In the United States, obesity is a costly (1) and devastating public health problem (2). There is disproportionate obesity prevalence in rural America, particularly the rural South (3,4). The obesity disparity in rural areas versus more urban and suburban areas of the United States may be a result of the food environment, rural food deserts in particular (5–7). Rural residents may live far from supermarkets, which stock more healthful foods than do corner stores (8,9). Therefore, rural residents may be more reliant on the less-healthful foods in corner stores (also referred to as convenience stores or food marts) and similar lower-volume food venues. Corner stores and small stores in rural areas may serve an important role for “filler” shopping (ie, purchase of small quantities of groceries before a big shopping trip is needed) (10) and for residents with limited access to transportation to urban areas.

Food environments can be conceptualized in terms of the community food environment (defined as spatial access to food venues) and the consumer food environment (defined as what consumers encounter in each food venue) (11). Food store audits are one way researchers have measured the consumer food environment, and these typically entail assessment of availability, price, and quality of foods available in traditional food venues such as supermarkets and grocery stores and in nontraditional food venues such as mass merchandisers (12). A growing amount of research has assessed the consumer food environment in urban areas (13–15) as well as in rural settings, such as rural Texas (8,16,17). Two review articles (18,19) provide comprehensive summaries of tools to assess the community and consumer food environments, and many resources are available via the National Cancer Institute’s Food Environment Measures website (https://riskfactor.cancer.gov/mfe/instruments/), a continually updated online repository for food environment assessment tools. Despite these resources and assessment tools, methods for conducting food store audits in rural areas of the United States have not been assessed extensively.

Several recent US federal initiatives have sought to engage communities to promote healthful food environments, including the Healthy Food Financing Initiative and the Centers for Disease Control and Prevention’s $372.8 million Communities Putting Prevention to Work (CPPW) initiative (20). To plan for promotion of healthful foods and to evaluate the effectiveness of such efforts, high-quality data are needed, and communities must choose from among the many audit tools available to collect such data. Furthermore, few examples are available of how information gathered from food audits can be efficiently compiled and disseminated to community leaders, thus informing policy makers on what evidence supports or promotes a more healthful rural food environment.

Federal efforts to engage communities to promote healthful food environments are evolving. Assessments of the consumer food environment must meet the needs of all stakeholders working to create more healthful food environments. These include public health practitioners, researchers, policy makers, retailers, and community advocacy groups (18). Thus, in this article we describe a case study to assess the consumer food environment in rural eastern North Carolina (Pitt County) to guide planning and implementation of a CPPW healthy corner store initiative. We discuss results and lessons learned and how these may inform similar efforts to plan, evaluate, and advocate promotion of more healthful food options in rural corner stores.

Overall, stores in rural Pitt County had lower mean NEMS-S-Rev scores than did the stores in more urban areas, which, by definition, included supermarkets (Table). However, supermarkets in urban areas did not seem to have healthful options as competitively priced as did corner stores in urban and rural areas, as indicated by the negative NEMS-S-Rev price score for supermarkets.

Among corner stores, the focus of the Pitt County CPPW initiative, those in rural areas (n = 17) had higher availability scores but similar price and quality scores than corner stores in urban areas (n =16). The availability and overall NEMS-S-Rev scores were slightly lower for corner stores in rural areas when corner stores in crossroads communities were excluded from the analysis.

Audited supermarkets had a price score of −2.1 and corner stores had a price score of 2.3, indicating that more-healthful items were more competitively priced in the corner stores audited than in the audited supermarkets. However, as expected, supermarkets had higher overall NEMS-S-Rev scores than corner stores. At corner stores, specifically, those in rural areas had higher NEMS-S-Rev availability scores than did corner stores in more urban areas, which suggests that corner stores in rural areas had more healthful options available than corner stores in urban areas. These results provided a baseline from which to implement and evaluate a CPPW healthy corner store initiative in Pitt County.

Our study has limitations. We used a small, nonrandom, purposive sample of food stores. Because we did not audit a representative or random sample of stores, audit results may not represent the overall patterns of availability, pricing, and quality of foods in Pitt County. However, we did purposively sample stores, ensuring that stores audited were frequented by rural and low-income customers, to ensure that CPPW efforts reach those most at risk for obesity. Also, because audit tools often measure only select food items, they may not capture the rural consumer food environment in its entirety. Analyses of national data related to rural consumers’ food choices can inform development of future audit tools to more accurately capture the rural consumer food environment. We were not able to assess certain aspects of stores (eg, product placement, whether the store sold food from a grill, presence of advertisements of unhealthful foods).

Strengths of our efforts include assessment of the availability, price, and quality of healthful versus unhealthful food items, using a validated audit tool. We evaluated appropriate audit tools based on available literature and selected tools to gather credible evidence on the basis of time, cost, and technical demand. We used a collaborative and tailored approach to engage community partners in the planning and evaluation of the CPPW healthy corner store initiative.

Our food store audit results were compiled and presented to the CPPW team to inform planning and evaluation of the healthy corner store initiative. NEMS-S-Rev scores were used to determine changes to make in corner stores and were used as an evaluation tool after healthful changes were made. Based on store owner or manager interest in partnering with the CPPW initiative, we selected 11 stores in which to conduct qualitative interviews with food store owners and managers, as reported in Part 2 of this evaluation report and as done by others (23,24) to determine relevant characteristics of the store’s customer base and customer shopping patterns and to learn about inventory decisions. Finally, we conducted baseline customer intercept surveys in 9 of the 11 selected corner stores to learn more about customer shopping patterns and healthful food options customers would purchase from corner stores, also reported in Part 2 of our formative evaluation report. We compiled tailored corner store reports for each of the 11 stores, and hand delivered the reports to stores with a letter thanking them for their participation. These reports and letters were used to build rapport with local store owners. Reports included aggregated and individualized NEMS-S-Rev results, as well as results of the store owner qualitative interviews and the customer surveys, and we distributed these to the CPPW project team as well as to each store owner.

When assessing the consumer food environment of small stores, store owners and managers may perceive the people conducting audits as competitors or fear that audit results will have negative repercussions. Therefore, auditor intentions must be clearly presented to store owners. Rapport with store owners and managers can be built during food audits, if the process is presented in a nonthreatening way. Although all audits for this study were conducted during daylight hours, the safety of auditors was occasionally an issue in corner stores. This issue can be resolved by partnership with community agencies that have connections to local law enforcement resources. In addition, as the NEMS-S-Rev did not include detailed information to assess sodium content of foods, as new nutrition recommendations emerge, such as those regarding sodium, audit tools should include some assessment of availability of low-sodium options. Finally, as recently suggested by Rose et al (25), because the NEMS-S-Rev does not include any assessment of the broader community food environment, a more complete picture of the rural community and consumer food environment could be provided by combining measures of food store access using geographic information systems, with measures of availability, pricing, and quality of healthful items as assessed using food store audit tools.

To aid the CPPW team in identifying which store to pilot the healthy corner store initiative, we also compiled a list ranking stores in terms of customer volume, location of the store (proximal to low-income areas), and willingness of the owner to provide more-healthful food in the store. The combination of these efforts, described here and in Part 2 of this report, as well as reports of previous efforts (23,24) guided CPPW planning for effectively promoting healthful foods in both rural and urban food stores.

There is a need to ensure that low-income residents, particularly those in the rural South, have access to healthful foods. Many US communities have been funded through the CPPW initiative to address the need for access to more-healthful food via environmental and policy changes (20). In Pitt County, as has been done in other communities across the nation, we collaborated with corner store owners to supply and promote more healthful food choices in rural and underserved areas, and to support corner stores as economically thriving and sustainable rural food venues. We hope that the Pitt County experience will offer guidance to others collecting empirical data to pursue policy and environmental changes in the rural food environment.