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(Second of two parts.) 
				WILKES-BARRE &mdash; According to a recent study by The Institute for Public Policy & Economic Development at Wilkes University, because socioeconomic and demographic characteristics are not uniform across geographic areas, factors like age, income and race can be associated with limited access to food.
				Demographic data presented in this report is sourced from the USDA Food Environment Atlas and uses the same definition of low access as above: more than one mile from a grocery store in urban areas and more than 10 miles in rural areas. It is important to note that relationships identified here may not necessarily be causal in nature.
				Ooms said seniors (people age 65 and older) were slightly less likely to have low access to a store than the overall population, while children (age 18 and younger) were slightly more likely to have low access than the overall population. More than 4,300 of all households in the region, representing 1.6 percent of Lackawanna County households and 1.9 percent in Luzerne, meet both the criteria of not having a car available and having low access to a store. Among all households regardless of grocery store access, approximately nine percent have no car available, according to the most recently available Census Bureau American Community Survey estimates.
				There were some differences across racial groups and between Hispanic and Non-Hispanic residents as well. Rates of low access were higher among the white population than several other nonwhite racial groups in both counties, and rates of low access were lower among Hispanic and Latino residents (of any race).
				Just five percent of Hispanic/Latino residents of Luzerne County had low access. Higher concentrations of Hispanic residents in certain neighborhoods that are not defined as low access may explain this finding. As shown on the access map of Luzerne County, there are no low access tracts in the city of Hazleton &mdash; home to a large community of Hispanic residents &mdash; using the standard definition. Rates of low access were moderate among Asian residents and considerably higher for residents of multiple races.
				&ldquo;Overall, these findings illustrate a prevalence of food access challenges across multiple racial and ethnic groups in both counties,&rdquo; Ooms said. &ldquo;As of 2015, there were estimated to be more than 77,000 total residents in the region living with low access to a food store. Of these, more than 3,700 were nonwhite and more than 2,150 were Hispanic or Latino regardless of race.&rdquo;
				Ooms further elaborated that, &ldquo;The cost of food also influences food decision-making. One measure of the relative cost of healthful versus less healthful food choices used by the USDA Food Environment Atlas is the ratio of the price of low-fat milk to the price of soda. As of 2010 (the most recent data available), the price of milk in the region is marginally higher than the statewide and national averages. The price of soda regionally and statewide is 97 percent of the national average price.&rdquo;
				Overall, regional data show that structural and geographic barriers to healthy food, including cost and lack of proximity to food stores, exist in many corners of Northeastern Pennsylvania and affect a broad range of population segments. These issues are very likely contributing to the region&rsquo;s unfavorable health outcomes in areas influenced by nutrition, including diabetes, heart disease and general health and wellness.
				In the face of the identified environmental and demographic disparities in food access, increasing food literacy through education may help counteract these structural disparities in food access and have a positive effect on health outcomes.
				Definitions for the concept of food literacy vary, but generally encompass themes of skills and behaviors, food and health choices, culture, knowledge, emotions, and food systems. The Food Literacy Center defines food literacy as &ldquo;understanding the impact of your food choices on your health, on the environment and on our economy.&rdquo;
				While geographic and financial barriers to healthy food choices exist in Northeastern Pennsylvania, these are not the only drivers of food decision-making. The level of education may play a role, and programming aimed at increasing food literacy and awareness has shown promising results.
				A 2013 study by the Food and Nutrition Service of the US Department of Agriculture found that among recipients of SNAP benefits (formerly known as Food Stamps), several educational programs were effective in increasing daily fruit and vegetable intake among both low-income elementary school students and low-income seniors. Two of these programs provided nutrition education in schools, as well as supplemental take-home materials and activities. The take-home materials helped parents and caregivers learn about ways to provide healthier foods on a tight budget. The third program provided direct education and take-home materials to adults aged 60 to 80 and senior centers. In addition to increasing fruit and vegetable consumption, children participating in the elementary school programs were more likely to choose low-fat or fat-free milk.
				Previous research has been particularly effective in demonstrating links between nutrition education and healthier choices in children and teens. One national study of high school students found that under a broad range of conditions, nutrition education resulted in increased knowledge, more positive attitudes toward nutrition and a measurable desire to include more healthful foods in their diets. That study also found that educator attitudes toward, and experience in, nutrition education were important factors in influencing students&rsquo; food choices.[xiv] Links between increased food knowledge and higher vegetable intakes have also been established across cultural contexts, as well as a link between parents&rsquo; nutrition knowledge and the food choices of their children.[xv] Research has also shown general nutrition classes to be effective at increasing healthy food choices among college students in a large university setting.[xvi]
				Food literacy
				Recent research has examined barriers to food literacy. One conceptual framework divides barriers to food literacy into five major types[xvii]:
				1. Knowledge, such as lack of information
				2. Attitudes, such as lack of interest
				3. Skills and abilities, such as lack of acquisition or application skills
				4. Resources, such as lack of time
				5. Environmental conditions, such as social norms, limited food choice, or other context-specific limitations.
				The last three of these five types represent external factors. These are among the most significant, representing more than half of reported barriers in one study. Examples of frequently identified external barriers include lack of learning time for individuals, lack of interested and trained teachers in school settings, lack of funding for community programming, and community food insecurity.
				As with many aspects of health, these external barriers to food literacy are also likely shaped by social determinants of health (SDOH). In 2018, The Institute published research on social determinants. That report identified SDOH as circumstances that can substantially affect individual and population health outcomes. They may appear as social, economic or physical characteristics that affect health, risk and/or quality-of-life. Dimensions of SDOH include, but are not limited to, income, education, race, ethnicity, LGBTQ+ status, and age. Statistical analysis of regional data showed that in Northeastern Pennsylvania, effects of social determinants on health outcomes are likely at least as strong as in statewide data.
				These social determinants are likely to be closely interrelated with some of the external barriers to food literacy mentioned. For example, language or cultural barriers could inhibit individual or community capacity to acquire food knowledge. Poverty and income constraints, at both the individual and community level, are also likely to affect food literacy through limitations on food choices and inadequate time or money for nutrition education.
				Promoting food literacy
				& expanding food access
				Regional food access data show that some pockets of the region lack nearby access to food outlets. Food access challenges vary by neighborhood, however. While the term &ldquo;food desert&rdquo; calls to mind a community without a large retail supermarket, many communities have a network of smaller convenience food options.
				A study of food environments in Buffalo, New York found that many predominantly nonwhite neighborhoods were not served by supermarkets but were served by networks of smaller grocery stores. That study suggested that rather than attempting to attract large supermarkets to under-served neighborhoods, it may be more efficient to support existing smaller grocery stores.[xx] One example of this principle could be working with independent grocery and convenience store owners to expand healthy food options at those stores.
				Nutrition education programs are also an important area of intervention to improve food-related health outcomes. Research from the US Department of Agriculture has identified a series of twenty-eight best practices in nutrition education for low-income audiences:
				This framework emphasizes several categories of best practices. In the area of program design, the curriculum should be evidence-based, include accurate content in key content areas and it should be based on appropriate behavior-change theories. The content should also be appropriate for the target audience and consider their language and literacy level.
				Programs should accommodate different learning styles, including visual, auditory and hands-on components. There should be experiential learning with minimal lecture. Contacts should be frequent enough and of long enough duration to achieve learning objectives.
				Educators are also important in program success. They should have expertise in both the content and teaching methods and be able to relate to the target audience. They should be trained appropriately, both initially and on an ongoing basis, with appropriate observation to ensure sufficient quality of education.
				Finally, there should be appropriate evaluative processes in place to measure impacts, sustain behavior change and progress toward meeting goals and objectives.
				Conclusions
				Data on health outcomes show that the Northeastern Pennsylvania region, compared to the Commonwealth as a whole, has significant health challenges, both generally and with respect to indicators linked to food and nutrition. There are also structural barriers to food access. Social determinants, such as income and poverty, language barriers and education, shape health outcomes broadly and can serve as external factors affecting food literacy.
				Geography also drives structural issues related to food access. There are several food deserts in the region. There are numerous tracts with limited food access &#8211; including rural, suburban, and urban communities. To address these gaps, more supermarkets may not be the most feasible answer &#8211; instead, there can be an effort to incorporate healthier options into existing food systems.
				Because many barriers to food literacy are external, increased nutrition education alone is insufficient to achieve widespread food literacy. Nonetheless, work to increase individual, school, and community-scale food literacy may be an effective way to mitigate the challenges posed by these structural barriers. Research has shown that nutrition education is broadly effective at increasing food knowledge and changing behaviors.
				Based on existing conceptualizations of food literacy, interventions should focus on building knowledge (both functional and critical) and changing attitudes toward food and nutrition. Nationally, there appears to be significant attention given toward education among children and young adults. This may reflect a need to start early to change community-wide food norms over the course of generations. However, it is also important to consider food literacy interventions for adults. Parents&rsquo; knowledge can affect children&rsquo;s food choices. Education for vulnerable or historically marginalized populations, like nonwhites and non-English speakers, must also be considered, keeping in mind what is known about social determinants of health.
				Some infrastructure for addressing regional food challenges is already in place. The Fresh Food Farmacy program, an initiative in Geisinger, is set to invest in distributing fresh, healthy food in order to improve long term health outcomes.
				Additionally, the region&rsquo;s network of food pantries and food banks work to provide healthful foods to those in need. Health education is offered in public schools, though the extent to which nutrition is taught and at what grade levels varies somewhat between district and school.
				Recommendations
				The Institute identified several recommendation that can guide further action in the area of nutrition education and programming in Northeastern Pennsylvania,
				First, existing pilots and programs aimed at providing fresh foods directly to those most in need as well as broad education and outreach to children and adults should continue and be further supported as dictated by community needs and ongoing assessment of outcomes.
				In order to address geographic barriers to food access, there may be an opportunity for a new collaborative effort to work with independent convenience or neighborhood store owners in order to make healthier options more available in these types of outlets. This may be a more appropriate and effective strategy than attempting to attract full-service grocery stores to under-served neighborhoods.
				There may also be opportunities for community-based solutions to food security issues such as community gardens, urban agriculture, or other innovative approaches to food systems. Going forward, further research or exploration of potential pilot projects is warranted.
				Parallel efforts can also be made to ensure healthier food choices are made available in school settings and reducing the availability of less healthy options such as soda in schools. There is limited data available on presence of healthy options versus less healthy ones in schools, including on the presence and comparative cost of beverage options.
				Finally, existing outreach and education programs for children and adults should be reevaluated, modified, or expanded where necessary in keeping with the best practices outlined above.
				In summary:
				&#8226; Programs should accommodate different learning styles, including visual, auditory and hands-on components. There should be experiential learning with minimal lecture. Contacts should be frequent enough and of long enough duration to achieve learning objectives.
				&#8226; Educators should have expertise in both the content and teaching methods and be able to relate to the target audience. They should be trained appropriately, both initially and on an ongoing basis, with appropriate observation to ensure sufficient quality of education.
				&#8226; Finally, there should be appropriate evaluative processes in place to measure impacts, sustain behavior change and progress toward meeting goals and objectives.
				&#8226; Educational programming on nutrition should be expanded into appropriate contexts such as in schools and early childhood education centers (for both students and their families), anti-poverty and social assistance programs, and in health care settings such as health care clinics.

Study: Age, income, race can be associated with limited access to food