Spatial and Spatio-temporal Epidemiology 11 (2014) 23–32

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Spatial and Spatio-temporal Epidemiology

journal homepage: www.elsevier.com/locate/sste

Original Research

Geographic access to healthy and unhealthy food sources

for children in neighbourhoods and from elementary schools
in a mid-sized Canadian city
Rachel Engler-Stringer a,⇑, Tayyab Shah b, Scott Bell b, Nazeem Muhajarine c
a
Department of Community Health and Epidemiology, University of Saskatchewan, 104 Clinic Place, Saskatoon, Saskatchewan, Canada
b
Department of Geography and Planning, University of Saskatchewan, Canada
c
Department of Community Health and Epidemiology, University of Saskatchewan, Canada

a r t i c l e i n f o a b s t r a c t

Article history: We examined location-related accessibility to healthy and unhealthy food sources for
Received 11 March 2014 school going children in Saskatoon, Saskatchewan. We compared proximity to food sources
Revised 23 June 2014 from school sites and from small clusters of homes (i.e., dissemination blocks) as a proxy
Accepted 12 July 2014
for home location. We found that (1) unhealthy food sources are more prevalent near
Available online 19 July 2014
schools in lower income than higher income neighbourhoods; (2) unhealthy compared
to healthy food sources are more accessible from schools as well as from places of resi-
Keywords:
dence; and (3) while some characteristics of neighbourhood low socio-economic status
Food environment
Children
are associated with less accessibility to healthy food sources, there is no consistent pattern
Nutrition of access. Greater access to unhealthy food sources from schools in low-income neighbour-
Geographical information systems hoods is likely a reflection of the greater degree of commercialization. Our spatial exami-
nation provides a more nuanced understanding of accessibility through our approach of
comparing place of residence and school access to food sources.
Ó 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

1. Background Food environments specifically are increasingly being

Rising rates of overweight and obese children in Canada
(Statistics Canada, 2010) and around the world (Wang and
Lobstein, 2006) are of concern due to health problems that
continue throughout the lifespan. Traditional approaches to
obesity intervention have focused on downstream inter-
ventions (educational, behavioural, and pharmacological)
and to date have produced limited success (Neff et al.,
2009; Jebb et al., 2007; Drewnowski, 2005). Given this,
solutions to the obesity epidemic are increasingly sought
upstream in the causal chain, in neighbourhood environ-
ments where children learn, play, and form life-long habits.
⇑ Corresponding author. Tel.: +1 306 966 7839.
E-mail addresses: rachel.engler-stringer@usask.ca (R. Engler-Stringer),
tayyab.shah@usask.ca (T. Shah), scott.bell@usask.ca (S. Bell), nazeem.
muhajarine@usask.ca (N. Muhajarine).
recognized as a critical determinant of community and pop-
ulation health (Townshend and Lake, 2009; Kirk et al., 2010;
Glanz et al., 2005). North American environments generally
promote food that is packed with calories (energy-dense
food) and offer little incentive for living an active lifestyle
(Swinburn et al., 1999), particularly in low income neigh-
bourhoods (Cummins and Macintyre, 2006). This research
is part of a larger study characterizing the food environ-
ment in Saskatoon, Saskatchewan for families with children
aged 10–13 years (Engler-Stringer et al., 2014). We have
chosen to focus on children aged 10–13 years for various
reasons. First, these pre-adolescent years are a time of rapid
physiological and psycho-social changes, and habits formed
during these years can impact behaviour throughout the
lifespan. Second, children in this age group are still quite
dependent on their caregivers for meals, but they are also
beginning to make their own food choices.

http://dx.doi.org/10.1016/j.sste.2014.07.001
1877-5845/Ó 2014 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
24 R. Engler-Stringer et al. / Spatial and Spatio-temporal Epidemiology 11 (2014) 23–32
There is a growing body of research examining the food
environments around schools, much of which focuses on
the distance between food stores and fast food restaurants
and schools (Austin et al., 2005; Day and Pearce, 2011;
Jennings et al., 2011; Kestens and Daniel, 2010; Robitaille
et al., 2010; Skidmore et al., 2009; Frank et al., 2006;
Seliske et al., 2009). A greater density of fast-food restau-
rants or convenience stores around schools in lower
socio-economic status (SES) neighbourhoods has been
found in various communities in Canada and elsewhere
(Day and Pearce, 2011; Kestens and Daniel, 2010;
Robitaille et al., 2010). The distance to and density of
fast-food restaurants have been associated with children’s
poorer food choice (Skidmore et al., 2009) and increased
weight status (Jennings et al., 2011).
Researchers in Quebec, Canada, have found that most
public schools in the province are located within a short
walking distance of at least one convenience store or fast-
food restaurant, and that schools in lower SES neighbour-
hoods are significantly more likely than schools in higher
SES neighbourhoods to have a fast-food restaurant within
walking distance (Robitaille et al., 2010). But, Kestens and
Daniel (2010) question if the reason for greater access to
unhealthy food for schools in lower income, compared to
higher income areas, is because areas with higher commer-
cialization show lower income levels. Gaps remain in
understanding if low-income neighbourhoods as a whole
have greater access to unhealthy food sources, or if only
schools in low-income neighbourhoods do.
Researchers across North America are arguing that
there is a clear need to explore the food environments of
children given the likely long-term health effects children
may experience due to poor nutrition and the limited
research available in this area (Baker et al., 2007; Branen
and Fletcher, 1999; Nicklaus et al., 2005). The purpose of
this research is to understand the location-related accessi-
bility to healthy and unhealthy food sources for children
aged 10–13 years attending elementary schools in a mid-
sized city in Canada, and to explore the neighbourhood fac-
tors that are associated with this accessibility. Elementary
schools in Saskatchewan include kindergarten to eighth
grade, and therefore children up to age fourteen. Our spe-
cific focus on this age group is their increased mobility and
ability to make some food purchasing decisions (Borradaile
et al., 2009), but also because they are not old enough to
drive, and therefore are more likely limited to within
neighbourhood travel.
The first objective of this research is to examine
whether elementary schools in lower socioeconomic
neighbourhoods, are more accessible (closer) to conve-
nience stores and fast food outlets (unhealthy food
sources) compared to elementary schools in higher socio-
economic status neighbourhoods. Then, to better under-
stand if greater geographical access to unhealthy food
outlets from schools in low-income neighbourhoods is a
reflection of a greater degree of commercialization of
low-income neighbourhoods, our second objective is to
determine the differences in distance-related accessibility
to unhealthy versus healthy food outlets between elemen-
tary schools and geographical centres of neighbourhoods.
Finally, our third objective is to explore whether neigh-
bourhood factors (socioeconomic, demographic) are asso-
ciated with distance-related accessibility to healthy and
unhealthy food sources, from elementary schools and from
places of residence as well as to find the direction of the
association between them.
2. Methods
2.1. Study location
This research was conducted in the City of Saskatoon,
Saskatchewan to investigate the geographic accessibility
to healthy and unhealthy food outlets for children aged
10–13 years. Saskatoon is a medium-sized Canadian city,
with about 253,000 residents, which makes it feasible to
collect in-depth information on the food environment in
the city as a whole (Engler-Stringer et al., 2014). Significant
health inequalities at the neighbourhood level have been
identified in Saskatoon’s low-income neighbourhoods
(Lemstra et al., 2006; Lemstra and Neudorf, 2008). These
inequalities are strongly associated with inequities in key
social determinants of health, i.e., income, education, and
Aboriginal cultural status, a trend found in Canada and the
world (Marmot, 2010; Canadian Institute for Health
Information, 2008; Mackenbach, 2006; Comission on
Social Determinants of Health, 2008). The health of Aborig-
inal populations is a particular concern in Saskatoon, where
1 in 10 self-identify as Aboriginal (vs 3.8% in Canada overall).
2.2. Data collection procedures
In order to geolocate the elementary schools (from kin-
dergarten to grade eight) in Saskatoon (n = 76), we started
with a list of all schools (and their addresses) located
within the boundaries of the City of Saskatoon. There are
three school boards – Public, Catholic (still within a system
of public funding), and Francophone, along with a small
number of private schools operating in the city of Saska-
toon.1 For this research, 43 public and 33 Catholic elemen-
tary schools were included and their address information
was downloaded from the Saskatoon Public Schools Division
and Greater Saskatoon Catholic Schools websites respec-
tively. We did not include the two Francophone and six pri-
vate schools in our analyses, which are less than 10% of
schools in the city.
In November 2010 we accessed a constantly updated City
of Saskatoon business licenses database from which we
extracted listings for grocery and convenience stores, as
well as fast food restaurants. Fast food restaurants are those
without wait staff, where patrons pay for meals before
receiving them and either self-carry the food to tables or
take it out (Austin et al., 2005). We have included in the cat-
egory of fast food restaurants chain coffee and donut shops
where food is available at low cost. Only fast food restau-
rants were included, rather than all restaurants, because
these are restaurants that offer food at a price point that is
accessible to children. Similar to other food environments
1
http://www.livingsaskatoon.com/education/elementary-and-high-
schools/.
 R. Engler-Stringer et al. / Spatial and Spatio-temporal Epidemiology 11 (2014) 23–32
research, we categorized convenience stores and fast food
restaurants as unhealthy food outlets because the majority
of the food choices available in these outlets are calorie-
dense and not usually nutrient-dense (Kestens and Daniel,
2010; Robitaille et al., 2010; Jennings et al., 2011). We cate-
gorized full-service grocery stores as healthy food outlets
because they contain a much wider range of healthy foods.
Grocery stores (chain or non-chain) were categorized as
such if they contained a full range of food categories, and
as convenience stores if they contained a narrower range
of foods. We did not include the category of specialty food
stores which are those that focus on one product category
only such as bakeries or health food stores.
The business database contained the latitudes and lon-
gitudes of each business location, with which we could
geolocate food outlets. We cross-checked the list from
the business license database with information from the
phone book. From this preliminary list, the research team,
with their knowledge of the city gained from past neigh-
bourhood-based built environments research, made
updates to include food outlets that had been missed.
The list of food outlets was later completed in February
of 2011 when research assistants went into each neigh-
bourhood to administer the Nutrition Environment Mea-
sures Survey for Stores (NEMS-S) (Glanz et al., 2007) and
the Nutrition Environment Measures Survey for Restau-
rants (NEMS-R) (Saelens et al., 2007). At that time, research
assistants found that some outlets had closed while others
had opened (or were otherwise not previously included on
the list). We used addresses in order to map all additional
food outlets found. Please see our larger study description
for more details on this process (Engler-Stringer et al.,
2014). In total 29 grocery stores (i.e., healthy food outlets),
and 156 convenience stores and 190 fast food restaurants
(i.e., 346 unhealthy food outlets) were included in our
analyses. Fig. 1 shows the study area including the loca-
tions of the food outlets and elementary schools.
The smallest Canadian census areal unit (i.e., dissemina-
tion block ‘‘DB’’)2 was considered a proxy to represent the
place of residence of the population of children attending
elementary schools and DB centroids were used to calculate
distance. Based on 2006 Census, there were 1825 DBs
(excluding 367 DBs having no population) with a mean pop-
ulation of 1113 in the study area. In Saskatoon, DBs are
almost exclusively a collection of only a few residential
blocks. Without accurate information about the home loca-
tion of every 10–13 year old child in the city, we felt this loss
of precision was a suitable trade off in order to estimate a
general distance of where children live to where they might
access healthy and unhealthy food outlets.
2.3. Data analyses
Initially, we calculated the road network distance from
elementary schools and places of residence to all food out-
lets by following three inter-related steps; Step 1 considers
2
http://www12.statcan.gc.ca/census-recensement/2011/ref/dict/
geo014-eng.cfm.
3
http://www12.statcan.gc.ca/census-recensement/2006/ref/dict/tables/
table-tableau-1-eng.cfm.
25
the proximity of healthy and unhealthy food outlets to
schools or DB centroids, Step 2 focuses on a comparison
of healthy and unhealthy food outlets by neighbourhood,
and Step 3 explores the associations between neighbour-
hood socio-demographic factors and access to healthy/
unhealthy food outlets from schools and from place of res-
idence by linear regression techniques. We preferred dis-
tance measures over the other methods (e.g., density
measures, buffers, etc.) in determining the proximity of
food outlets in part because they have no service restric-
tions or quota. The input datasets included were of three
types: a municipally defined neighbourhood layer (City of
Saskatoon, 2010) as a unit of analysis, the CanMAP Street-
files (DMTI Spatial, 2011) for the estimation of road net-
work distance, and Statistics Canada’s 2006 population
and dwelling census demographic data at the neighbour-
hood level (a customized 2006 Census data product for
the City of Saskatoon).
In order to calculate the distance from school locations
and DB centroids (or population centres) to the nearest
food outlets, the origin–destination (OD) cost matrix anal-
ysis was performed (ESRI, 2012). OD cost matrix solver is a
tool in the Network Analyst extension of ArcGIS that is nor-
mally used for larger datasets to measure the shortest
routes (or least-cost paths) along the network from multi-
ple origins to multiple destinations (ESRI, 2012). In this
research, school locations (n = 76) and DB centroids
(n = 1825) are set as origin locations while food outlet loca-
tions (n = 375) are added as destinations. We repeatedly
applied the OD cost matrix solver to calculate the shortest
paths along the road network from both school locations
and DB centroids to food outlets. In both cases, the follow-
ing analysis parameters (used to find the location of a point
from a network) were assigned to create the OD cost
matrix to ensure all locations were used in the analysis;
allowed U-turns, no lane restrictions, and a 100 m search
tolerance. The value of the shortest network path for each
origin–destination pair was stored in an attribute table
(OD cost matrix), which was then joined back to its respec-
tive spatial layers for further analysis.
Statistical and analytical treatment of distance mea-
sures in both spatial and tabular formats is completed in
three inter-related steps. In Step 1, we examined the prox-
imity of food outlets to elementary schools and DB cen-
troids to determine which type (healthy versus
unhealthy) tended to be closest. This is similar to the
method chosen by Kestens and Daniel (2010), and
Robitaille et al. (2010). 750 m (or about 15 min walking)
from each school location (n = 76) to healthy and
unhealthy food outlets in all directions was selected to
reflect destinations within a reasonable walking distance
(Seliske et al., 2012). Next we calculated the number of
healthy food outlets (grocery stores) and unhealthy food
outlets (convenience stores and fast-food restaurants)
located within the 750 m road network distance from each
school. We also calculated the proportion of schools with
and without each food outlet type within 750 m.
In Step 2, we investigated whether accessibility to
unhealthy versus healthy food outlets differs by neigh-
bourhood SES. For this, the distance from both schools
and DB centroids to the nearest healthy and unhealthy
26 R. Engler-Stringer et al. / Spatial and Spatio-temporal Epidemiology 11 (2014) 23–32
Fig. 1. Study area – Saskatoon neighbourhood map with locations of food outlets and elementary schools.
food outlets was measured using road networks. Next, by
using a locally defined neighbourhood boundary layer
(boundaries chosen by municipal government and well
known to residents), a neighbourhood score was calculated
by averaging the distance values for all schools as well as
DB centroids for healthy food outlets falling within a
neighbourhood. A similar procedure was applied to dis-
tances for all schools and DB centroids for unhealthy food
outlets to calculate neighbourhood scores.
For Step 3, we examined whether neighbourhood socio-
demographic characteristics are associated with access to
unhealthy/healthy food outlets from schools and places of
residence (DB centroids). To understand the relationship
between geographic accessibility to convenience stores
and fast food restaurants and neighbourhood socio-demo-
graphic factors, 2006 census data was used. In Canada, use
of census data is not new for micro-level analyses (e.g., cen-
sus tracts, city defined neighbourhoods, dissemination
areas, etc.) of distribution of social and healthcare resources
in relation to population needs (Chateau et al., 2012;
Matheson et al., 2012; Pampalon et al., 2012; Bell and
Hayes, 2012). After considering the data availability and
theoretical significance of socio-demographic variables that
are discussed in the literature (Chateau et al., 2012;
Matheson et al., 2012; Pampalon et al., 2012; Bell and
Hayes, 2012), we finalized a set of eight variables for this
study. One of these variables, housing affordability 2006 is
a derived variable that is an index of average household
income for Saskatoon compared to the average house price
for each neighbourhood (City of Saskatoon, 2007).
To explore the relationship between dependent vari-
ables and socio-demographic characteristics, a linear
regression (Ordinary least squares ‘‘OLS’’ regression) was
used. The four dependent variables are as following: a) dis-
tance to nearest healthy food outlet, b) distance to nearest
unhealthy food outlet, from each of DB centers and ele-
mentary school locations (2  2). All of these are continu-
ous variables. The exploratory regression tool in ArcGIS
software (similar to the forward stepwise method) was
applied to select the best possible model in each case
(Rosenshein et al., 2011). Table 1 shows the results
obtained from the OLS regression. Final models were
tested for the presence of spatial autocorrelation, a mea-
sure of spatial dependence, in the regression residuals.
We recalculated the selected OLS models (Model 1-Model
4) with a spatial weight matrix – queen contiguity (first
order neighbours, row-standardized) to estimate the Mor-
an’s I statistics (MI) using Geoda software (Anselin, 2004;
Anselin et al., 2006, 2010). There was only one model
(i.e., Model 2) that indicated the presence of spatial depen-
 R. Engler-Stringer et al. / Spatial and Spatio-temporal Epidemiology 11 (2014) 23–32 27

Table 1
Healthy food outlets mean distances from neighbourhoods and schools.
Mean distance from centre of neighbourhoods to nearest healthy food outlet
Distance (meters) 250- 500- 750- 1000- 1250- 1500- 1750- 2000- 2250- NH
<250 >2500
500 750 1000 1250 1500 1750 2000 2250 2500 Count
0-250
Mean distance from school to
nearest healthy food outlet

250-500 1 1
500-750 5 3 1 9
750-1000 1 3 1 5
1000-1250 1 7 1 1 10
1250-1500 2 2
1500-1750 1 2 1 4
1750-2000 1 2 1 4
2000-2250 1 1 2
2250-2500 1 1 2
>2500 2 3 5

Table 2
Unhealthy food outlets mean distances from neighbourhoods and schools.
Mean distance from centre of neighbourhoods to nearest unhealthy food outlet
Distance (meters) 250- 500- 750- 1000- 1250- 1500- 1750- 2000- 2250- NH
<250
500 750 1000 1250 1500 1750 2000 2250 2500 >2500 Count
0-250 1 2 3 6
Mean distance from school to
nearest unhealthy food outlet

250-500 6 8 14
500-750 3 7 4 14
750-1000 3 3
1000-1250 2 1 1 4
1250-1500
1500-1750 1 1
1750-2000
2000-2250
2250-2500 2 2
>2500
NH Count 1 11 18 9 1 1 1 2 44

dence in the regression residuals (MI = 0.254; p = 0.001).
This means the rest of the three models (Models 1, 3, and
4) have no spatial dependence and we can use the coeffi-
cient values estimated with the (non-spatial) OLS models.
In the case of Model 2 where the presence of spatial depen-
dence is indicated, we ran spatial regression as an alterna-
tive to account for the spatial autocorrelation. We ran
spatial lag regression and spatial error regression correc-
tions to adjust for spatial correlation and found that the
spatial error regression model was a better fit for the data
(AIC for OLS = 935.8; for spatial lag = 928.6, and for spatial
error = 923). In Table 1, Model 2 estimates are based on a
spatial error model.
3. Results
3.1. Accessibility to unhealthy food sources from elementary
schools by neighbourhood income level
There were a total of 10 schools (12.8%) located within a
750 m walking distance of a grocery store. We found 38
schools (48.7%) within a 750 m walking distance of at least
one convenience store and 21 schools (26.9%) within a
750 m walking distance of at least one fast food restaurant.
All together, across the city, 40 schools (51.3%) were
located within walking distance of at least one fast food
restaurant or convenience store. Table 2 presents the
number of each type of food store and restaurant within
750 m walking zones around each school.
Next, similar to Kestens and Daniel (2010), we exam-
ined the proportion of schools that are within walking dis-
tance of healthy or unhealthy food outlets in the highest
and lowest income quartile of neighbourhoods. Of the 21
elementary schools within the lowest income quartile
neighbourhoods 15 (or 71.4%) are located within walking
distance of a fast food restaurant or a convenience store.
In addition, 7 of these 15 schools (33.3%) are located within
walking distance of multiple fast food restaurants or con-
venience stores (unhealthy food outlets). In contrast, of
the 17 elementary schools within highest income quartile
neighbourhoods, only 6 of these (35.3%) have a fast food
restaurant or convenience store within walking distance;
further, none have more than one of these unhealthy food
outlets within walking distance.
3.2. Accessibility to healthy versus unhealthy food sources
from elementary schools or places of residence
A score was created for each individual neighbourhood
by averaging the distance values for all schools as well as
DB centroids to healthy and unhealthy food outlets that fall
within the neighbourhood boundary. The neighbourhood
scores obtained in all four cases are presented in Fig. 2
(maps a–d) and Tables 2 and 3. In Fig. 2, maps a-b show
28 R. Engler-Stringer et al. / Spatial and Spatio-temporal Epidemiology 11 (2014) 23–32

Fig. 2. Patterns of average distance to healthy and unhealthy food sources from elementary schools and neighbourhood geographical centres (based on a
neighbourhood score). Map a shows the mean distance (meters) of DB centroids to nearest healthy and map b unhealthy food outlets whereas the map c is
presenting the mean distance (meters) of schools to nearest healthy and map d unhealthy food outlets.

Table 3
Regression models showing significant neighbourhood factors associated with four outcome variables: distance from centre of neighbourhoods and elementary
schools to healthy or unhealthy food outlets.

Variables Distance from DB centroid to nearest food store Distance from school location to nearest food store
Unhealthy (Model 1) Healthy (Model 2)⁄ Unhealthy (Model 3) Healthy (Model 4)
b (p-values) b (p-values) b (p-values) b (p-values)
Constant 244.5 (0.038) 1785.8 (<0.001) 341.2 (0.158) 2174.9 (0.017)
Neighbourhood factor
Children aged 5–14 61.5 (<0.001) 63.8 (<0.001) 44.6 (0.011) 124.5 (<0.001)
Aboriginal population 25.6 (<0.001)
Housing affordability 2006 139.8 (0.089)
Lone parents 27.0 (<0.001)
Recent immigrants 2001–06 55.5 (0.005)
Unemployment rate 50.9 (0.002)
Low Income (LICO) families 30.7 (0.036)
Residential mobility (5 years) 35.6 (0.032)
Lambda (spatial error model) 0.62 (<0.001)
Adjusted R-squared 0.446 0.371 0.262 0.198
AIC 867.5 923.7 632.2 676.3
Degrees of freedom (df) 57 55 40 39
Moran’s index (residuals) 0.053 (0.786) 0.011 (0.353) 0.148 (0.150) 0.162 (0.102)

Significant at the 0.05 level
 R. Engler-Stringer et al. / Spatial and Spatio-temporal Epidemiology 11 (2014) 23–32
the 60 residential neighbourhoods (based on DB centroids)
whereas maps c-d show only the 44 neighbourhoods
where elementary schools are found. Comparison of
patterns in maps a–b show that the distance to healthy
food outlets (map a) is much greater than the distance
to unhealthy food outlets in a typical neighbourhood
(map b). This same pattern holds for schools, meaning that
accessibility is greater (shorter distance) to unhealthy
food outlets than to healthy food outlets from schools as
well.
Tables 2 and 3 compare results based on unhealthy and
healthy food outlets to show the cross tabulated relation-
ship between distance from places of residence and dis-
tance from schools to: unhealthy food outlets in Table 3
and healthy outlets in Table 2. Tables 2 and 3 show that
there are more neighbourhoods that are closer to unhealthy
food outlets whether from places of residence or from
schools (indicated by a greater number of neighbourhoods
clustered to the top left in Table 3) as compared to healthy
food outlets (shown by a more even, diagonal distribution
of neighbourhoods in Table 2). The colours in the cross clas-
sified neighbourhoods in Tables 2 and 3 represent the fol-
lowing: (1) neighbourhoods on the diagonal in grey are
neighbourhoods where the distance from school and neigh-
bourhood are equal; (2) neighbourhoods in the off-diagonal
in green favour schools over neighbourhoods, i.e., schools
have greater access to healthy eating sources than the
neighbourhood as a whole; (3) neighbourhoods in the off-
diagonal in red are those where the neighbourhood as a
whole has greater access to healthy foods than schools. In
essence, three types of neighbourhoods are depicted: good
neighbourhoods for school children in terms of easier
access to healthy foods are indicated in green, bad neigh-
bourhoods for school children in terms of greater access
to unhealthy food indicated in red, and neighbourhoods
where geographic access is equal in grey.
3.3. Neighbourhood factors associated with accessibility to
healthy versus unhealthy food sources from elementary
schools or centres of neighbourhoods (DB centroids)
Table 1 shows the regression results. The results of the
correlational analysis for the four dependent and eight SES
variables are shown in Tables 4 and 5. Neighbourhoods
with a higher proportion of children aged 5–14 in each
model are significantly related to each of the dependent
variables (less access to all four dependent variables, so
both healthy and unhealthy food sources). The larger the
proportion of Aboriginal population in a neighbourhood,
the more likely it was to have access to unhealthy food
outlets from place of residence (measured by DB cen-
troids); however, this was not related to any other depen-
dent variables. In testing the relationship between
socioeconomic variables and access to healthy and
unhealthy food outlets, we found that neighbourhoods
with greater housing affordability (2006), a larger propor-
tion of lone parents, and a larger proportion of recent
immigrants (from 2001 to 2006) are more likely to have
greater access (shorter distance) to healthy food outlets
from place of residence (i.e., DB centroids) than from
schools. Neighbourhoods with a larger proportion of low
29
income families and higher residential mobility scores
(5 years) are more likely to have greater access to healthy
food outlets from schools compared to place of residence
(DB centroids); whereas neighbourhoods with higher
unemployment rates are associated with greater access
to unhealthy food sources from schools compared to place
of residence.
In summary, we found that schools in the lowest
income neighbourhoods had twice as many unhealthy food
outlets within walking distance. We also found that a third
of the schools in the lowest income quartile neighbour-
hoods had more than one unhealthy food outlet within
walking distance, compared to none in the highest income
quartile. However, when we compared healthy and
unhealthy food accessibility from elementary schools and
neighbourhoods overall, only a few significant differences
were found. Overall, we did not find a consistent pattern
of significant differences between access to unhealthy food
sources from schools compared to neighbourhoods. Also,
significant differences in geographic access to unhealthy
food options in neighbourhoods overall were not found,
except that the larger the Aboriginal population in a neigh-
bourhood, the more likely it was to have access to
unhealthy food outlets from place of residence (DB cen-
troids). Similarly, the higher unemployment rate neigh-
bourhoods are associated with greater access to
unhealthy food outlets from schools.
4. Discussion
The pattern of these results indicates that children
attending school in disadvantaged neighbourhoods have
fewer healthy food options and are generally surrounded
by unhealthy opportunities. Overall we show that there
are more elementary schools with nearby unhealthy food
sources in lower income neighbourhoods than higher
income neighbourhoods (71% vs 35%). Also, unhealthy food
sources, compared to healthy food sources, are closer
(more accessible) to schools as well as centres of neigh-
bourhoods. Finally, some neighbourhood factors—higher
housing affordability, higher proportion of lone parents,
and higher proportion of recent immigrants—were inde-
pendently associated with greater accessibility (shorter
distance) to healthy food sources (grocery stores).
Our results indicating that lower income neighbour-
hood elementary schools have elevated access to
unhealthy food sources is consistent with results from
other Canadian jurisdictions (Kestens and Daniel, 2010;
Robitaille et al., 2010). It is unclear though what this means
for consumption of unhealthy foods available in these loca-
tions, and we agree with Kestens and Daniel (2010) that
further research is necessary to document food consump-
tion among elementary school children in relation to these
unhealthy food source locations. One study that has docu-
mented children’s convenience store purchases in outlets
near their schools, concluded that these purchases make
a significant contribution to their energy intake
(Borradaile et al., 2009).
There is evidence to indicate that food and eating habits
developed in childhood continue into the adult years
 30
Table 4
Correlation – distance from DB centroid to nearest unhealthy/healthy food outlet (FO) (n = 65).

Correlations (Pearson) Un-healthy Children aged 5–14 Aboriginal Housing affordability Lone Recent immigrants Un-employment Low Income Residential
FO Pop. 2006 parents 2001–06 rate families mobility
Healthy FO .753** .389** .045 .056 .200 .168 .046 .133 .148
Un-healthy FO 1 .270* .232 .344** .466** .007 .261* .319* .068
Children aged 5–14 1 .464** .051 .241 .108 .132 .194 .113
Aboriginal Pop. 1 .687** .787** .016 .664** .720** .204
Housing affordability 1 .623** .261* .563** .777** .247
2006

R. Engler-Stringer et al. / Spatial and Spatio-temporal Epidemiology 11 (2014) 23–32

Lone parents 1 .058 .469** .575** .072
Recent immigrants 1 .038 .497** .558**
2001–06
Unemployment rate 1 .677** .271*
Low Income families 1 .417**
Residential mobility 1
**
Correlation is significant at the 0.01 level (2-tailed).
*
Correlation is significant at the 0.05 level (2-tailed).

Table 5
Correlation - Distance from school location to nearest Unhealthy/healthy food outlet (FO) (n = 44).

Correlations (Pearson) Un-healthy Children aged 5–14 Aboriginal Housing affordability Lone Recent immigrants Un-employment Low Income Residential
FO Pop. 2006 parents 2001–06 rate families mobility
Healthy FO .522** .335* .007 .028 .053 .133 .013 .133 .140
Un-healthy FO 1 .252 .339* .374* .325* .093 .344* .406** .416**
Children aged 5–14 1 .287 .011 .071 .007 .049 .099 .322*
Aboriginal Pop. 1 .775** .822** .025 .787** .914** .542**
Housing affordability 1 .765** .034 .621** .758** .568**
2006
Lone parents 1 .067 .648** .797** .569**
Recent immigrants 1 .123 .215 .169
2001–06
Un-employment rate 1 .799** .622**
Low income families 1 .726**
Residential mobility 1
**
Correlation is significant at the 0.01 level (2-tailed).
*
Correlation is significant at the 0.05 level (2-tailed).
 R. Engler-Stringer et al. / Spatial and Spatio-temporal Epidemiology 11 (2014) 23–32
(Nicklaus et al., 2005; Kelder et al., 1994; Mikkilä et al.,
2005). On the other hand, we echo the concerns of other
researchers who have asked whether spatial food access
is as important a food environment indicator as has been
assumed to date (Charreire et al., 2010; Lytle, 2009).
Regardless, previous research has indicated that the dis-
tance to and density of food outlets are associated with
children’s food choices, but the impact is not large
(Skidmore et al., 2009). Also, Skidmore et al. (2009) have
argued that food choices are cumulative and while impacts
may appear to be small, they may be important for
increases in bodyweight over time. Finally, given that
unhealthy diet is so prevalent and a constant exposure,
the attributable fraction of unhealthy diet is likely to be
larger than other exposures that are less prevalent.
Our results seem to be consistent with the thesis that
greater access to unhealthy food sources from schools in
low-income neighbourhoods is more likely to be a reflec-
tion of the greater degree of commercialization of low-
income neighbourhoods, rather than the purposeful loca-
tion of unhealthy food sources near schools in low-income
neighbourhoods in particular (Kestens and Daniel, 2010).
Recent discussions about the issue of food swamps
(Fielding and Simon, 2011), urban environments with per-
vasive access to unhealthy food sources, particularly in
Canadian urban food environments (Canada, 2013) are rel-
evant here. In order to be consistent with our findings, per-
haps policy recommendations should focus more often on
both increasing access to healthy food sources, and limit-
ing access to unhealthy food sources (especially around
schools). Further research would be beneficial to discover
if the results found here are consistent in other
jurisdictions.
5. Conclusions
Our study found that unhealthy food sources are more
prevalent near schools in lower income neighbourhoods
than higher income neighbourhoods. Also, overall
unhealthy food sources, compared to healthy food sources,
are closer to schools as well as places of residence. Our
findings support the argument that greater access to
unhealthy food sources from schools in low-income neigh-
bourhoods is more likely to be a reflection of the greater
degree of commercialization of low-income neighbour-
hoods, rather than the purposeful location of unhealthy
food sources near schools in low-income neighbourhoods
in particular (Kestens and Daniel, 2010). Future research
on food environments would benefit from analyses of the
changing patterns of retail development in North American
urban environments. In particular, studies that take both
historical and business model perspectives on when and
where different food source types developed (for example,
larger or ‘big box’ format grocery stores versus smaller
neighbourhood stores, fast food restaurants, and conve-
nience stores) would be particularly useful. Overall, our
approach to examining spatial food access provides a more
nuanced understanding of accessibility than much of the
research to date through analyses that compare both home
and school access, and the differences between the two.
31
5.1. Study limitations
This is an ecological study and therefore results should
be interpreted with caution. It should also be noted that
elementary schools from the Public and Catholic schools
boards are included in this study. Omission of private
schools and Francophone schools from analysis may
slightly underestimate the accessibility scores. It should
also be noted that DB centroids, which represent the place
of residence and locations of schools and food outlets, may
carry some positional errors (for more details, see Griffith
et al., 2007; Zandbergen, 2007). Our study assumes that
children attend schools within their home neighbourhood,
which may or may not be the case. Finally, while we have
categorized fast food outlets and convenience stores as
unhealthy food outlets, this study does not actually report
on measures of the healthfulness of food within those out-
lets, and therefore may be misleading.
6. Conflict of interest
The authors declare that they have no competing inter-
ests. RES is the Principal Investigator of the larger study of
which this publication is one part. She conceived of the
research idea and guided the study design, primarily wrote
the introduction, discussion and conclusions. TS worked on
study design, carried out the analysis and primarily wrote
the methods and results sections. SB guided study design
and contributed to the methods and results sections. NM
is the co-Principal Investigator of the larger study of which
this publication is a part. He contributed to the research
idea and study design and contributed to the editing of
the publication. All authors read and approved the final
manuscript.
Acknowledgements
This research was funded by the Canadian Institutes for
Health Research (Grant #106643). We would like to
acknowledge the Smart Cities, Healthy Kids: Food Environ-
ment research team for their contributions to this research.
This study received approval from the Behavioural
Research Ethics Board at the University of Saskatchewan.
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