Understanding food security issues in remote Western Australian Indigenous communities

Key words: community stores, food access, food security, health policy, Indigenous, remoteness.

Indigenous people throughout the world experience higher morbidity rates and lower life expectancy than non-Indigenous people.¹ Although wealthier nations generally have better health outcomes than poorer countries for both Indigenous and non-Indigenous people, Australia seems to be an exception to this rule.² Among the Indigenous people of richer nations, Australian Aboriginals and Torres Strait Islander people experience social disadvantage, and are recognised as having an unacceptable gap in life expectancy compared with non-Indigenous people.^2,3 The World Health Organization states, ‘The diets people eat, in all their cultural variety, define to a large extent people’s health, growth and development’.^2,4 The burden of diet-related diseases, including obesity, hypertension, high cholesterol, cardiovascular disease, diabetes and renal failure, is higher in Indigenous Australians. Indigenous Australians experience a higher prevalence of mortality and morbidity from these diseases than non-Indigenous Australians.^5,6 Australian Indigenous infants are more likely to be still-born, have low birthweight and suffer from anaemia and malnutrition than non-Indigenous children.^7,8 A poor diet, including low fruit and vegetable intake, has been estimated to contribute to ~19% of the Indigenous health gap in Australia.⁹

Around 25% of Australia’s Indigenous people live in remote communities,¹⁰ and improving the supply, access to and consumption of nutritious food in remote areas is an important strategy for improving the health of Indigenous people.^11–13 Food insecurity has been associated with negative health outcomes¹⁴ and therefore is an important public health food policy priority.

Food security is defined by the Council of Australian Governments as ‘the ability of individuals, households and communities to acquire appropriate and nutritious food on a regular and reliable basis using socially acceptable means’.¹⁵

Geographical location influences the supply and affordability of nutritious foods. Pricing surveys have demonstrated that food can cost ~20–30% more in rural and remote Australian communities.^16–19 This disparity in cost between urban and remote settings has remained relatively unchanged for many years, and the more remote the greater the disadvantage.²⁰ In Western Australia (WA) in 2010, the fortnightly mean cost of a healthy food basket was 23.5% more in very remote areas compared with the cost in Perth, the capital city.¹⁹ Many remote communities experience food insecurity because the delivery of food is irregular, the nutritious choices are limited and often of low quality, food prices are high, and the ability to store and prepare food is inadequate.¹⁵ The factors that affect food security are complex and need to be explored at all levels.

Community stores in remote parts of Australia play a critical role in the nutritional health of their communities. They are often the only source of food, drinks and household hardware for most of the Indigenous community members. It is estimated that Indigenous people can purchase up to around 80–95% of their food at the local remote community store and takeaway store.²¹

Government interventions to improve the supply and demand for food in community stores vary according to state or territory. Intervention options depend on many factors, including the local conditions, available regulatory options, store ownership arrangements, community size and geographical location and political amenability. The Australian Government’s Northern Territory Emergency Response Intervention (NTER) was established to enable vulnerable groups to lead safe and healthy lives.²² The NTER introduced income management strategies, including a food basics card to assist people to buy essential everyday items, including nutritious food. Community store licensing improved the range and the quality of groceries available by ensuring stores were well managed and able to participate effectively in income management arrangements. Income management quarantines money for food. Electronic point-of-sale systems support effective retail management practices and transparency, and are a requirement for income management systems. The NTER improved the choice and quality of goods available, however food costs are still high and the demand for healthy food low.²

A review of the NTER found that, as well as electronic point of sale systems, access to a public health nutritionist was necessary to strengthen the community store’s ability to improve the supply and demand for healthy food.²² The work of public health nutritionists is to facilitate an organised community effort to improve food and nutrition to promote and protect population health.²³ An effective workforce to improve public health nutrition requires a team working across the continuum of care, from clinical dietitians to public health nutritionists. There is poor public heath nutritionist workforce capacity in Australia,²⁴ and it is likely that there is a lack of understanding of the potential contribution of this workforce to address food security issues.

Public health nutritionist competencies have recently been defined and include: an understanding of the factors that contribute to the health of a population, specialist skills in applying nutrition science to public health practice, analytical skills, an understanding of public health systems and the socio-political context, and skills in management, leadership and professional communication.²³ This skill set is valuable when working with community stores, as highlighted by what was learnt from the NTER. Public health nutritionists can assist store managers to improve the food supply by ensuring that preference is given to foods available for sale that are consistent with dietary recommendations, and also by helping to develop in-store nutrition promotions and community interventions to increase the demand for healthy food (e.g. social marketing, education and food preparation skills development). Table 1 describes the role of the nutrition workforce and specific public health nutrition practitioners.²⁵

Table 1.  Specialist Australian nutrition workforce competencies
Source: adapted from (24, 25)

The NTER intervention is unlikely to be duplicated or replicated in other jurisdictions due to its resource intensiveness and regulatory differences. Although Australian Government consultations have shed some light on the issues faced regarding food security in remote areas,²⁶ little has been done to quantify the problem in WA, or to determine local community perceptions of potential interventions.

Food stores in remote communities in WA are generally owned and run by Indigenous community organisations without direct government funding or subsidy and rely on the patronage of residents to trade. Most WA remote Indigenous communities consist of between 100 and 200 people – not sufficient to support a profitable business operation. Stores appear to primarily operate to provide food to remote populations rather than as a business enterprise. As such, for many of these remote communities the store is an essential service, albeit one that is typically poorly resourced.

As the main or only source of food for some communities in remote parts of Australia, their store plays a critical role in the community’s food security. Store managers have everyday contact with community members and consequently can provide insights into community life.

Interventions are more effective when there is local support. There is a dearth of evidence about the views of remote store owners regarding their main concerns about the supply and demand for healthy food, or the factors that would support them to address food security. This research aimed to collect census information to inform the development of intervention strategies to address food security in WA. It aimed to determine store managers’ perceptions of the extent of food insecurity in their communities, key concerns relating to food in remote stores, store operations, infrastructure and resource needs (particularly whether they had electronic point-of-sale systems and direct access to a nutritionist, as these were identified by the NTER as key to improving food security).

The study sample was all WA remote community stores, all of which had an Accessibility/Remoteness Index of Australia (ARIA) score of greater than 9.8 (indicating poor accessibility by road to services). The contact details for the stores were obtained from the Department of Health, and ethics approval was granted by Curtin University Human Research Ethics Committee. The map of grocery store locations in WA shows the remoteness of the community stores (Fig. 1).

Fig. 1.  Grocery store locations in Western Australia.

A short telephone survey was designed by the researchers in conjunction with the Food Unit of the Environmental Health Directorate at the Department of Health in WA. One researcher conducted all the telephone interviews after piloting and modifying the questionnaire. The survey began with an open-ended question asking managers to identify the main problems or issues they faced with their stores. All other questions were closed, with opportunity for further comment. A brief description of point-of-sale systems, nutritionists and food security were given if requested. Table 2 lists the survey questions.

Table 2.  Remote Western Australian community store managers’ survey questions

Data were entered into SPSS for Windows version 17.0 (SPSS Inc., Chicago, IL, USA). Multiple responses for the open-ended question were grouped and coded. Descriptive analyses were conducted for the other questions. As the survey was a census sample, the sample size was relatively small and the results homogenous, so further statistical analysis was not conducted.

There were 51 stores on the original Department list; however, nine had closed down and three were not contactable. Of the remaining 39 remote community store managers contacted, six refused to participate, resulting in an overall response rate of 84.6% (n = 33). Those refusing to participate said it was because they had been involved in research before that had not resulted in any positive action. The survey took 8 min on average to complete.

Managers were asked what, if any, problems or concerns they had about their stores and were given the opportunity for multiple responses by prompting with ‘anything else?’ Managers who identified problems tended to describe them, thus allowing the interviewer to collect some quotes regarding their concerns. Most managers (23; 76%) said there were major problems, and 10 (24%) reported no problems. From the 41 different responses obtained, six main areas of concern were identified. Transportation issues were the most commonly reported problem cited (46%). Transport-related issues were wide ranging and included: high transport costs, problems with refrigeration during the long journey, the distance food travelled to the remote location, and variable road conditions (e.g. seasonal flooding making access to the community difficult or impossible). Managers said that the limited variety of food available was due to high transport costs, summed up by one store manager ‘... an order of A$2500 worth of food costs A$2000 to transport, which is a ridiculous price’.

Specific problems relating to fruits and vegetables were identified by 20% of the store managers. Infrequent delivery, coupled with lack of storage and the impact of the freight cost on retail price reduced fruit and vegetable affordability. One store manager said that delivery of fresh food was sometimes delayed for 3–5 weeks due to poor road conditions and the road being washed away during the wet season.

Poor store condition, the high cost of maintenance, and lack of capacity to undertake repairs were concerns for two stores; one store reported that there was a lack of running water, while another said that communication problems within the community were of major concern. Table 3 provides a summary of store manager responses to the survey.

Table 3.  Community store managers’ responses to issues related to food security in Western Australia (n = 33)

Most stores (81%) had an electronic point-of-sale system: 35% had the MYOB Retail Manager system; 31% had an alternative program, and 16% did not know the name of their current program. Of the 18% who did not have an electronic point-of-sale system, a third said they would like to install one, and two-thirds saw no need because their stores were small or they were happy with their current practice.

Only 22% of store managers said a nutritionist worked directly with them at the store; however, although they had access to a nutritionist, most could not recall the duration or frequency of their involvement. Some said they did not need access to a nutritionist as they thought that the nutritionist currently working with the community (in a clinical role) or with the school was enough. A lack of money to employ staff and the feeling that customers would not be interested in speaking to nutritionists at point-of-sale were other reasons given for not needing access to a nutritionist. There was also complacency about the value of healthy eating; one manager said people in his community already knew the health risks of a poor diet, but still ‘…they only want to buy pies, sausages and coke and they do not want to change their diet’.