Fall 08

December 17

News Deserts, Food Deserts and How They Affect a Community’s Health

Allison Russell

MPH-RD Candidate, Class of 2017 Paper Adviser

UNC GILLINGS SCHOOL OF GLOBAL PUBLIC HEALTH DEPARTMENT OF NUTRITION INTRODUCTION

The most durable health problems in the United States are also among the most costly and preventable: chronic diseases and conditions such as heart disease, stroke, cancer, Type II diabetes, obesity and arthritis. These conditions are most prevalent among minority groups, resulting in health disparities.1 A health disparity occurs when a health outcome, either beneficial or detrimental, is seen to a greater or lesser extent between populations grouped by race, ethnicity, sex, socioeconomic status or other factors.2 These groupings, also known as the social determinants of health, impact the health outcomes of populations, communities and individuals. This paper highlights a dual health disparity status that many communities experience by being classified as both food deserts—communities with diminished food environments—and deserts— communities with diminished information environments. This paper proposes that a community that is a ‘dual desert’—one that is classified as both a food desert and a news desert—has poorer health outcomes than a community that is either a ‘single desert’ status or a ‘non-desert’, and it explores what can be done to mitigate the effects a dual disparity has on a community’s health. It is critical to study these correlations in order to properly understand disparate outcomes. The CDC acknowledges that eliminating health disparities is essential to improving the health of all Americans: “The future health of the nation will be determined, to a large extent, by how effectively federal, state and local agencies and private organizations work with communities to eliminate health disparities among those populations experiencing a disproportionate burden of disease, disability and death.”3 In its most recent Disparities Report the CDC reported that the prevalence of obesity increased significantly among men, and that substantial disparities persisted in the prevalence of obesity by race, sex and education between 2007 and 2010. The report also shows that the prevalence of diabetes is highest among men, Hispanics, people with less than a high school education, and people with income below the federal poverty line.3 The reports highlights the health disparities among sex, race, education and socioeconomic status. This paper will focus on two of the predominant chronic health conditions: adult obesity and diagnosed Type 2 diabetes (“diabetes”). In the United States the prevalence of obesity is 36.5%, and it can lead to many of the leading causes of preventable death, such as heart disease and stroke.4 The Center for Disease Control estimates the annual medical cost of obesity to be more than $150 billion, with obese people paying an average of $1,400 more in medical costs per year than people who are not obese.4 Among adults older than 20, the prevalence of diabetes is 9.6%, and more than 60% of adults with diabetes die of heart disease or stroke; people with diabetes have a mortality rate up to four times higher than people without diabetes.5 The American Diabetes Association estimates the cost associated with diabetes in the United States is more than $140 billion, which includes direct medical costs and indirect costs such as disability and premature mortality.6,7 There was an estimated 7,054 years lost before age 75 per 100,000 people due to diabetes in 2016.8 The greatest determinants of population health are social and economic factors (40%) and health behaviors (30%) [see Figure 1]. This paper focuses on how specific social and economic factors impact health behaviors and subsequently influence a community’s health. Social and economic factors include environmental factors such as the food environment and the information environment, and health behaviors include dietary decisions. This paper explores how food deserts, a condition of the food environment, and news deserts, a condition of the information environment, create a dual disparity and influence individual health behaviors and impact community health outcomes. The broadest determinants of individual health are the general socioeconomic, cultural and environmental conditions of the individual’s community [see Figure 3]. Community health, the aggregate of individual health outcomes, is determined by social relationships, environment and economy [see Figure 2]. Two environmental factors in the community health model are the food environment, which can create conditions for a food desert, and the information environment, which can create conditions for a news desert. The health of the community is one of the factors that impact the health of individuals living within the community.

FIGURE 1: Determinants of Population Health9

FIGURE 2: Determinants of Community Health10

FIGURE 3: Determinants of Individual Health11

The common thread through these three models of health determinants at the population, community and individual level is the environmental factor. ‘Environment’ is composed of many specific factors, and this paper will focus on the food environment and the information environment [see Figure 4]. This paper proposes that a county that has ‘dual desert’ status—one that is classified as both a food desert and a news desert—has poorer health outcomes than a community that has either ‘single desert’ status—one that is classified as either a food desert or a news desert, but not both—or ‘non-desert’ status—one that is not classified as either a food desert or a news desert. The rationale for this proposal is that a county’s dual disparity status as a food desert and a news desert compound to worsen the county’s health outcomes, which include adult obesity, diabetes and premature death. This paper utilizes case studies of counties from North Carolina and South Carolina to test this hypothesis.

FIGURE 4: The Environmental Conditions of Food Deserts and News Deserts Within the Model of Determinants of Individual Health

This paper has three main objectives: 1. To demonstrate via case study data that ‘dual desert’ status correlates to a worse effect on a community’s health than ‘single desert’ or ‘non-desert’ status. 2. To identify the gaps in current literature that do not address the dual impact of food desert and news desert status on a community’s health. Although there has been extensive research about effects that food deserts have on a community’s health, very little research has been conducted on the effect that news deserts have on a community’s health, and no research has been conducted on the overlapping effects that food deserts and news deserts have on a community’s health. 3. To propose conceptual research for future studies to evaluate how food deserts and news deserts overlap and interact to impact a community’s health.

BACKGROUND & CASE STUDIES

Food Deserts The primary diet-related risks in the current food system result from the overconsumption of food, and these risks contribute to the etiology of cardiovascular disease, obesity and diabetes.12 The dietary recommendations for mitigating these diseases and conditions are quite similar: to moderate sodium and energy intakes—particularly energy from saturated fats and refined carbohydrates—and to consume more fruits, vegetables and whole grains. The food supply does not align well with these guidelines, and many Americans have diets that entail an excess of refined carbohydrates, saturated fat and sodium.12 A major determinant of the behavior of deciding which foods to eat is the food environment: the access an individual has to grocery stores and restaurants. Generally, large chain supermarkets or grocery stores offer a wide selection of nutritious foods (fruits, vegetables, whole grains), while convenience stores and corner stores stock a limited supply of produce and offer a wide selection of processed foods and sugar-sweetened beverages, which are high in refined carbohydrates, saturated fat and sodium. Studies have found that greater access to fast-food restaurants, and the lower prices of these restaurants, are related to a diet high in saturated fat, refined carbohydrates and sodium.13 Some studies show the increased access to fast-food restaurants is associated with increased risk of obesity; studies have also found that increased access to supermarkets is associated with reduced risk of obesity, and increased access to convenience stores is associated with increased risk of obesity.14 Access to supermarkets and grocery stores is one of the criteria used to determine whether a community is a food desert. The USDA defines a food desert as “a low-income census tract where either a substantial number or share of residents has low access to a supermarket or large grocery store.”15 The USDA considers tracts as ‘low income’ if at least 20 percent of residents have income at or below the federal poverty level, or if the tract’s median family income is below 80 percent of the surrounding area’s median family income. The USDA considers tracts as ‘low access’ if at least 500 people, or at least 33% of the population, live more than 1 mile from a supermarket; for rural census tracts, the distance is more than 10 miles from a supermarket.15 There are 23 million people in the United States who live in food deserts.14 Mapping shows that areas designated as food deserts are often areas with high rates of obesity and chronic, diet-related diseases such as diabetes.14 A potential causal pathway between food access and body weight is that when a person has limited options for consuming nutritious food options—i.e. they live in a rural area that has several convenience stores but is 20 miles from the nearest grocery store—they will rely on the energy-dense options available at the convenience stores, and this dependency will likely result in weight gain [see Figure 5.] There is not sufficient evidence to confirm this causal pathway, but there is research that explores the relationship between consumption of fruits, vegetables and whole grains and health outcomes such as obesity and diabetes, and some broad conclusions can be drawn: plant-based foods (fruits, vegetables, whole grains) are linked to reduced risk of cardiovascular disease; high consumption of saturated fat and refined sugar are linked with higher risk of diabetes and cardiovascular disease; and sugar-sweetened beverages increase the risk of obesity, diabetes and cardiovascular disease.14

FIGURE 5: Proposed Pathway for How Food Deserts Impact Health

The following case study provides an example of this conceptual pathway by outlining health outcome data from a county in North Carolina and a county in South Carolina, both of which have ‘single desert’ status as food deserts.

TABLE 1: Single-Desert Status Case Study A: Food Deserts

Health Outcome Granville County, N.C. Georgetown County, S.C. Population 58,674 61,298 County Health Outcome Rank 34/100 22/46 Adult Obesity 36% 31% Diabetes Prevalence 12% 14% Premature Death 7,600 years 8,400 years

Analysis: This case study presents two counties with similar population sizes, a similar prevalence of adult obesity and a similar prevalence of diabetes. Both counties are in the upper 50% of their state’s county health outcome ranks, and they both have a greater prevalence of adult obesity and diabetes, and greater rates of premature death, than their respective state’s average and the average of top U.S. counties.

Hypothesis Support: This case study supports the paper’s hypothesis: it demonstrates that a county that is classified as a food desert has health outcomes that are worse than the average health outcomes for the state.

News Deserts The Community Information Ecosystem model outlines eight dimensions to use to measure the health of a community’s information environment [see Figure 6]. The three dimensions this paper focuses on are information landscape, information use and information impact:

• Information landscape: the physical and institutional infrastructures that support information production and flow (i.e. media outlets, such as local ). This dimension also describes the capacity of information producers (i.e. local newspapers) to support robust information flow. • Information use: how consumers utilize the information they receive. This dimension identifies the factors that influence how information is understood, shared and applied. • Information impact: the relationship between information, knowledge and large-scale behavior change. This dimension addresses how information affects individual and community well being.

These three dimensions are most directly impacted by the presence and quality of a local , and they have a significant impact on decision-making behaviors that influence health [see Figure 7].

FIGURE 6: The Community Information Ecosystem Model16

The presence and ownership of a local newspaper are factors that determine a community’s news desert status. A community is considered a news desert if it has experienced “the loss or significant diminishment of a news or outlet (such as a newspaper, magazine or local news radio or television program) that has historically provided reliable news and information that is essential to a community’s economy, governance and quality of life.”17 A news source, such as a newspaper, can be considered ‘diminished’ if an investment group, instead of a local owner or publishing group, owns it. Small town newspapers are especially appealing to private equity funds, hedge funds and other large investment groups because they are “cheap, asset-rich and well-positioned in non-competitive markets.”18 News deserts are an emerging research topic, so there is not yet national data that describes the prevalence of news deserts, but one report estimates that, since 2004, more than 650 community newspapers with a combined audience of 12.8 million have folded or been purchased and later shut down by investment groups.17 The American Society of Newspaper Editors estimates more than a 30% loss of local ’ jobs between 2009 and 2015.19 At the state level, investment groups like Civitas, New Media/Gatehouse and CNH Industrial Capital own more than 30 percent of North Carolina newspapers.17 Many such papers are in major metro areas such as Charlotte and Raleigh and provide news and information for smaller surrounding towns, as well as cities like Fayetteville, Wilmington and Winston-Salem.17 In many rural communities where the local paper either no longer exists or is owned by a national investment group, the majority of news comes from social media.20 This reflects the larger national issue of the veracity of news from social media, as social newsfeeds often provide users with stories that have not been fact-checked— some of which, like reporting on “chemtrails,” have been mistaken for well-reviewed science.21 Research has shown that news coverage prioritizes health issues for the public. When the news draws attention to specific topics, such as the prevalence of cancer or cardiovascular disease, the media has the ability to influence public opinion about the topic.22 Compared with national news, local news plays a central role in shaping public opinion and policy. As a traditionally central fixture of communities, local newspapers serve both a social and information function. 22 Additionally, the article’s content and how topics are discussed, framed and contextualized shape public perceptions of health issues and can increase or diminish public support for policy changes.22 Health disparities occur from inequalities at the institutional and policy levels, and they therefore require institutional-level and policy-level solutions and interventions. News stories that frame issues through the lens of health disparities contribute to setting the agenda at these levels and can lead to policy changes to reduce and eliminate health disparities. Research shows that journalists face barriers when covering disparities in local media.22 Journalists report that they consider several angles when developing health stories, which include public impact and personal behavioral change. Journalists report that it is difficult to employ a health disparities frame for several reasons: the difficulty of interpreting how study findings may impact different socioeconomic groups, and the difficulty of understanding how findings may translate across racial and ethnic groups.22 Ethnic media, a form a local media that has an audience of immigrants or community members for whom English is not their first language, performs an essential function of disseminating relevant information to minority communities.23 As a result, local ethnic media have the potential to reduce knowledge gaps because they are trusted and influential sources of health information that achieve both personal and community relevance. 23 Ethnic media are popular among racial and ethnic minorities who experience the bulk of health disparities; these communities suffer a disproportionate burden of diseases such as cardiovascular disease and diabetes, and they are often missed by the mainstream English-speaking channels that disseminate public health information.23 Given the communities they reach, local ethnic media sources that document health disparities and frame health topics through the lens of the social determinants of health have the potential to influence public perceptions of inequalities and mobilize community members to take action. These efforts will have an even wider reach if there is collaboration between local ethnic media and local mainstream media outlets. Newspaper ownership is important to a community’s health because owners and publishers make decisions about coverage that have an effect on the community’s information environment. Investment groups that own local newspapers often make dramatic reductions to staff, which limits the time spent on local, in-depth reporting and results in a reliance on reports from wire services, national organizations that gathers news reports and sell them to subscribing news outlets.18 A smaller staff limits the newspaper’s ability to provide reliable reporting on a wide range of issues, such as healthcare and public health, which often leads to “chasing clicks,” or providing content that is widely appealing but does not contribute to a larger discussion about issues that impact community health.18 In one study, journalists reported that some audiences find health disparity stories to be “less palatable,” so they are less likely to read or engage with the story and its information.22 This struggle to create local content and engage an audience results in a shift in focus from local to national issues, and a diminished editorial voice about local issues. These changes are especially apparent with local elections coverage and coverage of health news and health disparities, and these changes suggest that local news outlets may be contributing to health knowledge deficits. Several studies have concluded that communities are under-informed about health disparities and the social determinants of health, and one study conducted systematic media content analyses to determine the prevalence of stories that use a health disparity framework.23 Using cancer coverage as the exposure, the study conducted a multi-method content analysis of disparity health stories and non-disparity health stories in local English-language (“mainstream”) and Spanish- language (“ethnic”) print news in two low-income cities in New England. The study found that coverage and framing of health disparities only constituted 0.1 to 13.6% of all health news.23 Although some stories identified disparities and suggested causes and solutions, they often framed disparities in an individual context instead of an environmental or social context. For example, the stories attributed disparities to poor dietary habits instead of viewing those habits within the larger context of the food environment and the accessibility and affordability of nutritious food. The study concluded that health stories routinely missed opportunities to frame health topics through the lens of health disparities and the social determinants of health, which indicates there are opportunities for journalists to approach these stories in a more contextualized and effective manner.23 However, contextualized health stories benefit from collaboration with public health experts and other steps that require an additional time investment that may not be feasible for a diminished staff at a local newspaper that is investment- owned and not community-centric in its coverage.

The following case study provides an example of the conceptual pathway outlined in Figure 7 (on the following page) by outlining health outcome data from a county in North Carolina and a county in South Carolina, both of which have ‘single desert’ status as news deserts.

TABLE 2: Single-Desert Status Case Study B: News Deserts

Health Outcome Jones County, N.C. Barnwell County, S.C. Population 10,013 21,725 County Health Outcome Rank 68/100 37/46 Adult Obesity 34% 37% Diabetes Prevalence 15% 17% Premature Death 7,900 years 11,800 years Analysis: This case study presents two counties, one of which has a population twice the size of the other, but the counties have a similar prevalence of adult obesity and diabetes. Both counties are in the bottom 50% of their state’s county health outcome ranks. Both counties have a greater prevalence of adult obesity and diabetes, and greater rates of premature death, than their respective state’s average and the average of top U.S. counties.

Hypothesis Support: This case study supports the paper’s hypothesis: it demonstrates that a county that is classified as a news desert has health outcomes that are worse than the average health outcomes for the state.

FIGURE 7: Proposed Pathway for How News Deserts Impact Health

How Food Deserts and News Deserts Interact Communities that lack access to nutritious food and access to local news suffer from a double disparity that is reflected in these communities’ poorer chronic health outcomes when compared to counties that have more robust food and information environments. Both the food environment and information environment inform and influence a person’s behaviors and decisions, and these decisions impact and determine a person’s health outcomes, as well as the community’s health outcomes [see Figure 8]. This paper argues that access to nutritious food impacts chronic health outcomes because access to, and consumption of, nutritious foods supports and maintains a person’s general health, which helps prevent chronic health problems. This paper also argues that access to local news via locally owned newspapers impacts chronic health outcomes because local informs, engages and empowers citizens to make decisions that impact and improve their lives and shape their communities. Thus, a community that has ‘dual desert’ status has poorer health outcomes than a community that has either ‘single desert’ status or ‘non-desert’ status, resulting in a dual disparity and worse health outcomes, which are reflected in a higher prevalence of obesity, diabetes and premature death.

FIGURE 8: Proposed Pathway for How Food Deserts and News Deserts Interact to Impact Health

The following case study provides an example of this conceptual pathway by outlining health outcome data from a county in North Carolina and a county in South Carolina, both of which have ‘dual desert’ status as a food desert and a news desert.

TABLE 3: Dual Desert Status Case Study

Health Outcome Robeson County, N.C. Lee County, S.C. Population 134,197 17,896 County Health Outcome Rank 100/100 43/46 Adult Obesity 40% 44% Diabetes Prevalence 16% 17% Premature Death 12,100 years 10,600 years

Analysis: This case study presents two counties with significantly different population sizes, but they are both ranked within the bottom 10% of their state’s health outcomes. Both counties have a higher prevalence of adult obesity than both their state’s average and the average of top US counties. Both counties also have a higher prevalence of diabetes than their state’s average and the average of top U.S. counties. Both counties have much higher rates of premature death than their state’s average, and these counties’ rates of premature death are higher than their state’s rates, and are more than double the rates of premature death in top U.S. counties.

Hypothesis Support: This case study supports the paper’s hypothesis: it demonstrates that a county that is classified as both a food desert and a news desert has a health outcome rank, a prevalence of adult obesity and diabetes, and premature death rates, that are much worse than the state’s average. This case study support the statement that a ‘dual desert’ status has a compounding effect on worsening health outcomes, especially when compared to the case studies that show the effects of single desert status and non-desert status.

The following case study provides an additional example of the conceptual pathway presented in Figure 8 by outlining health outcome data from a county in North Carolina and a county in South Carolina, both of which have ‘non-desert’ status and are neither a food desert nor a news desert.

TABLE 4: Non-Desert Status Case Study

Health Outcome Orange County, N.C. Lexington County, S.C. Population 141,354 281,833 County Health Outcome Rank 2/100 6/46 Adult Obesity 23% 33% Diabetes Prevalence 8% 10% Premature Death 4,300 years 7,300 years

Analysis: This case study presents two counties, one of which has a population twice the size of the other, and both counties are ranked within the top 15% of their state’s health outcomes. Both counties have a lower prevalence of adult obesity than their state’s average and the top US counties’ average, although Lexington County’s prevalence of adult obesity is close to the state’s average. Both counties also have a lower prevalence of diabetes than their state’s average, and Orange County’s diabetes prevalence is equal to the top U.S. counties’ average. Both counties have lower rates of premature death than their state’s average, and Orange County’s rate of premature death is lower than the top U.S. counties’ average.

Hypothesis Support: This case study supports the paper’s hypothesis: it demonstrates that a county that is not classified as either a food desert or a news desert has better health outcome ranks, and has a prevalence of adult obesity and diabetes, and premature death rates, that are better than their state’s average.

METHODS

In an effort to compare data from states that are similar but not identical, this paper analyzes data from counties in North Carolina and South Carolina due to the similar percentage of rural populations in the states (both 34%) and the different population sizes in the states (North Carolina’s population is 10 million, and South Carolina’s population is half that, at 4.9 million). These points of analysis are valuable because they provide a relative comparison of states with vastly different population sizes but identical percentages of rural residents.

In the case studies, this paper utilizes the following data to assess health outcomes:

• Health outcome rank in the state: This number compares the county’s rank to the ranking of other counties, with 1 signifying the best health outcome.24 o North Carolina: 1-100 o South Carolina: 1-46 • Adult obesity: This number is the percentage of people 20 and older who reported a BMI greater than or equal to 30 kg/m2.24 o Top Counties in the US: 26% o North Carolina Average 30% o South Carolina Average: 32% • Diabetes prevalence: This number is the prevalence of diagnosed diabetes as indicated when respondents said “yes” to the question "Has a doctor ever told you that you have diabetes?" (This number does not include women who only experienced gestational diabetes.) 24 o Top Counties in the US: 8% o North Carolina Average: 11% o South Carolina Average: 12% • Premature death: This number is the years of potential life lost before age 75. (For example, a person dying at 30 contributes 45 years of potential life lost.) This measure is presented as a rate per 100,000 population and is age-adjusted to the 2000 US population. For the counties in the case studies, the leading causes of premature death were cancer and heart disease.24 o Top Counties in the US: 5,200 years o North Carolina Average: 7,200 years o South Carolina Average: 8,200 years

The official definitions for food deserts and news deserts use different groupings to categorize areas (census tracts and “communities”), so this paper utilizes counties as a standard metric for categorization. This paper employs the following definitions for food deserts and news deserts:

• Food Desert: at least 25% of the geographical area of the county contains census tracts that are considered “low income and low access at 1 and 10 miles” by the USDA Economic Research Service • News Desert: the county either does not have a local newspaper or all of the local newspapers are owned by an investment group instead of a local family or media organization

Further, this paper refers to counties as ‘dual deserts,’ ‘single deserts’ and ‘non-deserts.’ These identifications signify:

• Dual desert: the county is classified as both a food desert and a news desert • Single desert: the county is classified as a food desert or a news desert, but not both • Non-desert: the county is not classified as a food desert or a news desert

The predominant data sources for the case studies in this paper include the USDA’s Food Desert Locator25, UNC Center for Innovation and Sustainability in Local Media’s newspaper ownership database26, and the Robert Wood Johnson Foundation’s County Health Rankings and Roadmaps.24 DISCUSSION

This paper highlights the gaps in existing literature about how the quality of the information environment, or access to local news, impacts health outcomes at a community and a population level, as well as how food environments and information environments interact to impact health outcomes. In an effort to fill in these gaps, this paper introduces two hypothetical pathways that have not previously been discussed: a pathway for how access to local news impacts health outcomes, and a pathway for how food environments and information environments interact to influence behaviors and therefore impact health outcomes. Given that this paper is the first of its kind, there are several limitations to the case studies provided. This paper does not determine if there is a causal relationship between access to local news and better health outcomes, and it does not determine if there is a causal relationship between ‘dual desert’ status and worsened health outcomes. A big-picture limitation to this paper is that there are factors other than the food environment and the information environment that influence health outcomes: genetics, working and living conditions, and exercise habits impact health outcomes at the community and the population level. A potential confounder of this study is the rural status of some of the counties used in the case studies: rural community papers are more likely to fold or be susceptible to purchase by investment groups, and rural areas are more likely to have a greater number of convenience stores than grocery stores.14 Further, the models in this paper show a one-way directionality, but in reality health outcomes influence behaviors, such as health behaviors and dietary decisions, in the same way that decisions and behaviors influence health outcomes. The models used in this paper are effective starting points, but they are oversimplified. Keeping these limitations in mind, the case studies in this paper support the hypothesis that a county’s dual news desert and food desert status compound to worsen the county’s health outcomes such as adult obesity, diabetes and premature death. The case studies demonstrate that counties that are single deserts have worse health outcomes than counties that are non-deserts, and they demonstrate that counties that are dual deserts have worse health outcomes than single-desert and non-desert counties. To further the ideas and research presented in this case study, future studies would need to conduct statistical modeling to obtain a more definitive answer about the causative relationship between living in a dual desert and experiencing worse health outcomes than not living in a dual desert.

To expand upon the ideas and data presented in this paper, future studies might:

• Measure the key exposures of the presence and ownership of news outlets and the relative presence of supermarkets, grocery stores and convenience stores, and the key outcomes of adult obesity, adult diabetes and quality of life; a long-term study could also measure the rate of premature death; • Determine how many counties that are food deserts are also news deserts, and how many counties that are news deserts are also food deserts, to see if one desert is more likely to influence the existence of the other desert; • Present data that address health disparities and are adjusted for socioeconomic factors such as education level, income, race and rural status; • Examine how people access news and information—via smart phones, computers, printed media, broadcast media, etc. Research for this paper did not reveal a database that could provide this information at the state or county level, and such information could be used to quantify or estimate how much of the news people are consuming is local, regional or national. • Conduct media content analyses about the prevalence of health disparities framing in local print news, as the current media content analyses featured in the literature focus on regional and national news sources. • Compare rural and non-rural counties and their health outcomes to the quality of their information environments. Some news desert literature suggests a difference between rural and non-rural access to news and information, but research for this paper did not find a conclusive answer about any potential differences; North Carolina is about 35% rural, so it could be an appropriate state for such a case study. • Target local and ethnic news outlets for multilevel interventions designed to address health disparities.

Food deserts are commonly known and largely understood, and many interventions have already been implemented, and will continue to be implemented, to improve communities’ access to nutritious foods. However, news deserts are less well known and understood, and research for this paper did not reveal any active interventions to improve communities’ access to local news. Given the long-term threat of news deserts as the media landscape continues to change, there are long-term strategies that local newspapers can implement and invest in that may help prevent their collapse or purchase by an investment group. Newspapers can develop digital strategies to increase and sustain digital revenues in order to adapt to the inevitability of a media landscape that is shifting further toward a digital majority. Additionally, journalism schools can engage with local newspaper owners and publishers to help develop these digital plans and sustainable business strategies; journalism schools can also train students to have skills.17 There is a recent trend toward nonprofit news organizations that are supported by philanthropic foundations, organizational funders, and community donors. As an alternative to investment groups that may not be willing to accept small profit margins, philanthropic foundations’ investment in local media outlets may be a sustainable solution to the emerging threat of news deserts. There are several philanthropic foundations that have already invested in local and nonprofit media: the Lenfest Institute for Journalism has a mission of preserving local journalism nationwide, and it leverages the Philadelphia Inquirer, Philadelphia Daily News and philly.com as “petri dishes for innovation and experimentation” with local news.27 The Lenfest Institute and the Knight Foundation launched the Knight-Lenfest Newsroom Initiative in February 2017 to increase the sharing of best practices among metro newsrooms, and the MacArthur Foundation has committed to providing general operating grants for nonprofit news outlets.27,28 The American Press Institute recently collaborated with nonprofit media outlets, commercial media outlets, media scholars and media funders to develop two broad sets of guidelines of best practices for funders and nonprofit newsrooms. These guiding principles include transparency with the public, communication between grantors and grantees, sustainability and organizational health, and they reflect a national interest and investment in supporting local news outlets.29.,30 Perhaps the most immediate impact that journalists can have on the health of the community they serve is to contextualize their health reporting and frame health issues through the lens of health disparities and the social determinants of health. Research shows that journalists privilege health stories about lifestyle and individual responsibility and tend to deemphasize or disregard the larger socioeconomic factors that influence and drive individual decisions.31,31 Whether this disregard is intentional or not, journalists can work to be aware of the contexts and framework they employ in health stories, and they can collaborate with public health practitioners to produce contextualized stories that are translatable to many groups within their community. Journalists have a unique opportunity to educate the public and their community about healthcare and public health, and their stories must consider multiple audiences to be most effective and impactful. Raising public awareness of the relevance of the social determinants of health and the role health disparities play in a community’s health is a formidable communications challenge, but journalists can also utilize message design strategies in their work; these strategies include message framing, utilizing narratives and utilizing visual imagery.33 As journalists employ these strategies, they should draw attention to the social determinants of health, and they should actively work to avoid emphasizing negative stereotypes in the narratives and visuals they employ. Increasing local journalists’ formal awareness of, and ability to frame stories according to, health disparities and the social determinants of health could have significant downstream effects on the communities they serve, both in the form of public opinion around, and structural solutions for diminishing, health disparities.

REFERENCES

[1] Center for Disease Control. “Chronic Disease Overview.” Webpage. June 2017. Accessed December 2017. https://www.cdc.gov/chronicdisease/overview/index.htm

[2] Office of Disease Prevention and Health Promotion. “Disparities.” Webpage. Accessed December 2017. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities

[3] Center for Disease Control. “CDC Health Disparities and Inequality Report.” Web Report. 2013. Accessed December 2017. https://www.cdc.gov/minorityhealth/chdireport.html

[4] Center for Disease Control. “Adult Obesity Facts.” Webpage. August 2017. Accessed December 2017. https://www.cdc.gov/obesity/data/adult.html

[5] Center for Disease Control. “Diabetes.” Webpage. May 2017. Accessed December 2017. https://www.cdc.gov/nchs/fastats/diabetes.htm

[6] Center for Disease Control. “National Diabetes Statistics Report, 2017.” Web Report. 2017. Accessed December 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics- report.pdf

[7] Deshpande, Anjali D, Marcie Harris-Hayes, and Mario Schootman. “Epidemiology of Diabetes and Diabetes-Related Complications.” Physical Therapy 88.11 (2008): 1254–1264. PMC. Web. 6 Dec. 2017.

[8] America’s Health Rankings. “2015 Annual Report.” Interactive Web Report. Accessed December 2017. https://www.americashealthrankings.org/explore/2015-annual-report/measure/YPLL/state/ALL

[9] Minnesota Department of Health. “Creating Health Equity in Minnesota.” Webpage Diagram. 2017. Accessed December 2017. http://www.health.state.mn.us/divs/che/about/creatinghealthequity.html

[10] World Environmental Library. “Network for action on sustainability and health.” Webpage Diagram. 1996. Accessed December 2017. http://www.nzdl.org/gsdlmod?e=d-00000-00---off-0envl--00-0----0-10- 0---0---0direct-10---4------0-0l--11-en-50---20-about---00-0-1-00-0--4----0-0-11-10-0utfZz-8- 00&cl=CL2.1.3&d=HASH016e7435b2d660ff256992f1.3.2>=1

[11] BC Healthy Communities. “FAQs.” Webpage Diagram. 2017. Accessed December 2017. http://bchealthycommunities.ca/faq

[12] Committee on a Framework for Assessing the Health, Environmental, and Social Effects of the Food System; Food and Nutrition Board; Board on Agriculture and Natural Resources; Institute of Medicine; National Research Council; Nesheim MC, Oria M, Yih PT, editors. A Framework for Assessing Effects of the Food System. Washington (DC): National Academies Press (US); 2015 Jun 17. 3, Health Effects of the U.S. Food System. Available from: https://www.ncbi.nlm.nih.gov/books/NBK305175/

[13] National Research Council (US). The Public Health Effects of Food Deserts: Workshop Summary. Washington (DC): National Academies Press (US); 2009. Summary. Available from: https://www.ncbi.nlm.nih.gov/books/NBK208018/

[14] USDA Economic Research Service. “Access to Affordable and Nutritious Foods: Measuring and Understanding Food Deserts and Their Consequences.” Digital Report. June 2009. Accessed December 2017. https://www.ers.usda.gov/webdocs/publications/42711/12716_ap036_1_.pdf?v=41055

[15] DOsomething.org. “11 Facts About Food Deserts.” Webpage. 2017. Accessed December 2017. https://www.dosomething.org/facts/11-facts-about-food-deserts

[16] Local News Lab. “Mapping Your Community’s Information Ecosystem.” Web Article. March 2016. Accessed December 2017. https://medium.com/the-local-news-lab/mapping-your-community-s- information-ecosystem-fd6a8bd9f6ae

[17] Abernathy, Penelope Muse. “The Rise of the New Media Baron and the Emerging Threat of News Deserts.” 2016.

[18] Center for Innovation and Sustainability in Local Media. “Thwarting the Emergence of News Deserts.” 2017.

[19] American Society of Newspaper Editors. “2015 Census.” Webpage. 2015. Accessed December 2017. http://asne.org/content.asp?contentid=415

[20] Alliance. “News Deserts Threaten Rural Areas.” Web Article. February 2017. Accessed December 2017. https://www.newsmediaalliance.org/news-deserts/

[21] Dunne, Carey. “My month with chemtrails conspiracy theorists.” The Guardian. Article. May 2017. Accessed December 2017. https://www.theguardian.com/environment/2017/may/22/california- conspiracy-theorist-farmers-chemtrails

[22] Wallington, Sherrie Flynt et al. “Challenges in Covering Health Disparities in Local News Media: An Exploratory Analysis Assessing Views of Journalists.” Journal of community health 35.5 (2010): 487–494. PMC. Web. 6 Dec. 2017.

[23] Nagler, Rebekah H. et al. “Prevalence and Framing of Health Disparities in Local Print News: Implications for Multilevel Interventions to Address Cancer Inequalities.” Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology 25.4 (2016): 603–612. PMC. Web. 6 Dec. 2017.

[24] Robert Wood Johnson Foundation. “County Health Rankings and Roadmaps, County Snapshots.” Website. Accessed December 2017. http://www.countyhealthrankings.org/

[25] USDA. “Food Desert Locator.” Interactive Map. June 2017. Accessed December 2017. https://www.fns.usda.gov/tags/food-desert-locator

[26] Center for Innovation and Sustainability in Local Media. National Database of Local Newspaper Ownership. September 2017.

[27] Scutari, Mike. “Keeping the vultures at bay: is philanthropy the only hope for local news outlets?” Inside Philanthropy. Web Article. November 2017. Accessed December 2017. https://www.insidephilanthropy.com/home/2017/11/2/local-journalism-philanthropy-lenfest-institute

[28] MacArthur Foundation. “MacArthur Expands Its Commitment to Journalism and Media.” . May 2016. Accessed December 2017. https://www.macfound.org/press/press- releases/macarthur-expands-its-commitment-journalism-and-media/

[29] American Press Institute. “Guiding principles for funders of nonprofit media. Web Article. January 2017. Accessed December 2017. https://www.americanpressinstitute.org/publications/nonprofit- funders-guiding-principles/

[30] American Press Institute. “Guiding principles for nonprofit newsrooms. Web Article. January 2017. Accessed December 2017. https://www.americanpressinstitute.org/publications/nonprofit-newsrooms-guiding-principles/

[31] Friedman, D.B., Tanner, A. & Rose, I.D. “Health journalists’ perceptions of their communities and implications for the delivery of health information in the news.” J Community Health (2014) 39: 378. https://doi.org/10.1007/s10900-013-9774-x

[32] Hodgetts, Darrin et al. “Constructing health news: possibilities for .” Sage Journals. Web. 6 Dec. 2017. https://www.ncbi.nlm.nih.gov/pubmed/18073246

[33] Niederdeppe, Jeff et al. “Message Design Strategies to Raise Public Awareness of Social Determinants of Health and Population Health Disparities.” The Milbank Quarterly 86.3 (2008): 481– 513. PMC. Web. 6 Dec. 2017.