Sustainable nutrition perceptions and professional recommendations of Turkish nutrition and dietetics students: a qualitative focus group study | BMC Medical Education

Design and sampling

This qualitative study was conducted in university students enrolled in the nutrition and dietetics program. Focus group discussions were used to gather data. Focus groups are an interactive process among a group of participants interested in addressing a specific topic or research question [20, 24].

This study was conducted at Erciyes University, a well-established university in Türkiye. Erciyes University Nutrition and Dietetics program is the second program providing nutrition and dietetics education in Türkiye. This nutrition and dietetics program, which educates future professional dietitians, holds an accreditation certificate from the Health Sciences Education Programs Evaluation and Accreditation Association, an independent organization that evaluates health education programs [15] and the number of students studying in the program is 462 [28]. The quota occupancy rate of the program is 100%. In the nutrition and dietetics program curriculum, professional courses consist of both theoretical knowledge and clinical practice.

Nutrition and dietetics students are required to have 132 h of theoretical courses and 86 h of clinical practice with a focus on human nutrition. During this period, each nutrition and dietetics program student is provided with the opportunity to practice in the field/clinic/field for 4 days (24 h).”Sustainable Nutrition” was added to the curriculum as an elective course in the 2022–2023 academic year within the scope of the project titled” Assessment and development of an educational plan for dietitian candidates to promote sustainable nutrition in society” supported by the Scientific and Technological Research Council of Türkiye (TUBITAK), which is also related to the data of this study. The data of the study was collected before the start of the semester courses. Therefore, the students who participated in the study had not taken any courses on sustainable nutrition during their nutrition and dietetics education.

In this study, the purposive sampling method, which is a type of criterion sampling, was used to select participants. Purposive sampling involves intentionally selecting individuals who meet specific criteria relevant to the research objectives. The inclusion criteria were as follows: being over 18 years of age, being enrolled in the nutrition and dietetics program, and not having participated in elective or mandatory courses or training related to sustainable nutrition. Participants were required to be able to answer questions clearly, demonstrate openness to communication and cooperation, have no known memory issues, and voluntarily agree to participate. Participation was entirely voluntary, and the decision not to participate did not affect the academic success of the students. This approach ensured that the selected participants aligned with the study’s goals and characteristics.

Research questions

The following research questions were formulated to determine the aim of this study:

RQ 1. What is sustainable food or sustainable nutrition in human nutrition?

RQ 2. What are the determinants for sustainable food or sustainable nutrition? Environmental or external factors (climate change, awareness trend, social media, COVID-19, etc.), personal factors and motivational factors, etc.)

RQ 3. How can change towards sustainable food/nutrition in society be increased or sustained? (for students and dietitians)

Procedure and focus group interviews

Participants were selected from students in different grades of the nutrition and dietetics program to ensure a diversity of views. The aim was to include four to six students in each focus group session [10]. After obtaining permission from the dean’s administration, the researchers prepared informative invitations for program students interested in participating in the study. These invitations were shared on student notice boards and through student groups to maximize awareness. The selection of volunteers was conducted in a systematic manner to ensure fair and diverse representation:

Encouraging participation across all grades was successfully achieved. All students, regardless of grade level, were encouraged to volunteer for the study. Balanced representation was targeted. From the pool of volunteers, participants were chosen to maintain an equal representation across different grades. This approach ensured that no single grade dominated the discussions. A strategic process was implemented to ensure diversity. The final selection process prioritized demographic and viewpoint diversity to align with the study’s objectives. This ensured robust discussions and valuable insights from participants. As a result of this structured approach, each focus group session successfully included four to six participants from various grades, fulfilling the goal of representing a range of views and experiences.

All focus groups were conducted from September 2022 to October 2022. Focus group interview is a data collection technique carried out with a group participants with similar characteristics and accompanied by a moderator. It was an interaction process that was carried out with a group of people selected from among the individuals who were interested in the subject by addressing a specific topic and emerging about the research topic [10]. Students from the same grade and academic year (e.g., first-year or second-year students) were placed in the same focus groups. Participants came from similar or different social backgrounds, which include factors such as socioeconomic status, cultural influences, and family environment. No other criteria were used to organize participants into focus groups.

Participants received an information sheet and a consent form prior to the focus group interview sessions. At the beginning of each session, the purpose of the study, as well as an overview of the focus group process, were explained. Participants were informed that they could leave the focus group at any time during the session if they wished. Permission to record the interviews was obtained using an audio/video recorder (DJI Pocket 2 Creator Combo Gimbal camera, Dà-Jiāng Innovations Science and Technology Co. Ltd., Shenzhen, China). Participants were assured that the recordings would only be accessed by the researchers, participation was entirely voluntary, and they could withdraw from the study at any time without providing a reason. At the end of each session, students completed a questionnaire to collect demographic data. Anonymity was maintained by ensuring no personal information that could identify participants was collected. Each focus group lasted between 60 to 80 min. Facilitation was carried out by (Authors HD, AB, and EKA), who handled audio recording, and (Author NO), who asked questions and took notes during the sessions.

Focus group design questions

The questions in the semi-structured interview guide (Table 1), designed to address the research questions of this study, were developed within the framework of sustainability and behavioral change theories. Specifically, the theoretical foundation was derived from the Theory of Planned Behavior [2] and the Social Cognitive Theory [3], which provide insights into attitudes, beliefs, and social influences affecting sustainable nutrition practices. After welcoming the participants, an opening (and warm-up) on the topic was made, followed by introductory and transitional ice-breaker questions to facilitate engagement. The main questions were designed to elicit detailed discussions on sustainability perceptions, professional recommendations, and behaviors. The questions were developed using relevant literature [9, 35] and consultation with five experts from the fields of public health, nutrition, and sociology. To ensure the validity and clarity of the interview guide, the questions were tested in a pilot session with four participants. These pilot participants were randomly selected from among the first students who responded to the participation announcement, although two first-year students who applied were excluded from the main study. Since no modifications were deemed necessary after the pilot session, the data collected during this session were included in the analysis, adhering to the accepted approach for utilizing pilot data [21].

The questions consisted of an introductory question (icebreaker) to start the conversation and a transitional question more related to the topic of the study to steer the group discussions towards the purpose of the study. There were four main questions and most of the time was spent on these questions. The moderator followed the question guide in each session and asked probe questions where needed. Main questions had alternatives (probes). The probe questions allowed students to share and elaborate on their ideas. At the end of the focus groups, participants were asked to complete a short questionnaire collecting demographic information. The questionnaire was completed anonymously. There were seven questions related to age, gender, accommodation status, parental education, interest in the professional field, academic average and income. This information was used to better understand the sample and was not used for further analyses.

Data saturation is the point at which no new information or themes emerge from gathering additional data [35]. In our study, we continued conducting focus‐group interviews until no novel codes appeared in two consecutive sessions, ensuring comprehensive coverage of participants’ perspectives. This approach strengthens the credibility of our thematic analysis by demonstrating that further data collection would not have added meaningful insights. When the data started to be repeated, saturation was determined in the 4th focus group interview. At this point, the number of mention counts under the codes was quite sufficient and no new code was created. It was decided that data saturation was reached, and the sample of the study consisted of 20 participants.

Data analysis and trustworthiness

The data obtained from the questionnaire were analyzed using Microsoft Excel software (Microsoft Corporation, the United States), and descriptive statistics related to participant characteristics were calculated. After the completion of the focus group interviews, audio recordings were listened to within 24 h, and the raw data were transferred to the computer and converted into Microsoft Word documents (Microsoft Corporation, the United States). The recordings were transcribed verbatim, cleaned, and checked for accuracy.

Content analysis was conducted to organize and interpret similar data within the scope of specific concepts and themes. This process included preliminary reading, coding qualitative data, reaching themes, organizing data, interpretation, and reporting [10]. Hand coding was used for the data analysis. A list of codes (33 codes) was created and systematically grouped into the phenomenon of sustainable nutrition under three main categories: Conceptual meaning, Determinants: Environmental impact, and Role of dietitians.

To ensure the reliability of the coding process, two researchers independently coded a randomly selected interview transcript. They compared their results and resolved any discrepancies through discussion until consensus was reached. Following this preliminary process, one researcher coded the remaining transcripts. Subsequently, all codes across the dataset were reviewed and compared collaboratively by both researchers. Any inconsistencies or disagreements were addressed through discussion until full agreement was achieved. Finally, the agreed-upon codes were subjected to content analysis, resulting in the identification of three overarching themes. The finalized codes were then used to thematically code all focus group data using Microsoft Excel. For each identified factor, supporting quotes and the frequency (f) of mentions were presented in the findings section. The letter”P”was used to represent participant numbers. The frequency counts (f) of each factor are provided in brackets.

To ensure the trustworthiness of the data, the quality criteria for qualitative research—credibility, transferability, dependability, and confirmability—were employed [10]. Credibility was established through transparency and the use of a reflective dialogue approach during data collection and analysis. This approach involved several key steps: (1) participants were allowed to review the initial themes generated from their responses to ensure accuracy and relevance,(2) moderators engaged in reflective discussions on the notes taken during focus groups, allowing for deeper analysis and refinement of themes; and (3) honesty, truth, and proving self were emphasized by creating an open environment where participants felt comfortable expressing their perspectives without fear of judgment. The importance of the study was explained to the participants to encourage active engagement. All researchers, except for one, were academics working at the same university as the students, fostering familiarity and trust during the data collection process.

The research team consisted of individuals from diverse disciplines, including Nutrition and Dietetics, Public Health, Public Health Nursing, and Nursing Education. Validity was assessed based on the involvement of the two researchers who collected the data (from Nutrition and Dietetics and Public Health Nursing departments) and all authors who contributed to data analysis. One of the researchers (Author [AC]) held a qualitative data analysis certificate, ensuring further rigor. Throughout the interviews, issues of honesty, truthfulness, and self-reflection were emphasized by the authors.

Ethical considerations

This study was carried out as a part of  TUBITAK project number 122G123. The ethics committee approval, which is required for conducting studies related to the project, was granted by the Social and Human Sciences Ethics Committee of Erciyes University [Date: 15.09.2022/Approval No: 402 (ethical approval taken for the execution of the project) and Date: 30.07.2024/Approval No: 317 (ethical approval taken for the execution of the study)] and the procedures followed were in accordance with the Helsinki Declaration. Written informed consent was provided.