qualitative research in nutrition

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• > Journals
• > Public Health Nutrition
• > Volume 22 Issue 13
• > What is healthy eating? A qualitative exploration

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• Participants:
• Conclusions:

Supplementary material

What is healthy eating a qualitative exploration.

Published online by Cambridge University Press:  17 May 2019

• Supplementary materials

The present study aimed to explore how healthy food choices are translated into everyday life by exploring definitions of healthy food choices, perceptions of own food choice, and healthy food choice drivers (facilitators) and barriers.

An exploratory qualitative study design was employed using semi-structured face-to-face interviews. Convenience sampling was used to recruit participants. Interviews were audio-recorded, transcribed verbatim and cross-checked for consistency. Thematic analysis was used to identify patterns emerging from the data.

Canberra, Australia, October 2015–March 2016.

A total of twenty-three participants aged 25–60 years were interviewed. The mean age was 38 years and the mean BMI was 29·1 kg/m 2 . All male participants ( n 4) were within the healthy weight range compared with 58 % of female participants, with 26 % being overweight and 16 % being obese.

(i) Healthy food choices are important but are not a daily priority; (ii) healthy eating information is known but can be difficult to apply into everyday life; (iii) popular diets are used in attempts to improve healthy eating; and (iv) social media inspires and connects people with healthy eating.

Social media facilitates healthy food choices by providing access to healthy eating information. In addition to Facebook and Instagram, healthy eating blogs were highlighted as a source of nutrition information. Research should consider exploring the use of healthy eating blogs and whether these blogs can be used as a tool by dietitians to communicate procedural healthy eating information more effectively in the future.

According to the 2012 National Nutritional Survey, Australian adults are opting for diets low in fruits and vegetables, and consuming energy-dense foods high in fat, salt and sugar ( 1 ) . Long-term consumption of energy-dense foods is a major contributor to a range of chronic diseases including obesity ( Reference Pongutta, Chongwatpol and Tantayapirak 2 – Reference Flaherty, McCarthy and Collins 5 ) . The Australia’s Health 2018 report identified a range of diseases resulting from overweight and obesity, examples include various cancers, cardiovascular conditions, chronic kidney disease, diabetes, dementia, gallbladder disease, osteoarthritis and asthma ( 6 ) . It is estimated that 64 % of Australian adults are currently either overweight or obese, and it is predicted that by 2025, 34 % of Australian adults will be obese ( 1 , Reference Coopers 7 ) . Optimal nutrition and regular exercise are known preventive measures against obesity ( Reference Barbosa, Vasconcelos and Correia 8 ) . Improving an individual’s knowledge of healthy eating has been a central component in many interventions aiming to improve an individual’s nutritional intake ( Reference Barbosa, Vasconcelos and Correia 8 – Reference Sobal, Bisogni and Jastran 17 ) .

While there are many closely related and intertwined factors which contribute to the aetiology and maintenance of obesity, associations have been identified of improved nutritional knowledge with increased fruit and vegetable intake and lower intake of energy-dense foods ( Reference Barbosa, Vasconcelos and Correia 8 , Reference Paquette 18 – Reference Dunn, Mohr and Wilson 20 ) . Nutrition knowledge has been identified as influencing not only food choice and consumption, but also how individuals perceive and define healthy eating ( Reference Pandit-Agrawal, Khadilkar and Chiplonkar 3 , Reference Paquette 18 , Reference Hammer, Vallianatos and Nykiforuk 19 ) . Various studies conducted during the late 1980s and 1990s explored definitions of healthy eating ( Reference Povey, Conner and Sparks 21 – Reference Landry, Lemieux and Lapointe 25 ) . Most recently, a Canadian qualitative study explored perceptions and definitions of healthy eating and eating pleasure ( Reference Landry, Lemieux and Lapointe 25 ) . Responses from twelve focus groups suggested that healthy eating was described in accordance with characteristics related to the nutritional quality of food ( Reference Landry, Lemieux and Lapointe 25 ) , thus further supporting previous definitions from studies that categorised healthy eating by factors that were perceived to be important, for example ‘freshness’, ‘natural’, ‘fruits and vegetables’ ( Reference Povey, Conner and Sparks 21 – Reference Margetts, Martinez and Saba 24 , Reference Lake, Hyland and Rugg-Gunn 26 ) . Furthermore, many reasons may influence an individual’s perception of what factors are important when defining a healthy food choice, including current popular diet trends, health promotion campaigns, social media, family, friends, advice from health professionals and general nutrition knowledge ( Reference Mela 10 , Reference Bisogni, Connors and Devine 13 , Reference Sobal, Bisogni and Jastran 17 ) .

Of these factors, nutritional knowledge is especially important, and can be classified in accordance with the ability to recall and state nutritional facts (declarative knowledge) and the ability to apply these facts into everyday life (procedural knowledge) ( Reference Worsley 27 ) . Therefore, healthy eating is influenced by an individual’s ability to not only understand what a healthy food choice is, but also his/her ability to apply that understanding practically through daily food choices. To address the current obesity problem, an understanding of how individuals define and translate healthy eating (declarative and procedural knowledge) in everyday life is needed. Through this understanding, there is an opportunity to direct and influence future dietetic communication of healthy eating to adults. The present study aimed to explore how healthy food choices are translated into everyday life by exploring definitions of healthy food choices, perceptions of own food choice, and healthy food choice drivers (facilitators) and barriers.

An exploratory qualitative study design was utilised to investigate definitions of healthy eating, and how healthy food choices are translated into everyday life by adults, using convenience sampling. Convenience sampling was used to collect data from the recruitment of willing participants who were geographically accessible to the researcher, and catered for practical constraints, including researcher availability ( Reference Etikan, Musa and Alkassim 28 ) . This method allowed for the collection of data without requiring formal access to specific population lists and relevant contact details ( Reference Etikan, Musa and Alkassim 28 ) . Additionally, considering that the aims of the study are exploratory by nature, the collection of data from a wide range of individuals was pursued, in order to broadly provide insight into food choices made by individuals. A qualitative design was chosen to gain an understanding into how an individual gives meaning to the notion of a healthy food by exploring own perception of healthy food choices as well as perceived barriers and drivers (facilitators) ( Reference Bisogni, Jastran and Seligson 29 , Reference Ritchie, Lewis and Nicholls 30 ) . The COREQ checklist was utilised to ensure transparency when reporting the study methods (see online supplementary material, Supplemental Table S1 ) ( Reference Tong, Sainsbury and Craig 31 ) .

Participants

The study took place in the Australian Capital Territory, Australia. Adults were recruited from health-care centres, on Facebook and via community health based-newsletters. Individuals were eligible to participate if they met the following criteria: (i) aged 25–65 years; and (ii) could speak and understand English.

A semi-structured interview guide was developed based on a review of relevant literature. Questions from previous interview and focus group studies which investigated food choice and healthy eating were reviewed and influenced the development of a provisional question guide. Adaptions were made to the question guide after a soft pilot of the questions to fellow postgraduate research students (see online supplementary material, Supplemental Table S2 ). Interviews were conducted between October 2015 and March 2016, either face-to-face or via telephone with the researcher. Telephone interviews were also included to cater for participants who were willing to participate, however, could not meet face to face with the researcher due to factors including work and family time commitments. Individuals expressed their interest to participate by contacting the researcher via email. They were then directly contacted by the researcher and asked to complete a brief questionnaire to determine eligibility for participation and gather basic demographic data. Demographic data collected included participant gender (male, female, other), age, country of birth, self-reported height (in metres), self-reported weight (in kilograms) and highest level of education attained. An appointment was made to schedule either an individual face-to-face or telephone interview. Both signed and verbal consent was required before an interview commenced. The researcher (R.M.), who has qualifications in nutrition and dietetics and previous experience in conducting individual semi-structured interviews and focus groups, conducted all face-to-face and telephone interviews.

A total of nine open-ended questions were asked to allow participants to discuss their thoughts on healthy food choices, for example ‘Can you share your thoughts on what you describe a healthy food choice to be?’ Cues and probing questions were also used to clarify information and gain additional data, where the researcher felt appropriate. Hand-written notes were made during and at the end of each interview to record the researcher’s thoughts and ideas, as proposed by Fook and Gardner ( Reference Fook and Gardner 32 ) . Each telephone interview was audio-recorded using the app TapeACall (TelTech Systems, Inc.) and a Zoom H1 Audio Recorder was used during face-to-face interviews.

Data analysis

Data were collected and analysed concurrently. Thematic analysis was used to identify major themes relating to the translation of healthy food choices. The analysis followed the guidelines developed by Braun and Clarke ( Reference Braun and Clarke 33 ) . An essentialist paradigm was adopted as the principal interest of the research was to report interpretations, perceptions and meanings from the reality of the participant ( Reference Braun and Clarke 33 , Reference Clarke and Braun 34 ) . An essentialist paradigm acknowledges the importance of how individuals differ in the way reality is conceptualised and understood, finding meaning in the way individuals describe and perceive phenomena ( Reference Braun and Clarke 33 , Reference Clarke and Braun 34 ) . Thematic analysis as a qualitative method is used for identifying, analysing and reporting patterns within the data ( Reference Braun and Clarke 33 ) . This qualitative approach was chosen to allow for the collection of insightful data through the exploration of perceptions and thoughts of participants ( Reference Braun and Clarke 33 , Reference Harris, Gleason and Sheean 35 ) .

The process of analysis began with data familiarisation, whereby the primary researcher listened and re-listened to audio recordings of each interview. Each interview was then transcribed verbatim, read and re-read to ensure word-for-word transcription. Each transcript was given full and equal attention, enabling the generation of initial codes with aid from the qualitative data analysis software NVivo version 10. Initial codes were developed inductively by the researcher (R.M.) and continuously refined while analysing each transcript. Repetitive codes were clustered into one main code and all codes were analysed and broadly placed into subsequent themes. Each theme was then reviewed and refined, ensuring each theme contained a coherent pattern, supported by coded data. Themes were then defined and described with consideration to the research question, the degree of overlap and relationships with other themes (see Table 1 ). To ensure integrity and consistency of themes, researchers (J.K., R.B. and A.S.) were randomly assigned to a transcript and were all given a common transcript. Researchers read, re-read and reviewed codes and themes. All researchers met face-to-face to discuss each other’s interpretations of codes and themes. At the conclusion of the meeting there was common agreement on emerging codes and themes. In the current study, it was believed that the point of saturation occurred by the twenty-third interview, as no new emerging themes were present and ideas became repetitive.

Table 1 Theme generation from semi-structured interviews conducted with adults aged 25–60 years from Canberra, Australia, October 2015–March 2016

* P# refer to study participants.

Semi-structured interviews provided insight into the barriers and facilitators influencing the translation of healthy food choices among this population. The major themes that arose consistently from the data were: (i) healthy food choices are important, but not a daily priority; (ii) healthy eating information is known but can be difficult to apply into everyday life; (iii) popular diets are used in attempts to improve healthy eating; and (iv) social media inspires and connects people with healthy eating. Representative examples of quotes are shown in Table 1 .

A total of twenty-three participants aged 25–60 years were interviewed (see Table 2 for demographic characteristics). The mean age of participants was 38 years and the mean BMI was 29·1 kg/m 2 . All male participants ( n 4) were within the healthy weight range compared with 58 % of female participants, with 26 % being overweight and 16 % being obese, in accordance with the WHO criteria ( Reference De Onis and Habicht 36 ) . Data showed most participants were well educated with either a postgraduate or bachelor’s degree (30 and 39 %, respectively).

Table 2 General characteristics of the study participants: adults aged 25–60 years from Canberra, Australia, October 2015–March 2016

* Healthy weight range, BMI = 18·5–24·9 kg/m 2 ; overweight, BMI = 25·0–29·9 kg/m 2 ; obese, BMI ≥ 30·0 kg/m 2 .

† Australian Technical and Further Education (TAFE).

Participants were not only able to describe their perceptions of what constitutes a healthy food choice, but also acknowledge the importance of healthy food consumption. Healthy food choices were described differently among participants (see Table 3 ). The types of words and terminology participants used to describe healthy eating included: identifying specific foods (e.g. fruits and vegetables), the presence of macro- and micronutrients (e.g. protein, carbohydrates, fat, vitamins and minerals), the state and preparation of the food (e.g. natural, unprocessed and homemade), the occurrence of consumption (e.g. balance and variety) and perceived value of food (e.g. good and bad).

Table 3 Example descriptions associated with healthy eating from semi-structured interviews conducted with adults aged 25–60 years from Canberra, Australia, October 2015–March 2016

Theme 1: Healthy food choices are important, but not a daily priority

While definitions of a healthy food choice varied between participants, a common acknowledgement was the importance of a healthy food choice. Reasons as to why healthy food choices were described as important were linked to improved functioning in daily activities, well-being, improved physical activity performance and family relationships, as illustrated respectively by the following quotes:

‘Yeah so it’s really just changed my approach to life and making sure that I’m really focused on eating healthy because that’s my building block for everything that I’m doing.’ (P17)

‘I do make the effort to make those healthy food choices more regularly. I, mean I have to say it does make me feel a lot better.’ (P21)

‘Yes, so I think that depending on what you eat depends on how you feel, I feel like a lot of the good food you eat you get good energy from, for example, run longer and like last longer, depends on what you eat basically and how hard you can go.’ (P10)

‘It just keeps you accountable [because] you know that someone knows and you’re feeding someone else, it’s not just you that you’re choosing to give that food to, if that makes sense?’ (P8)

Interestingly, while participants commonly agreed that healthy food choices were an integral component of health and well-being, it was not always a daily priority:

‘It’s important, obviously not as important as it should be.’ (P1)

Importance of healthy food choices seemed to be assessed and re-prioritised daily:

‘It’s important, but not, not day to day like does that make sense? Oh, I guess at the moment, not so important … Depends on the day, depends on the moment … The food choices I choose and the food choices I choose at the moment are crap. They’re not healthy.’ (P2)

It appeared various factors influenced the positioning of the priority of healthy eating. A perceived lack of time due to work and family commitments saw the emergence of prior eating habits:

‘So, I suppose I just, you know, when you go to full time work and you have kids, you just revert to the same things.’ (P1)

Daily stressors and declining energy towards the end of the day were described to lower both expectations and the priority of healthy eating:

‘I just didn’t cope with the pressure and the stress of it and because I am an emotional eater particularly at work, I did not cope with the stress. So, of an afternoon I’d wander around sculling diet soft drinks and going to the candy machine and just getting my hands on whatever, I could to really act as a distraction.’ (P21)

Overall, healthy food choices appeared to be regarded as a luxury, second to obligatory daily activities described by participants as ‘life’:

‘It’s probably really important but the reality is that, in the moment, it doesn’t feel important … I really feel like our lives are so busy that nutrition has to be, it’s a priority that you have to choose, it’s something that’s not easy to choose.’ (P3)

Participants mainly described the feeling of not having the ‘luxury’ of time to make healthy food choices due to work and family commitments.

Theme 2: Healthy eating information is known but can be difficult to apply into everyday life

While most participants could describe aspects of healthy eating, translating and applying this knowledge into everyday life was perceived as challenging:

‘So, I would say that I am well across all the theory, so for me I know what a healthy portion looks like, I know what a healthy meal involves, but it doesn’t you know, necessarily translate into my food choices … I don’t know, [because] I feel I do know all the theory, I could pass the theory exam on nutrition, so it’s something else, for me it’s not knowing, for a lot of people I know it is, they have no idea what might be low GI [glycaemic index], they don’t even know what GI means, for me I do have all that knowledge you know, I’m just not putting into practice.’ (P1)

It was expressed that most participants had a knowledge of healthy food choices; however, they were not always chosen:

‘When I’m explaining all this, these are theoretically, I’m not saying I eat all of these, not all the time.’ (P22)

Confusion, along with uncertainly and fear about choosing the ‘wrong’ foods, were described as debilitating due to perceived consequences:

‘There’s so much different information out there … you’re almost paralysed by those choices because you’re afraid of choosing the wrong one and if you make a good one and it’s all good, you’re happy but if you make a bad one…’ (P2)

Mixed information from family, friends and the media also contributed to the aura of confusion, leading to self-doubt when making a food decision:

‘A lot of people will say you know, low fat is a really good way to go, other people will say actually the research is showing that low fat isn’t that great for you because they add extra sugar, and then sugar is bad for you and as you can tell, clearly I’m still not getting on top of my weight, so I’m very confused.’ (P3)

Theme 3: Popular diets are used in attempts to improve healthy eating

It appeared participants were currently, or previously, involved with different popular diets:

‘I’ve done the Atkin’s diet before, so anything that wasn’t a carb was good pretty much, I did 5:2 intermittent fasting until about a month ago.’ (P12)

Popular diets were perceived to be the solution for improving healthy food choices, assisting with ‘getting back on track’ with healthy eating:

‘I’ve been on the Atkins diet, I’ve been on Weight Watchers, I’ve been on Easy Slim, everything and everything that has come out over the years I have tried … I mean, when I was younger, I went to Jenny Craig.’ (P23)

Common diets described by participants included Weight Watchers, Jenny Craig, I Quit Sugar, Easy Slim, Atkins, local 12-week challenges and protein shake supplementation programmes:

‘[Laugh] Which diet have I not done? If you could give me a pill to lose weight you know within a month give it to me now.’ (P22)

A complicated relationship between participants and popular diets emerged. Paradoxically, on one hand, participants continuously tried different diets; however, on the other, acknowledged their lack of scientific rigour and failure to deliver on weight loss promises:

‘I’ll be honest, I recently brought another lot of supplements off the Internet, which logically I know there is no evidence that what they say is in it, is even in it, let alone that it will actually do what it says it would do … I’ve done the Atkins shakes, I’ve done the iso-whey powders, I have done what was it, Tony Ferguson shakes, god who knows?’ (P2)

Interestingly, despite acknowledging previously unsuccessful diet outcomes, this was continuously outweighed by personal testimonials or referrals:

‘Someone lost this much weight on that so I’ll, I’ll do that to see if that’s works for me [because] I’m that person, and it turns out to all be a sales pitch, but the problem is there’s so much of that in your face.’ (P9)

As participants moved from one diet to the next, they described confounding healthy eating messages and principles that they were exposed to. However, overall, the inability to maintain compliance with popular diets over time was commonly described as the factor limiting success:

‘I came across this diet, that diet, this food, that food plan, you know the paleo food, the clean eating, this eating, so I’ve you know, I’ve gone through all of that and I’ve printed all of that off and I’ve tried it, here and there you know, three or four days, I usually last about a week and it’s too difficult.’ (P22)

Theme 4: Social media inspires and connects people with healthy eating

Facebook and Instagram were commonly referred to as a source of healthy eating information. Participants described using these means to receive engaging and up-to-date information through posts:

‘I just follow a lot of fitness people on Instagram and they post meals that they’ve been eating, and I look them up. I think just, eating healthy, healthy lifestyle is big at the moment. I feel that everyone is posting, everyone is coming up with something new that’s healthy or an alternative for a bad food, and I feel like that’s becoming a trend, whatever I can see on Facebook or Instagram we look into it.’ (P10)

Interestingly, while the main social media platforms were identified as Facebook and Instagram, some participants referred to blogs as an emerging platform for accessible advice and information on healthy eating:

‘Probably more and more information has become more accessible so blogs and podcasts and that. I guess potentially maybe looking at more of those natural, gut health blogs.’ (P18)

It appears through the variety of different blogs available that niche information can be found that aligns with the interests of the participant. For example, blogs were described to be inspirational and motivating by connecting participants to other individuals’ personal journeys and experiences:

‘I guess, honestly blog reading it’s amazing, you can see other people’s journey. That may not work for you, but you may think a different way, it certainly made me think a different way.’ (P17)

The present study confirmed that definitions of health eating given by study participants are comparable to prior research ( Reference Povey, Conner and Sparks 21 , Reference Keane and Willetts 23 , Reference Lake, Hyland and Rugg-Gunn 26 , Reference Paquette 37 , Reference Buckton, Lean and Combet 38 ) . Interviews with twenty-three participants provided insight into what influences the translation of healthy eating information in daily life; and highlighted a potential new direction for the future development and improvement of healthy eating communication.

Despite the 20-year gap between prior research and the present study, healthy eating continues to be described in multiple ways ( Reference Landry, Lemieux and Lapointe 25 , Reference Lake, Hyland and Rugg-Gunn 26 , Reference Paquette 37 , Reference Buckton, Lean and Combet 38 ) . Healthy eating has been defined through foods which are perceived as being of benefit (e.g. fruits and vegetables) ( Reference Povey, Conner and Sparks 21 , Reference Margetts, Martinez and Saba 24 , Reference Lake, Hyland and Rugg-Gunn 26 ) ; through the perceived state and quality of a food (e.g. fresh, natural, unprocessed, homemade) ( Reference Margetts, Martinez and Saba 24 , Reference Lake, Hyland and Rugg-Gunn 26 ) ; through the concept of moderation (e.g. balanced) ( Reference Margetts, Martinez and Saba 24 ) ; and through macronutrient and micronutrient consumption (e.g. fat, carbohydrate, protein, vitamins and minerals) ( Reference Margetts, Martinez and Saba 24 ) . These factors were all evident in the current study, indicating that the findings are consistent with past research exploring definitions of healthy eating in the adult population.

Findings from the present study indicated that participants held a broad understanding of healthy eating, as most definitions were generally in line with nutrition recommendations from the Australian Dietary Guidelines ( 39 ) . This was similar to a previous study investigating the relationship between definitions of healthy eating and measured food intake ( Reference Lake, Hyland and Rugg-Gunn 26 ) . Results from a study based in the UK suggested participants had a broad understanding of healthy eating, generally in line with national nutritional guidelines in the UK ( Reference Lake, Hyland and Rugg-Gunn 26 ) . This declaration of knowledge may suggest that decades of healthy eating campaigns are being heard and associated with what constitutes a healthy food choice ( Reference Lake, Hyland and Rugg-Gunn 26 ) . Additionally, a large proportion of participants in the present study (69 %) reported to have obtained a tertiary qualification. This high proportion is similar to statistics from the 2016 Commonwealth Electoral Divisions which reported that 37·1 % of individuals aged 15 years and over living in the Australian Capital Territory have obtained a tertiary qualification ( 40 ) . Within the literature, it has been shown that nutrition knowledge and overall diet quality increase with level of formal education ( Reference Hendrie, Coveney and Cox 41 , Reference Backholer, Spencer and Gearon 42 ) . Considering the level of education reported by participants in the present study, this may have resulted in an overestimation of participant understanding of a healthy food choice in line with the Australian Dietary Guidelines. Despite this however, while participants had a broad understanding of healthy eating and could acknowledge the importance of healthy eating, participants reported difficulty in translating knowledge into daily practice ( Reference Pandit-Agrawal, Khadilkar and Chiplonkar 3 ) .

How individuals apply nutrition knowledge into daily practice has been a recurring challenge identified within the literature ( Reference Pandit-Agrawal, Khadilkar and Chiplonkar 3 , Reference Ares, Aschemann-Witzel and Vidal 4 , Reference Boles, Adams and Gredler 43 – Reference Raine 45 ) . A study conducted by Boles et al . evaluated a sugary drink mass media campaign in Portland, Ontario, in Canada ( Reference Boles, Adams and Gredler 43 ) . The study reported the mass media campaign was positively associated with knowledge about excessive sugar consumption, however no change in dietary behaviour was observed ( Reference Boles, Adams and Gredler 43 ) . This may shed light on the discrepancy between knowledge of the consequences of sugary drink consumption (declarative) and the application of knowledge by choosing different drinks with less sugar content (procedural) ( Reference Boles, Adams and Gredler 43 , Reference Davison, Smith and Frankel 46 ) . It is therefore argued that knowing about healthy eating does not always result in the translation (consumption) of healthy food choices ( Reference Lake, Hyland and Rugg-Gunn 26 , Reference Boles, Adams and Gredler 43 , Reference Davison, Smith and Frankel 46 ) , thus suggesting that future healthy eating education could benefit from disseminating procedural focused knowledge, to help address the described difficulty, in addition to targeting other determinants of food choice (e.g. perceived barriers and motivations to make healthy food choices) ( Reference Lake, Hyland and Rugg-Gunn 26 , Reference Bisogni, Jastran and Seligson 29 , Reference Boles, Adams and Gredler 43 , Reference Davison, Smith and Frankel 46 ) .

Traditionally, popular diets are seen to influence food choice through limiting variety of food choice ( Reference Khawandanah and Tewfik 47 ) , manipulating macronutrient ratios ( Reference Khawandanah and Tewfik 47 – Reference Dansinger, Gleason and Griffith 49 ) and liquidising foods ( Reference Khawandanah and Tewfik 47 ) . Defining popular diets remains ambiguous, as a handful of popular diets have been supported by scientific evidence, while others may not ( Reference Khawandanah and Tewfik 47 , Reference Gardner, Kim and Bersamin 48 , Reference Tsai and Wadden 50 ) . However, while popular diets can be defined in a variety of ways, they are most commonly described as any diet which promises rapid weight loss ( Reference Khawandanah and Tewfik 47 – Reference Dansinger, Gleason and Griffith 49 ) . A systematic review of several commercial and self-help weight-loss programmes was conducted to investigate the efficacy of weight-loss programmes in the USA ( Reference Tsai and Wadden 50 ) . With the exception of Weight Watchers, the review reported diminished dietary adherence and weight regain after 1- and 2-year follow-ups ( Reference Tsai and Wadden 50 ) . This finding was also supported by another randomised control trial comparing four diets (Atkins, Ornish, Weight Watchers and Zone Diet) ( Reference Dansinger, Gleason and Griffith 49 ) . Interestingly, while these findings support the notion that there are limited weight-loss benefits when following popular diets, individuals are still opting to participate, as highlighted by results from the present study. Therefore, despite the saturation of different diets available, there is still limited knowledge on how popular diets influence and impact long-term adult food choices ( Reference Khawandanah and Tewfik 47 , Reference Johnston, Kanters and Bandayrel 51 , Reference Gudzune, Doshi and Mehta 52 ) .

Interestingly, despite acknowledging a lack of scientific rigour and sustainability of popular diets, participants in the present study reported persevering and continuing to try different diets. Persevering through different popular diets despite limited weight-loss benefits may be influenced by the ease and promise of a ‘quick fix’ that individuals are offered through marketing ( Reference Malik and Hu 53 , Reference Alhassan, Kim and Bersamin 54 ) . The lack of sustainability of popular diets due to their restrictive nature has been discussed within the literature, highlighting regain of weight lost within the first 12 months ( Reference Malik and Hu 53 , Reference Alhassan, Kim and Bersamin 54 ) . As suggested by Malik et al. , low popular diet adherence is likely due to the difficulty experienced by individuals following specific guidelines ( Reference Malik and Hu 53 ) . A study investigating self-set dieting rules stated that only 27·6 % of participants ( n 132) reported following the same dieting rules at follow-up two months later. This suggests that there is low adherence to dieting rules set by the individual ( Reference Knäuper, Cheema and Rabiau 55 ) . The promise of quick weight loss from celebrity endorsements has also been argued to influence an individual’s participation in popular diets ( Reference Rousseau 56 ) . In addition, programmes are typically promoted through ‘success stories’ rather than scientific data ( Reference Rousseau 56 ) . However, clever marketing and celebrity endorsements often encourage individuals to try and follow popular diets that are often not compatible with the practicalities of everyday life (e.g. food intake restrictions during working hours, long food and meal preparation time, specific eating times during the week and unaccounted-for social events) ( Reference Rousseau 56 , Reference Williams and Williams 57 ) .

It is proposed that individuals turn to popular diets for procedural information about healthy food choices. When commencing a new diet programme, individuals are provided with a detailed set of guidelines that clearly specify how to eat healthily and the steps required to achieve this (e.g. weekly meal plans and shopping lists). By providing meal plans and shopping lists, nutrition information is already translated into daily tasks (procedural knowledge), allowing the individual to simply follow the instructions. It could be argued that the success of the popular diet industry is in part due to the identification of this discrepancy between an individual’s knowledge of healthy eating and the application of knowledge into daily life.

While findings from the present study highlight that participants use social media, particularly Facebook and Instagram, to gain up-to-date healthy eating information, it was also suggested by some participants that healthy eating blogs were accessed. Blogs have transformed from their origins of being used for personal online diaries, narrating an individual’s life journey, to presenting current news and acting as a platform for disseminating educational materials ( Reference Garden 58 ) . Currently, with information accessible continuously through social media, blogs are gaining popularity as a source of nutrition and health information ( Reference Dumas, Lemieux and Lapointe 59 ) . Nutrition and health-related blogs are not always written by dietetic professionals ( Reference Garden 58 ) . Rather, nutrition and health blogs may be written by the general population, celebrity personalities and companies who are describing their personal health, nutrition experiences and achievements ( Reference Garden 58 ) .

There is a growing body of research investigating the influence and nature of nutrition-related blogs ( Reference Dumas, Lemieux and Lapointe 59 – Reference Bissonnette-Maheux, Dumas and Provencher 62 ) . One study investigated the potential use of healthy eating blogs by participants who were categorised as having suboptimal dietary habits ( Reference Bissonnette-Maheux, Dumas and Provencher 62 ) . Participants were interviewed and questioned initially about their Internet and blog use, and were invited to participate in a follow-up focus group to discuss their perceptions of consulting healthy eating blogs to improve dietary habits ( Reference Bissonnette-Maheux, Dumas and Provencher 62 ) . Interestingly, participants highlighted the usefulness of blogs in receiving recipe ideas and tips to help improve diet quality ( Reference Bissonnette-Maheux, Dumas and Provencher 62 ) . Most recently, a study investigated the use of social media from the perspective of dietetic practice to investigate whether dietitians could help individuals make informed decisions about their diet to improve health ( Reference Dumas, Lapointe and Desroches 60 ) . That study highlighted the use of social media in dietetic practice already, with discussion forums being the most frequently used platform, followed by blogs and then Facebook ( Reference Dumas, Lapointe and Desroches 60 ) . This supports the growing interest in blogs within dietetic practice to improve the translation of nutrition knowledge ( Reference Dumas, Lapointe and Desroches 60 ) . However, while research is still in its infancy, there are recommendations for future research to investigate how dietitians can utilise blogs to promote healthy eating ( Reference Dumas, Lemieux and Lapointe 59 – Reference Bissonnette-Maheux, Dumas and Provencher 62 ) .

Considering the growing popularity of blogs, there is an opportunity to take advantage of what seems to be an attractive method of accessing healthy eating information ( Reference Dumas, Lemieux and Lapointe 59 ) . It is proposed that successful healthy eating blogs have formulated a method to engage their followers by providing relevant and valued nutrition information; they inspire their followers by translating healthy eating information and connect with their followers by posting frequently. Further investigation is warranted to assess if reading healthy eating blogs contributes to healthier food choices and to identify how future dietitians can better integrate evidenced-based healthy eating information into engaging blog posts. This could potentially strengthen the bridge between individuals seeking healthy eating information and dietitians.

The present study highlighted several key issues. Individuals have a broad understanding on what is a healthy food choice in line with the Australian Dietary Guidelines; healthy food choices are not always a daily priority; there are challenges with applying nutrition knowledge into everyday life; and blogs are being used to access nutrition information. The use of a reflexive diary by the main researcher during the collection and analysis of the interviews and team discussion during each stage of the study process enhanced the rigour and trustworthiness of findings ( Reference Graneheim and Lundman 63 , Reference Morrow 64 ) . A limitation of the study was the use of convenience sampling, as participant narratives are not necessarily representative of the wider community ( Reference Ritchie, Lewis and Nicholls 30 , Reference Graneheim and Lundman 63 , Reference Marshall 65 ) . Verification of results by a larger and more diverse sample size is needed ( Reference Ritchie, Lewis and Nicholls 30 , Reference Graneheim and Lundman 63 , Reference Marshall 65 ) . Data collected during the brief screening questionnaire were based on self-reported measures and may have resulted in an underestimation or overestimation of participant BMI. Additionally, the interpretation of findings must take into consideration that the quality of participants’ dietary intake was not evaluated.

It is recommended that future research continues to investigate the potential platform of blogs as an avenue to communicate healthy eating knowledge in a procedural manner. While there needs to be a larger collective knowledge on healthy eating blogs, this could potentially provide an opportunity for dietitians to communicate future healthy eating messages more effectively and to a larger population.

The present study suggested that even when individuals have a broad understanding of what constitutes a healthy food choice, there are challenges when translating this knowledge into everyday practice. Although other forms of social media were highlighted as an avenue for healthy eating information (Facebook and Instagram), healthy eating blogs could soon become a preferred source of information. Future research should consider exploring the use of healthy eating blogs and whether these blogs can be used as a tool by dietitians to communicate procedural healthy eating information more effectively in the future.

To view supplementary material for this article, please visit https://doi.org/10.1017/S1368980019001046

Acknowledgements

Financial support: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest: No conflict of interest to disclose. Authorship: R.M contributed to the study design, data collection, data analysis and wrote the manuscript. J.K., R.B., A.S. and K.M. provided research supervision, refined the study design, assisted in the interpretation and validation of data, and writing of the manuscript. Ethics of human subject participation: This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the University of Canberra Human Ethics Committee (HREC 16–192). Written and verbal informed consent was obtained from all subjects and verbal consent was witnessed and formally recorded.

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Qualitative research in nutrition and dietetics: getting started

2010, Journal of Human Nutrition and Dietetics

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A qualitative exploration of the future of nutrition and dietetics in Australia and New Zealand: Implications for the workforce

Rachel boak.

1 Council of Deans Nutrition and Dietetics, Queensland University of Technology, Brisbane Queensland, Australia

Claire Palermo

2 Monash Centre for Scholarship in Health Education, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton Victoria, Australia

Eleanor J. Beck

3 Faculty of Health, University of Wollongong, Wollongong New South Wales, Australia

Craig Patch

4 School of Allied Health, Human Services & Sport, La Trobe University, Melbourne Victoria, Australia

Fiona Pelly

5 School of Health and Behavioural Sciences, University of the Sunshine Coast, Sippy Downs Queensland, Australia

6 Faculty of Medical and Health Sciences, The University of Auckland, Auckland New Zealand

Danielle Gallegos

7 Woolworths Centre for Childhood Nutrition Research, Queensland University of Technology, Brisbane Queensland, Australia

Associated Data

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

We aimed to explore the future roles of nutrition and dietetics professionals, and what capabilities the workforce would need to fulfil these roles.

A qualitative interpretive approach was employed. We conducted individual interviews with nutrition and non‐nutrition thought leaders external to the profession. In addition, we conducted focus groups with experts within the nutrition and dietetics profession, academic dietetics educators and students/recent nutrition and dietetics graduates (total sample n  = 68). Key nutrition‐related issues and challenges, drivers for change and potential future roles of the profession were explored. Data were analysed using a team‐based thematic analysis approach.

Future roles of nutrition and dietetics professionals were described as food aficionados, diet optimisers, knowledge translators, equity champions, systems navigators and food systems activists, change makers, activists and disruptors. In addition, science was identified as a uniting framework underpinning the professions. An additional 16 critical capabilities were considered to underpin practice.

The results demonstrated that the current and future needs for workforce education and development need to address the impact of climate change, growing inequities, the democratisation of knowledge and the disruption of health and food systems. Education providers, regulators, professional associations and citizens need to work together to realise roles that will deliver on better health for all.

1. INTRODUCTION

Food and nutrition are central to optimising health and wellbeing, and crucial to the prevention and management of many diseases. 1 An ageing population, virtual worlds creating increased connectivity, the democratisation of knowledge and expertise, and demand for experience and social relationships have been highlighted as impacting on nutrition. 2 In addition, climate change, industrialised agriculture, and a globalised food supply all impact on the ability of nations, communities, households and individuals to maintain healthy dietary patterns. 2 , 3 Improving future health outcomes and the sustainability of the healthcare system requires shifting focus from treatment of illness to prevention or promoting health and wellbeing. 4 Complex and multi‐strategy responses are needed to address these emerging priorities. The nutrition and dietetics profession, that spans food and health systems, is ideally positioned to address these priorities. 1 Yet, data suggests this workforce is limited in number and may not be adequately prepared to address these priorities. 5

While comprehensive nutrition and dietetics workforce data is lacking, the data available suggest that the Australian and New Zealand dietetics workforce is small with approximately 6870 practitioners. 6 , 7 , 8 Traditionally, the public hospital sector was the dominant place of employment for dietitians. Emerging data suggests that employment in private practice is increasing, and separately, a large number of qualified dietitians work in unrelated occupations. 9 , 10 Less is known of the nutrition science workforce without dietetics qualifications other than the voluntary register of the Nutrition Societies highlighting approximately 150 registered nutritionists in Australia 11 and 208 registered nutritionists in New Zealand. 12 In the United Kingdom and United States, research has explored important future issues and directions for nutrition and dietetics workforces. 13 , 14 This suggests a growing demand for nutrition and dietetics professionals in areas such as community‐based chronic condition prevention and management, aged care, personalised nutrition, food and agriculture, and technology/digital health. 13 , 14 In addition, this data suggests that the profession will be challenged to increase in size and build its professional identity, its diversity, and consider specialisation and employability. 13 , 14 It is clear that the provision of nutrition and dietetics services has great potential to generate economic savings and improved population health outcomes based on prevention, even over nursing and medicine. 15 However, there is limited data describing the future requirements for, and the needs of, nutrition and dietetics professionals in Australia and New Zealand.

Therefore, the aims of the study were to explore the roles of nutrition and dietetics professionals in the future, and describe the capabilities the workforce would need to fulfil these roles. The findings will inform future nutrition and dietetics education and practice in Australia and New Zealand and consider nutrition and dietetics professionals globally as the leaders in the nexus between food and health.

We employed an exploratory qualitative study grounded in interpretivism. Interpretivism does not seek a single objective reality but rather privileges multiple perspectives through social interactions drawing on the experiences of researchers and participants. 16 We took a team‐based approach to data collection and analysis to support our interpretive approach in ensuring multiple views as we undertook the study. The team of senior dietitian‐nutritionist‐researchers from across Australia and New Zealand have experience in dietetics education, and practice in a range of settings. Reflexivity was applied during data collection, analysis and reporting, where robust iterative discussions were held between all authors, examining how each author's background and world view was influencing interpretation, and in line with our interpretivist approach to seek multiple meanings and interpretations to the data. 17 Human Research Ethics Committee (HREC) approval was provided by Queensland University of Technology (EC00171), The University of the Sunshine Coast Human Research Ethics (A201389), Monash University Human Research Ethics Committee (24447), Human Ethics the University of Auckland, Latrobe University Human Research Ethics (2000000231) and the University of Wollongong Human Research Ethics Committee (2020/199).

A maximum variation sampling 18 using the principles of information power 19 was used to gather the opinions of three different key groups: thought leaders within and external to the profession of nutrition and dietetics, students and recent graduates of the profession of nutrition and dietetics, academic dietetics educators and expert members of the profession. The potential sample of thought leaders was identified by the research team through brainstorming known leaders in the profession ensuring diversity of experiences. Those external to the profession were identified through web‐based searches related to future focused issues relevant to nutrition and dietetics. Many of the thought leaders were known to the researchers supporting the collection of rich data. An initial sample of 45 potential names was identified including participants from Australia, New Zealand, Pacific Islands, Canada, Europe and the United States. Current students and recent graduates from dietetics and nutrition science education programs were contacted through an email invitation or online learning platform by course coordinators from all accredited dietetics programs across Australia and New Zealand ( n  = 19 courses) at the time of the study. Nutrition science graduates were also invited to participate in the study via social media (private Facebook and LinkedIn). Practitioners, researchers, and interest group leaders were invited via the Australian and the New Zealand dietitian professional associations' weekly emails.

Data were collected through in‐depth interviews with thought leaders, and focus groups held with students, graduates and members of the profession. The interview and focus group questions were developed through a preliminary search of the literature on the future of nutrition and dietetics practice from other developed countries and related research in Australia 5 , 13 , 14 (Table  1 ; full question list available from the authors upon request). Questions were adapted for the different participant groups. Informed consent was obtained.

Overview of interview and focus group discussion guides and question logic

Interviews were conducted by all authors between June and December 2020. Focus groups were conducted by the first author between October and December 2020. Initial focus groups and interviews were conducted with another member of the research team present to facilitate consistency of approach and to provide feedback. Interviews and focus groups lasted between 60 and 90 min and were all undertaken through the online video communication platform Zoom (2021 Zoom Video Communications, Inc.). Data were audio‐recorded and transcribed verbatim using an automated transcription program (Otter.ai, 2016). All transcripts were reviewed against the audio‐recording to ensure the accuracy of the transcription. Each participant and focus group were given a code. All six interviewers completed contact summary sheets 20 for each interview and focus group. The contact summary sheet prompted interviewers to consider the main issues raised in the interview. It aimed to record salient, interesting, important, or illuminating points and take‐home messages. The sheet was completed after immersion in the interview transcript and were used to support data analysis.

The analysis approach was informed by thematic framework analysis. Framework analysis is a useful approach for team based analysis to ensure consistency in coding. 21 Initially a subset of four different interviews each were selected for analysis by one of each of three authors whereby each researcher analysed different sets of interviews. Line‐by‐line inductive coding of text was undertaken independently by these authors, who then came together to compare codes and their description. Codes were then compared and defined in short sentences to provide transparency to the coding framework such that it could be applied to the remainder of the data. All other transcripts were then coded by one of these three authors against this coding framework using Microsoft Excel (Microsoft Office, 2018). Where additional codes were identified as coding progressed, the coding framework was adapted to reflect the new code with regular meetings being conducted until data analysis was complete with the three authors to compare and contrast coding and any new codes and definitions. At the completion of coding, the three authors came together to examine the data in the context of the research questions and examine frequencies and patterns across the data. These patterns were then used to identify future roles and capabilities. One author also produced a mind map which documented key concepts from the data and where ideas overlapped or connected and compared identified roles with contact summary sheets. 22 , 23 The identified future roles of the profession and capabilities were then presented to all authors for consideration and review. These role descriptors and capabilities were then revised based on feedback and through a process of constant comparison with the mind‐map and until agreement was reached with all authors.

A total of 33 individual interviews and nine focus groups were conducted involving 68 participants (Table  2 ). A further 10 people were invited to interview but either did not respond ( n  = 7) or declined ( n  = 3) due to lack of availability. Of these, six were within the profession and four were external. Eighty‐five per cent of the interviewees ( n  = 29) were from Australia and New Zealand with the remaining participants from Canada ( n  = 2, United States ( n  = 1) and Europe ( n  = 1). Attempts to recruit professionals who were permanently based in the Pacific Islands was unsuccessful. A majority (85%) identified as either working in nutrition or dietetics with 40% working in academia (Table  2 ). Six roles that described the future nutrition and dietetics professionals were identified and potential new areas to utilise this expertise also illuminated from the data (Table  3 ) and are described below.

Characteristics of interview and focus group participants

Future new practice areas for the future nutrition and dietetics profession identified from the data

Sixteen capabilities that were essential to perform these roles were also identified including adaptability, advocacy, courage, creativity, critical thinking, cultural safety, curiosity, empathy, leadership, and the ability to translate science, build partnerships, be entrepreneurial, disruptive and solution focused, embrace diversity and use and create technology (Table  4 ).

Critical capabilities identified from 68 participants listed in alphabetical order

The first role was as food aficionados. Participants explained that the nutrition and dietetics workforce should be recognised as the experts on the contemporary human relationship with food and its application to health for people, communities, businesses and populations. They explained that the profession currently lacks the communication skills required. They recognised that the study of nutrients is important but will not be central to how nutrition and dietetics professionals activate optimal health and wellbeing through food in rapidly changing food, health and social environments. They explained that the nutrition and dietetics profession is unique in that it works with the materiality of food as it is converted to biological physicality, social identity and geographical place‐making. Having advocacy skills and being entrepreneurial with business literacy in their practice, was suggested as critical in transferring the enthusiasm for food and nutrition to others.

“ I think they [big organisations that are the face of nutrition] know …how complex it is to eat a good diet, and have a good relationship with food, but I don't know that we have the skills to communicate that and, you know, show people that we do really understand these things on a very deep level ” [INT019].

The second role was as diet optimisers in increasingly complex contexts. Participants described that nutrition and dietetics professionals will need to work simultaneously to optimise health and wellbeing as well as manage conditions with overlapping environmental, social, biological, transgenerational and comorbid drivers. It was acknowledged that this will require leading food and nutrition initiatives in settings that transcend the life course and are both inside and outside of the health system. They suggested that the future nutrition and dietetics professional will continue to focus on person‐centred care using person‐generated data and in consideration of individual social eco‐systems for the management of complex medical conditions. They recognised that future workforce will increasingly lead management of diet‐related disease through a combination of nutrition support, pharmaceutical prescribing and behaviour change counselling. As diet is critical to health, participants suggested that the nutrition and dietetics professional will be instrumental in building systems, in food and healthcare, and in developing the tools and education for other health professionals to ensure nutritional health is a priority.

“ [in the future] the majority of people are not in aged care facilities. They're at home, and … particularly if you live alone, the motivation to cook well, is less. So I think there's … a huge opportunity for helping, … having community eating opportunities, engaging people, socially, so they're not isolated, assisting with all of that food preparation, so that they're able to eat well ” [INT021].

“ we've got to make sure that when we are caring for people, we're not just caring for them, …we're not just coming in to do what's necessary for the bit of therapy. We're also… saying, Okay, what is the environment this person is living in,…does that in any way, influence their health, is that in any way, impeding … the therapy goals we're trying to achieve here ” [INT008].

The third role was as knowledge translators. Participants suggested that nutrition and dietetics professionals of the future will have the responsibility for generating evidence. In addition, they explained they will need to be able to interpret complex and rapidly evolving nutrition, health and social science knowledge between different groups of knowledge creators, holders and users, translated for practical use. They explained that this role requires defending scientific knowledge from distortion. It was suggested that nutrition and dietetics professionals will critically evaluate and interpret nutrition as a constantly evolving dynamic science and in a crowded information ecosystem. They suggested the workforce will have the responsibility for translating and communicating the scientific evidence in ways that are accessible, pragmatic and practical. They will have a pivotal role in developing and harnessing technologies that increase access to and application of this evidence. The future nutrition and dietetics professional will have the credibility to effectively communicate with broad audiences, to generate meaningful dialogue and to mitigate growing channels of misinformation. They will be an independent, robust and critical voice that will hold others accountable to the defensible science, specifically countering nonscience‐based food and nutrition misinformation which threatens to undermine or destabilise human health. They will practice the art of communication, balancing what people want to hear with what the science is saying. Strong science capability will support knowledge translation and communication.

“ We need to see that science was taken seriously.…we need to be out there often and make sure we've got good, strong messages that don't fight with each other. And telling people ‘what does that mean’? … it's not just the underlying knowledge that has to be good, but the messages about what to do about it.? And I think … part of it is we're just not out there enough ” [FG8].

The fourth role was as equity champions. The participants explained that the future nutrition and dietetics professionals will have to broker partnerships and collaborations that harness and combine their learned expertise in food, nutrition and dietetics with the lived expertise of the communities they serve. They suggested that they will need to be adept at placing the context of people's lives as central to achieving health and health equity through food. They will be able to build capacity and learn from the strengths of Indigenous cultures and other communities to optimise health through food and eating. Access to nutritious food was recognised by participants as a determinant of health and as such nutrition and dietetics professionals need to have a deep, working understanding of the implications of these determinants and how they impact on equitable access to a nutritious food supply. They will need to apply an equity, trauma‐informed lens to all of the work that they do. The inequities associated with poverty and geographical isolation are urgent issues that will likely continue into the future. The future nutrition and dietetics professional will have the learned expertise to draw on a deep understanding of the science and systems. They will be curious about, and continually seek to integrate the lived life experiences of individuals, communities, businesses and populations in optimising health.

The participants reported that learned expertise of future nutrition and dietetics professionals will only be validated in partnerships with those with lived experience. This includes having the ability to identify and understand how dominant paradigms and ideologies, for example heteronormativity, ableism, colonialism and capitalism, all impact the socio‐cultural aspects of food consumption and health outcomes. Future workforces will need to be transdisciplinary, cross‐system leaders making sense of the complex context underpinning equitable access to health for all through food. Being curious and culturally safe will be necessary to champion equity. Embracing diversity within and outside the profession and disrupting the power of their learned expertise where it is warranted is crucial.

“ That's the beautiful thing … is that we can influence positive change at so many different levels across so many different areas. And I think, you know, being more aware of the strength based cultural determinants, not just the more deficit focused social determinants … …. those are a bit more deficit lens as opposed to the cultural determinants ” [INT017].

The fifth role was as systems navigators and food systems activists. Participants suggested that nutrition and dietetics professionals into the future will have to navigate the complexity of and interaction between food and health systems with social, education, political and economic systems. They will have a leading role in systems change and with defending and building ecologically sustainable, just and healthy food supplies. As the world and contexts become increasingly complex and uncertain, they will not only need to be systems thinkers they will need to connect and reimagine these systems. The participants recognised that diet was a modifiable risk factor, but the role of structures and systems which create and perpetuate dietary health problems was a barrier. They will be instrumental in providing leadership to enable other actors within health and food systems to work in ways that go beyond a biomedical model. They will facilitate dietary change and healthy eating through understanding social, cultural, economic and historical drivers of food choices and dietary patterns.

The participants described that future nutrition and dietetics professionals will be the food system activists leading action on generating a sustainable, equitable and healthy food supply for healthy dietary patterns at individual, community and population levels. They will create and use the scientific evidence on climate, environment, diet and health to inform interventions and guidelines developed with scientific consensus to inform recommendations for nutrition sensitive production and consumption. They will be the leaders at the intersection of recommended food consumption patterns for human health and recommended food systems models which are ecologically sustainable and just, for restoring a safe climate for planetary health. Increasingly their work will also involve leading the preparation and response for food emergencies related to natural, climatic, biological and political disasters. They will work to mitigate threats to the vital relationship that people have with food, from within rapidly changing and fraught food systems. To do this they will need capabilities in lobbying, activism and courage.

“ you cannot call yourself a health professional … unless you advocate fiercely and frequently for the health of the planet, there are no healthy people on a ruined uninhabitable planet, … I think that that becomes a mission and the mantra and a message that that every dietitian can embrace ” [INT026].

The sixth and final role was as change makers, activists and disruptors. Participants explained that nutrition and dietetics professionals will need to drive change to protect the health of the community through food and nutrition. They will perform this work though a sophisticated understanding of the ethical, legal and political frameworks needed to ensure that appropriate positions, services and research are prioritised, financed and delivered. In the future the participants explained that the workforce will be negotiating the complex interactions between protecting human health, creating financially viable, profit‐generating solutions and ensuring equitable access. They will be involved in generating and using scientific evidence in financially constrained, politically motivated environments. The future nutrition and dietetics professional will have a deep, nuanced understanding of the ethics of engagement, and the conflicts of interest that need to be managed. They will proactively disrupt systems to ensure equitable access to a healthy food supply and nutrition support. They will be the change‐makers, by challenging the status quo and working in partnerships to develop solutions. To do this the participants explained that the future workforce need to be risk takers, capacity builders and will need to embrace technology and finding solutions through entrepreneurial endeavours and critical thinking. They will also need to be adaptable and resilient.

“ …we need to learn how to change society. And we need to learn how to be social justice activists or advocates to do so….Can we be open to…[being] legislators, lobbyists, bureaucrats, activists?…[we]…won't be afraid to stake political opinions, won't be afraid… ” [INT007].

4. DISCUSSION

This study explored the future roles of nutrition and dietetics professionals and the capabilities needed to fulfil these roles. Potential future roles of Australian and New Zealand nutrition and dietetics professionals have been imagined, with data revealing that future professionals will be food aficionados, diet optimisers, knowledge translators, equity champions, systems navigators and food systems activists, change makers, activists and disruptors. Sixteen critical capabilities were reported. These findings provide key information to shape education and training, work practice and context into the future such that they are effectively positioned to improve nutritional health outcomes.

This study's findings concur with international research on the future of nutrition and dietetics, affirming the need for a clear professional identity, amplifying visibility and influence, embracing advances in science and technology, diversity, career advancement, knowledge translation, evidence generation and systems navigation and building its employability. 13 , 14 In addition, it affirms the growing demand for nutrition and dietetics professionals in areas such as community‐based chronic condition prevention and management, aged health, personalised nutrition, food and agriculture, and technology/digital health. 13 , 14 The work has also highlighted the importance of nutrition and dietetics professionals generating evidence as well as translating it into practice. The importance of the professions' role in generating and translating research is stronger in this study than has been found in other work. 13 , 14 In addition, a number of novel findings unique to this study were identified, these include, needing nutrition and dietetics professionals that are capable of defending and building sustainable, just and healthy food systems, opportunities to build capacity and learn from the strengths of Indigenous cultures, the key importance of the human relational connection with food, and being change agents and activists to disrupt the status quo. These novel findings reflect the suggested urgency for nutrition and dietetics to reinvent itself in a world of increasing complexity and uncertainty 24 , 25 and highlight the emerging roles which must be embraced if they are to have impact and truly make a difference. Advances from the previous work in the United States 13 and United Kingdom 14 may reflect increasing urgency on climate action, and also the global pandemic, further highlighting the dynamic nature of health and health practice, and the quintessential requirements for nutrition and dietetics professionals to manage change.

As described above the emerging roles and future of nutrition and dietetics described by the participants in this study may be explained by shifts in the population's understanding of climate change and growth in technology. There has also been an enormous growth in social media and knowledge democratisation 26 seen over the several years since these studies were undertaken, which has likely contributed to the study participants' perspectives. The undertones of the participants' perspectives across the data suggests that it is time for a significant cultural shift in the nutrition and dietetics profession which has been previously raised by others. 24 Cultural change requires a culture of learning and being comfortable with uncertainty, whereby innovations and entrepreneurial ideas are embraced and where failing is viewed as learning. 27 In addition, no one single approach will change professional or organisational cultur,e and complex interventions are needed to affect cultural change. 28 Key nutrition and dietetics professional organisations and individuals must work alongside those tasked with educating the future professionals to consider adaptation and embracing new ways of doing, and being to be able to rise up and remain salient and relevant into the future.

The critical capabilities identified in this study are largely reflected in the recently updated 2021 National Competency Standards for Dietitians in Australia, 29 and the 2017 New Zealand standards. 30 However many of the capabilities identified in this study do not reflect current nutritionist competencies, 31 except for those identified for public health nutritionists. 32 While the professions of dietitian, nutrition scientist, nutritionist and public health nutritionist have been delineated in previous work, 33 this study highlights blurred boundaries between these professions as well as incorporating potential for professions that may currently sit outside the traditional nutrition and dietetics space. There is a need for those that currently identify with these distinct professions to work together to potentially create a collective professional identity such that they can overcome these boundaries. This includes education providers, regulators and professional associations. While this study identified future roles, the descriptors and critical capabilities did not define professional boundaries. Flexibility of roles across health care is highlighted as a key part of addressing health shortages, and work practice and context gaps. 34 These boundaries exist across other areas of health care and can be successfully navigated. 34 This data shows there is an urgent need for action in different areas of practice and context, further highlighting the current size and capability of the workforce as inadequate. 5 It is time to define a unified nutrition and dietetics profession, which works together to develop as food aficionados, diet optimisers, knowledge translators, equity champions, systems navigators and food systems activists, change makers, activists and disruptors. Education providers may benefit from considering concept‐based approaches 35 as they consider transformation of curricula to meet these needs.

The strengths of this study include the diverse and large qualitative data sample that drew on perspectives inside and outside nutrition and dietetics, and the team‐based approach to data analysis. While this sample aimed to recruit Indigenous nutrition and non‐nutrition thought leaders across Australia and New Zealand we acknowledge that this sample was small with only three participants identifying as Indigenous across the two countries. Therefore the perspectives of Indigenous peoples on the future of nutrition and dietetics are unlikely to be fully captured.

Overall this current study offers an updated and extended vision of the potential emerging future roles in nutrition and dietetics into the future. It provides specific insights for the nutrition and dietetics professionals in Australia and New Zealand and is also globally relevant. The results point to the need for future nutrition and dietetics workforce education and professional development to address the impact of climate change, growing inequities, the democratisation of knowledge, and the disruption of health and food systems. Education providers, regulators, professional associations and citizens need to work together to realise roles that will deliver on better health for all.

CONFLICT OF INTEREST

This study was supported by the Council of Deans Nutrition and Dietetics Australia and New Zealand who are funded by an annual membership fee paid by 18 participating universities in support of this research. Claire Palermo is Chair of the Australian Dietetics Council and Dietitians and Nutritionist Regulatory Council. Danielle Gallegos is supported by the Queensland Children's Hospital Foundation through a philanthropic grant from Woolworths, she is a Board member of the International Confederation of Dietetic Associations (ICDA). Fiona Pelly is an academic member of the Australian Dietetics Council. Claire Palermo is Associate Editor of Nutrition & Dietetics. They were excluded from the peer review process and all decision‐making regarding this article. This manuscript has been managed throughout the review process by the Journal's Editor‐in‐Chief. The Journal operates a blinded peer review process and the peer reviewers for this manuscript were unaware of the authors of the manuscript. This process prevents authors who also hold an editorial role to influence the editorial decisions made.

AUTHOR CONTRIBUTIONS

DG and RB conceptualised the study with input from all authors. All authors collected interview data, RB collected focus group data. DG, RB and CP analysed data with verification from all authors. DG, RB and CP drafted the manuscript. All authors contributed to revising and editing manuscript.

ACKNOWLEDGMENT

Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australian University Librarians.

Boak R, Palermo C, Beck EJ, et al. A qualitative exploration of the future of nutrition and dietetics in Australia and New Zealand: Implications for the workforce . Nutrition & Dietetics . 2022; 79 ( 4 ):427‐437. doi: 10.1111/1747-0080.12734 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Rachel Boak and Claire Palermo are considered as joint first authors.

Funding information Danielle Gallegos is currently funded by the Queensland Children's Hospital Foundation via a philanthropic grant from Woolworths.

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Qualitative Research Methods for Nutrition

Course details, course description.

NUTR 310 teaches principles and practical skills of qualitative inquiry in an interactive seminar format.  Participants will learn how to design and carry out qualitative research through weekly background readings and written assignments, critical case-study discussions, and practical class exercises.  They will also take part in the design, implementation, analysis, and evaluation of a local qualitative research project that involves practical, hands-on experience.  The first part of the course will focus on the foundations of qualitative inquiry, qualitative methods, their strengths and challenges, standards for quality, and tools for critical assessment of insights derived from these methods. The second part of the course will be dedicated to learning how to design qualitative studies, including data collection, data management strategies, and approaches to data analysis. Participants will gain practical experience by developing and implementing a small research study, which will include the elements of research design, field-note documentation, participant observation, in-depth interviews, focus groups, visual methods, analysis, and writing/dissemination. 

In Spring 2024, this course will be offered 100% Online Synchronous.

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• Volume 14, Issue 6
• Perceptions of families and healthcare providers about feeding preterm infants in the neonatal intensive care unit: protocol for a qualitative systematic review
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• http://orcid.org/0009-0008-5313-9272 Willow R Schanz 1 ,
• Aunum Akhter 2 ,
• Georgette Richardson 3 ,
• http://orcid.org/0000-0003-0229-966X William T Story 4 ,
• Riley Samuelson 5 ,
• http://orcid.org/0000-0002-7026-0006 Aamer Imdad 6
• 1 The University of Iowa Roy J and Lucille A Carver College of Medicine , Iowa City , Iowa , USA
• 2 Division of Neonatology , The University of Iowa Health Care, Stead Family Department of Pediatrics, Roy J and Lucille A Carver College of Medicine , Iowa City , Iowa , USA
• 3 Division of Pediatric Psychology , The University of Iowa Health Care, Stead Family Department of Pediatrics , Iowa City , Iowa , USA
• 4 Department of Community and Behavioral Health , The University of Iowa College of Public Health , Iowa City , Iowa , USA
• 5 University of Iowa Hardin Library for the Health Sciences , Iowa City , Iowa , USA
• 6 Division of Gastroenterology, Hepatology, Pancreatology and Nutrition , University of Iowa Health Care, Stead Family Department of Pediatrics, Roy J and Lucille A Carver College of Medicine , Iowa City , Iowa , USA
• Correspondence to Dr Aamer Imdad; aamer-imdad{at}uiowa.edu

Introduction The underdevelopment of preterm infants can lead to delayed progression through key early milestones. Demonstration of safe oral feeding skills, constituting proper suck-swallow reflex are requirements for discharge from the neonatal intensive care unit (NICU) to ensure adequate nutrition acquisition. Helping an infant develop these skills can be draining and emotional for both families and healthcare staff involved in the care of preterm infants with feeding difficulties. Currently, there are no systematic reviews evaluating both family and healthcare team perspectives on aspects of oral feeding. Thus, we first aim to evaluate the current knowledge surrounding the perceptions, experiences and needs of families with preterm babies in the context of oral feeding in the NICU. Second, we aim to evaluate the current knowledge surrounding the perceptions, experiences and needs of healthcare providers (physicians, advanced practice providers, nurses, dietitians, speech-language pathologists and occupational therapists) in the context of oral feeding in the NICU.

Methods and analysis A literature search will be conducted in multiple electronic databases from their inception, including PubMed, CINHAL, Embase, the Cochrane Central Register for Controlled Trials and PsycINFO. No restrictions will be applied based on language or data of publication. Two authors will screen the titles and abstracts and then review the full text for the studies’ inclusion in the review. The data will be extracted into a pilot-tested data collection sheet by three independent authors. To evaluate the quality, reliability and relevance of the included studies, the Critical Appraisal Skills Programme checklist will be used. The overall evidence will be assessed using the Grading of Recommendation Assessment, Development and Evaluation criteria. We will report the results of the systematic review by following the Enhancing Transparency in Reporting the synthesis of Qualitative research checklist.

Ethics and dissemination Ethical approval of this project is not required as this is a systematic review using published and publicly available data and will not involve contact with human subjects. Findings will be published in a peer-reviewed journal.

PROSPERO registration number CRD42023479288.

• Paediatric gastroenterology
• Systematic Review
• Percieved Social Support
• NEONATOLOGY

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2024-084884

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STRENGTHS AND LIMITATIONS OF THIS STUDY

This will be a systematic review evaluating both the perspectives of families and neonatal healthcare professionals on feeding practices of preterm infants in the neonatal intensive care unit (NICU).

Evaluating the perspectives of both family members and neonatal healthcare professionals involved in the care of preterm babies with feeding difficulties may uncover shared grievances and mutually beneficial opportunities for quality improvement in the NICU.

Included studies might be conducted in diverse settings, so generalisability to clinical practice may be affected by cultural, language and healthcare systems context.

Introduction

An estimated 13.4 million babies were born preterm (<37 weeks gestation) in 2020, which represented about 10% of all live births worldwide. 1 Preterm birth is a serious health event that contributes to significant morbidity, mortality and increased healthcare cost in neonates. Over 40% of premature infants will experience feeding difficulties, such as struggling to develop typical feeding reflexes (sucking, swallowing, appropriate breathing) and coordinated oesophageal bolus transport. 2 Consequently, feeding difficulties are associated with elevated healthcare costs due to increased length of stay in the neonatal intensive care unit (NICU) and invasive measures, such as a central line or other parenteral support, to supply the infant with adequate nutrients. 3 4 Poor feeding skills are associated with increased morbidity through malnutrition and growth restriction as well as increased mortality through oropharyngeal aspiration. 5 6

Despite the global prevalence, expense and severity of feeding difficulties, no universal guidelines function as the gold standard of care for feeding preterm infants. 7 The resulting high variability in approach may lead to dissatisfaction among NICU families and healthcare professionals. Families of preterm infants have been shown to express concerns about the technicality of feeding interventions, communication with providers regarding their child and feeling isolated from the feeding approaches in the NICU. 8 Tube feeding, a common feeding intervention for preterm infants, has been associated with increased cost, rehospitalisation, stress and anxiety for families. Due to the emotional nature of feeding a newborn, family members may struggle with learning to feed their infant in this manner. 8 Additionally, nurse perceptions of oral feeding in the NICU have emphasised the impactful role they hold in teaching feeding techniques and relieving emotional distress for the family, which has highlighted a need for greater collaboration between the family and care providers. 9 Family integrated care has been perceived to be helpful in the reduction of maternal stress by parents of preterm infants as well as a necessary and feasible care model by neonatologists and NICU nurses that has the potential to lower length of hospitalisation, decrease healthcare costs and improve breastfeeding rates in preterm infants. 10–12 The approach to feeding preterm infants requires a multidisciplinary effort, including the family, nurses, dietitians, occupational therapists, speech-language pathologists, social workers, advanced practice providers and physicians. Despite these experiences being reported, there is still limited understanding regarding the perceptions of families and caregivers on feeding preterm infants in the NICU. 13 14 This qualitative systematic review aims to analyse the current global knowledge of the perceptions, experiences and needs of families and healthcare staff (nurses, physicians, advanced practice providers, dietitians, occupational therapists, social workers and speech-language pathologists) involved in the feeding process of preterm infants in the NICU, as well as possible improvements to decrease barriers to high-quality care.

Methods and analysis

This systematic review will be conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. 15

Literature search

Systematic electronic queries, available in online supplemental appendix A , will be conducted in major databases, including PubMed, CINHAL, Embase, the Cochrane Central Register for Controlled Trials and PsycINFO from their inception to date of inquiry. Key terms used in the search are those related to population, context and phenomena of interest (perspectives, views, needs, experiences, perceptions, barriers, challenges). Studies will not be excluded based on the publication year, publication status, geographical location or language. Thus, this analysis will include studies from all countries. Studies evaluating specific racial, gender, geographic, age (of family or provider) differences will be included in this review as long as they evaluate qualitative aspects of our phenomena of interest. Bibliographic software (EndNote) will be used to combine database search results, and duplicates will be removed.

Supplemental material

Eligibility criteria.

The populations of interest include families of preterm infants (parents, mother, father, grandmother, grandfather and guardians) and neonatal healthcare professionals (nurses, physicians, advanced practice providers, caregivers, dietitians, speech-language pathologists, social workers and occupational therapists) involved in the feeding care of preterm infants. For this review, preterm birth will be defined as gestational age <37 weeks at birth. If relevant, additional definitions such as late preterm: 34–36 weeks, moderately preterm: 32–34 weeks, very preterm: 28–32 weeks, extremely preterm: <28 weeks gestational age at birth, will be used and clearly reported.

We are interested in the global state of enteral and oral feeding in preterm infants while in NICUs from the perspective of both families and healthcare providers.

Phenomena of interest

The main phenomena of interest are the experiences and perceptions of families with preterm infants and healthcare providers of preterm infants as outlined below:

Family experiences regarding NICU feeding practices.

Family perceptions of NICU feeding practices.

Family needs regarding care of infants with feeding difficulties.

Family barriers regarding care of infants with feeding difficulties.

Healthcare staff perceptions of the NICU feeding practices.

Healthcare staff needs regarding care of infants with feeding difficulties.

Healthcare staff barriers regarding care of infants with feeding difficulties.

Screening and selection of studies

Screening of studies will be conducted through systematic review software Covidence by three authors (WRS, GR and AI). The initial review will consist of title and abstract filtering for relevance to systematic review objective by three authors (WRS, GR and AI). For studies to progress to future screening, they must evaluate the perceptions regarding feeding practices of preterm infants in the NICU in one of our two populations of interest: (1) families and (2) healthcare providers. Studies deemed irrelevant or out of context will be excluded, such as those evaluating children in the paediatric intensive care unit and those evaluating NICU graduates following up in outpatient clinics. The second stage of study selection will include a complete text review of each potential article by three authors (WRS, GR and AI). Conflicts at all stages will be resolved by discussion and contacting a senior author. Additionally, the references of relevant reviews will be evaluated for inclusion in the review. In the case that only an abstract is available for a given study, authors will be contacted to obtain information on and evaluate methods and results. If we are unable to obtain additional information, the abstract will be evaluated exclusively by inclusion criteria. If a paper is published in a language other than English, we will attempt to translate the article for use in this review. If we are unable to translate the article, we will exclude it from this review.

Data extraction

Data extraction will occur independently by three authors (WRS, GR and AI) and subsequent comparison will occur. Conflicts will be resolved through discussion. To standardise data acquisition, a custom data extraction template will be piloted and used in Covidence. Information to be collected from each study will include:

Study design, study duration, study setting, setting country/region, study year and interventions.

Participants

Recruitment methods, including inclusion and exclusion criteria; group differences; sample size; sample size calculation; relevant baseline characteristics (family participants: maternal age, infant gestational age at birth, infant weight at birth, race/ethnicity, etc.; healthcare professional participants: role, experience, race/ethnicity, etc.); intervention groups.

Qualitative: Phenomena of interest (perceptions, experiences, change in satisfaction, change in feeding rate, etc); definitions of phenomena of interest.

Quantitative (if regarding phenomena of interest): variable type (continuous, dichotomous, qualitative); reporting measure (continuous variable: CIs, SD, SE, etc; dichotomous variable: the number of participants, percentage of participants, OR, etc; qualitative); statistical significance of outcome (p value).

Major themes addressed

Stress, anxiety, fear, needs, barriers, satisfaction, etc.

Other relevant constructs

First-order constructs (participant quotes); second-order constructs (author interpretations).

This data extraction protocol is modelled from thematic analysis principles of qualitative evidence synthesis and recommendations by the Cochrane Qualitative and Implementation Methods Group guidance for data extraction and data synthesis. 16 17 After data extraction, these data will be exported to Excel for synthesis and organised by relevant population.

Data synthesis

Data will be synthesised for each relevant population and outcome combination by three authors (WRS, GR and AI). Major themes will be described in a narrative fashion and simple descriptive statistics may be utilised for clarity. In the case of studies having quantitative measures of our qualitative interests, we will report the data as follows: If relevant, dichotomous data will be reported with OR, 95% CIs, and risk ratios, and continuous data will be reported as confidence intervals. Significant construct findings will be reported as quotes, percentages or other descriptive reports. Any inconsistencies or discrepancies between studies will be considered and reported. Data will be reported in narratives and tables for presentation.

Reporting results

Once the study analysis is complete, we will provide a narrative synthesis of all included studies and analysis between comparable studies. We will compare knowledge, beliefs, attitudes and perceptions of families with infants in the NICU within this population as well as compare these findings to the knowledge, beliefs, attitudes and perceptions knowledge of neonatal healthcare professionals. We will include all findings listed in the ‘Phenomena of interest’ section. Reporting of results will be in accordance with PRISMA and Enhancing Transparency in Reporting the synthesis of Qualitative research guidelines. 15 18

Critical appraisal of the studies

To evaluate the quality, reliability and relevance of the included studies, we plan to follow the Critical Appraisal Skills Programme checklist. 19 This tool is often used to appraise qualitative research and is adaptable to emphasise particular areas of interest within our research question. It is recommended by Cochrane and complements the use of the Grading of Recommendations Assessment, Development and Evaluation—Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQ) approach through evaluating the strengths and weaknesses of each study rather than on the basis of exclusion. This tool will be used by three members of the review team (WRS, GR and AI), and disagreements will be mediated through conversation.

Certainty of review findings

The GRADE-CERQ approach will be used to evaluate the overall certainty of evidence. 20 This approach is a comprehensive framework used to assess the overall certainty of the evidence for an outcome using study characteristics such as study design, inconsistency, indirectness of evidence, risk of bias, publication bias and imprecision estimates. We will include the GRADE-CERQ assessment results in an evidence profile that contains certainty ratings, including very low, low, moderate or high, based on the evidence across studies for primary outcomes. We will follow the GRADE-CERQ guidelines for assessing confidence in our qualitative evidence findings, which are based on four components: methodological limitations, relevance, adequacy and coherence. Based on analysis in each of these categories, the study will be given a score of either strong or weak. Concerns with any of the components may reduce our confidence in a review finding.

Patient and public involvement

Ethics and dissemination.

This is a qualitative systematic review that evaluates data present in the public domain through published studies and does not involve contact with human subjects. As a study of published literature, this study was not subject to formal IRB (Institutional Reviw Board) approval. We anticipate that the systematic review will be complete by fall of 2024 and will be submitted for publication in a peer-reviewed journal.

Ethics statements

Patient consent for publication.

Not applicable.

Acknowledgments

The authors would like to acknowledge Paul Casella for his help in editing the manuscript

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Contributors Conceptualisation: WRS, AA, GR and AI; Methodology: WRS, AA, GR, WTS, RS and AI; Writing–original draft preparation: WRS and AI; Writing–review and editing: WRS, AA, GR, WTS, RS and AI. All authors have read and agreed to the published version of the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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New framework for qualitative behavioral intelligence research

• From CGIAR Initiative on Market Intelligence
• Published on 28.06.24

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Photo: Women’s focus group in Amhara state, Ethiopia (credit, Zemen Alayew)

Martina Cavicchioli, Berber Kramer, Carly Trachtman

Understanding how farmers and consumers choose varieties and products remains an important focus for CGIAR Initiative on Market Intelligence. A recently published International Food Policy Research Institute (IFPRI) Brief written by Martina Cavicchioli, Berber Kramer, and Carly Trachtman introduces a conceptual framework to describe the factors that inform farmers’ varietal uptake choices. The framework integrates farmers’ choices and behaviors alongside more contextual and technical aspects of seed uptake. The framework can support qualitative research design and data analysis for generating intelligence about farmers’ decision-making about seed products, which may be of use to government agencies, nongovernmental organizations, and companies that operate in the seed sector.

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Critically appraising and utilising qualitative health research evidence in nutrition practice

Affiliations.

• 1 York University, School of Nursing, Toronto, ON, Canada.
• 2 University of Saskatchewan, College of Pharmacy and Nutrition, Saskatoon, SK, Canada.
• 3 Department of Nursing, Brock University, St Catharines, ON, Canada.
• 4 McMaster University, School of Nursing, Hamilton, ON, Canada.
• PMID: 37964644
• DOI: 10.1111/jhn.13259

Background: Evidence-based decision-making and practice recommendations are commonly based on findings from quantitative studies or reviews. In the present study, we provide an overview of how to incorporate findings from qualitative research into the evidence-based decision-making process.

Methods: To illustrate how qualitative evidence can be integrated into the decision-making process, we have outlined a clinical nutrition scenario and the process for sourcing credible evidence to inform decision-making. A qualitative health research study was selected and appraised using the Critical Appraisal Skill Programme (CASP) appraisal tool for qualitative research. Based on the results of the critical appraisal, the study quality is considered, and we discuss whether the qualitative evidence can be applied to practice.

Results: A detailed description of how the qualitative findings can be used conceptually and instrumentally in practice to address the clinical nutrition scenario is provided.

Conclusions: Developing skills in critically appraising findings from qualitative studies will increase awareness and utilisation of this type of evidence in practice and policy, with a goal to ensure that patient/client perceptions are considered, leading to enhanced person-centred care or systems.

Keywords: critical appraisal; qualitative research.

© 2023 The Authors. Journal of Human Nutrition and Dietetics published by John Wiley & Sons Ltd on behalf of British Dietetic Association.

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Seeburger EF , Gonzales R , South EC , Friedman AB , Agarwal AK. Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety. JAMA Netw Open. 2023;6(4):e239057. doi:10.1001/jamanetworkopen.2023.9057

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Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety

• 1 Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
• 2 Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
• 3 Penn Urban Health Lab, University of Pennsylvania, Philadelphia
• 4 Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia

Question   How do emergency nurses view electronic health record–based behavioral flag notifications in relation to workplace safety and patient care?

Findings   This qualitative study interviewed 25 emergency nurses and described their views on workplace violence, safety, and patient care. Electronic health record flags were described as providing a helpful advisory for nurses but were thought to be unenforceable and riddled with process roadblocks as well as potentially perpetuating bias in care.

Meaning   These findings suggest opportunities for improvements in the implementation of behavioral flags as well as system-level approaches to addressing the risk of workplace violence in health care settings.

Importance   Emergency nurses experience high levels of workplace violence during patient interactions. Little is known about the efficacy of behavioral flags, which are notifications embedded within electronic health records (EHRs) as a tool to promote clinician safety.

Objective   To explore the perspectives of emergency nurses on EHR behavioral flags, workplace safety, and patient care.

Design, Setting, and Participants   In this qualitative study, semistructured interviews were conducted with emergency nurses at an academic, urban emergency department (ED) between February 8 and March 25, 2022. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Data analysis was performed from April 2 to 13, 2022.

Main Outcomes and Measures   Themes and subthemes of nursing perspectives on EHR behavioral flags were identified.

Results   This study included 25 registered emergency nurses at a large academic health system, with a mean (SD) tenure of 5 (6) years in the ED. Their mean (SD) age was 33 (7) years; 19 were women (76%) and 6 were men (24%). Participants self-reported their race as Asian (3 [12%]), Black (3 [12%]), White (15 [60%]), or multiple races (2 [8%]); 3 participants (12%) self-reported their ethnicity as Hispanic or Latinx. Five themes (with subthemes) were identified: (1) benefits of flags (useful advisory; prevents violence; engenders compassion), (2) issues with flags (administrative and process issues; unhelpful; unenforceable; bias; outdated), (3) patient transparency (patient accountability; damages patient-clinician relationship), (4) system improvements (process; built environment; human resources; zero-tolerance policies), and (5) difficulties of working in the ED (harassment and abuse; unmet mental health needs of patients; COVID-19–related strain and burnout).

Conclusions and Relevance   In this qualitative study, nursing perspectives on the utility and importance of EHR behavioral flags varied. For many, flags served as an important forewarning to approach patient interactions with more caution or use safety skills. However, nurses were skeptical of the ability of flags to prevent violence from occurring and noted concern for the unintended consequences of introducing bias into patient care. These findings suggest that changes to the deployment and utilization of flags, in concert with other safety interventions, are needed to create a safer work environment and mitigate bias.

Workplace violence from patients to clinicians is unfortunately common in emergency care, as 70% of emergency nurses and 20% of physicians report being physically assaulted and an even greater percentage report being verbally harassed by patients. 1 , 2 More alarming is that 46% of nurses reported experiencing workplace violence or harassment during their most recent shifts. 3 Of these interactions, one-third were physical assaults. 3 Health care clinician exposure to workplace violence has been linked to absenteeism, lowered morale, and decreased productivity. 4 - 6 Research has demonstrated that burnout and issues of workplace safety can lead to more medical errors, which can be especially dangerous in emergency care settings. 7 , 8

Research has identified risk factors associated with hospital-based violence. These risk factors range from societal factors (outside conflict), institutional factors (long wait times, emergency department [ED] crowding, fallout from death notifications or other difficult conversations, barriers to reporting violent incidents), and patient characteristics (dementia, delirium, intoxication, or undertreated mental illness). 9 - 11 There is an absence of data on which health system–based interventions are effective for reducing risk of workplace violence.

A handful of solutions designed to prevent or mitigate patient to clinician violence exist. A US survey found that 40% of EDs screen for weapons, 38% have metal detectors, 16% provide staff with violence prevention workshops, and 10% offer self-defense training. 1 Electronic health records (EHRs) offer a way to address clinical workplace violence—primarily through behavioral notification or alerts commonly referred to as flags. These flags are created after an initial incident of verbal harassment, physical assault, or another behavioral issue to alert and notify future clinicians. The flag is then embedded within the patient’s health record, and subsequent clinicians are notified via an immediate alert (eg, “pop-up”) requiring formal acknowledgment. These flags are intended to act as an early notification for clinicians to be aware of safety, violence, or behavioral concerns when caring for patients in future encounters.

While behavioral flags represent a potential solution to addressing workplace violence in the ED, little is known about their utility, effectiveness, or potential for unintended consequences on care. The EHR provides a unique landscape at the intersection of patient experience, clinical care, and equity. A recent study found that Black patients were 2.5 times more likely to have negative descriptor language in the EHR. 12 Additionally, hospital-based physicians report that the EHR negatively impacts clinician-patient communication. 13 Behavioral flags may compound these existing issues. Less is known about the perceptions and impact of behavioral flags in a clinical environment. 11 This study explores this issue by going to the source closest to these flags: emergency nurses, who have the most interaction with patients and who are at the highest risk of violence. The objective of this qualitative study was to assess emergency nurse perceptions, beliefs, and attitudes toward EHR behavioral flags.

This qualitative study used semistructured interviews of registered emergency nurses at an urban, academic, level I trauma center ED from February 8 and March 25, 2022. Participants were consented verbally. Interviews were designed to focus on their perceptions, beliefs, and attitudes toward the use of EHR behavioral flags. This project was approved by the University of Pennsylvania Institutional Review Board. Written consent was waived because the study presented no more than minimal risk to participants. The study followed the Consolidated Criteria for Reporting Qualitative Research ( COREQ ) reporting guideline.

Using a convenience, snowball sampling technique, participants were recruited in person or via email across weekday and evening shifts. For variation, sampling was conducted across different shifts, times of day, and points in the shift. The sample size allowed for thematic saturation. Participants were compensated with a $30 gift card for their time.

Within the study site health system, any ED clinician (eg, physician, nurse, resident physician, or technician) can place a behavioral flag in the EHR after an incident of verbal, physical, or sexual assault or another safety issue (eg, a patient attempting to break into a medication cart). The submission includes information about the time and date of the incident, the patient, and an open-text field to describe the incident. Variation exists at the hospital site level on if, and when, flags are reviewed by an administrator or leader. At the study site, flags can be reviewed by the ED unit-based multidisciplinary leadership team. The flag is displayed as both an icon in the EHR and as a pop-up notification when the patient medical record is opened. There are no specific policies or procedures that dictate actions that must be taken by staff if a flag is present; instead, the behavioral flag system was created to make clinicians aware of a patient who may compromise their safety. Furthermore, there is no standardized process for the removal of a flag. In the study health system, fewer than 1% of all ED patients have a behavioral flag.

Semistructured interviews with participants were conducted in person or via telephone by a trained qualitative research team member (E.F.S.). The interviewer used an interview guide developed by all members of the study team, consisting of qualitative researchers and emergency physicians with expertise in burnout and equity (E.F.S., E.C.S., A.B.F., and A.K.A.) (eAppendix in Supplement 1 ), and pilot tested (E.F.S. and R.G.). The guide included open-ended questions and subsequent probing questions about the usefulness and impact of flags. Participants self-reported demographic characteristics such as their age, sex, race (Asian, Black, White, or multiple races) and ethnicity (Hispanic or non-Hispanic [Latinx or non-Latinx]), and ED tenure. Informed by research indicating racial disparities in behavioral flag issuance, nurses were asked about their perspectives on how racial bias may be introduced and its impact on flagging patient behavior. Recently published data note disparities in flag prevalence, with Black patients flagged at higher rates than White patients (4.0 vs 2.4 flags per 1000 patients) and male patients and those who utilize Medicaid also flagged more often. 14 Thus, the decision to include this focus question within these interviews was made a priori. 14 Interviewers noted that the number of flags tended to be greater for Black patients, disproportional to their representation in the patient population. Interviewers followed up with probing questions asking the participant why they did or did not believe racial bias plays a role. All interviews were recorded, transcribed, and deidentified using the Rev professional transcription service 15 and reviewed for accuracy.

A thematic analysis of interview responses was conducted using the constructivist paradigm. An initial codebook using a grounded theory approach for analyzing interview responses was developed, then revised iteratively throughout the coding process. Revisions were applied to future codes as well as retroactively to already-coded segments wherein the new code was a more appropriate categorization, known as a constant comparative coding approach. Two authors (E.F.S. and R.G.) assessed a subset of 5 transcripts (20%) for interrater reliability and reached consensus. Member checking was not conducted. NVivo, version 12 (QSR International), was used for data storage, management, and coding. 16 Data analysis was performed from April 2 to 13, 2022.

This qualitative study included 25 registered emergency nurses at a large academic health system, with a mean (SD) tenure of 5 (6) years in the ED. Participant characteristics are summarized in Table 1 . Their mean (SD) age was 33 (7) years; 19 were women (76%) and 6 were men (24%). Participants self-reported their race as Asian (3 [12%]), Black (3 [12%]), White (15 [60%]), or multiple races (2 [8%]); 2 participants (8%) did not report this information. Participants self-reported their ethnicity as Hispanic or Latinx (3 [12%]) or non-Hispanic or non-Latinx (22 [88%]). The demographic background of study participants mirrored that of nursing staff throughout the department.

Five main themes were identified using directed content analysis. Benefits of flags (theme 1) was used when positive use or application of flags was discussed. Content was categorized as issues with flags (theme 2) when a negative use, application, or downstream effect of behavioral flags was discussed. Patient transparency (theme 3) was applied when opinions related to greater information sharing with patients about behavioral flags in their EHR were shared. Content was categorized as system improvements (theme 4) when suggestions or ideas to improve the behavioral flags process or increase ED workplace safety were provided. Finally, content was categorized as difficulties of working in the ED (theme 5) when narratives illuminated the challenges of working in the ED contributing to behavioral flag use were shared. The 5 themes, subthemes, and illustrative quotes are summarized in Table 2 .

Nurses identified strengths of behavioral flags, particularly that they provided a useful advisory that a patient may be verbally or physically aggressive. Similarly, participants who had placed a flag in a patient’s EHR did so to hopefully provide awareness to future clinicians.

In extreme cases, more than half of ED nurses believed that the behavioral flag prevented a potentially dangerous interaction, as the flag enabled the nurse to be more prepared and activate other safety training in advance. This is particularly important for patients with a flag documenting past homicidal ideation, as this forewarning prompts nurses to search for concealed weapons that were not captured on initial screening. Relatedly, behavioral flags for some patients with a violent history allowed staff to strategically place these individuals in clinical areas with additional staff support in the event that a violent or aggressive action occurred.

Approximately one-fifth of nurses indicated that the presence of a behavioral flag made them more understanding or compassionate toward a patient, particularly if the patient was thought to be unhoused. Almost all participants described underlying, unmet mental health and substance use needs of patients that commonly contribute to behaviors leading to a flag. This was then frequently followed up by nursing desires to provide more behavioral health services from the ED.

Several issues with the documentation process for behavioral flags were identified. Numerous administrative, or process, concerns were outlined. In particular, nurses expressed concern that the process to place a flag in the EHR is too long, is complex, and requires information that is tangential to the goal of the flag (eg, race, ethnicity, or sex) and, once submitted, there is little to no follow-up from supervisors or the health system. These issues often make nurses ask, “Why bother?”—especially at the end of a long shift.

The majority of participants viewed flags as unhelpful, noting that actual patient discipline “never happens” or the presence of a flag “doesn’t change anything.” These participants indicated that while a flag may make them proceed with increased caution, the flag itself will not prevent a patient from becoming violent. Complaints over the annoyance of another EHR-based, pop-up window or the formatting of the notification (eg, small text, difficult to read) were also discussed.

In extreme situations and in a minority of cases in which a patient receives multiple flags for repeated violence or egregious behavior, participants cited concerns regarding the overall effectiveness of the flag notification. Nearly all nurses described the repeated flags as having “no teeth” and being largely unenforceable because of the Emergency Medical Treatment and Labor Act.

There was concern that the flag may negatively bias the patient-nurse interaction. Concerns over the introduction of bias were either theoretical or had been witnessed, or the participant had admitted to shifting their approach and treating the patient “differently” in a way they viewed as negative, whether implicitly or explicitly. More than half of participants said that flags prompted them to approach the patient with caution informed by the flag documentation. Participants were insistent that a change in approach, however, did not impact the quality of clinical care provided.

While participants acknowledged that flag placement can be biased against individuals who use the ED frequently or people with addiction, many felt that there was no association between the racial or ethnic identity of the patient and whether they received a flag. The notion that more Black than White ED patients have flags was largely attributed to the patient population. Others, however, did feel that race and ethnicity play a role in who receives a flag, what kinds of behaviors are tolerated, and to what degree. For example, several described a greater tolerance for harassment and abuse from White patients by physicians, making them less likely to intervene or provide support to nurses.

There was concern over inappropriate or irrelevant flags. All participants discussed the subjective nature of the flag narrative content. This content varied between verbal harassment and sexual assault of staff without regulation or standardization.

Participants also noted that on some occasions, staff may escalate situations with patients, which can cause an unnecessary issuance of a flag. The majority of participants noted that burnout and staffing issues have contributed to stress and place nurses on edge, making them more likely to “snap.” A few participants also mentioned that some of their colleagues generally have more of a propensity to be confrontational than others.

Participants also acknowledged that wait times in the ED are long, that patients may be in pain or otherwise feeling unwell, and that the circumstances surrounding the ED visit may provoke patient behavior that is otherwise uncharacteristic. Relatedly, nurses indicated a problem with patients having flags from years prior with no subsequent issues, and therefore, the flag is irreflective of the individuals’ actual demeanor.

Nurses interviewed were asked whether patients should always know if their EHR contains a behavioral flag. Nurses described the need for patient accountability, and they stated that notifying them would make patients “aware” that security and supervising staff knows of their behavior.

There was concern that more widespread notification of a behavioral flag would be “damaging” to future patient-clinician relationships and the patient’s overall relationship with the health system.

In response to the myriad flag issues outlined, nurses described potential improvements to the process. The following improvements were mentioned: make the reporting form easier to complete, increase follow-up and communication after a flag is submitted, standardize the issuing of a flag, provide greater education for staff on the workplace violence reporting process, and perform a continual review for flag removal.

Improvements to the physical environment of the ED were also suggested. Participants overwhelmingly described the danger presented by the physical layout of the triage room as well as issues with patient room doors that can only open in 1 direction. The desire for increased video surveillance and more security staff (especially for more secluded areas), as well as more careful screening of visitors, was also discussed.

Human resource solutions were also mentioned. Solutions included the following: provide more effective and/or role-playing de-escalation trainings, make a more concerted effort to hire nursing staff from diverse backgrounds, and hire psychiatrists specifically for the ED to more readily address the mental health and substance use difficulties overrepresented in patients with behavioral flags and the high-utilizer population of the ED overall.

Finally, there was a desire for lower tolerance of incidents of verbal and physical violence from ED and health system leadership, especially when an extreme incident of workplace violence occurs. This included more forceful “no tolerance” policies in the case of harassment or violence, greater legal support, and acknowledgment that this level of harassment and abuse sustained daily is a serious issue.

When asked if they had ever documented an incident to issue a behavioral flag, nurses often described the incident that prompted it. These experiences were aggregated, describing a breadth of daily violence and harassment. The experiences described included sexual assault, physical violence, and daily verbal harassment.

In many instances, participants attributed the inappropriate patient behaviors to underlying and unmet mental health needs and substance use disorder needs. They stated that greater resources and access to care are needed.

More than half of participants also noted that the COVID-19 pandemic contributed to more tense interactions. They attributed this change to conversations about vaccination, masking, or ripple effects related to staffing, long wait times, health system strain, and increases in gun violence.

This qualitative study of emergency nurse perceptions of EHR behavioral flags aimed to address a critical gap in understanding these flags and their potential for reducing workplace violence from patients to staff and implications for patient care. This study had 3 important findings.

First, while flags provided staff with a useful warning, fulfilling in part the initial motivation for their use, several concerns emerged that nurses viewed as precluding flags from truly moving the needle in promoting clinician safety. These seemingly contradictory viewpoints present a nuanced view of both useful and nonuseful components of flags. From these participant perspectives, there is a greater need for consistency in the system-level response to a flagged incident, particularly by those reviewing the documentation of an initial incident, and a consistent response to patients who display the largest risk toward staff safety is also needed. From these perspectives of ED nurses, the lack of leadership follow-up, a belief that the flags do not decrease violence, and complaints of a long and complex documentation system create a dangerous, self-enforcing mechanism in which workplace violence and harassment is underreported and thus leaves all staff, patients, and visitors at risk.

Second, the disparate perspectives on the influence of bias in flags provided interesting insight into their potential unintended consequences. Emerging research has reported observable implicit bias in EHR descriptions of patients, in the perception of how violent a patient is, and in clinical decision-making. 12 , 17 , 18 Despite the nurses’ mixed perspectives on the intersection of race and flagging in this study, other work by this team has shown that Black patients disproportionately receive flags compared with White patients. 14 As part of the expressed desire for better and more effective trainings to address workplace violence, these findings suggest that it would be worthwhile to include trainings that specifically address the relationship between racism and flags as well. Other procedures, such as a periodic review of patient behavioral flags and the utilization of a patient advisory board to provide policy guidance, could be introduced in an effort to mitigate systemic racism related to flags. Addressing issues of health inequity is also fundamental to improving public health.

Finally, participants readily identified solutions to remediate the behavioral flag and workplace safety issues described in the interviews. The need to reconfigure triage was something mentioned in almost every interview, as its layout posed major staff and patient safety risks. Other built environment solutions, like bidirectional opening doors to ensure staff always have safe passage out of patient rooms, were also repeatedly mentioned. Other suggestions provided, especially those to improve documentation and communication, could also be implemented to remedy process complaints. These findings suggest that the issue of violence in the ED can be readily improved.

This qualitative study has several limitations. Participants were registered emergency nurses from an urban, academic health system. The sample comprised mainly White women, reducing data variance and insight from individuals in other roles and those with diverse racial and ethnic backgrounds. However, our sampling approach allowed for more in-depth understanding of nurse relationships with behavioral flags, which is especially relevant given that nurses are the primary clinicians interacting with patients in the ED; typically, there is 1 registered nurse for every 4 to 5 patient rooms. Nurses, compared with other ED staff, are also less likely to feel safe. 19 Participants volunteered and thus sampling bias was present. Lastly, the increased stress and workplace violence–related events attributable to COVID-19 and gun violence in this setting at the time of this study may have influenced responses. However, the increased focus on improving mental health and employee wellness also as a result of those 2 factors makes this work especially timely and important.

Emergency nurse perspectives on the effectiveness of behavioral flags vary. For many, flags serve as a helpful alert to approach patient interactions with caution or employ safety skills learned through other trainings. The ability of flags to prevent violence from occurring altogether seems unlikely. The findings of this study suggest that changes are needed to improve the process from initial documentation through follow-up and enforcement, especially for patients who pose a high risk of violence. Changes to the clinical environment are also needed. It is important to underscore that there is risk of bias, particularly racial bias, in the issuing of flags and clinician reactions to reading them in a patient’s EHR, and an effort to implement measures to mitigate bias while keeping nurses and staff safe should be considered. One kind of intervention alone is not enough to prevent violence in the ED altogether; future research should explore what other procedures or policies, in concert with behavioral flags, are most effective in reducing incidents of harassment or assault in the ED. Future work by this research team will explore the outcomes associated with flags on patient care, particularly whether having a flag in a patient’s EHR in perpetuity affects their care.

Accepted for Publication: March 6, 2023.

Published: April 20, 2023. doi:10.1001/jamanetworkopen.2023.9057

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Seeburger EF et al. JAMA Network Open .

Corresponding Author: Emily F. Seeburger, MPH, Penn Urban Health Lab, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, 407 Blockley Hall, Philadelphia, PA 19104 ( [email protected] ).

Author Contributions: Ms Seeburger had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Seeburger, Friedman, Agarwal.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Seeburger, Agarwal.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Seeburger, Friedman, Agarwal.

Administrative, technical, or material support: Gonzales, Friedman, Agarwal.

Supervision: Friedman, Agarwal.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This work will be presented at the Society for Academic Emergency Medicine Annual Meeting; May 19, 2023; Austin, Texas.

Data Sharing Statement: See Supplement 2 .

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