Abstract
In this study, we explored the relationship between the food environment and food security among rural adults during the COVID-19 pandemic. Researchers, with assistance from community partners, conducted a cross-sectional survey assessing the impact of COVID-19 on food access, food security, and physical activity in 9 rural South Carolina (SC) counties. This survey was administered to a purposive sample (N = 587) from August 2020 to March 2021. The dependent variable was a binary indicator of food insecurity (past 3 months), in accordance with the USDA Household Food Security Survey Module. Independent variables were sociodemographic characteristics, food environment factors (eg, shopping at grocery stores, partial markets, and farmers' markets), and shopping behaviors during the pandemic. Overall, 31% of respondents were food insecure. Food security status differed by income and household composition. Results indicate that the odds of food insecurity were higher for respondents who shopped frequently at partial markets (adjusted odds ratio [AOR] = 1.61, 95% confidence interval [CI]: 1.01-2.56) and shopped more for food before the pandemic than during the pandemic (AOR = 1.68, 95% CI: 1.07-2.64). Findings underscore the importance of examining the relationship between the food environment and food insecurity during COVID-19 in rural settings.
Keywords: food access, food environment, food insecurity, rural health
THE FOOD ENVIRONMENT in which one lives has a profound bearing on household and community well-being. Healthy food is often unavailable to rural communities and is one of the key domains of the social determinants of health.1 The food environment is defined broadly as the geographic area where and how food is available to residents.2 Thus, individual diet and food consumption choices are shaped by proximity to food sources and by the types of food residents can access and afford.3 Consider, for example, a rural resident who does not live in close proximity to healthy food retail outlets, or a rural resident who lives in a food environment characterized by majority fast food retailers, convenience stores, or partial markets that have few affordable healthy food choices. As one examines rural communities and the food environment in which people live, key concerns emerge around healthy food access, food security, and the built environment.
Food insecurity refers to an inability to meet vital dietary needs, defined by the United States Department of Agriculture (USDA) as a household's lack of access “to enough food for an active, healthy life” at all times.4–6 In 2019—prior to the novel coronavirus pandemic (COVID-19)—food insecurity rates in the United States (US) dropped to their lowest point in more than 2 decades at 10.9% of the total population. At that time, rates in the Southeastern US region (12.3%) were above the national average; similarly, food insecurity rates for households with children were higher in the Southeast (16.6%) than in the national average (14.8%).7
COVID-19 introduced additional health and socioeconomic barriers worldwide, which exacerbated economic hardship, particularly among food insecure and rural populations.4 Job loss and economic distress illuminated the food needs of rural communities.8,9 Rural food environments became increasingly restricted due to social distancing protocols, supply chain issues, and altered consumer shopping patterns.10–12 Although some households reported experiencing food insecurity for the first time, others reported accepting financial help from family or friends and participating in food assistance programs more consistently than before the onset of COVID-19.13 Ultimately, the pandemic and economic recession led to an increase in food insecurity rates.14 In 2021, it was reported that nearly 1 in 8 adults (12.9%) and 1 in 6 children (17.9%) experienced food insecurity.4
Recent evidence shows that high food insecurity individuals experience reduced access to quality food, disrupted eating patterns, and decreased overall food consumption.6 This lends support to studies demonstrating the connection between food insecurity and diet-related health issues such as obesity and diabetes.15–17 Nevertheless, the risk of experiencing food insecurity unequally varies across sociodemographic groups. These disparities demonstrate that food insecurity is disproportionately experienced by women, African American and Hispanic populations, unmarried individuals, households with children, and persons with incomes below the poverty line.18,19 In addition, rural populations are more likely to experience higher economic instability and unemployment rates than urban populations,20–23 placing them at an increased risk of experiencing food insecurity. Of note, research identifies poverty and unemployment as the primary predictors of food insecurity in the rural US.24 However, limited research considers the association between food insecurity and demographic factors within rural (as compared with urban) contexts in the US.25
Characteristics of rural food environments that foster food insecurity include limited grocery store availability and limited economic infrastructure to support existing grocery stores. Rural grocery stores tend to be located in the most densely populated towns, which limits food access for residents who live far from these locations and do not have easy access to transportation.26 This may cause some rural residents to rely on food retail outlets that contain less healthy food options, such as partial markets (eg, CVS and Dollar General), convenience stores (eg, gas stations and mom-and-pop stores), and fast-food restaurants.27 Taken together, poverty, unemployment, and limited access to grocery stores reflect systemic issues that shape the context of food insecurity for rural populations.28,29
The purpose of this study is to explore the relationship between the food environment and food security among rural adults during the COVID-19 pandemic, specifically in South Carolina. From 2019-2021, the average prevalence of food insecurity in South Carolina (12.6%) was higher than the national prevalence (10.4%).8 In South Carolina, individuals living in rural areas may be prone to higher rates of food insecurity due to the presence of food deserts, as historically 29% of nonmetropolitan counties in the South have been classified as such.30 This research contributes to the relatively minimal literature on rural food insecurity in the US by purposively studying rural South Carolina residents and their food environment during the COVID-19 pandemic.
METHODS
A cross-sectional survey was developed to inform programmatic work conducted at a public university among 9 rural counties in South Carolina. Selected counties were identified as rural because they do not include urbanized areas (≥50 000 people) or urban clusters (≥2500 and <50 000 people). The survey assessed food access, physical activity, and community dynamics among low-income residents of these counties. Research team members developed questions about the impact of COVID-19 on several factors pertaining to food insecurity. A detailed description of the measures is provided later. Institutional review board approval was obtained from Clemson University IRB # 2020-188.
The study sample was a purposive, convenience sample of low-income, rural residents. The recruitment strategy involved leveraging campus-community relationships with organizations that provided services to this population during the pandemic such as food pantries, senior centers, cooperative extension, faith organizations, and community centers. These organizations promoted the study, gathered contact information from residents interested in taking the survey, and provided locations for survey administration.
Data collection occurred from August 2020 to July 2021. Data were first collected by telephone (August 2020 to March 2021) and then in-person (July 2021). Individuals were eligible to participate in the survey if they were an adult, resided in 1 of the 9 study counties, and spoke English or Spanish. To take the survey by telephone, individuals provided a telephone number and mailing address to receive an incentive and a printed copy of informed consent. Both telephone and in-person data collection were conducted by a trained team of students and staff from the public university. The team was trained about the project's purpose, verbal delivery of the informed consent process and survey sections, and data entry, in addition to being institutional review board certified.
After respondents expressed interest in completing the survey, participant eligibility was confirmed by trained students. Prior participation in university-sponsored programming was not a condition of eligibility. For most survey administration, the survey items were read to respondents and responses were recorded into Qualtrics data entry software. Across the 9 counties, 1115 potential survey respondents were contacted, of whom 713 completed the survey, for a 64% response rate. In sum, 580 surveys were completed via telephone, and 133 surveys were completed in person. All survey respondents received a $10 gift card via mail or in person.
Measures
Our binary outcome measure of household food insecurity (1 = food insecure; 0 = food secure) was based on the USDA's Household Food Security Survey Module: Six-Item Short Form.31 Similar to past research, the time period was adapted from 12 months to 3 months to ensure that the reference period was during COVID-19.32 This decision to use the 3-month time frame was also appropriate, given that the South Carolina governor issued a stay-at-home order on April 5, 2020. Respondents were asked 5 questions related to nutrition and financial concerns. In alignment with procedures from the USDA food security module, respondents were designated as “food insecure” if they provided an affirmative response to more than 1 of the 5 questions.
Independent variables were conceptualized as self-reported sociodemographic characteristics and food environment factors. The sociodemographic factors examined were age in years (18-44 years, 45-64 years, 65 years and older), biological sex (1 = female; 0 = male), non-Hispanic race group (white, Black, multiracial), annual household income level (<$20 000; $20 000-$34 999; $35 000-$49 999; $50 000-$74 999; at least $75 000; refused response), employment status (employed, unemployed, retired, unable to work), and 2 binary measures of household composition. Respondents were considered multiracial if they selected more than 1 category that was not limited to Black or white. Household composition was assessed through binary (1 = yes; 0 = no) indicators on whether respondents lived with a minor child in their home or were married.
To assess respondents' food environment during COVID-19, we asked respondents whether they had never, sometimes, often, or always bought food from the following food store types in the past 3 months: supermarkets or grocery stores, partial markets, and farmers' markets or produce stands. Answers of “often” or “always” were coded as 1, while “sometimes” and “never” were coded as 0. In addition, we asked respondents whether their shopping frequency at these same food stores during the pandemic was different when compared with the time before the pandemic. Response options were in accordance with a 5-point Likert scale, ranging from much more often before COVID-19 to much less often before COVID-19. From this, we created a categorical variable to capture the impact of COVID-19 on the respondents' food environment, with possible answers of shopping for food at these same stores: more often, about the same, and less often before COVID-19.
Statistical analysis
Of the 713 adult respondents, respondents missing complete data on the outcome of interest (n = 20) were excluded. Respondents with missing data on sociodemographic and food environment factors were also excluded (n = 106). To retain sample size and statistical power, individuals who did not report their annual household income (n = 67) were not excluded. The final sample included 587 respondents with complete data on all study variables. Descriptively, we stratified the sample by food insecurity status and used Mann-Whitney tests to assess significant proportional differences in the nonparametric sample. We employed multivariate logistic regression to determine factors correlated with food insecurity during the COVID-19 pandemic. To determine statistical significance, P values less than .05, odds ratios, and 95% confidence intervals were used. The dataset analyzed in the current study is not publicly available but may be available from the corresponding author upon reasonable request. All analyses were conducted using STATA 16.33
RESULTS
Overall, 30.8% of respondents were food insecure. In this purposive sample, one-third (31.9%) of respondents were at least 65 years of age, 84.3% were female, 41.2% were white, 56.4% had annual household incomes less than $35 000, 45.8% were employed, almost 12% were unemployed (11.6%) or unable to work (11.8%), and 30.8% were retired (Table 1). Approximately, 35.3% of respondents lived in a household with child(ren) present, and 42.3% were married. During COVID-19, the majority (89.4%) of respondents often or always shopped for food at grocery stores, 23.2% often or always shopped at partial markets, and 16.4% often or always shopped at farmers' markets. Thirty-one percent of respondents reported shopping at these same stores more often before the COVID-19 pandemic, while 15.7% of respondents reported shopping at these same stores less often before the COVID-19 pandemic.
TABLE 1. Description of Sociodemographic Factors and Food Environment in Rural South Carolina During COVID-19 by Food Insecurity Status (N = 587)a.
| Total | Food Secure, n (%) | Food Insecure, n (%) | P | |
|---|---|---|---|---|
| 406 (69.2) | 181 (30.8) | |||
| Age in years | .034 | |||
| 18-44 | 173 (29.4) | 117 (28.8) | 56 (30.9) | |
| 45-64 | 227 (38.7) | 144 (35.5) | 83 (45.9) | |
| 65+ | 187 (31.9) | 145 (35.7) | 42 (23.2) | |
| Sex | .560 | |||
| Male | 92 (15.7) | 66 (16.3) | 26 (14.4) | |
| Female | 495 (84.3) | 340 (83.7) | 85 (85.6) | |
| Race (non-Hispanic) | .001 | |||
| White | 242 (41.2) | 185 (45.5) | 57 (31.5) | |
| Black | 321 (54.7) | 207 (51.0) | 114 (63.0) | |
| Multiracial or other | 24 (4.1) | 14 (3.5) | 10 (5.5) | |
| Household income | <.001 | |||
| <$20K | 195 (33.2) | 101 (24.9) | 94 (51.9) | |
| $20K to $34 999 | 136 (23.2) | 94 (23.1) | 42 (23.2) | |
| $35K to $49 999 | 60 (10.2) | 49 (12.1) | 11 (6.1) | |
| $50K to 74 999 | 59 (10.1) | 49 (12.1) | 10 (5.5) | |
| ≥$75K | 70 (11.9) | 65 (16.0) | 5 (2.8) | |
| Refused | 67 (11.4) | 48 (11.8) | 19 (10.5) | |
| Employment | .014 | |||
| Employed | 296 (45.8) | 195 (48.0) | 74 (40.9) | |
| Unemployed | 68 (11.6) | 43 (10.6) | 25 (13.8) | |
| Retired | 181 (30.8) | 138 (34.0) | 43 (23.8) | |
| Unable to work | 69 (11.8) | 30 (7.4) | 39 (21.5) | |
| Children in home | <.001 | |||
| No | 380 (64.7) | 290 (71.4) | 90 (49.7) | |
| Yes | 207 (35.3) | 116 (28.6) | 91 (50.3) | |
| Married | <.001 | |||
| No | 339 (57.7) | 208 (51.2) | 131 (72.4) | |
| Yes | 248 (42.3) | 198 (48.8) | 50 (27.6) | |
| Grocery stores | .797 | |||
| Otherwise | 62 (10.6) | 42 (10.3) | 20 (11.1) | |
| Often or always | 525 (89.4) | 364 (89.7) | 161 (88.9) | |
| Partial markets | <.001 | |||
| Otherwise | 451 (76.8) | 332 (81.8) | 119 (65.7) | |
| Often or always | 136 (23.2) | 74 (18.2) | 62 (34.3) | |
| Farmers markets | .923 | |||
| Otherwise | 491 (83.6) | 340 (83.7) | 151 (83.4) | |
| Often or always | 96 (16.4) | 66 (16.3) | 30 (16.6) | |
| Pre-COVID-19 food shopping at same stores | .269 | |||
| Shopped more | 180 (30.7) | 113 (27.9) | 67 (37.0) | |
| Shopped the same | 314 (53.6) | 233 (57.5) | 81 (44.8) | |
| Shopped less | 92 (15.7) | 59 (14.6) | 33 (18.2) |
aProportional differences calculated using Mann-Whitney U tests.
Significant proportional differences by food insecurity status were observed across age, race, income, and employment status such that greater proportions of food insecure respondents were younger than 65 years (77%), non-white (69%), had household incomes less than $35 000 (75%), and were unemployed (14%) or unable to work (21%). Moreover, a greater proportion of food insecure respondents represented households that were with children (50%) and unmarried (72%). During COVID-19, the proportion of respondents who reported often or always shopping at partial markets was nearly double for food insecure (34%) compared with food secure (18%) respondents. Proportional differences by food insecurity status were not evident for shopping at grocery stores, farmers' markets, or the impact of COVID-19 on food shopping at these same stores.
Table 2 presents the association between sociodemographic factors, food environment, and odds of being food insecure during COVID-19 while holding other variables constant. Age, sex, race, and employment status were not found to be significantly associated with food insecurity in the full model. Respondents at income levels above $20 000 had lower odds of being food insecure compared with those with incomes less than $20 000. In addition, the odds of being food insecure were lower for respondents who were married (adjusted odds ratio [AOR] = 0.59, 95% confidence interval [CI]: 0.37-0.92) and almost 3 times greater for respondents with children in their household (AOR = 2.70, 95% CI: 1.7-4.27).
TABLE 2. Odds of Food Insecurity in Rural South Carolina During COVID-19 (N = 587).
| Adjusted Odds Ratio (95% Confidence Interval) | |
|---|---|
| Age in years | |
| 18-44 | Referent |
| 45-64 | 1.06 (0.62-1.80) |
| 65+ | 0.48 (0.21-1.09) |
| Sex | |
| Male | Referent |
| Female | 0.98 (0.55-1.74) |
| Race (non-Hispanic) | |
| White | Referent |
| Black | 1.01 (0.64-1.57) |
| Multiracial or other | 1.77 (0.66-4.73) |
| Household income | |
| <$20K | Referent |
| $20K to $34 999 | 0.52* (0.30-0.88) |
| $35K to $49 999 | 0.23** (0.10-0.51) |
| $50K to 74 999 | 0.28** (0.12-0.65) |
| ≥$75K | 0.09** (0.03-0.27) |
| Refused | 0.51 (0.25-1.00) |
| Employment | |
| Employed | Referent |
| Unemployed | 1.09 (0.57-2.08) |
| Retired | 1.37 (0.66-2.81) |
| Unable to work | 1.90 (0.96-3.76) |
| Children in home | |
| No | Referent |
| Yes | 2.70* (1.70-4.27) |
| Married | |
| No | Referent |
| Yes | 0.59* (0.37-0.92) |
| Grocery stores | |
| Otherwise | Referent |
| Often or always | 1.31 (0.69-2.51) |
| Partial markets | |
| Otherwise | Referent |
| Often or always | 1.60* (1.01-2.56) |
| Farmers markets | |
| Otherwise | Referent |
| Often or always | 0.73 (0.42-1.28) |
| Pre-COVID-19 food shopping at same stores | |
| Shopped the same | Referent |
| Shopped more | 1.68* (1.06-2.64) |
| Shopped less | 1.66 (0.93-2.97) |
*P < .05.
**P < .01.
Among food environment characteristics, we did not find frequent food shopping during COVID-19 at grocery stores or farmers' markets to be significantly associated with food insecurity status. However, we did find frequent shopping at partial markets to be associated with greater odds of food insecurity (AOR = 1.60, 95% CI: 1.01-2.56). Finally, respondents who shopped for food more often prior to the pandemic had greater odds of being food insecure (AOR = 1.68, 95% CI: 1.06-2.64) when compared with those who shopped for food the same amount prior to the pandemic, in the full model.
DISCUSSION
The purpose of this study was to explore the relationship between the food environment and food security during COVID-19 among a community sample of rural adults. The key findings indicate that the odds of being food insecure were higher for respondents who frequently shopped for food at partial markets and went food shopping more before the pandemic. In addition, the odds of being food insecure were higher among respondents with household incomes below $20 000, households with children in the home, and individuals who were not married. As food insecurity is associated with adverse health outcomes, findings offer insight to rural populations that may be vulnerable to diet-related health inequities.19,34,35 This study intentionally examines the food shopping experience of rural South Carolina residents to contribute to the literature on food insecurity in the rural US.
The findings presented in this study that revealed income and household composition differences in food security status are consistent with those presented in national studies, which have identified a higher prevalence of food insecurity among households characterized as low-income, headed by unmarried persons, and with dependent children.18,19,35,36 Even so, these studies did not disaggregate results by urban and rural geographies. Of note, the current community sample did not observe a significant relationship between race and food insecurity. This finding was not consistent with established research that suggests that minority populations experience food insecurity at disproportionately higher rates than white populations.18,35 We likely observed no association between race and food insecurity because rural participants lived under similar conditions, as evidenced by their presence at data collection recruitment sites. On the other hand, our null finding regarding race supports recent evidence that suggests that food access and affordability barriers were shared across race/ethnicity during the COVID-19 pandemic.13,37 For example, a nationally representative study found that households headed by Black, Asian, Hispanic, or other racial/ethnic minorities were not significantly more food insecure than white households during the pandemic.37 However, this study did not discern whether this finding was consistent across US census regions or urban and rural areas. As this body of knowledge grows, future research should contextualize food insecurity and variation by demographic factors within geographic locations to advance health equity in research.
Interestingly, we observed a significant relationship between shopping at partial markets and food insecurity but no such significant relationship for shopping in grocery stores or farmers' markets. This finding was consistent with past research that found that convenience store or partial market prevalence was positively associated with poorer health outcomes among rural counties.38 Given our finding that food insecure rural residents may frequent partial markets as a source of food for their households, we recommend greater consideration of programs such as the healthy corner store market initiative and food cooperatives as sources of healthy affordable food. These programs provide healthy food options in small retail outlets by encouraging electronic benefits transfer use, providing added cold storage for fruits and vegetables, and sourcing healthy food from local growers. These programs have been successful across the US and provide access to healthy food in areas that are typically void of healthy food options for rural consumers.39–41 Furthermore, some local areas may consider policy options that encourage partial markets, such as Dollar Stores, to provide a larger variety of healthy food options.
Although this community study could not discern the motivations for food shopping behaviors during COVID-19, previous studies suggest that rural food environments among low-income populations may be more dynamic than the food retail outlets that are closest to home.42–44 For example, low-income residents of rural Louisiana communities described outshopping—leaving the parish to find food that was a lower price and better quality—and greater transportation time and costs as major features of the food environment.42 A recent study of South Carolina residents living in food deserts found that community food resources may be used more frequently than grocery stores.43 Here, community food resources referred to food banks, food pantries, and food provided by churches and other social services. Relatedly, altered food shopping behaviors became an apparent consequence of the pandemic due to the economic recession and unprecedented shortages in food stores. In turn, federal and local relief policies were enacted to expand food access through community food resources across persistently and newly vulnerable populations. As one national study found, food insecure respondents purchased fewer healthy foods during the pandemic.44 This may be the result of expanded food access through community food outlets and reduced reliance on retail food outlets among the food insecure. Our finding of decreased food shopping during the pandemic, in this community sample, lends support to this literature. Since COVID-19 and relief policies spanned multiple years, future research should explore the impacts of these policies on food shopping patterns, especially among those who experienced food insecurity.
This study had several limitations. Its cross-sectional design limits our ability to make causal inferences. Because of the purposive sampling strategy, study findings are not generalizable to less rural areas in South Carolina or other regions of the US at different time periods. In addition, in-person survey administration did not occur in all counties. This was due to high COVID-19 rates in other counties and resource constraints. The food security measure employed did not include the sixth question about hunger concerns that is included in the USDA measure of food insecurity. However, we used this food security measure to address nutrition and financial concerns, following the examples of other investigators who used an abbreviated version of the USDA food security scale.45,46 To the authors' knowledge, this is the first study to examine the associations between the food environment and food security among a rural population during COVID-19—a public health crisis. Future studies that detail the relationship between the rural food environment, food shopping patterns, and individual health outcomes are needed to contribute to this limited, yet growing field in rural health.
This study examined the food environment of 9 rural South Carolina counties during the COVID-19 pandemic. Studies such as ours offer important insights to better contextualize food insecurity and the rural food environment during the pandemic, as it increased food insecurity.31 Our findings indicate that partial markets were an important feature of the rural food environment for adults who experienced food insecurity during the pandemic. The salient demographic characteristics for this sample included living in households with low incomes, with children in the home, and headed by unmarried persons. Future research is warranted to better understand the nuances of these findings and to document the impact of the COVID-19 pandemic on adults' experiences in accessing affordable and healthy food in rural food environments.
Footnotes
The authors acknowledge partner organizations and participants who made this study possible.
Partial funding for this research came from Centers for Disease Control and Prevention High Obesity Program (no. NU58DP006562) and Blue Cross/Blue Shield of South Carolina Foundation (grant no. 2019-21).
The findings and conclusions in this report are those of the authors and do not represent the Centers for Disease Control and Prevention or Blue/Cross/Blue Shield of South Carolina Foundation.
The authors declare no conflict of interest.
Contributor Information
Samuel L. K. Baxter, Email: baxter@clemson.edu.
Caitlin E. Koob, Email: ckoob@clemson.edu.
Cassius M. L. Hossfeld, Email: chossfe@clemson.edu.
Sarah F. Griffin, Email: sgriffi@clemson.edu.
Catherine Mobley, Email: camoble@clemson.edu.
Leslie H. Hossfeld, Email: lhossfe@clemson.edu.
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