This guidance brief provides an overview of secondary data sources (data collected by another organization) that may be useful in assessing food access, food environments, and diet-related health needs in your community. The brief concludes with some recommendations for collecting primary data (original data such as surveys, interviews, focus groups and environmental assessments) on food-related health needs in low-income communities. Primary data on underserved populations are vital for prioritizing health needs and informing intervention strategies. 

Because collecting and analyzing data requires significant time and financial resources, hospitals and health systems are increasingly finding that collaborating with public health departments, schools of public health, community health and development organizations, food policy councils, food system advocacy groups, and other organizations is an effective way to maximize assessment resources and rally the community around a set of shared opportunities to improve community well-being and promote healthy, equitable, and sustainable food systems. Additionally, there are a wide variety of CHNA consultants that assist facilities and community collaboratives with conducting community health assessments and developing health improvement strategies. 

Secondary data sources

Secondary data (data collected by other organizations) can be very valuable in assessing food access, food environments, and diet-related health needs in your community.

Food insecurity (economic indicators)

Data sources assessing food insecurity deal primarily with the financial factors impacting food access. This includes measures of income and poverty, including eligibility for government assistance programs such as SNAP (Supplemental Nutrition Assistance Program), WIC (Women, Infants, and Children Food Nutrition Services), and TANF (Temporary Assistance for Needy Families) and eligibility for free and reduced-price school meals. Food insecurity assessments may also evaluate food prices. 

Low and very low food security (USDA)

The U.S. Department of Agriculture (USDA) identifies two levels of food insecurity. Low food security is identified when individuals report reduced quality, variety, or desirability of diet, but with little or no indication of reduced food intake. Very low food security is identified when multiple indications of disrupted eating patterns and reduced food intake are reported. 
 

Map the Meal Gap (Feeding America)

Feeding America’s Map the Meal Gap is one of the most widely used and easy to access sources of community-level data on food insecurity. The Map the Meal Gap index estimates county-level food insecurity by income categories and also estimates the food budget shortfall reported by food insecure individuals, which can illuminate the severity of food insecurity in a community.

Percentage of households receiving WIC/SNAP (USDA Food and Nutrition Service)

Because the U.S. Department of Agriculture notes how many Americans are actually receiving these benefits (as opposed to how many are merely eligible for them), enrollment numbers for these programs provide a useful way of assessing the demonstrated need for food assistance. Note that the data is only available at the state level.

Percentage of students eligible for free/reduced-price lunch (National Center for Education Statistics)

The percentage of students eligible for free or reduced-price school meals provides a proxy measure for the concentration of low-income students within a school. This indicator divides public schools into categories (high-poverty, mid-high poverty, and low-poverty) on the basis of the percentage of students eligible for free or reduced-price lunch; high-poverty schools are those where more than 75 percent of the students are eligible for free or reduced-price lunch. This is a useful indicator of vulnerability to food insecurity at the local level.
 

Percentage of population participating/number of meals served in National School Lunch, School Breakfast, and Summer Feeding programs

Statistics on participation in government school feeding programs provide a useful picture of both child poverty (since eligibility for these programs is determined by income levels) and the food insecurity with which it is closely linked.

Federal poverty level (U.S Census Bureau) 

The federal poverty level has a strong correlation with food insecurity, and the poverty level as estimated by the American Community Survey is a common component of measures of food insecurity.

Food price indices (USDA Economic Research Service and Feeding America)

A food price index reveals differences in food costs at the county level and indicates regions where greater income may be needed to meet food needs. Food price data can be combined with income data to estimate food budget shortfalls.

Percent additional tax on soda or packaged snacks (The University of Illinois-Chicago’s Bridging the Gap Program)

Data on whether or not a given state places additional taxes on unhealthy food and beverages like chips and soda can be a good illustration of that state’s overall food environment. If these products are more expensive as a result of tax, they may be less frequently consumed by residents of the state in question.

Food access (geographic indicators)

Data sources that measure food access are those that assess the physical environment in which residents make their food choices. These consist of measures of the distance a consumer needs to travel to reach food outlets. Another subset of measures in this category assesses the density of various types of food outlets for a given number of residents. 

Percentage or number of households with “low food access” (USDA) 

The U.S. Department of Agriculture’s Food Environment Atlas provides a useful way of visualizing the varying degrees of geographic isolation from food sources. It is a useful complement to the sources above, which place more emphasis on financial constraints to food access.

Grocery store density (USDA)

This data can be usefully combined with the distance-focused “low food access” measure to provide additional information on food outlet access in different communities. Note that the most recent data is from 2012.

Fast food restaurant density (USDA)

The U.S. Department of Agriculture uses this data to assess the availability of unhealthy food in a given community, which contributes to unhealthy dietary patterns and risk of diet-related health conditions. Note that the most recent data is from 2012.

Number of convenience, supercenter, and specialized food stores (Census Bureau’s County Business Patterns)

Knowing the number of any given category of food store in an area can provide a clear sense of the nutritional quality of the food available in that area. For example, convenience stores tend to sell a large variety of soda and chips, but little to no fresh produce. If an area has more convenience stores than conventional grocery stores, it can be a sign that there aren’t many nutritious food options available in that community.
 

Modified Retail Food Environment Index (mRFEI) (CDC’s Division of Nutrition, Physical Activity and Obesity)

This index compares the quality of the retail food offerings available at the census-tract level. 

Environments Supporting Healthy Eating Index (African American Collaborative Obesity Research Network and Community Commons) 

The Environments Supporting Healthy Eating (ESHE) Index boasts a unique combination of data in one score, particularly in its measure of state policies. The index is a way to compare county food environments among peers, within the context of a state’s relative strength or weakness in encouraging healthy eating.

SNAP/WIC authorized retailer density (USDA)

Authorized retailers who offer the Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children Food and Nutrition Services (WIC) must meet the U.S. Department of Agriculture’s (USDA) nutritional standards for healthy food inventory.This measure provides a reliable way to capture additional outlets that sell healthy food options, such as corner stores and farmers markets. Note that the most recent data is from 2012.

Local food directories (USDA Agricultural Marketing Service)

The U.S. Department of Agriculture’s (USDA) Agricultural Marketing Services Farmers Market Directory is a searchable tool that provides information about healthy, local food sources in your community. Assessing the availability of farmers markets and other outlets for purchasing local, healthy food is a valuable component of understanding community food environments.
 

Number of farms with direct sales (USDA)

The U.S. Department of Agriculture’s Agricultural Marketing Services directory of farms that sell directly to consumers is a searchable tool that provides information about healthy, local food sources available in communities across the country.
 

Combined economic and geographic indicators

Some assessments of communities with inadequate access to healthy food options combine measurements of low economic access with low geographic access. 

Food Environment Index (County Health Rankings & Roadmaps)

County Health Rankings’ Food Environment Index is useful as a simple metric for comparison of healthy food access among counties. It is most useful for making initial comparisons between similar areas’ food environments before delving deeper with other tools. 
 

Food Access Research Atlas (USDA) 

This tool provides local areas (census tracts) that are both low-income and low-access.

Note: tool does not work properly in Google Chrome browser, but functions smoothly in all other browsers.

Communities of Excellence in Nutrition, Physical Activity, and Obesity Prevention (California Department of Public Health) 

The unique strength of Communities of Excellence in Nutrition, Physical Activity, and Obesity Prevention (known as CX3) is its ability to display accurate and recently collected data at the level of individual neighborhoods, without having to rely on estimates for smaller areas based on data collected at the national level. While the tool only covers California as of 2017, CDPH’s Nutrition Education and Obesity Prevention Branch is willing to share their data collection tools with agencies and organizations affiliated with it “via project grants, awards, and partnerships” and can support evaluators outside of California to make use of the tool.
 

Food behaviors (behavioral health indicators)

The most widely available data sources on food-related behavioral health indicators are those with information on the purchase or consumption of fruits and vegetables, sugar-sweetened beverages, and high-sodium foods; the frequency of family meals; and consumption of fast-food restaurant meals.

National food consumption data from CDC’s Behavioral Risk Factor Surveillance Survey (BRFSS) 

As a group, these food behavior indicators provide information about the decisions eaters are making in the context of their food environments. While this data can be a valuable component of community health needs assessments (CHNA), the Centers for Disease Control and Prevention’s BRFSS survey 5-year averages for food behaviors aren’t up to date as of 2017 due to changes in collection practices between 2009 and 2011 (namely greater weighting of cell phone responses and new questions on fruit and vegetable consumption). Data has not been made available for the county level since then.
 

Family meal frequency (CDC National Survey of Children’s Health) 

Eating meals together as a family is a healthy food behavior. This data source from the Centers for Disease Control and Prevention (CDC) can provide useful reference information, but it is available at the state level only.
 

Fast food/full-service restaurant expenditures per capita (Census Bureau) 

Eating meals in fast food restaurants is on average considered a less healthy food behavior. This data source can provide useful reference information, but it is available at the state level only.
 

Composite reports

These searchable databases enable users to generate reports that capture multiple dimensions of food environments and eating behaviors, together with diet-related health outcomes, in their communities.

Food Environment Reports (Community Commons)

Community Commons’ Food Environment Reports is useful for gaining a comprehensive understanding of a community’s food environment. Using a wide variety of sources, the tool provides reliable data through a user-friendly, searchable interface.
 

Food Environment Atlas (USDA) 

The Food Environment Atlas is an indispensable catch-all directory of U.S. Department of Agriculture food environment data. The easy-to-use map presentation makes data simple to compare between states and counties.
 

Primary data

Community health needs assessments (CHNAs) should evaluate not only secondary data sources but also collect and analyze primary data (original data such as surveys, interviews, focus groups and environmental assessments) about community health needs, especially in underserved communities (such as in low-income census tracts or neighborhoods identified as having greater needs and fewer resources).

Primary data are vital to help hospital leaders make difficult decisions about where to direct limited resources to address a community’s most pressing health challenges.

Key informant interviews, focus groups, and community surveys are all useful ways to identify food-related resources, challenges, and priorities in particular communities.

Thoroughly identifying community organizations and resources addressing food needs and food environments is an important step in the CHNA process. These organizations can provide critical insights, help develop interview questions and surveys, facilitate or participate in data collection, and assist with data analysis and needs prioritization.

Key informant interviews

These interviews are valuable for gathering insights from key stakeholders and other community leaders.

For hospitals looking to understand food-related health needs in their CHNA process, key informant interviews with staff at food banks, soup kitchens, other organizations that work with low-income and underserved populations, and food advocacy organizations can provide critical insights into priority issues as well as opportunities and assets to address these needs in the community.

In Florida, Orlando Health Arnold Palmer Hospital for Children interviewed food bank staff, leaders of racial and ethnic minority communities, local business leaders, school officials, and advocates for the homeless as part of a CHNA process that investigated three interconnected community health challenges: obesity, poverty, and lack of access to healthy food. Arnold Palmer’s selection of a diverse group of key informants helped to identify the serious threat posed by diet-related disease and a lack of healthy food options to the community’s youth.

Focus groups 

Focus groups can elicit vital experiences and insights from members of your community. The conversational atmosphere of these meetings makes people feel at ease expressing their beliefs and concerns.It is recommended that these not be held at the hospital but at a community location.

In California, Sutter Health Eden Medical Center conducted four targeted focus group meetings as part of its 2016 CHNA process, meeting with and hearing concerns from a group of Spanish-speaking residents, residents of two vulnerable “communities of concern,” and individuals recovering from battles with drug and alcohol addiction. The individuals who participated in these focus groups shared their personal experiences of living in largely unhealthy food environments, helping to inform implementation strategy programming from the hospital centered on healthy food provision.

Surveys 

Surveys that ask community members about their health concerns are important tools for collecting data on pressing needs in the community. Surveys can include questions about food access, food behaviors, or diet-related health conditions as part of a more general survey, or can focus more narrowly on food environments and food needs. In order to collect responses from vulnerable population groups, it is useful to work with community organizations that work with these groups to administer surveys.

The USDA Economic Research Service provides a variety of standardized survey tools and other resources to assess food insecurity. Using these instruments will strengthen the validity and reliability of the resulting data and maximize comparability with national statistics.

In Oregon, Providence Hood River Memorial Hospital mailed a food survey to over a thousand households in its service region. In addition, surveys were hand-administered in targeted areas to ensure participation from non-English speaking, elderly, and/or low-income households.

Sample questions to include in interviews or focus groups

1. Is it difficult for you to get the food you want/need? If so, how often is this a problem?
2. In the past year, have you or any of your family members:
   • worried about running out of food
   • run out of food
   • skipped entire meals
   • gone without food so that children could eat
   • experienced more than one of these obstacles to eating
3. What makes it hard for you and your family to eat healthy meals?
   • cost
   • distance to store
   • transportation
   • time for shopping and food preparation
   • shopping on a budget
   • inexperience in preparing healthy meals
   • language/cultural barriers
   • taste preferences
4. Would you be interested in participating if any of the following programs were created in your community?
   • food preservation classes (canning, drying, freezing, etc.)
   • cooking classes
   • nutrition and healthy eating classes
   • community land for gardening
   • gardening classes
5. Do you know of any farmers markets that sell fruits and vegetables on certain days, fairly close to where you live?
6. How sure are you about where to get fresh fruits and vegetables in your neighborhood?

Learn more/additional resources

• Public Health Institute’s Making Food Systems Part of Your Community Health Needs Assessment provides valuable guidance for assessing and addressing local food environments in community health assessments.

• Researchers at the University of Pennsylvania have developed a series of validated Nutrition Environment Measure Surveys and tools to assess the healthfulness of food offerings, price, quality, and marketing in retail food outlets.