Access to Healthy Food Bellamy Road Estate, Mansfield
Executive Summary
Food Initiatives Group NHS Nottinghamshire County
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Contents 01 Introduction 1.0 Aims, Objectives & Outputs 1.1 Commissioning & Partners 02 The Access to Healthy Food Agenda 2.0 Food Poverty 2.1 Access to Healthy Food 2.2 Food Access Literature Review 03 Choosing Bellamy Road Estate 3.0 Background & Practical Considerations 3.1 Public Health Factors 3.2 Applicability in other Geographical Localities 04 Methodology 4.0 Desk Based Research Review of Health and Social data Food Outlet Mapping 4.1 Quantative Practical Investigations Food Mapping Shopping Baskets Surveys 4.2 Qualitative Practical Investigations Questionnaires Focus Groups 05 Findings 5.0 Quantative Findings Food Outlet Mapping Shopping Baskets Surveys 5.1 Qualitative Findings Questionnaires Focus Groups 06 Discussion & Recommendations 6.0 Discussion 6.1 Recommendations
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01 Introduction
1.0 Aims, Objectives & Outputs Project Aims The aim of the research project was to consider the issues of access to a healthy diet, rather than simply access to food in Mansfield. The project focused on an area of Mansfield that experiences poor health and higher levels of obesity. The barriers that limit access to healthy food were to be assessed. The research project, through NHS Nottinghamshire County, has further aims to obtain the commitment of key local stakeholders to deliver an Action Plan for change. Project Objectives Establish baseline information on shopping habits including methods of access to food. Establish baseline information on food knowledge, food attitudes, food consumption, availability and prices of healthy foods. Outputs Identify gaps, or improvements needed, in provision to improve diet and access to healthy food. NHS Nottinghamshire County to use these recommendations to create an Action Plan for change that will identify which organisations should lead or contribute and what resources may be required.
1.1 Commissioning & Partners
NHS Nottinghamshire County (Nottinghamshire County teaching Primary Care Trust) commissioned the Food Initiatives Group (FIG) to undertake this study to investigate access to healthy food in an area of Mansfield Town, north Nottinghamshire. The study was carried out as part of the NHS Nottinghamshire County Service Level Agreement with Groundwork Greater Nottingham who manage the FIG project. Additional funds from NHS Nottinghamshire County were made available to carry out the study, which began in November 2009 and was completed in April 2010. NHS Nottinghamshire County and project partner the East Midlands Public Health Observatory (EMPHO) had identified Mansfield as having a population with a poor public health profile when compared nationally, regionally and at a county level. Non-‐communicable food related diseases such as obesity, diabetes and heart disease were considered at high levels. It was therefore thought appropriate to investigate barriers to healthy eating in an area of Mansfield with high levels of multiple deprivation. Practical recommendations were asked of this study that could help reduce any barriers to a healthy diet that were found through the research. ‘Access to Healthy Food, Bellamy Road Estate, Mansfield’ also received invaluable support from Mansfield District Council, Bellamy Road Stakeholders Group and Bellamy Road Tenants and Residents Association. 3
02 The Access to Healthy Food Agenda
2.0 Food Poverty The World Health Organisation Food define the opposite of food poverty as ‘food security’, describing food security as, “ When all people, at all times, have access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life”. Individuals living in food insecure households are unable to meet these criteria and are therefore subject to food poverty.i Dietary needs for an active and healthy life are defined by the Department of Health as: • eat plenty of carbohydrates • eat at least five portions of fruit and vegetables every day • cut down on the amount of fat, sugar and salt in your diet • eat enough vitamins and minerals • drink enough fluids Approximately seventy thousand deaths could be avoided in the UK annually if the public consumed diets that adhered to these nutritional guidelines and it is estimated that two billion pounds are spent each year within the NHS treating diet related illnesses.ii
2.1 Access to Healthy Food
Food Access is a way of describing the causes of inadequate diets that lead to the health inequalities described above known as Food Poverty. Food Access can be broken down into 4 interrelated causal factors, often referred to as the 4 ‘A’s’ of Food Access.iii. Accessibility Physical accessibility looks at where shops are situated in a neighbourhood and how they can be reached by foot, car, taxi or public transport. For those who do not have access to adequate public or private transport, not being able to get to the shops is a defining factor in their ability to buy healthy affordable food. Defining Physical Accessibility This report has adopted the physical access to healthy food standard developed by the Government Office for the West Midlands whose report ‘Developing a physical accessibility standard for healthy food in the West Midlands’iv recommended the following standard: “Percentage of households within 20 minutes, by walking, cycling or using public transport, of a place where fruit and vegetables are sold.” Availability Access to healthy food is reduced if shops do not stock a reasonable range of healthy foods on a regular basis. Just stocking potatoes and onions for example is not sufficient for provision of a healthy diet. Local shops may not stock healthy options, such as fruit and vegetables, due to a 4
shorter shelf life, lower profit or a perceived lack of interest. This in turn may reduce sales and so create a self-‐reinforcing cycle. Affordability Expenditure on food is the most flexible part of household budgets as the amount spent on food is often whatever is left over when other financial commitments have been dealt with. When unexpected costs happen, the amount available to spend on food is reduced. Low-‐income food purchasers often find it easier to guarantee enough calories for their household by buying low cost, high energy foods that store for long periods. High energy foods are often foods high in non-‐ milk extrinsic sugars (NMES). NMES consumed at the levels below are detrimental to the consumer’s health. ‘The percentage of energy from NMES is strongly dependent on income, decreasing as income rises. Households in the lowest 30% income bracket may in some cases derive more than 20% of their energy intake from NMES.’v Awareness Life pressures, a poor understanding of a healthy a diet, poor cooking skills and a lack of concern about personal current and future health can all be barriers to accessing a healthy diet. Confusing and contradictory messages about nutrition and healthy foods in the media and from manufacturers, compounded by lack of consistency and clarity regarding food labeling, can exacerbate these barriers.
2.2 Food Access Literature Review
Access to Healthy Food research, sometimes called Food Mapping, has been undertaken in England since at least 1996 when the seminal report on food poverty ‘The Making of Modern Malnutrition: An Overview of Food Poverty in the UK.vi The review below describes the findings from previous FIG work on the subject as well some innovative or influential work from other organisations. vii FIG Access to Healthy Food Research Barriers to Healthy Food (Sneinton and Eastwood), 2002 • Barriers can be overcome by supporting existing shops. • Living alone and being a working parent can act as barriers to a healthy diet. • The benefits of social eating e.g. through lunch clubs. Access to Healthy Food in Ashfield, 2007 • ‘Healthy food deserts’ existed in many deprived areas where health is poor. • Cheap unhealthy food is easily accessed in ‘Healthy food deserts’. Mapping Access to Healthy Food in Nottingham City (West Area), 2008 • The most accessible food retail destinations are the supermarkets. • The least accessible destinations are the local shops clusters by foot. • The elderly have the worst levels of accessibility to healthy shops. • Most of the stores did not have all the items in the healthy baskets. 5
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Healthy ‘shopping baskets’ were more expensive in local food shops. Takeaway outlets had a significant impact on school children.
Other Access to Healthy Food Research Derbyshire Food and Health Needs Assessment, 2009viii • Lone parents and lone pensioners were the main population groups considered to have inadequate access to healthy food outlets. • A large number of residents did not have access to private transport but public transport was not always an appropriate option, often due to pushchair number restrictions on buses. • The weight of groceries impacted on the ability to purchase sufficient amounts of healthy food. • There was a clear need to improve the cooking skills of the local population. • Most people were aware of what constituted a healthy diet, but many did not feel that they were able to translate this knowledge into practice. • Healthy eating was a low priority for some families as other issues took precedence. Shopping for Food: Accessing healthy affordable food in three areas of Hackney, 2006ix • Fresh fruit and vegetables are widely available from small independent retailers. • Healthier options of other foods are not accessible in all areas. • There are wide price variations of healthy food baskets and for some groups, over a one-‐ month period, the difference can amount to the price of a weekly shop. • Physical access within shops is a problem (neither buggy or wheelchair friendly). • Public transport is inadequate for many elderly people and young mothers. Mapping the Availability of Healthy Food in Sandwell, 2001x • Most residents have poor access to fruit and vegetables. • Most residents live within 500m of a shop selling food. • Most residents live within walking distance of a shop selling cigarettes and sweets. • Local shops are struggling to survive and believe that selling fresh fruit and vegetables is too difficult.
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03 Choosing Bellamy Road Estate
3.0 Background & Practical Considerations Background The Bellamy Road Estate was developed in the 1970s using the Radburn layout to house workers for the nearby mining industry, who arrived as migrant workers chiefly from the North East of England, Scotland and Wales. Since the pit closures from the mid-‐1980’s the area has suffered steady economic decline with high structural unemployment often spanning a number of generations. This type of housing can lead to a number of social problems:xi • lack of distinction between public and private space • very little defensible space • confusing house layouts • remote car parking spaces Efforts to revive the social and economic fortunes of the estate have been hampered by financial mismanagement of funds. There has been local and national media interest on the estate focusing on perceived poor Local Authority involvement, lack of services and high levels of crime and anti-‐social behaviour. More recently a number of agencies formed a Bellamy Road stakeholders group and have made significant progress in listening to local needs and acting decisively on solving local issues. The stakeholders group along with the older Tenants and Residents Association have also enabled positive outcomes for the estate. Current and Planned Developments Mansfield District Council is building 43 new family houses on the Bellamy Rd estate as part of the Local Authority New Build program. This will act as a catalyst for the regeneration of the estate and a master-‐planner has been employed who will engage with residents to identify solutions for any problems. This regeneration aims to provide Social, Economic, Demographic, Environmental and Physical benefits. In addition, group of landowners and developers, the Lindhurst Group, have submitted a planning application for a 23-‐hectare 1,700 home ‘neighbourhood’ just South of the Bellamy Road estate. The neighbourhood would include business units, shops, sports centres and a school. If the development goes ahead it could present opportunities for the Bellamy Road estate to benefit through planning legislation that allows local planning authority to enter into an agreement with a developer to demand local social benefits in association with the granting of planning permission. Practical Considerations To map Access to Healthy Food two geographical areas have to be defined:
1. The target population area 2. The area that the target population will access for food shopping The choice of these areas can be problematic particularly in urban areas where the defining of a target population or shopping area may be arbitrary or generate poor quality data due to those areas being adjacent to other residential or shopping areas. It is only further into a mapping project that actual population shopping habits are revealed and this may result in reformulation of the project at a cost to that projects’ capacity. Choosing the Bellamy Road estate in Mansfield minimised these potential problems as the estate is a geographically well-‐defined area so minimising adjacent borders to other residential neighbourhoods as shown in Diagram 1.
Diagram 1: Bellamy Road Estate The Bellamy Road Estate is bordered by Bellamy Rd, Old Newark Rd and Redruth Drive. The above map demonstrates the difference in length of routes between the official pedestrian route to Oak Tree Lane Tesco from the centre of Bellamy Road Estate in contrast to an illegal shortcut across waste ground favoured by Bellamy Road residents, which cuts a significant distance off the journey time.
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Intuitive, common sense assumptions were also used to minimise the need for redefining the target food outlets once research was underway. It was considered likely that residents of this geographically well-‐defined estate would shop for food within the estate boundaries, travel to the nearest supermarket or the most accessible shop cluster, here Mansfield Town Centre. These assumptions were found to be correct once qualitative research into shopping habits were underway.
3.1 Public Health Factors
Mansfield has some of the poorest health outcomes in Nottinghamshire and it is because of this NHS Nottingham County specified Mansfield as a target area for this research. The East Midlands rates poorly compared to the rest of England (East Midlands Health Profile 2009xii) and Nottinghamshire compared to the East Midlands (Nottinghamshire County Joint Strategic Needs Assessmentxiii) regarding many health issues particularly those associated with poor diets and low physical activity. • Mansfield has the highest free school meals eligibility in Nottinghamshire but the highest & second highest gaps for eligible pupils eating school dinners. • Mansfield has the greatest childhood obesity rates across the County. • Mansfield District has the worst life expectancy figures in Nottinghamshire. The Bellamy Rd estate in the Lindhurst ward of East Mansfield and this area has some of the poorest health outcomes within Mansfield. In terms of the overall index rankings, one of Lindhurst’s three constituent Super Output Areas features within the 10% most deprived in England. There is an 8-‐year gap in life expectancy for men between the fifth most and least deprived areas of Mansfield (JSNA Mansfieldxiv).
3.2 Applicability in other Geographical Localities
The Bellamy Road estate has a distinctiveness brought about by its economic, social and political history. However, this study believes there are sufficient similarities with other urban areas in Nottinghamshire and the UK for the findings and recommendations of this report to be applicable. The similarities are: • Poor health outcomes. • High unemployment. • High levels of indices of multiple deprivation. • Negative local sentiments regarding social isolation and service provision. Furthermore, a brief review of the findings from previous studies into Access to Healthy Food described above show that areas of high deprivation tend to have poorer access to healthy food due to a combination of poor accessibility, affordability, awareness and availability. 9
04 Methodology The research team consisted of the FIG Project Officer and three research assistants using Desk Based Research, Quantative Practical Investigations and Qualitative Practical investigations.
4.0 Desk Based Research
Review of health and social data Public health data and online maps were used to identify an area that could be effectively mapped with capacity available and in line with the commissioning public health remit. This is explained in more detail above. Food Outlet Mapping Online maps and food licensing data were used to define an intuitive approach to the choice of food outlets to map. Licensing data obtained from Mansfield District Council’s Environmental Health Department showed the location and type of food outlets in Mansfield. Accessibility of the food outlets by walking and public transport was assessed by EMPHO using GIS public transport analysis Accession software.
4.1 Quantative Practical Investigations
Food Mapping Location and Accessibility of food outlets Desk based research was verified by on the ground mapping. Results showed the most likely food outlet locations for estate residents were: Egmanton Road cluster of 3 shops on the Bellamy Road estate (nearest shops) Tesco, Oaktree Lane (nearest supermarket and proxy for other Supermarkets) Mansfield Town centre cluster (nearest large cluster within 20 minutes travel) These food outlets or clusters were then investigated regarding their accessibility from Bellamy Road estate and availability of the items in a healthy ‘shopping basket’. Shopping Basket Survey The healthy ‘shopping basket’ survey form was developed from previous food access work, in particular ‘Mapping Access to Healthy Food in Nottingham City’. The survey recorded the price and availability of a basket of food items that represent a healthy diet based on current dietary guidelines.
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4.2 Qualitative Practical Investigations
Food Questionnaires A questionnaire was used to record and then analyse information regarding access to healthy food from Bellamy Road estate residents and covered four broad areas. Shopping habits Eating habits Views on health and diet Views on barriers to healthy eating The questionnaire design was adapted from previous FIG access to healthy food research and was distributed to every household on the estate. Respondents were entered into a prize draw to encourage participation. Microsoft Office Access was used to analyse the data. Limitations of the Questionnaire Research 45 out of 750 households responded which is 6% (research target was 10%). Discussions with the Bellamy Road Stakeholders group and TARA showed this was a normal level of participation for any activity on the estate. This suggested high levels of social alienation and negative attitude towards the efficacy of official bodies. Poor literacy was also suggested by the TARA as an issue.
Focus Groups
Focus groups were used to compliment, validate and expand the quantitative and questionnaire research. This method of research is particularly useful due to the personal nature of discussions around diet and health. Quantative research into diet is also often unreliable because of this so a number of research methods are more likely to yield useful results.xv xvi 5 Focus Group cohorts were chosen to represent potentially vulnerable groups except for the St Peter’s School Berry Hill group (see Table 1). All the groups met together regularly expect for the Single Men’s group. There was no existing meeting place or group for men on the estate (e.g. no local pub or sports club) suggesting high levels of isolation for this demographic. The focus groups were recorded and a number of questions acted as prompts to the group with a facilitator guiding the discussion. The sessions always began with a range of healthy snacks to break the ice.
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Table 5: Focus Groups Cohorts Focus Group Pre-‐existing group Description Numbers Bingo Yes Age 50+ Male & Female 8 Bellamy Children's Centre Yes Young Mothers Group 5 Single Men No Age 18 -‐ 65 men living alone 7 YMCA Art Club Yes Age 13 -‐ 18 Male & Female 3 St Peter’s School Bellamy Rd Yes Mothers Bellamy Rd Estate 2 St Peter’s School Berry Hill Yes Mothers Berry Hill area 4 Limitations of the Focus Group Research The YMCA Art Group representing young people yielded inadequate results for meaningful analysis due to external factors and was not used in this research.
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05 Findings
5.0 Quantative Findings
Food Outlet Mapping Summary There is a reasonable physical access to all target food outlets for everyone on the Bellamy Road estate. All travel times are within the West Midlands Standard of 20 minutes except the southern half of the estate, which is within 25 minutes of travel time to the Oaktree Tesco. There is a cost to shopping outside of the estate. Shopping outside the estate would limit the amount of shopping purchased if walking or public transport was used. That limit would depend on physical health and ability. Local Food Shops (Egmanton Road) Walking Every resident of the estate, except possibly those with mobility problems, is within 20 minutes walking time of the three food outlets on Egmanton Rd. Oaktree Lane Tesco Public Transport Every resident on the Bellamy Road estate is within 20 minutes travel to the Oaktree Lane Tesco. The journey costs £0.90 return without a bus pass. Walking Research assistants timed the walk to Oaktree Tesco along the main road. Walking travel time between the Bellamy Road estate and Tesco was approximately 20 minutes. This would be longer with shopping bags. The route is along a main road and not designed to ensure safe or pleasant walking. The qualitative research found no residents who used this route. Diagram 1 shows the preferred walking route to the Oaktree Lane Tesco via an unofficial path takes under 15 minutes. This is quicker than the standard walking route despite being over uneven surfaces. The route is through a gap in the fence behind Acorn Way Industrial Estate. The route appears to have been fenced off recently (and the fence quickly trampled to the ground). It’s very informal, unsteady underfoot and badly lit. Despite this, it appears to be well used. Research assistants counted three people within 15 minutes all with Tesco bags. Informal discussions with the walkers revealed they were returning to the Bellamy Rd estate. The Oaktree Lane Tesco offers a delivery service and charges for this service (between £3.50 and £6.50 depending on delivery times). No evidence was found of this service being used on the Bellamy Road estate. This service would require a debit or credit card and an Internet connected computer.
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Other Supermarkets Morrison’s, Sainsbury’s and Asda are all on the periphery of Mansfield and are only reasonably accessible by residents using private car or taxi. Journey times from the Bellamy Road estate by car are all under 20 minutes out of rush hours. Town Centre Shopping Public Transport GIS showed that the southern half of the estate is within 25 minutes travel time of Mansfield Town centre and the northern half within 20 minutes travel time. All Mansfield town centre food outlets are within 500 metres of the central bus station. Private Car Mansfield town centre by private car or taxi takes less than 20 minutes outside of rush hours. Private cars would have to pay for parking.
Shopping Basket Surveys
Availability of Healthy Food The target areas are below and the results are summarised in terms of price and availability in Table 2.: Egmanton Road cluster on the Bellamy Road estate (2 retail food outlets) Tesco superstore on Oaktree Lane Mansfield Town centre cluster (Supermarket, Freezer Shops, Independent Shops including Market Stalls) Table 2: Healthy Shopping Basket Findings Egmanton Road Shops Egmanton Road Shops + Oak Tree Lane Tesco supplement to complete basket Oaktree Lane Tesco Cheapest Town Centre Cheapest Independent + Town Centre
Healthy Basket Unavailable Items £15.44 1 out of 14 £16.89 £13.25 £12.30 £17.27
None None None None
Egmanton Road Shops These are the most accessible shops and most of the healthy basket shopping items are available if using both food outlets on Egmanton Road. These shops are more expensive than the cheapest town centre and the Oaktree Tesco even without having to buy the unobtainable item (wholemeal pasta) from the Tesco. Oaktree Lane Tesco All the healthy basket items are available and the supermarket is cheaper than its geographically nearest competitor, the Egmanton Road shops. It is over £2.00
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cheaper than the local shops including the unobtainable item from Egmanton Road. Even with a £0.90 bus fare the Tesco would offer better value for money. Mansfield Town Centre Mansfield Town centre offers the cheapest option for buying the entire healthy basket of food. It is over £1.00 cheaper than Tesco and over £3.00 cheaper than the Egmanton Road shops. To make this saving a shopper would have to pay to get to the town centre and engage in a considerable amount of ‘shopping around’ in different outlets. This may be inconvenient for residents either because of time or having to carry shopping bags for a long period of time. Those with mobility issues or young children may also have difficulty. The low cost of the town centre shops is largely the effect of the very low cost freezer stores. Qualitative research found Mansfield Town centre not a popular option for the Bellamy Road estate residents. Single Person Issue Shopping Basket items that were sold in pack sizes too large for single people to use without a possibility of unnecessary waste were most prevalent in the Egmanton Road shops and Marks & Spencer’s.
5.1 Qualitative Findings
Questionnaires Demographic Composition of Bellamy Road Estate 25% of respondents were retirement age or above. About 1/2 of respondents live alone. 30% of respondents were below 60 years old and not economically active. This is well above the National Average from April-‐June 2010 of around 8.0%. As an area of high unemployment, and therefore low income, the Bellamy Road estate will have a high percentage of households where differences in costs of any basket of food will have a significant impact. The overwhelming demographic composition of respondents is from the White British ethnic group. This demonstrates that Bellamy Road estate is largely ethnically homogenous. This has implications for cooking and culture. The majority of respondents live in households without children, though households with children tended to have higher numbers of children than the national average. Household Providers: Who Shops? Who Cooks? The vast majority of respondents are both the sole shoppers and cooks for the household with the remainder sharing some duties. This validates the responses in
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the questionnaire as the vast majority of respondents have a significant degree of input into the duties of shopping and preparing food. Health and the Bellamy Road Estate 60% of respondents reported having serious, often multiple, health problems. The most common of health problems reported, heart disease and diabetes, could by caused or exacerbated by poor diet. Healthy Diet 77% considered their diets to be ‘Fairly Healthy’, 15% their diets to be unhealthy and 8% responded ‘Didn’t know’. This response appears to conflict with the high levels of poor health in the area and amongst the respondents. Furthermore, respondents showed a good understanding of the links between health, diet and what constitutes a healthy diet. Given the rates of non-‐communicable food related diseases, particularly diabetes, this is surprising. This suggests support is needed not only for awareness raising of healthy eating but of motivation as an precursor to changing behaviour. Food Shopping Diagram 2: Where do you mostly shop? Where Do You Mostly Shop? 35 30 25 20 15 10 5 0 Local Egmanton Road Shops
Oak Tree Tesco
Other Town Centre Freezer Store Open Market Supermarket
The nearest supermarket, Oak Tree Tesco, was the preferred choice for respondents. This is not surprising since it offers the best value and range in the shopping basket survey. The majority of respondents supplement their food purchasing with food sourced from local shops, however about a third do not utilise local shops to top up food from. 16
The majority of respondents to this survey do not require or have access to a private vehicle when going food shopping. Other than walking, private vehicles are the single most common form of travel to the shops. Getting to the shops 32% of respondents used a private vehicle to get to the shops whilst 68% either walked or used a combination of walking and public transport. 5% of respondents found it harder to return with shopping than to access their preferred food retailer. This was largely the result of carrying heavy shopping. On the whole (87% of respondents) did not report problems accessing their usual food retailer. Diagrams 3 shows that value for money is the primary rationale behind respondent’s desired food retailer. Quality is the least common factor. There is no major over-‐riding factor as most respondents picked two or more criteria for their desired food retailer. This showed shoppers were balancing economic and quality choices when food shopping. Diagram 3: Why do you shop where you shop? Rationale behind Desired Food Retailer 20 18 16 14 12 10 8 6 4 2 0 Quality
Value For Money
Choice
Convenience
Diagram 4 shows the reasons respondents were reluctant to use Bellamy Road Shops. Price is the most evident. Choice and Quality also feature as factors deterring potential customers. This corresponds to factors that influence respondent’s preferred food retailer. This is confirmed in Diagram 30. 17
Diagram 4: If You Never Use Egmanton Road Shops Why Not?
Respondents
If You Never Use Bellamy Road Shops, Why Not 10 9 8 7 6 5 4 3 2 1 0
Series1
Choice
Quality
Price
Fear of Crime
Distance & Access
N/A
Reason
Diagram 5: What would help you buy more fruit and veg from Egmanton Rd Shops? What Would Help You Buy More Fruit & Veg From Local Egmanton Road Shops on Bellamy Road Estate? 18 16 14 12 10 8 6 4 2 0 More To Buy
Wider Range
Cheaper Prices
Not Interested in buying Fruit and Veg
Diagram 6 shows a strong desire for ‘Better Local Shops’ suggesting improvements to the range, price and quality would be financially beneficial for the Egmanton Road shops.
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Diagram 6: What Would Make Shopping Easier? What Would Make Shopping Easier? 35 30 25 20 15 10 5 0 Better Local Shops
Better Public Transport Access
Help with Access
Cooking Over 70% of respondents agreed that they cooked food from scratch with fresh and around 30% were unable to prepare food in this way. When asked ‘If You Do Not Cook Using Fresh Ingredients, Why Not?’ the two most common answers were ‘Time’ and ‘No point cooking for one’ suggesting cooking skills that were not being used for other reasons. ‘Confidence’ and ‘Cooking Skills’ were also significant factor. Cook & Eat classes may have a role in improving access to healthy food. Diagram 7: What type of cooking do you do? What Type Of Cooking Do You Do? 35 30 25 20 15 10 5 0 Sandwiches, snacks and other cold food
Heating up ready meals, tins etc
Food Assembly-tins, microwave,premade
Food from scratch with fresh ingredients
Don't really cook
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Location of majority of meals eaten 83% of all meals prepared for the consumption of respondents are prepared at home. Only 3% obtained the majority of their food from takeaways. Issues around retail food shopping are therefore an essential part of any program to improve diet or food access in this community. 7% skipped one of the three meals (breakfast, lunch, and evening meal). Cooking Skills The 63% of respondents had a desire to learn better cooking skills. The largest group were those who had confidence in cooking but wanted to learn better skills. There was a lack of desire to learn cooking skills from those with few or no confidence already and this may be an issue regarding more general confidence or awareness raising. 74% of respondents would definitely like to engage with cooking courses offered locally. This dropped to 34% if participants would have to pay for this service. Local Food Initiatives 40% of respondents would use a good quality, healthy, affordable local cafe and 60% would not. 32% would use a local community allotment and 68% would not. There was some ambivalence about the desire for the two food initiatives mentioned above. A previous community cafe and allotment had proved popular in the past in the estate. The support for a community allotment, at around third of respondents, may be enough to support such a project dependent on time commitment and skills regarding those interested.
Focus Groups
Summary Below is an overview of all Bellamy Road Focus Group observations excluding the St Peter’s School Berry Hill, which is used for comparator purposes only. All the groups are described above in Table 5. Any themes, similarities, differences or comments of interest have been noted. This helps us understand attitudes and behaviours regarding food on the estate. The analysis has been interspersed with verbatim quotations to illustrate observations. The observations have been arranged under the following groupings: o All Bellamy Road Estate focus groups o Individual Bellamy Road Estate focus groups o Bellamy Road Estate and St Peter’s School Berry Hill focus groups
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Within each grouping observations have been arranged under the following headings: • Favourite Foods/Best Food Memory • Cooking Ability and Cookery Lessons • Availability of Healthy Food • Barriers to healthy food Key observations All the groups are critical of the healthy food on offer from the local Egmanton Road shops i.e. too expensive and poor quality. Favourite foods, and best food memories, are similar across all groups. Traditional British meals such as stews and casseroles are most often mentioned. The notable exception is in the (more affluent) St Peter’s School Berry Hill group, which add international foods. Participants seem aware of the issues around eating healthily, although there is confusion about how to effectively address these in their own eating habits. Each group was unsure of exactly what they should be eating reflecting confusion about current health messages. Cooking ability varies within the groups. Older residents tend to be the most confident and active. Single men very rarely cook for a variety of reasons, not always due to lack of skills. Berry Hill residents are very confident in their cooking ability and were the most keen to express this. There is a general view that cooking skills are being lost and that is a negative development. Most of the participants use supermarkets to get their food but are aware that this can be inconvenient without a car. Most groups also mention at least one less usual source of food including farm shops & food from allotments. Some recall a mobile shop going round the estate selling farm produce. Aspirations and knowledge around healthy eating were well informed but economic and physical access barriers prevented these being realised. Time was an issue with regard to shopping and cooking regardless of employment status or family size. Food culture (sharing, cooking for pleasure) was not mentioned except as a memory
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Single Men’s Group The results from this group have been expanded on as they faced particularly acute issues. The Single Men Group seemed much less confident in their cooking skills and were aware that their diets were unhealthy. Many stated that they didn't cook at all: instead, ate soup, microwave meals and takeaways. One respondent revealed that he only ate a proper meal twice a week, Thursdays and Sundays at the community centre. Most of the time, he ate toast at lunch and soup in the evening. A few seemed more confident, and prepared fresh food at weekends, enough to last a few days re-‐heated. Time was the main reason given despite some of the group not being in paid work (though some were heavily involved in non-‐paid activities). In this group the majority used supermarkets to find healthy food usually Tesco. However, price was a bigger issue than freshness. There was repeated and forceful comment on the frustrations of cooking for one. Oversized packets and portion sizes as well as the frustration of having to walk all the way to Tesco for a small amount of fresh veg. They found waste particularly frustrating. Time for eating also seemed to be an issue for this group and cooking food wasn’t perceived as a relaxing or creative activity for this group.
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06 Discussion & Recommendations
6.0 Discussion
The Bellamy Road estate is both geographically, architecturally and socially isolated. The desire for a GP practice, better employment prospects and better social care provision on the estate was mentioned frequently and unprompted in discussions. These issues were often considered more important than issues regarding diet and health. Current housing plans as well as social and economic initiatives to address issues on the estate present an ideal opportunity to address the issue of poor access to healthy food. This poor access is best summed up by using the four ‘A’s’ used to describe food access of Accessibility, Availability, Affordability and Awareness. This study has resulted in findings that suggest that another category, related to awareness should be added. That is Motivation or Attitude Accessibility Everyone on the Bellamy road estate is within the 20 minute (West Midlands standard) travel to an outlet that sells fresh fruit and vegetables. However, the price, range and quality of the produce on offer means residents never, rarely or reluctantly use outlets on the estate. These local shops stock most of the healthy food basket but price is a major barrier. Residents relying on public transport or walking have greater access problems due to infrequency of public transport or the problem of walking to, and especially back from, the local Tesco. This supermarket is the preferred option so much so that residents have created an informal, even illegal, route to the supermarket. Availability The Egmanton Road shops have most of the items in the healthy basket though it is clear that the fresh fruit and vegetables are of unacceptable quality and of a range so limited as to stop utilisation of those outlets. Local, fresh produce is desired and residents are willing to travel or otherwise bear some cost, such as time, to purchase it. Affordability Shopping for healthy food at the local shops is considerably more expensive than the local Tesco even accounting for travel costs. Many residents still use the Egmanton Road shops suggesting accessibility often overrides affordability. This will be particularly true for those not wishing to walk long distances with shopping bags. Awareness Residents seem largely aware of what constitutes a healthy diet and the consequences of following or not following such eating habits. However, price is the main barrier followed by time and motivation.
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Attitude/Motivation Most residents shop to cook at home even if not necessarily from scratch and would welcome better quality, more affordable healthy foods available on the estate. Food culture was rarely mentioned except in the context of good food memories and favourite foods. Many skilled cooks didn’t use their skills because they felt there was little point and this was particularly evident in men who lived alone. Time was the main barrier to cooking for mothers. There is small but significant numbers of respondents, who skip meals, aren’t interested in healthy eating and have no desire to do so. This hard to reach group, within hard to reach groups, will require any project to improve diet to partner with local stakeholders and services to be successful in creating behaviour change. After the main research was completed on the estate FIG took part in an event as part of the Big Lunch celebration. At the event the Bellamy Road community allotment and other allotment holders, with help from the YMCA, set up a fresh fruit and veg stall with produce from the allotments. Donations were asked for, in exchange for produce. It was remarkable how quickly this fresh produce was taken up and there were frequent requests for something similar to happen weekly.
6.1 Recommendations
i) Existing Community Nutrition teams should engage with Bellamy Road Stakeholders Group and input into their Action Plan to ensure food related health issues are included in local strategies. ii) Lobby for free public transport provision to local supermarket with bus operators, Tesco and Mansfield District Council. iii) Existing service provision should consider the range of cook and eat classes. Classes should be based around healthy traditional meals with a take home meal included. Food culture rather than the more medicalised ‘healthy food’ approach may prove a more suitable method of behaviour change. Support for healthy eating should be focused in practical help that can alleviate barriers of time and financial resources for the residents. Use of a variety of venues tailored to the needs of specific client groups including: For mothers at Children’s centres or schools based on low cost, quick meals. Crèche facilities essential to ensure good take-‐up of classes. For men living alone. Inclusion of non-‐food social activities and allowing walk-‐ in clients would increase uptake. Intergenerational ‘food memories’ cook and eat classes would build on the positive cultural food memories that are mostly based on childhood or family meals.
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iv) The new housing on the Bellamy Road estate, the appointment of a Master Planner and the potential new village to the south of the estate, all represent unique opportunities to include access to healthy food in local and regional strategies as well as opportunities raise funds in to support such initiatives. This should include a more outward facing, attractive and accessible shopping centre. v) Increase local provision of a wide range of affordable, good quality fresh fruit and vegetables through one or combination of the following initiatives: o Engagement with Egmanton Road shops to better source, display and promote fresh fruit and vegetables. The Change4Life Convenience Store Scheme is a useful and successful model. The profitability of fresh produce should be promoted through recent hard economic evidence. o Increased use of the Bellamy Road Community Allotment. Discussion Mansfield district council regarding informal sales or distribution of excess allotment produce on the estate. It is recommended that any allotment project should seek support from the Federation of City Farms and Community gardens. o Feasibility of a food co-‐op for the estate. There is national support and successful local models to draw best practice from. o Feasibility of the Egmanton Road cafe as a ‘food hub’ for fresh produce sales, cook and eat classes and low cost healthy food provision. Discussion with current leaseholders (YMCA) and local shops so as not to negatively impact local business is essential. These recommendations require support and most would require further funding. A small part of the budget for this research has been allocated to seed fund a project subject to approval by the Ashfield and Mansfield Health Partnership. FIG will be able to signpost to other funding sources and support for any project approved.
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i
FAO. Practical Guide: Basic Concepts of Food Security. EC -‐ FAO Food Security Programme, 2008 Choosing a Better Diet: A Food and Health Action Plan. Department of Health, 2005 iii Local Action on Food Archive at http://www.sustainweb.org/page.php?id=234 iv Developing a physical accessibility standard f or healthy food in t he West Midlands. Department for Health West Midlands, 2 009 v Family Food in 2007. Office for National Statistics/Defra, 2007 vi Leather, S. The Making of Modern Malnutrition: An Overview of Food Poverty in t he UK. London: Caroline Walker Society, 1996 vii Previous FIG research on healthy food access can be obtained by contacting Groundwork Greater Nottingham viii Derbyshire Food and Health Needs Assessment. EMPHO, 2009 ix Caraher et al. Shopping for Food: Accessing healthy affordable food in three areas of Hackney, London Borough of Hackney, 2006 x Dowler, Blair et al. Mapping the Availability of Healthy Food in Sandwell. University of Warwick, 2001 xi Radburn and the American Planning Movement. Journal of the American Planning Association, Volume 46, Issue 4, 1980, pages 424-431. ii
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East Midlands health Profile, 2009. APHO and Department of Health, 2010 Nottinghamshire County Joint Strategic Needs Assessment 2009. Nottinghamshire tPCT, Bassetlaw PCT, Nottinghamshire County Council, 2009 xiv Joint Strategic Needs Assessment Mansfield. www.nottinghamshire.gov.uk/jsna-chapter4.pdf xv Murcott, A (Editor). The Nation's Diet: The Social Science of Food Choice. Longman, 1998 xiii
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Rabiee, F. Focus-group interview and data analysis, Proceedings of the Nutrition Society (2004), 63, 655–660
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