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Food insecurity in rural settings is complex and not fully understood, especially from the perspective of low-income and Black residents. The goal of this study was to use qualitative methods to better understand experiences with food access and perceptions of the food environment among low-income, predominately Black rural Louisiana residents in the United States. Data were collected from focus group discussions (FGD) and focus group intake forms. Study participants were all rural residents eligible to receive at least one nutrition assistance program. FGD questions focused on perceptions of the food environment, with an emphasis on food access. Participants (n = 44) were predominately Black and female. Over half (n = 25) reported running out of food before the end of the month. Major themes included: store choice, outshopping, methods of acquiring foods other than the grocery store, and food insecurity. Concerns around price, quality, and transportation emerged as factors negatively impacting food security. Understanding residents’ perceptions and experiences is necessary to inform contextually appropriate and feasible policy and practice interventions that address the physical environment and social conditions that shape the broader physical food environment in order to achieve equitable food access and food security.

What is already known about this topic? Policy, systems, and environmental (PSE) change strategies combined with education are known to support healthy behavior change and obesity prevention in a community-based setting. What is added by this report? We share the process through which coalitions in rural Louisiana implemented PSE change. What are the implications for public health practice? By understanding the process, potential barriers, and time needed to establish and create fully operational community coalitions, communities can implement strategies to improve community engagement and entities funding PSE work can set better grantee expectations, ultimately leading to more sustainable obesity prevention interventions.

Background Nutrition interventions promoting healthy food choices aim to address health challenges of residents in low-income environments. Research about the effectiveness of nutrition interventions in low-income populations is limited, particularly for those in rural areas. Behavioral economics (BE) strategies demonstrate effectiveness for improving eating behaviors in some settings. However, the efficacy of BE interventions in retail food stores serving low-income populations residing in rural and urban geographies is nascent. Objective This systematic literature review aims to identify and compare nutrition interventions implemented in rural and urban low-income retail food stores, including BE strategies when applied. Methods This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reviewers searched five databases for peer-reviewed publications from October 2010 to October 2019. Included studies implemented a nutrition intervention in low-income retail food stores and provided a quantitative outcome evaluation with results separated by rural and urban geography. BE interventions were analyzed based on the MINDSPACE framework for behavior change. Results Forty-six separate publications (n ¼ 20 rural, n ¼ 26 urban) in the United States, Canada, Europe, New Zealand, and Australia were included. Researchers independently rated publications as low risk of bias (n ¼ 4), moderate (n ¼ 18), or high risk of bias (n ¼ 24) using the Quality Assessment Tool for Quantitative Studies. Studies (n ¼ 18) demonstrated positive outcomes for customer purchases, store sales, or participant intake of targeted healthy foods. Overall, most effective interventions included point-ofpurchase signage (n ¼ 16) and product placement strategies (n ¼ 4 urban). Rural studies included financial incentives combined with participant education (n ¼ 2) and incorporated culturally appropriate messengers and/or symbols (n ¼ 5) to improve healthy food purchases and intake. Conclusions Improved research quality and tailored evidence-based interventions, including BE strategies, are necessary in retail food environments to promote healthy eating behaviors in low-income populations.

High rates of obesity and chronic disease exist in the southeastern United States (US). Knowledge about the attitudes, beliefs, and barriers of the rural low-income Louisiana population regarding healthy eating is limited. Focus Group discussions based on the Theory of Planned Behavior (TPB) were conducted in rural parishes (N = 3) with low-income residents of Louisiana (N = 29). Grounded Theory methods and cross-case analysis were used. The participants were primarily single Black females of age 18–30 years who earned a high school diploma, were employed, and had children. Beliefs included healthy eating was physically beneficial, yet financial impacts and the low palatability of healthy foods were barriers. Professional resources for nutrition education were limited which led to reliance on friends, family, and the internet. Friends and family were positive and negative influences on eating choices. Control beliefs included the high prices and low palatability of healthy foods, the wide availability of Energy Dense Nutrient Poor (EDNP) foods, and low motivation to sustain eating behavior changes. Formative research to optimize campaign distribution channels may improve accessibility to social marketing support and healthy eating resources. Persuasive messages that address control beliefs are needed in social marketing campaigns for rural low-income Louisiana environments.