Social and ethnic-racial inequities in the occurrence of food deserts in a Brazilian capital

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Social and ethnic-racial inequities in the occurrence of food deserts in a Brazilian capital

https://doi.org/10.21203/rs.3.rs-3117295/v1

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This study described the occurrence of food deserts and its relationship with the socioeconomic characteristics of the area. This is an ecological study based on secondary data from the city of Porto Alegre/Brazil. Food deserts were defined based on the density of establishments that sell healthy foods. The socioeconomic variables analyzed were the Health Vulnerability Index, percentage of illiterate people, percentage of people with per capita income of up to half a minimum wage, and percentage of households made up of people who identify as Black, Brown, or Indigenous. Statistical and spatial analyses were conducted using census tracts as units of analysis. Almost half of the census tracts were classified as food deserts (n = 1150/48.3%), with higher concentration in the peripheral areas of the city. Tracts with a high risk of health vulnerability (very high HVI), those with the highest percentage of black and indigenous peoples (Quartile 4), the highest percentage of illiterate people (Quartile 4), and the highest percentage of people living on less than ⅕ minimum wage (Quartile 4), were about twice as likely to be classified as a food desert. For all variables, a dose-response relationship was observed. The results show that in the city of Porto Alegre food deserts were associated with worse environmental and social conditions, and a greater presence of ethnic-racial minority groups. Social and ethnic-racial inequities might shape the city environment, making access to healthy foods more difficult for the most vulnerable populations, with possible repercussions on food consumption, food security and other health outcomes.

Nutrition & Dietetics

Social Inequities

Food Deserts

Food environment

Race/skin color

Food deserts are socially vulnerable geographic areas where residents have limited access to healthy food options, such as fresh and minimally processed foods (Cummins & Sally, 2002). They can be considered a mechanism by which social inequities can lead to negative health outcomes, including unhealthy diet, obesity, and non-communicable chronic diseases (Almeida et al., 2022; Chen et al., 2016; Budzynska et al., 2013; Salinas-Roc et al., 2022).

Currently, most of the literature on food deserts focuses on countries in the Global North, mainly the United States. North-American studies that seek to understand the formation of food deserts suggest that expanding large supermarket chains into the higher-income outskirts of cities offered consumers food options with better quality, variety and price, however, it forced the closure of smaller neighborhood grocery stores, creating areas where varied and affordable food is available only for those who own cars or can afford public transportation (Beaulac et al., 2009; Walker et al., 2010). These studies also demonstrate that lower-income neighborhoods with a greater presence of black people have fewer establishments that sell healthy food options (Li & Ashuri, 2018; Richard et al., 2012).

In Brazil, although research on the food environment has expanded in the last decade (Jaime et al., 2011; Pessoa et al., 2015; Backes et al., 2019 Almeida et al., 2021; Leite et al., 2021, Araújo et al., 2022), studies on food deserts are quite recent. Only in 2018 the Brazilian government conducted a survey that proposed a methodology specific to the country for mapping food deserts and identified the frequency of these deserts in Brazilian capitals (Caisan, 2018). From this, initial research has attempted to understand the distribution dynamics of food deserts in the country, as well as to discuss their metrics (Honório et al., 2022) and their relationship with social vulnerabilities (Honório et al., 2021; Davies et al., 2017).

Brazil is a country of average economic growth, located in the Global South, marked by deep socioeconomic and racial inequalities that are reflected in inequities in the access to and consumption of healthy foods (Canuto et al., 2019) and in the morbidity and mortality of the population (Powell-Wiley et al., 2022; Landmann-Szwarcwald & Macinko, 2016). Furthermore, as a country in the Global South, its urbanization patterns are different than those observed in countries in the Global North. In this sense, studies that help to understand the dynamics of the development of food deserts and their relationship with social inequities in access to healthy food options in countries of the Global South, such as Brazil, are necessary. The aim of the present study was to describe the presence of food deserts in a capital of a southern Brazilian state and its relationship with socioeconomic traits.

2.1 Study design and unit of analysis

This is an ecological study carried out in the city of Porto Alegre, state of Rio Grande do Sul, Brazil. The city has an estimated population of 1,492,530 people, and a Municipal Human Development Index considered to be very high (0.805) (Ibge, 2010; Ipea, 2017). With about 20% of its population self-reporting as black (brown - “pardo” + black), it is the Brazilian capital with the highest rates of social inequality between the white and black populations in the country (Ipea, 2017).

Neighborhood units were used as census tracts, since It is the minimum political-administrative unit used by IBGE (the Brazilian Institute of Geography and Statistics) to collect statistical data in Brazil (IBGE, 2010). All census tracts in the city (n = 2433) were considered eligible for the study, except those with confidential or missing data.

2.2 Study variables

In this study, food deserts were classified following the methodology proposed by the Brazilian government in the Technical Mapping of Food Deserts (Caisan, 2018). Information on establishments that sell food was obtained from the State Treasury Department of the state of Rio Grande do Sul and refer to 2020. The database contained information such as address, name, and main activity of the establishment, classified according to the National Classification of Economic Activities (CNAE). This classification is a national instrument used to standardize the codes of economic activities and the categorization criteria used by the different offices of the National Tax Administration Board. Seventeen types of establishments were included, in addition to farmer’s markets, totaling eighteen types of establishments. The geographic coordinates were drawn based on the addresses, and the points were plotted on the map with the aid of a geoprocessing software.

Using the NOVA classification (Monteiro et al., 2010), it was possible to characterize the profile of the food items sold by the establishments. They were divided into three groups: (1) establishments offering mainly or exclusively fresh or minimally processed foods, such as butchers, fruit and vegetable stands, fishmongers, street vendors selling unprocessed or minimally processed products (e.g. coconut, garlic, spices, fruits, sugarcane juice, raw beans, pineapple, green corn, and honey), in addition to street fairs and farmer’s markets; (2) mixed establishments, such as bakeries, restaurants, grocery stores and supermarkets; and (3) establishments that mainly or exclusively offer ultra-processed foods, such as bars, convenience stores, candy shops, snack bars, street vendors that exclusively or mainly sell ultra-processed foods (for example, cookies, hot dogs, hamburgers, fried snacks, pastries, popsicles, processed potato chips, confectionery, chocolate).

In order to classify the establishments based on the level of food processing (in natura or minimally processed, mixed or ultra-processed), food acquisition data from the Family Budget Survey (POF 2008–2009) (Ibge, 2021) was analyzed, as it pointed out which types of food were purchased by the Brazilian population in the different types of establishments included in the study.

The density of health-food establishments per 10,000 inhabitants was considered to determine food deserts. First, healthy-food establishments were grouped, including those that sell mainly in natura, minimally processed and mixed foods, then the total number of healthy-food establishments was divided by the population of the census tract and multiplied by 10,000. Finally, the census traits that fell below the 25th percentile of the density of healthy-food establishments were considered food deserts. This method followed the proposal of the Brazilian technical survey (Caisan, 2018). Honório et al., (2022) conducted a study comparing different metrics for assessing food deserts in Brazil, corroborating the superiority of this metric for the Brazilian scenario.

It was decided to use a composite indicator, the Health Vulnerability Index (HVI), to investigate possible social inequalities where there were food deserts. The HVI included eight variables assessed as environmental and socioeconomic dimensions, and it has been used in other studies (Almeida et al., 2021; Leite et al., 2021, Araújo et al., 2022). The environmental dimension included: percentage of households with inadequate water supply, percentage of households with inadequate or absent garbage collection services, and percentage of households with inadequate or absent sanitary sewer services. The socioeconomic dimension included the ratio of the number of residents per household, percentage of illiterate people, percentage of people with per capita income of up to half a minimum wage, average nominal income of people in charge of the household, and percentage of households made up of people who self-report as black, brown (“pardo” in Portuguese ) and/or indigenous. Information from the 2010 demographic census was used, which the most up to date (Ibge 2010).

Scores in HVI range from 0 to 1, with values close to 1 indicating high social vulnerability and values close to zero indicating low or nonexistent social vulnerability. The level is categorized according to the following cutoff points: low risk – values below the mean of the HVI; medium risk – HVI values between mean and mean + 0.5 SD; high risk – HVI values between mean + 0.5 SD and mean + 1.5 SD; very high risk – HVI values over the mean + 1.5 SD.

The variables percentage of illiterate people, percentage of people with per capita income of up to half a minimum wage, and percentage of households made up of people who self-report as black, brown and/or indigenous were analyzed separately in order to deepen the understanding of possible social and racial inequalities. For these analyses, these variables were classified according to the quartiles of the distribution.

2.3 Data analysis

Numerical variables were tested for normality using the Shapiro–Wilk test. Variables that exhibited a pattern close to (parametric) normality were presented as mean and standard deviation and associated with the presence of food deserts. Variables that showed a non-parametric pattern were described by median and interquartile range, and association with the other variables tested using the Kruskal–Wallis test.

The occurrence of food deserts was presented in absolute and relative frequency and its association with the other variables was tested using Pearson’s chi-square. Prevalence ratios and their respective confidence intervals were determined using Poisson Regression. A significance level of 5% was considered for all association analyses. Data were analyzed using Stata Version 14.

With the goal of understanding the distribution of the results throughout the city’s territory, thematic maps of the census tracts of Porto Alegre were generated by superimposing the information from the geospatial database built for the investigation: binary classification of the tracts into food desert/not food desert, HVI food classifications and race/skin color classification, residents’ income and schooling. Mappings and spatial analyses were carried out using the GeoDa 1.20 software (https://geodacenter.github.io/download.html).

Fifty-two census tracts that had confidential or missing data were excluded, totaling a final sample of 2381 census tracts. The final sample of establishments that sell food was 10,871 establishments.

Of the 2381 census tracts analyzed, 48.3% (n = 1150) were classified as food deserts. It is also noteworthy that the deserts are less present in the central area of the city (black circle), seeming to be more concentrated in the peripheral areas or outskirts of the city (Fig. 1).

Table 1 presents the average values of the indicators that make up the HVI according to the sectors classified as food deserts. Sectors classified as food deserts show higher means for all environmental indicators. They also showed higher means of self-reported black, brown and indigenous residents, of illiterate people, of households with per capita income of up to ½ a minimum wage, and lower nominal monthly income. About 15% of the census tracts were classified as at medium risk for health vulnerability, 15.4% as high risk, and 8.9% as very high risk. The higher the level of vulnerability of the sector, the greater the prevalence of food deserts.

Table 1

Characterization of tracts classified as food deserts according to variables that make up the health vulnerability index (HVI). Porto Alegre, Brazil.
Variables	Total (n = 2381)		Deserts
Variables	Total (n = 2381)		Yes (n = 1150)		No (n = 1231)
	Median or (n) %	SD	Median or % %	SD	Median	SD	p-value #
Inadequate sewage services^b	5.69	15.81	8.19	18.74	3.37	12.05	< 0.001
Inadequate garbage collection services^c	0.33	2.53	0.51	3.32	0.16	1.43	< 0.001
Black, brown and indigenous population ^d	18.26	14.38	22.80	15.29	14.02	12.02	< 0.001
Ratio of Residents ^e	2.77	0.56	2.91	0.58	2.64	0.50	< 0.001
Per capita income up to ½ MW ^f	5.03	9.07	7.10	10.81	3.09	6.51	< 0.001
Nominal monthly income ^g	823.01	687.27	630.35	584.66	1002.99	726.31	< 0.001
Illiterate residents ^h	8.48	5.12	10.04	5.53	7.02	4.24	< 0.001
Health Vulnerable Index
Low	(1454) 61.1		36.58		63.42		< 0.001*
Average	(347) 14.6		61.67		38.33
High	(367) 15.4		67.30		32.70
Very high	(213)8.9		73.70		26.30
#Student’s t-test
* Pearson’s chi-square
^a Percentage of households with inadequate or no water supply
^b Percentage of households with inadequate or absent sanitary sewer services
^c Percentage of households with inadequate or absent garbage collection services
^d Percentage of residents who self-report as black, brown and/or indigenous
^e Ratio of residents per household
^f Percentage of households with per capita income up to ½ MW (minimum waves)
^g Average nominal monthly income
^h Percentage of illiterate people – considering the total number of people aged over 5 years old

Figure 2 shows the prevalence ratio and 95% confidence intervals of the association between food deserts and HVI, race/skin color, illiteracy and income. The sectors with a high risk of health vulnerability (very high HVI), those with the highest percentage of black and indigenous peoples (Quartile 4), the highest percentage of illiterate people (Quartile 4), and the highest percentage of people living on less than half a minimum wage (Quartile 4), are about twice as likely to be classified as food deserts. For all variables, a dose-response relationship was observed.

Figure 3 presents the spatial distribution of census tracts colored based on food deserts according to the HVI levels; and, Fig. 4 shows the spatial distribution of the sectors classified as food deserts colored according to the quartiles of the distribution of the three socioeconomic variables under study.

The results showed that almost half of the census tracts in the city of Porto Alegre are food deserts, and the concentration is higher in the most peripheral areas of the city. In addition, the greater the health vulnerability, the percentage of black, brown, and indigenous residents, the presence of illiterate people, and the lower the income of people residing in the sectors, the greater the probability of the sector being a food desert. That is, food deserts were associated with worse environmental and social conditions and with a greater presence of ethnic-racial minority groups in the city of Porto Alegre.

In line with these results, other studies found that areas classified as food deserts (or with less access to nutritiously dense foods) had lower income, lower literacy rates and higher prevalence of black populations (Dunn, Sharkey& Horel 2012; Bower et al., 2014; Franco et al., 2014; Yingru Li, et al., 2021; Gripper et al., 2022). The systematic review carried out by Beaulac, et al., (2009) was conducted in high-income countries such as Canada, the United Kingdom and the United States and also highlighted that lower-income areas with a greater predominance of black people have fewer supermarkets, which for these countries is a marker of consumption of foods considered to be healthy. Similar results were found by Walker et al., (2010), with a systematic review of studies carried out only in the United States, where in addition to fewer establishments considered healthy in areas with a predominance of African-American residents, it was observed that lower-income individuals had greater difficulty in traveling to the supermarket, due to not having a car or not being able to afford public transportation costs.

In Brazil, studies on this topic are scarce. Honório et al., (2021), when analyzing the presence of food deserts in the city of Belo Horizonte, a state capital in southeastern Brazil, highlighted that the census tracts classified as food deserts were mostly located in sectors of greater health vulnerability, with lower availability of essential services, lower per capita income and lower average number of literate individuals, corroborating the findings of this study. However, no difference was observed in the location of food deserts between central and peripheral regions, as was the case in the present study.

Possible explanations for the results found in our study include the fact that the opening of food establishments results from known processes occurring from urban spatial economy. The location of these establishments is strategic and is determined by the type of business, generally concentrated in urban centers where there is greater circulation of people and greater concentration of populations of higher socioeconomic status. This may explain why populations living in the outskirts of cities are more exposed to food deserts (Almeida et al., 2021; Leite et al., 2021, Araújo et al., 2022).

In addition, the development of cities in Brazil, as well as in other countries, was influenced by historical and political events, resulting in an unequal society, which in many cities, such as Porto Alegre, is reflected in social-spatial segregation, characterized by the peripheralization of poverty and the black population. Polidoro & Canavese (2017) described the historical development of the city of Porto Alegre and, according to the authors, the descendants of enslaved people, migrants and rural and low-income workers could not access the central areas of the city and were dislocated to peripheral areas, leading them to face a series of problems related to lack of urban mobility, low access to opportunities and more precarious housing. This pattern is also observed in other studies conducted in countries of the Global North, where peripheral city areas have worse infrastructure when compared to central areas (Bower et al., 2014; Cooksey Stowers et al., 2020). Thus, the occurrence of food deserts seems to be directly linked to the historical processes of production and unequal occupation of urban spaces.

Regarding the ethnic-racial inequalities evidenced by our results, based on an analysis that intersects race and class, the difficulty in accessing healthy and nutritionally dense food items, marked by the occurrence of food deserts, can be considered a manifestation of structural racism (Gripper et al., 2022). Structural racism can be defined as a form of racial discrimination reproduced in society as customs, practices and laws and incorporated into people’s daily lives (Krieger, 2020; Nazroo, et al., 2020; Devakumar et al., 2022). In this case, although Brazil has never established racial segregation laws, as was the case in the USA and South Africa, public and economic policies for the occupation of rural and urban spaces have been responsible, even if indirectly, for the maintenance of racial segregation processes. In this sense, the structural racism manifested in food deserts can have consequences for food and health through two main mechanisms: (1) structural racism shapes (Nazroo, et al., 2020) people’s environments and opportunities, and thus black, brown and indigenous peoples in the study were more likely to live in a food desert, and this obstacle in accessing healthy food options can lead to negative health outcomes (Fong et al., 2020; Chen et al., 2016) (2) experiences of racial discrimination when accessing food establishments far from their homes can induce the overactivation of stress pathways and also result in negative health outcomes, through the embodiment of social experiences (Krieger, 2020; Nazroo et al., 2020; Rodrigues et al., 2022). Complementarily, we analyzed the association between race/skin color and the presence of food deserts adjusted for income and illiteracy, and the results demonstrate an independent association between being black or indigenous and having less access to healthy foods, demonstrating that racism is a factor independent of income or education in the outcome under study.

4.1 Strengths and limitations

The results of this study must be interpreted considering some limitations, namely: (1) its ecological approach, which makes causal inference impossible, but generates hypotheses that must be tested by other study designs; and (2) use of socioeconomic data from the Brazilian CENSUS 2010, due to the delay in carrying out the 2020 census in the country.

On the other hand, the following can be considered as strengths: (1) the pioneering approach to studies of the food environment in Brazil by using an indicator that contemplates the racial inequalities of the population and amplifies the debate on the subject; (2) the robust and nationally-referenced methodology used to classify the food deserts; and (3) based on the results of this study, it is possible to develop proposals for improving access to healthy foods throughout the national territory, with a focus on combating social and racial inequalities. Social inequalities are understood as unfair differences between different population groups, referring to differences between groups based on income, education, gender, access to opportunities, socioeconomic status, among others. Racial inequalities are differences between groups based on race/skin color, which characterize racism (Krieger, 2020; Nazroo et al., 2020; Devakumar et al., 2022).

Finally, as has been suggested by Gálvez Espinosa et al., (2017), who analyzed food environments based on social health determinants, the food environment is an intermediate determinant of health. Thus, in the development of public policies aimed at ensuring access to adequate and healthy food options, it is essential to take into account the place where individuals reside and the availability of opportunities. It should also be considered that the construction of healthier food environments is based on combating all forms of discrimination and guaranteeing greater access to fair incomes, education, housing and sanitation for minority populations. Food and nutritional security stand out as feasible alternatives for improving the quality of food for the population exposed to food deserts, such as the development of community gardens and farmer’s markets.

From the results of the present study, it can be concluded that there is a relationship between the distribution of environmental, social and ethnic-racial traits and the occurrence of food deserts in the city of Porto Alegre. Thus, social and ethnic-racial inequalities seem to shape the city environment, making access to healthy foods more difficult for the most vulnerable populations and generating food inequalities for people residing in peripheral areas of the city. This denotes clear social inequalities that influence healthy habits and, consequently, the health parameters of the population. Thus, it is suggested that future studies investigate these patterns in other Brazilian cities and in the Global South as a whole, in addition to identifying the impact of the presence of food deserts on food consumption, food security and other health outcomes, such as obesity and chronic non-communicable diseases.

Funding:

Larissa Loures Mendes– The National Council for Scientific and Technological Development (CNPq) n. 4/2021 – Research Productivity Scholarship – PQ – Process n. 312979/2021-5. Raquel Canuto – The National Council for Scientific and Technological Development (CNPq) n. 9/2022 – Research Productivity Scholarship – PQ – Process n. 306656/2022-1

The authors declared that they have no conflict of interest

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Social and ethnic-racial inequities in the occurrence of food deserts in a Brazilian capital

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Abstract

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1. INTRODUCTION

2. METHODOLOGY

2.1 Study design and unit of analysis

2.2 Study variables

2.3 Data analysis

3. RESULTS

4. DISCUSSION

4.1 Strengths and limitations

5. CONCLUSION

Declarations

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References

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