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Between exposure, access and use: Reconsidering foodscape influences on dietary behaviours
Health & Place 44 (2017) 1–7
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Health & Place journal homepage: www.elsevier.com/locate/healthplace
Between exposure, access and use: Reconsidering foodscape influences on dietary behaviours
MARK
⁎
Christelle Clarya,b, , Stephen Augustus Matthewsc, Yan Kestensa,b a
Département de médecine sociale et préventive, Université de Montréal, 7101 avenue du Parc, Montréal, Québec H3N 1X9, Canada Centre de recherche du centre hospitalier de l′ Université de Montréal (CRCHUM), tour St-Antoine - S02-340, 850 rue St-Denis, Montréal, Québec H2X 0A9, Canada c Departments of Sociology and Anthropology, Pennsylvania State University, 211 Oswald Tower, University Park, PA 16802, United States of America b
A R T I C L E I N F O
A BS T RAC T
Keywords: Access Conceptual Dietary behaviours Exposure Food environment Mobility
Good accessibility to both healthy and unhealthy food outlets is a greater reality than food deserts. Yet, there is a lack of conceptual insights on the contextual factors that push individuals to opt for healthy or unhealthy food outlets when both options are accessible. Our comprehension of foodscape influences on dietary behaviours would benefit from a better understanding of the decision-making process for food outlet choices. In this paper, we build on the fundamental position that outlet choices are conditioned by how much outlets’ attributes accommodate individuals’ constraints and preferences. We further argue that food outlets continuously experienced within individuals’ daily-path help people re-evaluate food acquisition possibilities, push them to form intentions, and shape their preferences for the choices they will subsequently make. Doing so, we suggest differentiating access, defined as the potential for the foodscape to be used at the time when individuals decide to do so, from exposure, which acts as a constant catalyst for knowledge, intention, preferences and routine tendency. We conclude with implications for future research, and discuss consequences for public policy.
1. Introduction In recent decades, interest in food environment influences on dietary behaviours has grown. First, the limited impact of education programs and individual-level interventions has pushed the field of public health to move from a behavioural change perspective to an ecological approach emphasizing contextual influences on health (Green et al., 2000; Story et al., 2008). Second, the development of advanced technologies in geography (e.g. Geographic Information Systems (GIS)) has facilitated the wide-scale production of environmental variables (Cromley and McLafferty, 2011; Moore and Carpenter, 1999). Finally, in westernised cities, food is mostly acquired through market-guided retail systems. If food choices operate within the limit of what the food system has to offer, associations between the food environment and dietary behaviours are to be expected. With the exception of some marginal distribution channels like community gardens, accessing food is conditional upon accessing retail food outlets (i.e. stores and restaurants). Commonly referred to as ‘community nutrition/food environment’ (Glanz et al., 2005) or more simply ‘foodscape’ (Winson, 2004), food outlets have therefore often been used as the basic unit of observation for assessing environmental influences on dietary behaviours (Charreire et al., 2010; Caspi et al., ⁎
2012). Because in-store supply has been shown to drive purchase (Curhan, 1974, 1973; Black et al., 2014; Wilkinson et al., 1982; Desmet and Renaudin, 1998; Chevalier, 1975; Eisend, 2014), outlets providing a wide range of healthful foods (e.g. fruit and vegetable), like supermarkets, grocery stores, and fruit and vegetable stores (Black et al., 2014; Ohri-Vachaspati et al., 2011) have often been considered “healthy”. Conversely, convenience stores and fast-food restaurants have been termed “unhealthy”, due to limited healthful foods options (Black et al., 2014; Ohri-Vachaspati et al., 2011; Reedy et al., 2010). Standing behind the commonly held assumption that the foodscape influences health behaviours by enabling or limiting the use of healthy and unhealthy food outlets (Story et al., 2008), research has mostly focused on potential access – i.e. the potential for food outlets to be used. Put differently, attention has focused on whether the conditions for using healthy and unhealthy outlets were met (Charreire et al., 2010; Caspi et al., 2012). Yet, discrepancies between the findings of studies testing associations between access to food outlets and dietary outcomes have limited our ability to clearly understand how the foodscape shapes dietary behaviours (Caspi et al., 2012; Feng et al., 2010; Giskes et al., 2007). Alongside criticisms about food outlets being labeled as either “healthy” or “unhealthy” without any nuance (Vernez Moudon et al.,
Corresponding author. E-mail address: [email protected] (C. Clary).
http://dx.doi.org/10.1016/j.healthplace.2016.12.005 Received 8 February 2016; Received in revised form 14 December 2016; Accepted 23 December 2016 1353-8292/ © 2017 Elsevier Ltd. All rights reserved.
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Fig. 1. Conceptual framework depicting foodscape influences on dietary behaviours.
operation, car-park, store loyalty cards) and the customers' ability to accommodate these factors; and 5) Acceptability, as the feeling of socio-cultural harmony with both staff, customers and food items (Cannuscio et al., 2014, 2010; Wang et al., 2007). The way individuals use the foodscape is hence conditional upon the wider ‘context’ within which individuals are embedded (Siordia and Matthews, 2016). Thus, a low income may create competition between food purchase and other primary needs (e.g. pay rent), leaving little option but to visit cheap food outlets at the expense of nutritional quality. In a similar vein, long working hours plus having to look after kids may considerably shrink the time available for food purchase, ruling out the possibility to visit distant outlets, though online businesses and services now enable us to more easily participate in spatially separated activities. Because both foodscape's characteristics and individuals’ life circumstances tend to change over space and time, the food outlet individuals choose in a specific situation may not be selected in a different spatio-temporal context (Matthews, 2012). For instance, an increase in income or the opening of a new store opposite from home may change one's ability to access (un)healthy options. Conversely, outlet closure or newly vegetarian friends exerting pressure to rule out food outlets serving meat may well constrain them. Tracking how individuals use their changing environment over time would not only help picture more realistically the overall healthfulness of individuals’ behaviours, but also build a better understanding of the reasons underlying the variety of choices and diversity of behaviours (Matthews, 2012). In practice, access has mostly been approached through the lens of food insecurity, with most attention focusing on the lack of access to healthy outlets (see literature on food deserts (Morton and Blanchard, 2007; Pearson et al., 2005; Smoyer-Tomic et al., 2006)). Although healthy food insecurity is a worrying reality that needs urgent action, many people are likely to find themselves in a position of choice among a range of food outlets from healthy to unhealthy. Yet, current
2013), it has been argued that place and health research too often fails to adopt a relational approach (Cummins et al., 2007) when looking at how the food environment relates to dietary behaviours. People are selective within the foodscape (Entwisle, 2007; Bhatnagar and Ratchford, 2004; Cannuscio et al., 2014), and may be so variably across their life course. Therefore it is not the characteristics of an outlet per se that designate that an outlet is a potential candidate for use, but instead those characteristics in relation to individuals’ propensity for, and desire to, accommodate them in a specific situation (Cummins et al., 2007). Put differently, both individual and foodscape characteristics interrelate to create the conditions of access. This perspective follows the line of argument by Anthony Giddens, who has conceptualised human action at the interplay of “structure” (as rules and resources inherent in social practices) and “agency” (as the capabilities of human to act) (Giddens, 1984). Recognising environmental influences on individual choices has helped consideration of health-related behaviours as a collective rather than an individual attribute. Frohlich and Potvin's expression collective lifestyles, used to describe the “shared way of relating and acting in a given environment”, provides a useful analytical concept to inform the existence of patterns of expression amongst people in similar environments (Frohlich et al., 2001). Borrowing from Penchansky and Thomas’ work (Penchansky and Thomas, 1981), recent conceptualisations of access have constructively built on five dimensions of interrelation or ‘fit’: 1) Availability, as the existence of adequate supply of food outlets regarding people's need; 2) Spatial accessibility, as the relationship between the location of food outlets and the location of individuals, accounting for transportation resources, travel time, distance and cost; 3) Affordability, as the relationship between prices and the customers' ability to pay; 4) Accommodation, as the relationship between the manner in which the food outlets are organized to accept customers (e.g. hours of 2
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also driven by the unconscious (Simon, 1955). Extensive literature based on laboratory and in-store experiments brings evidence that environmental cues shape dietary behaviours without much conscious deliberation (Cohen and Farley, 2008; Dijksterhuis et al., 2005; Herman and Polivy, 2005; Ilmonen, 2001). This perspective is explored in the next three sections.
conceptual proposals lack insights on how the foodscape shapes the healthy or unhealthy choice people make when both options are accessible to them. To address this gap, we suggest that improved understanding of foodscape influences on (un)healthy behaviours would benefit from a greater consideration of the factors shaping the decision-making process for food outlet choices when various options, healthy and less healthy, meet the conditions for use. In this paper, we argue that the decision to opt for a specific outlet type relies on both the discrete moments when individuals willing to use the foodscape consider their latitude to acquire food (i.e. assess the opportunities accessible to them) and the way individuals interpret and react to foodscape exposures over the life course. Doing so, we highlight how the decision-making process for food outlet choice is a mental activity being constantly reassessed. This conceptual position is synthesized in Fig. 1 and described in detail below. We follow this description with a discussion of the implications for future research, and briefly discuss consequences for public policy.
2.1. Foodscape's propensity to stimulate food desire Humans appear to have an innate liking for sweet and salty flavours, and energy-dense foods (Drewnowski and Greenwood, 1983; Birch, 1999), though this tendency evolves throughout the life course partly due to socio-cultural and “information” (e.g. advertising) influences (Fig. 1B) (Birch, 1999; Desor et al., 1975). Moreover, food cues provoke an automatic desire for eating (Cohen and Farley, 2008; Wansink et al., 2006), regardless of appetite (Cornell et al., 1989), meal setting (de Castro and Brewer, 1992), and whether the food actually tastes good (Wansink and Kim, 2005). The amount of effort required to refrain from eating when food is present is substantial (Baumeister et al., 1998), though this may be varying with personality traits (Davis et al., 2007; Beaver et al., 2006). In westernised societies, food outlets (Kestens et al., 2010; Burgoine and Monsivais, 2013) and off-site advertising such as print media and road signs (Lowery and Sloane, 2014) have become ubiquitous. Exposure to such cues may trigger unhealthy behaviours. There is evidence of positive associations between exposure to unhealthy food outlets and unhealthy diet (Paquet et al., 2010; BooneHeinonen et al., 2011; Burgoine et al., 2014), though some studies did not find significant relationships (Caspi et al., 2012). Among possible reasons for discrepant results is that the ubiquitous presence of unhealthy food outlets may lead to relatively uniform levels of exposure across populations, precluding the detection of any effect in crosssectional studies. Interestingly, a large-scale longitudinal study which used repeated measures of both foodscape and diet over 20 years has provided evidence that greater exposure to fast-food restaurants around the home location promotes greater fast-food consumption (Richardson et al., 2015). Differential responsiveness to food cues provides another plausible explanation for this inconsistency of evidence. For instance, Paquet et al. found a positive relationship between exposure to fast-food restaurants and fast-food consumption only for individuals with high reward-sensitivity (Paquet et al., 2010). Finally, desire for food activated by surrounding food cues may not translate in food outlet use simply because food outlets remain inaccessible, referring back to the dimensions of affordability, accommodation and acceptability introduced above. Overall, the point we are making here is that foodscape exposure may push individuals to form intentions (“I want to eat”) (Fig. 1D), but whether individuals eat or not will depend on individuals’ ability to repel this automatically-activated desire, and/or the level of access to the foodscape.
2. Access and the overlooked question of alternatives Under rational choice theory, individuals are assumed to have complete knowledge of the relevant aspects of their environment and a well-organized and stable system of preferences providing them with the ability to act in their own self-interest with full awareness of how that self-interest is achieved (Simon, 1955). Along this line, food choice has mainly been considered from a utility-optimization perspective. Individuals are seen as rational agents evaluating food outlets along five accessibility-related dimensions, i.e. availability, spatial accessibility, affordability, convenience and acceptability, and then patronizing the food outlet considered to be the best available option (Bhatnagar and Ratchford, 2004; Cannuscio et al., 2014). If we assume that people implicitly weight outlet characteristics to arrive at a choice, then not only should the attributes of a given outlet type and individuals’ characteristics be considered, but so too should the attributes of potential alternatives (Rose et al., 2009). Hence, sound conceptualisations of access should encompass the relative assessment of healthy and unhealthy food outlets with regard to relevant criteria for choice (Fig. 1A). Now, although it can be argued that outlet choice relies to some extent on a rational decision-making process, considering individuals as utility-maximizers with full awareness of how to achieve this maximisation is challenged by at least two elements: knowledge of the environment is rarely perfect and individual's computational capacities are limited (Simon, 1955). First, to make the best possible use of the foodscape, individuals would need all the relevant information about food outlets’ attributes (Welsh and MacRae, 1998). Yet, individuals do not have perfect knowledge about the environment. Wang et al. reported that, in a context of grocery store implementation, 40% of the locals who did not shop at the new store were not aware that the store existed (Wang et al., 2007). The range of alternatives that people acknowledge or perceive may therefore be substantially more limited than the actual alternatives that exist (Simon, 1955). Knowledge acquisition depends on both social (e.g. friends, colleagues) and information (e.g. TV and off-site advertising, phone applications providing location-based services) environments (Fig. 1B). It can further be gained through foodscape use (Fig. 1H) and exposure (Fig. 1C) (Flamm et al., 2008) – foodscape exposure here referring to the food outlets an individual encounters in the succession of situations he/she is in (i.e. the food outlets within his/her daily trajectories or path). Because the environment we live in is neither uniform over space, nor static over time, physical movement and social interactions are easier in some directions than others and change over the life span (Matthews, 2011). As a result, knowledge tends to be acquired in an anisotropic and evolving way. The second element that challenges the basic assumption of rational agents is the possibility that decisions are
2.2. Foodscape's normative dimension There is evidence that individuals tend to rely on environmental cues to gauge what it is socially appropriate to eat, referred to as norms of appropriateness (Herman et al., 2003). Benchmarks of appropriateness can be derived from physical cues denoting the popularity of a product (Herman et al., 2003; Burger et al., 2010). For instance, the presence of a large number of empty wrappers may be an incentive to buy the product as it is the visible expression of other consumers’ purchase preferences. Yet, the degree to which the foodscape itself may provide benchmarks vis-à-vis food purchase and consumption has been largely ignored. The foodscape is man-made. The choice of location for a new food outlet often relies on location-allocation models aiming to identify location(s) which would ensure enough customers’ patronage to secure the economic viability of this food outlet (Current et al., 1990). When 3
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emotional bonds with the physical site, transforming non-cognitive routines into a genuine place attachment (Milligan, 1998). This in turn decreases perceived substitutability of the chosen food outlet by alternatives (Milligan, 1998). Surely, routines can break down under specific circumstances (e.g. residential mobility, pay rise, child birth), pushing individuals to reassess available foodscape opportunities (Flamm et al., 2008). Moreover, it is possible that routines coexist with more isolated purchase behaviours. For instance, individuals may report frequent use of a supermarket for main shopping, complemented by the occasional visit to other food outlets that serve different purposes, such as lunch in a fast-food restaurant near a friend's home. Yet, overall, even when a person uses the foodscape the way that she has defined for herself in the first place, she cannot escape the mental imprint left by this addition of experience (Pred, 1983). This suggests that the historic use of the foodscape shapes preferences for future foodscape use (Fig. 1F/H). Yet, assessing foodscape exposure over a relatively short time window misses the temporal dynamics of exposures and choices. Such considerations invite for more investigation of life course experiences, for example exploring whether foodscape exposures at a particularly vulnerable periods of life (e.g. adolescence) have long-lasting effects on food outlet choices later in life.
the food outlet demonstrates its viability in the food landscape, we can assume that it is being used. As highlighted earlier, the use of a given food outlet may be constrained by a lack of alternatives, unselfconsciously stimulated by exposure to appealing food cues, or consciously favored by individuals. But regardless of the reason behind individuals’ use of food outlets, the resulting foodscape is a materialised reflection of consumers’ patronage over time (Fig. 1G). Building from this argument, we suggest that the relative densities of healthy and unhealthy outlets may serve as normative benchmarks in the consumer's choice of using healthy rather than unhealthy (and vice-versa) food outlets. There is evidence that the higher the proportion of healthy food outlets around home, the higher fruit and vegetable purchase and intake (Mason et al., 2013; Clary et al., 2014), the better the overall quality of diet (Mercille et al., 2012), and the lower the consumption of fast-food and soda (Babey et al., 2011). It could be argued that these relationships are not underpinned by the normative influence of the residential foodscape on food outlet choices, but instead by individuals modifying their local environment through their purchasing behaviours. Yet, evidence suggests that individuals tend to conduct their primary food shopping beyond the vicinity of the home (Cannuscio et al., 2014, 2013; Hillier et al., 2011; Kerr et al., 2012; Inagami et al., 2006; Aggarwal et al., 2014; Krukowski et al., 2013). If people's dietary behaviours reflect the overall nature of their local environment, though they shop outside of its boundaries, this may be because people behave in accordance with the norms of their local environment, which they have progressively internalized. Consistent with this rationale, Moore et al. found that the density of fast-food restaurants around the home was not associated with patronising fast-food restaurants near the home. Yet the odds of having a healthy diet decreased by 12–17% for every standard deviation increase in fast-food residential exposure (Moore et al., 2009). Foodscape influences may potentially be spatially and temporally distinct from food purchasing/eating episodes (Shearer et al., 2015). Along this line, Herman et al. differentiated situation-specific from person-specific norms (Herman and Polivy, 2005). While the former refers to norms that may be inferred from the situation in which a food choice is made, the latter occurs when norms are internalized through past experiences. Overall, this suggests that foodscape exposure may shape preferences in how the foodscape is being used (Fig. 1E).
3. Towards the need to differentiate access from exposure We have highlighted how the decision-making process for food choice by a person is a mental activity being constantly reassessed. On the one hand, the latitude to acquire food for personal gain evolves at daily and lifelong scales, due to both changing foodscapes and people's mobility and varying life circumstances. On the other hand, the decision-making process for food choice is also shaped by how individuals interpret and react to the foodscapes they get exposed to day after day over the life span. Foodscapes experienced within a dailypath help people evaluate and re-evaluate food acquisition possibilities (by expanding their foodscape literacy), push them to form intentions (by stimulating their desire to eat), and shape their preferences for the choices they will subsequently make (for instance by suggesting which food outlets are socially appropriate to use, or encouraging the repetition of familiar past choices) (Pred, 1983). Hence, we here outline connections between the flow of foodscapes’ exposure ‒ which acts as a catalyst of knowledge, intentions, preferences and routine tendency‒ and the discrete moments when individuals willing to use the foodscape consider which options are accessible and satisfying given their present situation. This perspective invites the need to consider the mechanisms by which the foodscape shapes health behaviours as dynamic, fluid and continuous across space and time, though they are often modeled as spatially fragmented and a historic (Matthews, 2012; Matthews and Yang, 2013). Our proposal additionally invites us to differentiate exposure from (potential) access, though these two notions tend to be used interchangeably in literature on foodscapes. Failure to recognise this important distinction may lead to an underestimation of foodscape influences on dietary behaviours. For instance, an environment abundantly supplied with unhealthy food outlets that also provides access to a few healthy food outlets may be erroneously considered as healthpromoting if the focus is only on access, because the propensity of foodscape exposure to encourage unhealthy behaviours would be overlooked. We could also be wrong to conclude that an environment is health-promoting simply because individuals are exposed to high densities of healthy food outlets, without looking at whether these outlets are actually accessible (i.e. affordable, convenient and acceptable). Finally, our proposal highlights how individuals’ dietary behaviours rely alternatively on rational and less-conscious decision-making mechanisms. The relevance of distinguishing between two decision systems has been thoroughly explored by Kahneman and Tversky
2.3. Foodscape and routines Using the foodscape to acquire food is a recurrent activity (Gustafson et al., 2013; White et al., 2004; Harnack et al., 2000; Orfanos et al., 2009). Over time, food acquisitions tend to become routine (Ilmonen, 2001), with one (or a few) outlet type(s) repetitively visited for main food purchases (White et al., 2004). Repetitive use of the same food outlet(s) may result from a scarcity of options to choose from. For instance, the time remaining after completion of fixed commitments such as work may constrain people to visit the only food outlets located on the commute back and forth from home to the workplace. Yet, the foodscape propensity to foster routines may have an origin other than restricted access. An experimental work on the condition under which purchase choices are made has shown that as the number of alternatives involved in the purchase decision increases, individuals are more likely to guide their choice toward the same option time after time (Anderson et al., 1966). Repeating past choices may be a heuristic decision mechanism to facilitate decisions in complex situations. For risk-averse individuals, a satisfactory experience is used as relevant information for future decisions and subsequent preference formation situations (Fischer and Frewer, 2009). That is, people like what they know, and choose what they like (Cooke, 2007). Therefore, repeatedly visiting some outlets may be viewed as a way to ease the decision-making process as to where to shop in situations of multiple choices (Ilmonen, 2001). Eventually, repetitive visits may foster 4
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(Fig. 1J) would help better capture how the compilation of exposures experienced throughout the life span shapes health behaviours (Matthews, 2012). Exploiting the opportunities offered by “natural experiments” (Petticrew et al., 2005) ‒ such as openings/closures of certain types of outlets or shifts in the type of outlets dominating a foodscape ‒ and more generally the reliance on longitudinal designs would help better account for the life-long foodscape influences that shape dietary behaviours.
(Kahneman, 2003). These scholars have highlighted how individual action is mainly driven by intuition, a form of thought coming “spontaneously to mind, without conscious search or computation, and without effort”, but at times is also driven by deliberate decisions relying on analytic assessments (i.e. reasoning). Among the factors that push a person to engage variably in one or the other system of deciding, Kahneman and Tversky have listed time pressure, concurrent involvement in a different cognitive task, intelligence and exposure to statistical thinking (Kahneman, 2003). Inter-individual variability in the processing of information available in the environment has also been outlined ‒ structured along gender (Croker et al., 2009), socioeconomic characteristics (Boone-Heinonen et al., 2011) and psychosocial traits (Paquet et al., 2010). Yet, a comprehensive understanding of all the elements that lead individuals to base their food outlet choices on reasoning or on intuition is still needed.
8. Conclusion The father of medicine, Hippocrates wrote “Let food be your medicine”, and introduced over two millennia ago the now well-argued idea that a balanced diet is essential to good health. So why do people continue to eat unhealthily when the detrimental consequences are so well-known? As brought to light by this proposal, it may partly be because eating healthily is shaped by factors that are beyond the control and/or awareness of individuals. In westernised cities, the abundance of food sources gives the impression of choice. Yet, the necessity to meet certain constraints (spatio-temporal, financial, practical and socio-cultural) may restrict access to the foodscape to the point that no healthy options are rendered accessible. In addition, the compilation of exposures to food outlets over time may push people to repetitively form, without much deliberation, healthy or unhealthy intentions regarding foodscape use. Surprisingly, the involvement of national and international authorities has (and is still) mainly relied on nutrition education of the population rather than on modifications at the structural level of food retailing. In a context of globalisation and neo-liberal economic sovereignty (Chopra et al., 2002), the dominance of consumerism above health (Caraher and Coveney, 2004) and the control of food distribution by dominant food institutions (Welsh and MacRae, 1998) may have hampered foodscape alterations. Yet, a few national initiatives, like the recent US ban of artificial trans-fat in foods by the Food and Drug Administration, demonstrate that the food environment is modifiable. Strong guidance on which foodscape alterations could benefit the health of populations would certainly help move forward on this matter. We suggest that local, sporadic and isolated interventions on the foodscape, such as implementation of one supermarket in the midst of a multitude of unhealthy food outlets, may not be enough to foster significant changes in a population. Instead, we suggest that shifting the ratio of healthy to unhealthy food outlets, especially through reducing the presence of unhealthy outlets, may be a promising avenue to explore. Overall, this proposal invites us to step away from making individuals the only practical levers for action regarding (un)healthy eating, and to better consider the multiple ways by which the foodscape also shapes dietary behaviours.
4. Implication for future research Practical guidance to improve our way of assessing potential access has been produced elsewhere (see for example (Bhatnagar and Ratchford, 2004; Lytle, 2009; Chen and Kwan, 2015)). We will therefore confine ourselves briefly to suggesting directions for future research that may enable better assessment of foodscape exposure. 5. Adopting an activity-space perspective when assessing exposure Exposure assessment has often overlooked the temporal processes across geographic space, even though foodscape exposure is a byproduct of the individual's participation in temporally and spatially defined life activities (Matthews and Yang, 2013; Perchoux et al., 2013). The subset of all locations within which an individual has direct contact as a result of his or her daily mobility (Fig. 1I) should be more widely used to assess, both at shorter (e.g. day) and longer (e.g. lifecourse) timescales, the compilation of exposures experienced over time (Matthews and Yang, 2013; Kestens et al., 2016). Some recent studies in literature on the foodscape have adopted an activity-space approach (e.g. Shearer et al., 2015; Zenk et al., 2011)). However, this practice still remains marginal. Technical tools such as GPS devices and web-based computer applications that track individual movements over time and behaviours across space have large potential for deriving activity-space exposures (Chaix et al., 2012), though temporal coverage issues need to be addressed (Matthews and Yang, 2013). 6. Better assessing the content of exposure When exploring the extent to which exposure to unhealthy food outlets encourages unhealthy dietary behaviours, looking at unhealthy outlets’ density within the activity space may be valuable. Similarly, when questioning the normative influences of the foodscape on the intention to utilize healthy and unhealthy outlets, looking at how the relative densities of healthy and unhealthy outlet experienced daily relate to dietary behaviours may be a promising avenue for research. Qualitative investigations on perceptions of the environment ‒ for example through using ecological momentary assessments (EMAs) (Stone and Shiffman, 1994) ‒ may complementarily help progress in this regard (Matthews and Yang, 2013). How far relationships between foodscape exposure and dietary behaviours are generalizable (or variable) across populations would also deserve greater attention.
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Health & Place journal homepage: www.elsevier.com/locate/healthplace
Between exposure, access and use: Reconsidering foodscape influences on dietary behaviours
MARK
⁎
Christelle Clarya,b, , Stephen Augustus Matthewsc, Yan Kestensa,b a
Département de médecine sociale et préventive, Université de Montréal, 7101 avenue du Parc, Montréal, Québec H3N 1X9, Canada Centre de recherche du centre hospitalier de l′ Université de Montréal (CRCHUM), tour St-Antoine - S02-340, 850 rue St-Denis, Montréal, Québec H2X 0A9, Canada c Departments of Sociology and Anthropology, Pennsylvania State University, 211 Oswald Tower, University Park, PA 16802, United States of America b
A R T I C L E I N F O
A BS T RAC T
Keywords: Access Conceptual Dietary behaviours Exposure Food environment Mobility
Good accessibility to both healthy and unhealthy food outlets is a greater reality than food deserts. Yet, there is a lack of conceptual insights on the contextual factors that push individuals to opt for healthy or unhealthy food outlets when both options are accessible. Our comprehension of foodscape influences on dietary behaviours would benefit from a better understanding of the decision-making process for food outlet choices. In this paper, we build on the fundamental position that outlet choices are conditioned by how much outlets’ attributes accommodate individuals’ constraints and preferences. We further argue that food outlets continuously experienced within individuals’ daily-path help people re-evaluate food acquisition possibilities, push them to form intentions, and shape their preferences for the choices they will subsequently make. Doing so, we suggest differentiating access, defined as the potential for the foodscape to be used at the time when individuals decide to do so, from exposure, which acts as a constant catalyst for knowledge, intention, preferences and routine tendency. We conclude with implications for future research, and discuss consequences for public policy.
1. Introduction In recent decades, interest in food environment influences on dietary behaviours has grown. First, the limited impact of education programs and individual-level interventions has pushed the field of public health to move from a behavioural change perspective to an ecological approach emphasizing contextual influences on health (Green et al., 2000; Story et al., 2008). Second, the development of advanced technologies in geography (e.g. Geographic Information Systems (GIS)) has facilitated the wide-scale production of environmental variables (Cromley and McLafferty, 2011; Moore and Carpenter, 1999). Finally, in westernised cities, food is mostly acquired through market-guided retail systems. If food choices operate within the limit of what the food system has to offer, associations between the food environment and dietary behaviours are to be expected. With the exception of some marginal distribution channels like community gardens, accessing food is conditional upon accessing retail food outlets (i.e. stores and restaurants). Commonly referred to as ‘community nutrition/food environment’ (Glanz et al., 2005) or more simply ‘foodscape’ (Winson, 2004), food outlets have therefore often been used as the basic unit of observation for assessing environmental influences on dietary behaviours (Charreire et al., 2010; Caspi et al., ⁎
2012). Because in-store supply has been shown to drive purchase (Curhan, 1974, 1973; Black et al., 2014; Wilkinson et al., 1982; Desmet and Renaudin, 1998; Chevalier, 1975; Eisend, 2014), outlets providing a wide range of healthful foods (e.g. fruit and vegetable), like supermarkets, grocery stores, and fruit and vegetable stores (Black et al., 2014; Ohri-Vachaspati et al., 2011) have often been considered “healthy”. Conversely, convenience stores and fast-food restaurants have been termed “unhealthy”, due to limited healthful foods options (Black et al., 2014; Ohri-Vachaspati et al., 2011; Reedy et al., 2010). Standing behind the commonly held assumption that the foodscape influences health behaviours by enabling or limiting the use of healthy and unhealthy food outlets (Story et al., 2008), research has mostly focused on potential access – i.e. the potential for food outlets to be used. Put differently, attention has focused on whether the conditions for using healthy and unhealthy outlets were met (Charreire et al., 2010; Caspi et al., 2012). Yet, discrepancies between the findings of studies testing associations between access to food outlets and dietary outcomes have limited our ability to clearly understand how the foodscape shapes dietary behaviours (Caspi et al., 2012; Feng et al., 2010; Giskes et al., 2007). Alongside criticisms about food outlets being labeled as either “healthy” or “unhealthy” without any nuance (Vernez Moudon et al.,
Corresponding author. E-mail address: [email protected] (C. Clary).
http://dx.doi.org/10.1016/j.healthplace.2016.12.005 Received 8 February 2016; Received in revised form 14 December 2016; Accepted 23 December 2016 1353-8292/ © 2017 Elsevier Ltd. All rights reserved.
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Fig. 1. Conceptual framework depicting foodscape influences on dietary behaviours.
operation, car-park, store loyalty cards) and the customers' ability to accommodate these factors; and 5) Acceptability, as the feeling of socio-cultural harmony with both staff, customers and food items (Cannuscio et al., 2014, 2010; Wang et al., 2007). The way individuals use the foodscape is hence conditional upon the wider ‘context’ within which individuals are embedded (Siordia and Matthews, 2016). Thus, a low income may create competition between food purchase and other primary needs (e.g. pay rent), leaving little option but to visit cheap food outlets at the expense of nutritional quality. In a similar vein, long working hours plus having to look after kids may considerably shrink the time available for food purchase, ruling out the possibility to visit distant outlets, though online businesses and services now enable us to more easily participate in spatially separated activities. Because both foodscape's characteristics and individuals’ life circumstances tend to change over space and time, the food outlet individuals choose in a specific situation may not be selected in a different spatio-temporal context (Matthews, 2012). For instance, an increase in income or the opening of a new store opposite from home may change one's ability to access (un)healthy options. Conversely, outlet closure or newly vegetarian friends exerting pressure to rule out food outlets serving meat may well constrain them. Tracking how individuals use their changing environment over time would not only help picture more realistically the overall healthfulness of individuals’ behaviours, but also build a better understanding of the reasons underlying the variety of choices and diversity of behaviours (Matthews, 2012). In practice, access has mostly been approached through the lens of food insecurity, with most attention focusing on the lack of access to healthy outlets (see literature on food deserts (Morton and Blanchard, 2007; Pearson et al., 2005; Smoyer-Tomic et al., 2006)). Although healthy food insecurity is a worrying reality that needs urgent action, many people are likely to find themselves in a position of choice among a range of food outlets from healthy to unhealthy. Yet, current
2013), it has been argued that place and health research too often fails to adopt a relational approach (Cummins et al., 2007) when looking at how the food environment relates to dietary behaviours. People are selective within the foodscape (Entwisle, 2007; Bhatnagar and Ratchford, 2004; Cannuscio et al., 2014), and may be so variably across their life course. Therefore it is not the characteristics of an outlet per se that designate that an outlet is a potential candidate for use, but instead those characteristics in relation to individuals’ propensity for, and desire to, accommodate them in a specific situation (Cummins et al., 2007). Put differently, both individual and foodscape characteristics interrelate to create the conditions of access. This perspective follows the line of argument by Anthony Giddens, who has conceptualised human action at the interplay of “structure” (as rules and resources inherent in social practices) and “agency” (as the capabilities of human to act) (Giddens, 1984). Recognising environmental influences on individual choices has helped consideration of health-related behaviours as a collective rather than an individual attribute. Frohlich and Potvin's expression collective lifestyles, used to describe the “shared way of relating and acting in a given environment”, provides a useful analytical concept to inform the existence of patterns of expression amongst people in similar environments (Frohlich et al., 2001). Borrowing from Penchansky and Thomas’ work (Penchansky and Thomas, 1981), recent conceptualisations of access have constructively built on five dimensions of interrelation or ‘fit’: 1) Availability, as the existence of adequate supply of food outlets regarding people's need; 2) Spatial accessibility, as the relationship between the location of food outlets and the location of individuals, accounting for transportation resources, travel time, distance and cost; 3) Affordability, as the relationship between prices and the customers' ability to pay; 4) Accommodation, as the relationship between the manner in which the food outlets are organized to accept customers (e.g. hours of 2
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also driven by the unconscious (Simon, 1955). Extensive literature based on laboratory and in-store experiments brings evidence that environmental cues shape dietary behaviours without much conscious deliberation (Cohen and Farley, 2008; Dijksterhuis et al., 2005; Herman and Polivy, 2005; Ilmonen, 2001). This perspective is explored in the next three sections.
conceptual proposals lack insights on how the foodscape shapes the healthy or unhealthy choice people make when both options are accessible to them. To address this gap, we suggest that improved understanding of foodscape influences on (un)healthy behaviours would benefit from a greater consideration of the factors shaping the decision-making process for food outlet choices when various options, healthy and less healthy, meet the conditions for use. In this paper, we argue that the decision to opt for a specific outlet type relies on both the discrete moments when individuals willing to use the foodscape consider their latitude to acquire food (i.e. assess the opportunities accessible to them) and the way individuals interpret and react to foodscape exposures over the life course. Doing so, we highlight how the decision-making process for food outlet choice is a mental activity being constantly reassessed. This conceptual position is synthesized in Fig. 1 and described in detail below. We follow this description with a discussion of the implications for future research, and briefly discuss consequences for public policy.
2.1. Foodscape's propensity to stimulate food desire Humans appear to have an innate liking for sweet and salty flavours, and energy-dense foods (Drewnowski and Greenwood, 1983; Birch, 1999), though this tendency evolves throughout the life course partly due to socio-cultural and “information” (e.g. advertising) influences (Fig. 1B) (Birch, 1999; Desor et al., 1975). Moreover, food cues provoke an automatic desire for eating (Cohen and Farley, 2008; Wansink et al., 2006), regardless of appetite (Cornell et al., 1989), meal setting (de Castro and Brewer, 1992), and whether the food actually tastes good (Wansink and Kim, 2005). The amount of effort required to refrain from eating when food is present is substantial (Baumeister et al., 1998), though this may be varying with personality traits (Davis et al., 2007; Beaver et al., 2006). In westernised societies, food outlets (Kestens et al., 2010; Burgoine and Monsivais, 2013) and off-site advertising such as print media and road signs (Lowery and Sloane, 2014) have become ubiquitous. Exposure to such cues may trigger unhealthy behaviours. There is evidence of positive associations between exposure to unhealthy food outlets and unhealthy diet (Paquet et al., 2010; BooneHeinonen et al., 2011; Burgoine et al., 2014), though some studies did not find significant relationships (Caspi et al., 2012). Among possible reasons for discrepant results is that the ubiquitous presence of unhealthy food outlets may lead to relatively uniform levels of exposure across populations, precluding the detection of any effect in crosssectional studies. Interestingly, a large-scale longitudinal study which used repeated measures of both foodscape and diet over 20 years has provided evidence that greater exposure to fast-food restaurants around the home location promotes greater fast-food consumption (Richardson et al., 2015). Differential responsiveness to food cues provides another plausible explanation for this inconsistency of evidence. For instance, Paquet et al. found a positive relationship between exposure to fast-food restaurants and fast-food consumption only for individuals with high reward-sensitivity (Paquet et al., 2010). Finally, desire for food activated by surrounding food cues may not translate in food outlet use simply because food outlets remain inaccessible, referring back to the dimensions of affordability, accommodation and acceptability introduced above. Overall, the point we are making here is that foodscape exposure may push individuals to form intentions (“I want to eat”) (Fig. 1D), but whether individuals eat or not will depend on individuals’ ability to repel this automatically-activated desire, and/or the level of access to the foodscape.
2. Access and the overlooked question of alternatives Under rational choice theory, individuals are assumed to have complete knowledge of the relevant aspects of their environment and a well-organized and stable system of preferences providing them with the ability to act in their own self-interest with full awareness of how that self-interest is achieved (Simon, 1955). Along this line, food choice has mainly been considered from a utility-optimization perspective. Individuals are seen as rational agents evaluating food outlets along five accessibility-related dimensions, i.e. availability, spatial accessibility, affordability, convenience and acceptability, and then patronizing the food outlet considered to be the best available option (Bhatnagar and Ratchford, 2004; Cannuscio et al., 2014). If we assume that people implicitly weight outlet characteristics to arrive at a choice, then not only should the attributes of a given outlet type and individuals’ characteristics be considered, but so too should the attributes of potential alternatives (Rose et al., 2009). Hence, sound conceptualisations of access should encompass the relative assessment of healthy and unhealthy food outlets with regard to relevant criteria for choice (Fig. 1A). Now, although it can be argued that outlet choice relies to some extent on a rational decision-making process, considering individuals as utility-maximizers with full awareness of how to achieve this maximisation is challenged by at least two elements: knowledge of the environment is rarely perfect and individual's computational capacities are limited (Simon, 1955). First, to make the best possible use of the foodscape, individuals would need all the relevant information about food outlets’ attributes (Welsh and MacRae, 1998). Yet, individuals do not have perfect knowledge about the environment. Wang et al. reported that, in a context of grocery store implementation, 40% of the locals who did not shop at the new store were not aware that the store existed (Wang et al., 2007). The range of alternatives that people acknowledge or perceive may therefore be substantially more limited than the actual alternatives that exist (Simon, 1955). Knowledge acquisition depends on both social (e.g. friends, colleagues) and information (e.g. TV and off-site advertising, phone applications providing location-based services) environments (Fig. 1B). It can further be gained through foodscape use (Fig. 1H) and exposure (Fig. 1C) (Flamm et al., 2008) – foodscape exposure here referring to the food outlets an individual encounters in the succession of situations he/she is in (i.e. the food outlets within his/her daily trajectories or path). Because the environment we live in is neither uniform over space, nor static over time, physical movement and social interactions are easier in some directions than others and change over the life span (Matthews, 2011). As a result, knowledge tends to be acquired in an anisotropic and evolving way. The second element that challenges the basic assumption of rational agents is the possibility that decisions are
2.2. Foodscape's normative dimension There is evidence that individuals tend to rely on environmental cues to gauge what it is socially appropriate to eat, referred to as norms of appropriateness (Herman et al., 2003). Benchmarks of appropriateness can be derived from physical cues denoting the popularity of a product (Herman et al., 2003; Burger et al., 2010). For instance, the presence of a large number of empty wrappers may be an incentive to buy the product as it is the visible expression of other consumers’ purchase preferences. Yet, the degree to which the foodscape itself may provide benchmarks vis-à-vis food purchase and consumption has been largely ignored. The foodscape is man-made. The choice of location for a new food outlet often relies on location-allocation models aiming to identify location(s) which would ensure enough customers’ patronage to secure the economic viability of this food outlet (Current et al., 1990). When 3
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emotional bonds with the physical site, transforming non-cognitive routines into a genuine place attachment (Milligan, 1998). This in turn decreases perceived substitutability of the chosen food outlet by alternatives (Milligan, 1998). Surely, routines can break down under specific circumstances (e.g. residential mobility, pay rise, child birth), pushing individuals to reassess available foodscape opportunities (Flamm et al., 2008). Moreover, it is possible that routines coexist with more isolated purchase behaviours. For instance, individuals may report frequent use of a supermarket for main shopping, complemented by the occasional visit to other food outlets that serve different purposes, such as lunch in a fast-food restaurant near a friend's home. Yet, overall, even when a person uses the foodscape the way that she has defined for herself in the first place, she cannot escape the mental imprint left by this addition of experience (Pred, 1983). This suggests that the historic use of the foodscape shapes preferences for future foodscape use (Fig. 1F/H). Yet, assessing foodscape exposure over a relatively short time window misses the temporal dynamics of exposures and choices. Such considerations invite for more investigation of life course experiences, for example exploring whether foodscape exposures at a particularly vulnerable periods of life (e.g. adolescence) have long-lasting effects on food outlet choices later in life.
the food outlet demonstrates its viability in the food landscape, we can assume that it is being used. As highlighted earlier, the use of a given food outlet may be constrained by a lack of alternatives, unselfconsciously stimulated by exposure to appealing food cues, or consciously favored by individuals. But regardless of the reason behind individuals’ use of food outlets, the resulting foodscape is a materialised reflection of consumers’ patronage over time (Fig. 1G). Building from this argument, we suggest that the relative densities of healthy and unhealthy outlets may serve as normative benchmarks in the consumer's choice of using healthy rather than unhealthy (and vice-versa) food outlets. There is evidence that the higher the proportion of healthy food outlets around home, the higher fruit and vegetable purchase and intake (Mason et al., 2013; Clary et al., 2014), the better the overall quality of diet (Mercille et al., 2012), and the lower the consumption of fast-food and soda (Babey et al., 2011). It could be argued that these relationships are not underpinned by the normative influence of the residential foodscape on food outlet choices, but instead by individuals modifying their local environment through their purchasing behaviours. Yet, evidence suggests that individuals tend to conduct their primary food shopping beyond the vicinity of the home (Cannuscio et al., 2014, 2013; Hillier et al., 2011; Kerr et al., 2012; Inagami et al., 2006; Aggarwal et al., 2014; Krukowski et al., 2013). If people's dietary behaviours reflect the overall nature of their local environment, though they shop outside of its boundaries, this may be because people behave in accordance with the norms of their local environment, which they have progressively internalized. Consistent with this rationale, Moore et al. found that the density of fast-food restaurants around the home was not associated with patronising fast-food restaurants near the home. Yet the odds of having a healthy diet decreased by 12–17% for every standard deviation increase in fast-food residential exposure (Moore et al., 2009). Foodscape influences may potentially be spatially and temporally distinct from food purchasing/eating episodes (Shearer et al., 2015). Along this line, Herman et al. differentiated situation-specific from person-specific norms (Herman and Polivy, 2005). While the former refers to norms that may be inferred from the situation in which a food choice is made, the latter occurs when norms are internalized through past experiences. Overall, this suggests that foodscape exposure may shape preferences in how the foodscape is being used (Fig. 1E).
3. Towards the need to differentiate access from exposure We have highlighted how the decision-making process for food choice by a person is a mental activity being constantly reassessed. On the one hand, the latitude to acquire food for personal gain evolves at daily and lifelong scales, due to both changing foodscapes and people's mobility and varying life circumstances. On the other hand, the decision-making process for food choice is also shaped by how individuals interpret and react to the foodscapes they get exposed to day after day over the life span. Foodscapes experienced within a dailypath help people evaluate and re-evaluate food acquisition possibilities (by expanding their foodscape literacy), push them to form intentions (by stimulating their desire to eat), and shape their preferences for the choices they will subsequently make (for instance by suggesting which food outlets are socially appropriate to use, or encouraging the repetition of familiar past choices) (Pred, 1983). Hence, we here outline connections between the flow of foodscapes’ exposure ‒ which acts as a catalyst of knowledge, intentions, preferences and routine tendency‒ and the discrete moments when individuals willing to use the foodscape consider which options are accessible and satisfying given their present situation. This perspective invites the need to consider the mechanisms by which the foodscape shapes health behaviours as dynamic, fluid and continuous across space and time, though they are often modeled as spatially fragmented and a historic (Matthews, 2012; Matthews and Yang, 2013). Our proposal additionally invites us to differentiate exposure from (potential) access, though these two notions tend to be used interchangeably in literature on foodscapes. Failure to recognise this important distinction may lead to an underestimation of foodscape influences on dietary behaviours. For instance, an environment abundantly supplied with unhealthy food outlets that also provides access to a few healthy food outlets may be erroneously considered as healthpromoting if the focus is only on access, because the propensity of foodscape exposure to encourage unhealthy behaviours would be overlooked. We could also be wrong to conclude that an environment is health-promoting simply because individuals are exposed to high densities of healthy food outlets, without looking at whether these outlets are actually accessible (i.e. affordable, convenient and acceptable). Finally, our proposal highlights how individuals’ dietary behaviours rely alternatively on rational and less-conscious decision-making mechanisms. The relevance of distinguishing between two decision systems has been thoroughly explored by Kahneman and Tversky
2.3. Foodscape and routines Using the foodscape to acquire food is a recurrent activity (Gustafson et al., 2013; White et al., 2004; Harnack et al., 2000; Orfanos et al., 2009). Over time, food acquisitions tend to become routine (Ilmonen, 2001), with one (or a few) outlet type(s) repetitively visited for main food purchases (White et al., 2004). Repetitive use of the same food outlet(s) may result from a scarcity of options to choose from. For instance, the time remaining after completion of fixed commitments such as work may constrain people to visit the only food outlets located on the commute back and forth from home to the workplace. Yet, the foodscape propensity to foster routines may have an origin other than restricted access. An experimental work on the condition under which purchase choices are made has shown that as the number of alternatives involved in the purchase decision increases, individuals are more likely to guide their choice toward the same option time after time (Anderson et al., 1966). Repeating past choices may be a heuristic decision mechanism to facilitate decisions in complex situations. For risk-averse individuals, a satisfactory experience is used as relevant information for future decisions and subsequent preference formation situations (Fischer and Frewer, 2009). That is, people like what they know, and choose what they like (Cooke, 2007). Therefore, repeatedly visiting some outlets may be viewed as a way to ease the decision-making process as to where to shop in situations of multiple choices (Ilmonen, 2001). Eventually, repetitive visits may foster 4
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(Fig. 1J) would help better capture how the compilation of exposures experienced throughout the life span shapes health behaviours (Matthews, 2012). Exploiting the opportunities offered by “natural experiments” (Petticrew et al., 2005) ‒ such as openings/closures of certain types of outlets or shifts in the type of outlets dominating a foodscape ‒ and more generally the reliance on longitudinal designs would help better account for the life-long foodscape influences that shape dietary behaviours.
(Kahneman, 2003). These scholars have highlighted how individual action is mainly driven by intuition, a form of thought coming “spontaneously to mind, without conscious search or computation, and without effort”, but at times is also driven by deliberate decisions relying on analytic assessments (i.e. reasoning). Among the factors that push a person to engage variably in one or the other system of deciding, Kahneman and Tversky have listed time pressure, concurrent involvement in a different cognitive task, intelligence and exposure to statistical thinking (Kahneman, 2003). Inter-individual variability in the processing of information available in the environment has also been outlined ‒ structured along gender (Croker et al., 2009), socioeconomic characteristics (Boone-Heinonen et al., 2011) and psychosocial traits (Paquet et al., 2010). Yet, a comprehensive understanding of all the elements that lead individuals to base their food outlet choices on reasoning or on intuition is still needed.
8. Conclusion The father of medicine, Hippocrates wrote “Let food be your medicine”, and introduced over two millennia ago the now well-argued idea that a balanced diet is essential to good health. So why do people continue to eat unhealthily when the detrimental consequences are so well-known? As brought to light by this proposal, it may partly be because eating healthily is shaped by factors that are beyond the control and/or awareness of individuals. In westernised cities, the abundance of food sources gives the impression of choice. Yet, the necessity to meet certain constraints (spatio-temporal, financial, practical and socio-cultural) may restrict access to the foodscape to the point that no healthy options are rendered accessible. In addition, the compilation of exposures to food outlets over time may push people to repetitively form, without much deliberation, healthy or unhealthy intentions regarding foodscape use. Surprisingly, the involvement of national and international authorities has (and is still) mainly relied on nutrition education of the population rather than on modifications at the structural level of food retailing. In a context of globalisation and neo-liberal economic sovereignty (Chopra et al., 2002), the dominance of consumerism above health (Caraher and Coveney, 2004) and the control of food distribution by dominant food institutions (Welsh and MacRae, 1998) may have hampered foodscape alterations. Yet, a few national initiatives, like the recent US ban of artificial trans-fat in foods by the Food and Drug Administration, demonstrate that the food environment is modifiable. Strong guidance on which foodscape alterations could benefit the health of populations would certainly help move forward on this matter. We suggest that local, sporadic and isolated interventions on the foodscape, such as implementation of one supermarket in the midst of a multitude of unhealthy food outlets, may not be enough to foster significant changes in a population. Instead, we suggest that shifting the ratio of healthy to unhealthy food outlets, especially through reducing the presence of unhealthy outlets, may be a promising avenue to explore. Overall, this proposal invites us to step away from making individuals the only practical levers for action regarding (un)healthy eating, and to better consider the multiple ways by which the foodscape also shapes dietary behaviours.
4. Implication for future research Practical guidance to improve our way of assessing potential access has been produced elsewhere (see for example (Bhatnagar and Ratchford, 2004; Lytle, 2009; Chen and Kwan, 2015)). We will therefore confine ourselves briefly to suggesting directions for future research that may enable better assessment of foodscape exposure. 5. Adopting an activity-space perspective when assessing exposure Exposure assessment has often overlooked the temporal processes across geographic space, even though foodscape exposure is a byproduct of the individual's participation in temporally and spatially defined life activities (Matthews and Yang, 2013; Perchoux et al., 2013). The subset of all locations within which an individual has direct contact as a result of his or her daily mobility (Fig. 1I) should be more widely used to assess, both at shorter (e.g. day) and longer (e.g. lifecourse) timescales, the compilation of exposures experienced over time (Matthews and Yang, 2013; Kestens et al., 2016). Some recent studies in literature on the foodscape have adopted an activity-space approach (e.g. Shearer et al., 2015; Zenk et al., 2011)). However, this practice still remains marginal. Technical tools such as GPS devices and web-based computer applications that track individual movements over time and behaviours across space have large potential for deriving activity-space exposures (Chaix et al., 2012), though temporal coverage issues need to be addressed (Matthews and Yang, 2013). 6. Better assessing the content of exposure When exploring the extent to which exposure to unhealthy food outlets encourages unhealthy dietary behaviours, looking at unhealthy outlets’ density within the activity space may be valuable. Similarly, when questioning the normative influences of the foodscape on the intention to utilize healthy and unhealthy outlets, looking at how the relative densities of healthy and unhealthy outlet experienced daily relate to dietary behaviours may be a promising avenue for research. Qualitative investigations on perceptions of the environment ‒ for example through using ecological momentary assessments (EMAs) (Stone and Shiffman, 1994) ‒ may complementarily help progress in this regard (Matthews and Yang, 2013). How far relationships between foodscape exposure and dietary behaviours are generalizable (or variable) across populations would also deserve greater attention.
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