1. The study used mixed methods including in-store assessments, GIS analysis, and Photovoice to understand barriers and opportunities for accessing healthy foods in a low-income urban neighborhood in Madrid, Spain. 2. Residents identified economic crisis, lack of opportunities, unequal resources, and high exposure to fast food marketing as barriers through Photovoice discussions. 3. Small neighborhood stores and public markets were highlighted as opportunities, with most residents able to access higher quality stores within 10 minutes by walking. 4. The mixed methods approach provided insights to develop 7 community-generated interventions to promote a healthier local food environment.

1. Julia Díez, Roberto Valiente, Ana María Olea, Carmen
Ramos, and Manuel Franco
Objective and perceived access
to healthy foods: a mixed
methods study using on field
measures, GIS and Photovoice
PhotoVoice is a project co-funded by
in collaboration with

2. http://hhhproject.eu
Objective and perceived access to
healthy foods: Background
• Low-income groups live in neighborhoods with less
available and affordable fresh fruits&vegetables
• Engaging residents may improve the understanding of
local food environments and help designing effective
interventions
• Mixed methods research may help to better
understand perceived barriers and facilitators to
healthy eating.

3. http://hhhproject.eu
Objective and perceived
access to healthy foods: Aim
To identify barriers and opportunities for
accessing healthy foods using mixed methods:
1. In-store assessments
2. GIS
3. Photovoice

4. http://hhhproject.eu
Objective and perceived access
to healthy foods: Methods
Study context
- Urban poor area, comprising one administrative
neighborhood (≈ 35000 pop.) in Madrid (Spain).
- 12 residents (31-72) participated in evaluating their
local food environment through Photovoice.
Los Rosales
(study area)
Madrid
municipality
Foreign-born 24.8%
Unemployment 18.7%
Low educational level 28.7%
Car ownership 36.1%

5. http://hhhproject.eu
Objective and perceived access
to healthy foods: Methods
1. In-store assessments
• We used an adapted version of the NEMS-s survey,
developed and validated by Glanz et al.
• NEMS-S survey examines the availability, quality and
cost of healthy food options versus less-healthier foods
• Outcome  Healthy Food Availability Index (from -7 to
49)
• Field audits were conducted within a random sample of
a 50% of each food store type
• In-store audits lasted a mean of 7.13 minutes (SD: 4.03,
range: 2-17 min.)

6. http://hhhproject.eu
Objective and perceived access
to healthy foods: Methods
2. GIS
• We obtained the most up-to-date data on the retail food
environment from Madrid City Council´s database
• We calculated “Healthy Food Availability Index” average
scores per store type (high, medium, and low) with
kernel density analysis
• We calculated potential residents´ walking access to
food stores with a high HFAI score by means of a street
network analysis

7. http://hhhproject.eu
Objective and perceived access
to healthy foods: Methods
3. Photovoice
• 12 residents met in small group
discussion over one and a half
month
• They took photographs of positive
and negative aspects of their local
food environment
• Residents critically discussed and
identified themes that emerged
from their photographs and
narratives

8. http://hhhproject.eu
Objective and perceived access
to healthy foods: Analysis
Residents identified 17 relevant physical
and social features
Healthy food availability index (HFAI)
score (-7 to 49): availability, quality and
cost
Walking access with a street network
analysis.

9. http://hhhproject.eu
Objective and perceived access
to healthy foods: Results

10. http://hhhproject.eu
Economic crisis and poverty
• 33% of the neighborhood food stores
were found permanently closed
• Participants highlighted lack of
economic opportunities and unequal
distribution of resources
Marketing
• Placement and promotions were not
objectively measured
• Participants noted a high exposure to
fast food at supermarkets
Objective and perceived access
to healthy foods: Barriers

11. http://hhhproject.eu
Objective and perceived access
to healthy foods: Opportunities
Small neighborhood stores and public markets
• 59.4% of food stores were traditional stores (mean
HFAI 10.84); 34.4% corner stores (mean HFAI 33.6);
and 6.2% supermarkets (mean HFAI ranged 36.5)
• Residents highlighted traditional food stores as offering
healthier, better quality of products and better customer
service
Walkability
• 78.7% of residents can access high healthy food stores
within 5 minutes, and 98.7% within less than 10 min.
• Grocery shopping was mentioned as an opportunity to
be physically active for elderly residents

12. http://hhhproject.eu
Theme 3: Food retailers

13. http://hhhproject.eu
Objective and perceived access to
healthy foods: Conclusions
By combining quantitative and qualitative methods,
we developed 7 concrete community-generated and
place-based interventions promoting a healthier
local food environment.