Food Access, Affordability, and Quality in a Paraguayan Food Desert by Meredit
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Residence in a Deprived Urban Food Environment: Food Access, Affordability, and Quality in a Paraguayan Food Desert by Meredith Gartin A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy Approved April 2012 by the Graduate Supervisory Committee: Alexandra Brewis Slade, Chair Amber Wutich Christopher Boone ARIZONA STATE UNIVERSITY August 2012 ABSTRACT Food deserts are the collection of deprived food environments and limit local residents from accessing healthy and affordable food. This dissertation research in San Lorenzo, Paraguay tests if the assumptions about food deserts in the Global North are also relevant to the Global South. In the Global South, the recent growth of supermarkets is transforming local food environments and may worsen residential food access, such as through emerging more food deserts globally. This dissertation research blends the tools, theories, and frameworks from clinical nutrition, public health, and anthropology to identify the form and impact of food deserts in the market city of San Lorenzo, Paraguay. The downtown food retail district and the neighborhood food environment in San Lorenzo were mapped to assess what stores and markets are used by residents. The food stores include a variety of formal (supermarkets) and informal (local corner stores and market vendors) market sources. Food stores were characterized using an adapted version of the Nutrition Environment Measures Survey for Stores (NEMS-S) to measure store food availability, affordability, and quality. A major goal in this dissertation was to identify how and why residents select a type of food store source over another using various ethnographic interviewing techniques. Residential store selection was linked to the NEMS-S measures to establish a connection between the objective quality of the local food environment, residential behaviors in the local food environment, and i nutritional health status. Using a sample of 68 households in one neighborhood, modeling suggested the quality of local food environment does effect weight (measure as body mass index), especially for those who have lived longer in poorer food environments. More generally, I find that San Lorenzo is a city-wide food desert, suggesting that research needs to establish more nuanced categories of poor food environments to address how food environments emerge health concerns in the Global South. ii DEDICATION For my Grandparents, Harry, Hazel, and Charlee, who always supported me, but who passed away before they could see me complete my “lessons.” And, for my Mom and Dad iii ACKNOWLEDGMENTS This document was made possible through a network of collaboration and support. It would be impossible for me to thank everyone who helped me along the way, so I extend a general note of appreciation to all who contributed. Foremost, I was generously supported by the Arizona State University Graduate Research Support Program; Contract ID Number: 1292. Thanks also, to my parents and my Aunt Shaaron for their “small grants fund” and for having faith in my research goals. To Nikki Murdick and Jay St. Vincent, thank you for always being just a phone call away and willing to help during my education (and my whole life). To Mom and Dad, in many ways, this has been a group project and I am blessed to have both of you to nurture and believe in my ambitious goals. Thank you both for always making me laugh and teaching me how to focus on the ‘theater of life’ and not the trials. Thank you to my field team in Paraguay: Cristina Segovia Arce, Rodrigo Arce, and Marcos Freira; and, the undergraduate, Arizona State students, John Jackman and Elizabeth Kiehne who came to Paraguay and assisted in the data collection of the food environment. In particular, I would like to thank Benjamin Jewell. Ben, you have been an integral part of the last five years and this entire process. Thank you for all your insights, suggestions, optimism, and help with this research, but more iv importantly for your appreciation of good music and food. I am so grateful for your assistance in the field and your visit to San Lorenzo. I would like to thank the communities of San Lorenzo who made me feel welcome, shared meals with me, joked with me, and made me feel a part of their daily lives. I am especially grateful to Luis Amarilla and his family and to Cristina Segovia Arce and her family for helping to get me settled in San Lorenzo, teaching me how to cook the local cuisine, and laughing with me at my very rough Guaraní pronunciations of words and phrases. My committee also guided and assisted me through the development of this project. Amber, thanks for all your advice and suggestions over these years. I am especially grateful that you shared your passion for research and developing new questions and possibilities. Chris, thanks for always bringing sincerity and kindness to our discussions during the last 6 years. Last, but certainly not least, I thank my mentor and advisor of over a decade, Dr. Alexandra Brewis Slade. Alex, without your vision Global Health would not be at Arizona State nor would I. As I wrote this dissertation, I was reminded of the “early years.” I have made decisions with your guidance and you have never steered me in a wrong direction. I am grateful to have found a mentor as loyal, generous, and thoughtful as you. Thank you for my start, my middle, and my new beginning. And, as I prepare to graduate, thank you for my future. v TABLE OF CONTENTS Page LIST OF TABLES............................................................................................ viii LIST OF FIGURES .......................................................................................... xii CHAPTER 1 INTRODUCTION ........................................................................... 1 Global Health Perspective .......................................................... 2 Food Deserts in the Global North and Global South ................ 4 Literature Review ..................................................................... 19 Research Hypotheses .............................................................. 40 Structure of the Document ...................................................... 44 2 METHODS AND PROCEDURES ............................................... 46 Research Design .......................................................................48 Data Collection: Phase I—Exploration ................................... 56 Data Collection: Phase II—Explanation of Food Stores ......... 66 Data Collection: Phase II—Explanation of Households ......... 71 Data Management and Analysis .............................................. 79 3 A FOOD DESERT IN THE GLOBAL SOUTH? SAN LORENZO, PARAGUAY ........................................................................... 88 Findings in San Lorenzo, Paraguay ........................................ 89 Summary of Findings ............................................................. 108 4 EXPLANATIONS OF HOUSEHOLD FUNCTIONS: SHOPPING IN THE FOOD DESERT ...................................................... 111 vi CHAPTER Page Coping in Food Deserts ........................................................... 114 Household Forms: Sample Demographics ........................... 118 The Rio Barrio: Field and Interview Observations ............... 122 Content Analysis ..................................................................... 135 Summary of Findings ............................................................. 154 5 MODELS OF NUTRITIONAL RISK: DIET IN THE FOOD DESERT ............................................................................... 158 Food Deserts, Dietary Diversity, and Obesity Risk .............. 160 San Lorenzo Population Sample ........................................... 164 Summary of Findings ............................................................. 185 6 DISCUSSION AND CONCLUSION .......................................... 199 Conclusions............................................................................. 219 REFERENCES ............................................................................................. 221 APPENDIX A PARAGUAY NEMS-S SAMPLE FORMS .............................. 240 B HUMAN SUBJECTS REVIEW DECISION AND HOUSEHOLD SURVEY INSTRUMENTS .................................................. 253 C FIELD SITE MAPS ................................................................. 283 D FOOD STORE COMPARISONS ............................................ 288 E DIETARY AND NUTRITIONAL OUTCOMES ..................... 296 vii LIST OF TABLES Table Page 1.1. Inquiry Line 1 Hypotheses: Food Environments in the Proposed Food Desert .............................................................. 42 1.2. Inquiry Line 2 Hypotheses: Residential Perceptions of Access and Subsequent Coping Strategies .......................................... 43 1.3. Inquiry Line 3 Hypotheses: Interaction of Food Desert and Residential Access/Strategies with Health Concerns ............. 44 2.1. Data Collection Time Table ...................................................... 53 2.2. Inquiry Line 1 Hypotheses: Food Environments in the Proposed Food Desert .............................................................. 67 2.3. Inquiry Line 2 Hypotheses: Residential Perceptions of Access and Subsequent Coping Strategies .......................................... 71 2.4. Inquiry Line 3 Hypotheses: Interaction of Food Desert and Residential Access/Strategies with Health Concerns ............. 72 2.5.