger scale. Given the opportunity, having stricter guidelines on demographics for the
participating organizations would have kept the target population at the forefront of the study.
Recommendations for Future Research
Future research on this problem of practice would be important to understand the
aftermath of the COVID-19 pandemic and its impact on nutritional health. It will take years to
fully measure the long-term effects of this virus; however, future research can certainly focus on
the systemic and structural inequalities that have been exacerbated for those in low
socioeconomic classes. Subsequent research can benefit from primarily focusing on the short and
long-term effects of mental health in relation to nutrition for those living in or close to poverty
level. A parallel study could also look at the relationship between mental and nutritional health
regardless of socioeconomic status.
Future research could expand the current study from a mixed methods survey to a
complete mixed methods methodology, as in-depth interviews could yield new information.
Since new questions arose based on the answers by participants’ further probing questions could
be added after certain questions. In addition, probing questions could be used based off the
participants’ answer to the question using an if-then formula. It is recommended that future
research examine this problem of practice in various locations within the United States, not just
Southern California, where this study was focused. This study could be applied beyond urban
low-income areas to rural low-income areas, as well as areas that have higher population
densities of Asian, American Indian, and Hawaiian or Pacific Islander individuals. Expanding
the research to various locations would shed light on the difference in assistance from the
federal, state, and local levels.
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Conclusion
The U.S. food industry and the existence of food deserts has unequal health outcomes for
individuals in low-income urban areas (Béné et al., 2018). Growing economic inequality has
contributed to food insecurity, obesity, and other chronic diseases due to poor nutrition (Elmes,
2018). The health-related consequences from a poor diet affect more than the individual: the
societal and economic costs are also increasing (Boris, 2011). Cheap high-calorie food comes
with a variety of tolls for consumers, including taxes for agricultural subsidies, healthcare
expenses, and the three main causes of death associated with poor dietary intake and being
overweight (Franck et al., 2013). The current pandemic further spotlights this problem due to
COVID-19’s negative impact on compromised health, and increased barriers to access to
nutritious food during a shelter-in-place order (Petetin, 2020).
The purpose of this study was to look at participants’ knowledge and perceptions about
nutrition and healthy food availability in low-income urban areas in Southern California by using
Albert Bandura’s (1998) social cognitive theory as it relates to health promotion. The study also
examined how a global pandemic contributes to the existing problem during unprecedented
times. This study highlighted how food consumption is affected by the increasing socioeconomic
gap and a global pandemic, and it contributes to knowledge about ways to achieve social equality
through nutrition. Exploratory analyses of this study showed that a majority of participants have
self-reported knowledge of nutrition and its importance on health and the prevention of chronic
illnesses. Regardless of income, most of the participants’ perceptions of healthy food access
were that fresh produce and healthy foods are costly and require a time commitment for
preparation. Individuals in the lower income brackets tend to purchase food based on sales and
what they can afford. When it comes to effects of the COVID-19 pandemic on food
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consumption, many study participants referenced mental health concerns, changed eating habits
from pandemic induced stress and less grocery trips resulting in increased purchasing of
nonperishable foods.
As the economic gap continues to widen, so will increases in food insecurity, obesity, and
other chronic diseases due to poor nutrition (Elmes, 2018). However, the societal and economic
costs affect everyone, not just those of a lower socioeconomic status. An obese person’s
healthcare costs are approximately 42% more per year than someone of normal weight (Bastian
et al., 2017) and with estimated 2018 healthcare costs above $344 billion per year, taxpayers
account for about half of all medical spending (Boris, 2011). This study highlights that the
affordability of healthy food and mental health surrounding a crisis impact food consumption
and contribute to nutrition inequality in urban low-income individuals.

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95
Appendix A: Survey Protocol
Question
Open
or
closed
Level of
measurement Response options RQ
Concept being measured
(from emerging
conceptual framework)
1. Age Range Closed Nominal 18-25, 26-36, 37-50, 51-60, 61-
70, Over 70
D Demographic
2. Gender Closed Nominal Female, Male, Trans, Non-binary D Demographic
3. Ethnicity Nominal American Indian or Alaska
Native, Asian, Black or African
American, Native Hawaii or other
Pacific Islander, White
D Demographic
4. Marital Status Closed Nominal Single, Married, Divorced, Living
with Partner
D Demographic
5. Household Size Closed Nominal 1, 2,3,4,5, 6 or more D Demographic
6. I have no problem getting to the
grocery store and buying the
food I want.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
3 Environmental
7. I can afford the food items that
I would like to purchase.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
3 Environmental
8. Fresh fruits and vegetables are
expensive.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
2 Environmental
9. I eat at least 5 servings of
vegetables every week.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
2 Behavior

96
Question
Open
or
closed
Level of
measurement Response options RQ
Concept being measured
(from emerging
conceptual framework)
10. There are aspects of my diet I
would like to change if I
could.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
2 Behavior
11. In your opinion what do you
think would help you get
closer to your ideal nutrition?
Open Open Open 3 Behavior
Environmental
12. I buy food based on what I can
afford.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
2 Environmental
13. I prefer fast food over cooking
at home.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
2 Behavior
14. Describe the types of food you
eat on a weekly basis.
Open Open Open 2 Behavior
15. Eating more plants and
vegetables can reduce my risk
of cancer, diabetes, obesity
and heart disease.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
1 Person
16. Good nutrition is important to
overall health.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
1 Person
17. I feed my kids the same food
that my parents/guardian fed
me.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
1/2 Behavior
18. My food options have changed
since the COVID-19
pandemic.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
3 Environmental

97
Question
Open
or
closed
Level of
measurement Response options RQ
Concept being measured
(from emerging
conceptual framework)
19. Getting food has become more
difficult since the COVID-19
pandemic.
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
3 Environmental
20. Were you able to buy the
recommended two weeks’
worth of food at one time, in
order to follow COVID-19
social distancing guidelines
by health officials?
Closed Ordinal Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree
3 Environmental
21. How has the COVID-19
pandemic changed your food
consumption?
Open Open Open 3 Environmental
22. What is your highest level of
education?
Closed Ordinal Did not finish high school,
graduated high school,
community college, Bachelor’s
degree, Graduate degree
D Demographic
23. What is your income level? Closed Ordinal Less than $20,000, $20,000-
$34,999, $35,000- $49,999, Over
$50,000
D Demographic

Note. RQ = Research question.

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Asset Metadata

Creator Fetkin, Brittany (author)

Core Title Food deserts and perceptions of food access in urban low-income areas

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2021-12

Publication Date 09/16/2021

Defense Date 07/29/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag affordability,agribusiness,agricultural industry,animal agriculture,animal welfare,Bandura,cancer,cardiovascular disease,cheap meat,chronic illnesses,COVID-19,Dairy,Diabetes,disadvantaged nutrition,economic costs,environmental barriers,expensive produce,factory farming,fast food,fat,food access,food behavior influences,Food consumption,food crisis,food deserts,food education,food environment,food insecurity,food justice,Food production,food programs,food related behavior,food scarcity,food subsidies,food sustainability,food system,food-related stress,global crisis,Government policy,government subsidies,health inequality,health prevention,healthcare costs,heart disease,high calorie,Hunger,low nutrition,low-income,low-income neighborhoods,malnourished,meal planning,Meat,meat and dairy industry,Minorities,minority neighborhoods,misconceptions of nutrition,nutrient-poor,Nutrition,nutritional knowledge,nutrition-based health outcomes,nutrition-income,OAI-PMH Harvest,obesity,organic,overweight,pandemic,perceptions of healthy food,poor health,poor nutrition,Poverty,processed food,Produce,retail red-lining,saturated fat,social inequality,socioeconomic gap,socioeconomic status,subsidy,sustainability,systemic,time management,unequal access,unequal health outcomes,United States Department of Agriculture,Urban areas,USDA,vegan,Vegetables

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Adibe, Bryant (committee member), Muraszewski, Alison (committee member)

Creator Email brittanyfetkin@gmail.com,fetkin@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC15918330

Unique identifier UC15918330

Legacy Identifier etd-FetkinBrit-10070

Document Type Dissertation

Format application/pdf (imt)

Rights Fetkin, Brittany

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu