FAQ

The FET was developed to facilitate the collection of data that can: provide insights into the relationship between diets and people’s food environment, measure changes in food environments over time, and to help identify potential levers for interventions and policies that target food environments. The FET was designed to provide researchers and practitioners with a systematic and practical set of assessments to measure the external (i.e., objective) and perceived (i.e., personal) food environment in dynamic low- and middle-income country settings (LMICs), including wild, cultivated, and built environments.  

The development of the FET took place over the course of two and a half years. We engaged in a series of steps to develop the FET and to address our project aims, which were to: 1) Develop Perception-based FE Tool for LMICs; 2) Modify existing external FE Tools for LMICs; 3) Pilot Test and Refine FE Tools; and 4) Develop FE Toolbox Protocols. This figure provides an overview of those steps. To the extent possible, we built on existing tools measuring the food environment, particularly the USAID Advancing Nutrition Guidelines for Market-Based Food Environment Assessments.1 Overall, the process of developing the tools was incredibly iterative and included Delphi surveys and in-country workshops with food environment experts, cognitive testing, and piloting of the tools in urban (high- and low-income), peri-urban, and rural settings in both India and Cambodia. After the pilot testing, we removed one of the tools (the Produce Desirability Tool) from the Toolbox, given that it did not sufficiently capture the quality dimension of the food environment in LMIC settings.

This introduction provides an overview of the FET, its development, and how to use it. Alongside this introduction, you will find the suite of assessments, their instructions manuals, data collection programming files, and ‘how to videos’ to help provide an overview of their use. We also provide instructions to help guide the analysis of the data collected using the FET assessments. 

There are several definitions of food environments that have been published in the literature. We define the food environment as: “the consumer interface with the food system that encompasses the availability, affordability, convenience, promotion and quality, and sustainability of foods (Downs et al., 2020).” Food and beverages can be acquired from different types of food environments including the built (informal and formal), natural (cultivated and wild), kin and community, and supplemental food assistance and aid (see definitions for these food environment types below). The food environment assessments included in the FET are designed to be applicable to these different food environment types and can be used to identify the different food environment types in a community. 

Overview of food environment types (Adapted from: Downs et al., 2020, Bogard et al., 2021)

• Natural food environments include both wild (e.g., water bodies, wetlands, forests, jungles, etc.) and cultivated (e.g., fields, gardens, pastures, etc.) environments where people access food for their own consumption.  
•  Built food environments includes both informal and formal market food environments. Informal market food environments include wet markets, mobile vendors, kiosks, etc. whereas formal markets include supermarkets, restaurants, and other formal retailers. The same vendor types (e.g., street vendors) could be informal or formal, depending on the context. Formal vendors are regulated in some way, whereas informal vendors are not.   
• Kin and community (or social networks within communities) includes gift or exchange of food from friends, neighbors, or other community members, food obtained from social or cultural gatherings as well as food remittances.
• Supplemental food assistance and aid is food provided through government or non-governmental food provision systems. This includes food provided through schools, public distribution systems, etc.

In addition to having different types of food environments, there are also two overarching food environment domains: external (i.e., objective) and perceived (i.e., personal) food environments. The perceived food environment domain comprises the interaction between the external dimensions of the food environment and the individual factors that influence people’s lived experiences interfacing with their food environments. We used the definition of the personal food environment domain from the conceptual framework developed by Turner et al. (2018), including accessibility (i.e., physical distance, time, space, mode of transport, etc.), affordability (i.e., purchasing power), and convenience (i.e., relative time and effort of preparing, cooking, and consuming food as well as time allocation). To guide our conceptual framing of the external food environment we used the adapted High-level Panel of Experts report on Nutrition and Food Systems’ food environment dimensions which includes: food availability (type and diversity of foods on offer), food affordability (food prices, alone and in comparison to income and expenditures), food properties (safety, quality, appeal, convenience, and sustainability), vendor properties (location and type), and food messaging (promotion, advertising, and information about food) (Fanzo et al., 2021).  The FET assessments include tools that assess both the objective and perceived food environment.  

This table provides an overview of the assessments included in the FET as well as the types, and dimensions, of food environments that they address. We provide more detailed descriptions of each of the assessments as well as the instructions for their implementation in the Toolbox. The goal is not for every tool in the FET to capture information across all food environment types, domains, and dimensions, but rather for the different assessments to be used in a complementary way to address diverse food environments in a comprehensive way. However, researchers and practitioners can choose to select individual assessments or use the package in its entirety, depending on the goals of their projects. This figure depicts the different levels of data collection for each of the tools.

The FET has been designed to provide tools that comprehensively capture the different dimensions of food environments in diverse settings. The tools that a given researcher or practitioner decides to use will depend on their research questions, goals, and the resources available. We provide key considerations for using the FET below. For each of the assessments, you’ll find a cover page describing the tool, the tool itself, an instructions manual, a programming file (where applicable) to collect the data using electronic tablets, and a ‘how to’ video that provides an overview of the tool.

The first step is to identify the research questions and goals for a given project. The research questions will directly inform which tools you should plan to use from the FET. While the FET has been designed to include tools that measure all food environment dimensions, it is not necessary to use the Toolbox in its entirety. Researchers and practitioners are encouraged to use the tools that are relevant to their research questions. Moreover, in several of the assessments we provide optional modules. You should keep in mind your research question when deciding which modules to include in the implementation of each of the tools. We include a decision tree below to inform which assessments to use based on your research questions and project goals.

The communities that should be targeted for the food environment assessments included in the FET should be informed by the research question.

Each tool included in the FET provides an overview of sampling considerations. There is no “one size fits all” for approaching the sampling of communities, markets, vendors, or individuals as part of the FET implementation. The sampling approach will be dependent on the research questions and project goals.

The assessments included in the FET include questions that will be answered based on food groups. For each of the assessments, we provide potential food groups that can be considered. In recognition that different researchers have different needs, you can make changes to the food groups, including using validated food groups that have been used to measure diet quality such as the Diet Quality Questionnaire [1] or the Global Diet Quality Score.[2] Identifying the best food groups to use for the tools was one of the most difficult tasks of developing the Toolbox. We began by considering the Diet Quality Questionnaire food groups and making changes to these groups to make them more applicable to food environment research (e.g., including edible oils and fats). After many discussions as a team, as well as in workshops with key food environment experts in India and Cambodia, we made substantial changes to the groups. During the process of making these changes, we piloted using NOVA classifications [3] as part of the food groups; however, we found these to be difficult for enumerators to conceptualize in practice. The final list of food groups includes both a core list of food groups as well as optional groups. These food groups are used in most of the assessments included in the Toolbox. However, we encourage research teams to carefully consider the goals of their work and to make changes to the food groups as they see fit. Moreover, depending on the research questions it may make sense to solely focus on specific food groups (e.g., fruits and vegetables or animal-source foods).

[1] Project GDQ. Diet Quality Questionnaire (DQQ) Food Group Classification Guide.

[2] Intake 2022. Global Diet Quality Score Toolkit. Washington, DC: Intake – Center for Dietary Assessment/FHI Solutions.

[3] Monteiro, C.A., Cannon, G., Lawrence, M., Costa Louzada, M.L. and Pereira Machado, P. 2019. Ultra-processed foods, diet quality, and health using the NOVA classification system. Rome, FAO.

Researchers and practitioners are encouraged to review their research question, study population, and study setting to determine which FET assessments they should use and how they should be formatted. We provide guidance to help teams to format the tools based on their research needs. More specifically, we provide a pre-emptive module that researchers can complete to customize the formatting (e.g., food groups used, modules used, etc.) of the different assessments to facilitate their implementation in the field. Where relevant, changes can be made to the inclusion of food groups, food environment types, seasons, and optional modules. This process allows for the assessments to be tailored for your own work.

Many of the tools are best captured using electronic tablets. For those tools, we have provided programming files that have been formatted for use in KoboHumanitarian. However, the programming files, which are in excel, can be used with other data collection platforms with minimal changes.

It is important to always consult your Institutional Review Board (IRB) to obtain approval for your research protocol. While many of the assessments are observational, there are also components that include interactions with vendors and community members which constitutes human subjects’ research. It is important to ensure that the appropriate clearances are obtained prior to conducting the research. In addition to obtaining approval from IRBs, it is also important to ensure that any approvals and permits required from local governments, market management, etc. are obtained.

The FET allows researchers and practitioners to capture data that describes the different types, domains, and dimensions of food environments. It is not designed to measure dietary intakes or food supply chains. However, the tools included in the FET can be used alongside the collection of dietary data to examine relationships between dietary intakes and food environments or alongside food supply (or value) chain analysis to understand factors influencing food choice that are more upstream in the supply chain.

The assessments included in the FET have been pilot-tested. The face-validity has also been assessed by experts in food environment research. However, the FET has not undergone a thorough validation of the assessments at this time and we plan to continue to work towards their validation in future work.

The toolbox can be cited as:

The FET is one suite of tools that can be used to measure food environments in LMICs. However, there are many other assessments that can complement the FET in terms of comprehensively measuring food environments in LMICs. We provide examples of these resources in the instruction manuals for each tool.

This work is funded through the Innovative Methods and Metrics for Agriculture and Nutrition Action (IMMANA) programme, led by the London School of Hygiene & Tropical Medicine (LSHTM), in partnership with Tufts University and the University of Sheffield. IMMANA is co-funded with UK Aid from the UK government and by the Bill & Melinda Gates Foundation INV-002962 / OPP1211308. We are grateful for the resources and support of the IMMANA program.

We would also like to acknowledge our advisory board members (Drs. Gina Kennedy, Amos Laar, Khris Nicholas, and Chris Turner) who provided extensive feedback on the assessments throughout the FET development process. We would also like to acknowledge the River in Transition project team. Earlier versions of the tools used in that project were leveraged for the Food Environment Toolbox.

We would also like to acknowledge the participants of our Delphi survey as well as the key stakeholder workshops in India and Cambodia for their invaluable insights into modifying the assessments. The final FET assessments are much stronger thanks to their thoughtful inputs.