A conceptual framework of the values of nutrition health professionals in the Netherlands

ABSTRACT

Nutrition health professionals play important roles in developing and implementing healthy eating strategies for socioeconomically disadvantaged populations. However, the values of nutrition health professionals that inform and underly their everyday decisions and practices are not explicit. The purpose of this study was to identify and synthesize the key values of nutrition health professionals. An explorative qualitative research design was used in which a purposive sample of nutrition health professionals (n = 29) were interviewed. The ‘Values Wheel of Nutrition Health Professionals (VWNHP)’ was created, consisting of 16 values organized into six groups of complementary values – self-transcendence, self-enhancement, openness to change, conservation, connection, and perseverance. The VWNHP may be utilized as a tool to support the critical reflection in health promotion training and practice needed to address nutrition inequities.

KEYWORDS:

• Values
• nutrition
• low socioeconomic status
• health promotion
• critical reflection

Introduction

In most developed countries, health inequities persist between people with different levels of socioeconomic advantage. While there are many factors contributing to health inequities, one important modifiable risk factor is nutrition (Alkerwi et al. 2015). Due to complex environmental barriers to attaining healthy diets, groups of people with less favorable socioeconomic circumstances than others in the same society – hereafter referred to as socioeconomically disadvantaged populations (SDPs) – have a higher intake of energy-dense, nutrient-poor foods and lower intake of fruit, vegetables, and whole grains (Geurts et al. 2017; McGill et al. 2015). This is in opposition to international recommendations for sustainable healthy diets that are high in fruit, vegetables, legumes, nuts, and whole grains, but limited in salt, free sugars and total fats, and highly processed food (FAO and WHO 2019). As more countries start to experience the epidemiological transition to more noncommunicable and lifestyle-related diseases, nutrition inequities will become more common (Adams 2020). To reduce or eliminate nutrition inequities, it is thus important to develop more effective strategies to support healthy eating practices in SDPs.

Nutrition health professionals play important roles in efforts to improve healthy eating in SDPs and their daily decisions, actions, and practices are influenced by values. Values operate at individual and collective (e.g. professional) levels and are defined as stable and enduring beliefs forming basic convictions of what individuals or social groups consider right, good, or desirable (Moyo et al. 2016). Values construct the motivational bases of people’s perceptions, attitudes, and behaviors towards the achievement of specific higher-order goals (Schwartz 2012). As such, values are inherent in the design of healthy eating strategies (Kelly et al. 2015). However, more work is needed to explicitly identify the values that shape the foundation of practices, decisions, and goals in public health and health promotion practice (Gregg and O’Hara 2007).

Critical reflection is the process of assessing and challenging practices, beliefs, and values from the individual and collective level to promote awareness, learning, and improvement in public health and health promotion practice (Tremblay et al. 2014; Tretheway et al. 2015). While several critical reflection models have been identified as being relevant to public health and health promotion, their use in guiding the critical reflection process remains under-researched (Alexander et al. 2020; Tretheway et al. 2015). To enable nutrition health professionals to reflect on and express their values, it is important to first have insight into the key values underpinning practice.

To our knowledge, no research has assessed the values of nutrition health professionals with a role in the development of healthy eating strategies in SDPs and sought to develop a model to guide professionals in critical reflection. As such, the purpose of this qualitative research is to identify the key values of nutrition health professionals at a local level and synthesize this knowledge into a conceptual framework of values.

Methods

Study design and theory

An explorative qualitative research design was used to investigate nutrition health professionals’ values regarding strategies to improve healthy eating in SDPs. This study was part of a larger study that examined the values influencing and underpinning strategies to promote healthy eating in SDPs in the Netherlands. The study received ethical approval by the Social Sciences Ethics Committee of Wageningen University & Research (09215846). Unlike the larger study, the theoretical basis of this study was informed by Schwartz (2012) who identified a comprehensive set of basic values recognized in all cultures which underlie individual decision making, attitudes, and behavior.

Schwartz’s theory of basic human values encompasses four broad groups of values: self-transcendence, self-enhancement, openness to change, and conservation. Values that fall under the group ‘self-transcendence’ primarily serve collective interests and include benevolence and universalism. Values that fall under the group ‘self-enhancement’ primarily serve individual interests and include achievement, power, and hedonism. Values that fall under the group ‘openness to change’ reflect independent thought and flexibility to change and include self-direction, stimulation, and hedonism. Finally, values that fall under the group ‘conservation’ reflect order and resistance to change and include security, conformity, and tradition.

Study population

A purposive sample of key informants was selected using a maximum variation sampling to capture a wide range of perspectives from nutrition health professionals in the Netherlands (Patton 2015). Nutrition health professionals were defined broadly as those with a stake in improving human health through improved eating behaviors. For example, dieticians are specialized in nutrition assessment, monitoring, and counseling. General practitioners provide health education, individual counselling, and act as a gateway to specialist care (e.g. dietician referral). Municipal health services (MHS) develop and implement public health and health promotion programs tailored to the needs of local communities. National health promotion institutions such as the Netherlands Nutrition Centre specialize in developing health promotion programs focused on a specific theme (e.g. nutrition or health disparities). Finally, researchers from academic institutions contribute knowledge concerning determinants of healthy eating, nutrition inequities, and effective healthy eating strategies.

Nutrition health professionals were recruited through the personal network of the researchers, snowball sampling, and web searches of relevant organizations. Professionals were invited to participate via email, with telephone follow up if necessary. A total of 29 participants were interviewed (Table 1), at which point it was subjectively determined by the researchers that themes were well-developed and no new or discrepant information was found in the data (Patton 2015).

Table 1. Characteristics of research participants

Characteristic	n^a
Self-identified gender
Female	24
Male	5
Experience in current role (years)
< 5	11
6–10	4
11–15	4
16–20	2
> 20	8
Profession
General practitioner (GP)	7
Dietitian (D)	4
Academic (A)	6
Professional at health promoting institution (HP)	7
Professional in municipal public health services (MHS)	9

^aFour participants worked in more than one profession category; as such, the sum exceeds the total number of 29

Data collection

In-depth, semi-structured interviews were conducted between October 2020 and January 2021 through online audio-visual communication. The interviews were conducted in English or Dutch – based on the participants’ preference – and audio-recorded to allow for verbatim transcription following verbal consent. An interview guide was developed using the principles of Appreciative Inquiry, which makes use of storytelling to explore participants’ underlying values (Bäckström et al. 2018; Frankel, Karnieli-Miller, and Inui 2020). By having participants focus on their best experiences and dreams, the interview technique established a dynamic environment in which participants told stories and values were revealed (Michael 2005). The interviews lasted on average 41 minutes (ranging from 33 to 70 minutes).

Data analysis

The interview transcripts were analyzed using reflexive thematic analysis, a method to analyze qualitative data which focuses on identifying, analyzing, and reporting patterns within data (Braun and Clarke 2006, 2019). Transcripts were loaded in Atlas.ti qualitative data analysis software and the analysis was performed in six phases: Phase 1) One researcher read the transcripts to become immersed and familiarized with the data; Phase 2) One researcher performed inductive coding with a semantic and latent approach to identify relevant data. Semantic codes identified the explicit and surface meanings of the data, staying close to the participants own words and capturing the explicit meaning. Latent codes had a more interpretative and conceptual orientation to the data, capturing the implicit meaning; Phase 3) Codes were sorted into overarching themes and subthemes based on the four groups of values from Schwartz’s theory of basic human values. Two new overarching values were also formed based on the codes that clustered together or which did not fit into the existing value groups (see Supplementary File 1); Phase 4) Themes were reviewed to ensure an accurate representation of the data set; Phase 5) Themes were further defined and clear definitions and names were generated; and Phase 6) The results were interpreted and synthesized through a narrative summary. In phases 3–6, all researchers discussed codes and themes and reached consensus.

Results

The nutrition health professionals expressed a total of sixteen different values, which are grouped into six complementary groups of values: 1) self-transcendence, 2) self-enhancement, 3) openness to change, 4) conservation, 5) connection, and 6) perseverance (Table 2). Professionals were more similar in their values than they were different, and values did not differ based on profession.

Table 2. Overview of the values of nutrition health professionals

Group	Value	Value items
Self-transcendence	Compassion	Caring, empathy, feeling for someone, wishing the best, innocence
	Consideration	Contribute, helpfulness, generosity, make a difference, support
	Universalism	All-embracing, acceptance, nonjudgmental, respect, all-encompassing, appropriateness, inclusiveness, egalitarianism, equality, equity, fairness, justice, solidarity, understanding
Self-enhancement	Hedonism	Enthusiasm, fun, satisfaction, pleasure, humor, passion, interest
	Personal growth	Challenging, diversity, inspiration, personal development, reflection, learning, growth, new insights
	Personal success	Achievement, recognition, pride, prove something
Openness to change	Freedom	Act without constraints, opportunity, independent thought
	Inventive	Creative, innovative, new ideas
	Open-minded	Open, receptive, daring, flexibility
Conservation	Concreteness	Order, clear definitions, demarcate
	Conventional	Traditional, resistance to change, conform, adherence, obedient
	Evidence-based	Proven, scientifically justified
Connection	Relationship	Connection, involvement, relatedness, trust, bond, on the same level, listening, recognizance, comfortable, safety, relying
	Working together	Collaboration, interdisciplinary, learning from each other, unified, undivided, joint effort
Perseverance	Commitment	Ambition, active, dedication, conviction, importance, longing
	Willpower	Drive, determination, discipline, motivation, attention, sense of urgency

Self-transcendence

Values that fell under the group self-transcendence served collective interests and emphasized concern for the welfare and interests of others. The value that came across most frequently amongst all nutrition health professionals (n = 29) was universalism, which reflects an inclusive and equal treatment to ensure the welfare of all population groups. Nutrition health professionals highly valued equal opportunities for all people, including the ability to buy and prepare healthy foods and access information about nutrition. Additionally, professionals emphasized that efforts should be made to understand the position of SDPs:

A lot of people eat unhealthy when they have a low income also because, for example, a bag of French fries, huh, is much cheaper than potatoes, vegetables and a piece of meat hè so then it’s better to eat fries with a frikandel, that’s much cheaper. So yes, you have to eat anyway, so I can understand why you would choose to eat them more often. (D12)

Another value frequently expressed by almost all nutrition health professionals (n = 28) was compassion. Nutrition health professionals expressed concern for others and wanting the best for SDPs: ‘Well, I think true success is that the people that you work with feel better and have reached their goals’ (E01). In addition, professionals expressed empathy for the circumstances of SDPs. As one professional stated: ‘Well the most important thing is that you can empathize with the other person’s point of view’ (D10). The final self-transcendence value frequently expressed by most nutrition health professionals (n = 23) was consideration, which reflected the desire of professionals to contribute to the health of SDPs and do something meaningful: ‘I’m proud of doing research that brings it a little further, the world’ (E10).

Self-enhancement

Values that fell under the group self-enhancement served individual interests, emphasizing the pursuit of one’s pleasure, interests, and relative success. Most nutrition health professionals (n = 22) expressed the value hedonism, which reflects pleasure or sensuous gratification for oneself. Nutrition health professionals valued having fun and getting satisfaction or pride out of their job by contributing to and improving the health of others. For instance, one nutrition health professional reported to get satisfaction out of ‘the moment people indicate that they feel that they are feeling better’ (D13).

Another value expressed by almost all the nutrition health professionals (n = 25) was personal growth, which stimulates a person towards self-development. Nutrition professionals valued the diversity provided within their job: ‘I think the possibility to work with many different people on different projects. So, say the variety and diversity in themes, but also in people, colleagues, that I am not working on the same thing every day’ (D02). In addition, professionals highly valued the challenges of their job: ‘The more complex the more I like it because then we have to puzzle together and then when we succeed, it’s with the greatest difficulty, so to speak, then when you achieve a result that is just fantastic’ (D12). Finally, many nutrition health professionals (n = 19) valued personal success.

Openness to change

Values that fell under the group openness to change reflected independent thought, flexibility to change, and openness to new experiences. All nutrition health professionals stated they were open to other people’s opinions and new approaches: ‘I always try to be very open to other people’s opinions (…) So I, yeah, I always strive to create also an atmosphere, like during meetings that people feel free to also share their opinion’ (E05). Other values representing openness to change, but expressed less often by nutrition health professionals, were inventive and freedom. Both values reflected creative and innovative actions and the ability to act without constraints within their job: ‘But I think in research there’s more room to do that. There’s more room to explore your interests and (…) Yeah, that’s what I do value’ (E07).

Conservation

Values that fell under the group conservation reflected self-restriction, order, and resistance to change. About half of the nutrition health professionals (n = 13) expressed the value conventional, which reflects conforming or adhering to accepted standards or viewpoints. As one professional remarked: ‘We still tend to, me included, we still tend to look at the world from our own perspective. From our own professional perspective as well’ (E08). Several nutrition health professionals reported being stuck within the traditional lines of thought within the organization they work for or preferring to use traditional research methods: ‘When it comes to specific interventions, well the RCT remains more or less the golden standard’ (E03). Some nutrition health professionals (n = 6) also expressed the value evidence-based, referring to knowledge supported by scientific evidence to inform strategies: ‘It is always good, I think, to make use of things of which you know it works’ (D04). Lastly, concreteness was valued by several nutrition health professionals (n = 7) which reflected specific and definite groups, goals, and outcomes. As explained by one professional: ‘I think it’s really important to know like what would your end outcome, kind of what would your goal be to achieve and really determine what the outcome is’ (E13).

Connection

Values that fell under the group connection represented the connection between professionals as well as between professionals and SDPs. Almost all the nutrition health professionals (n = 28) valued working together, reflecting cooperation and openness to other viewpoints. Nutrition health professionals expressed getting joy out of collaborating with other professionals and organizations. Nutrition health professionals valued multiple and different perspectives through interdisciplinary collaboration: ‘And I think that with the goals that we have within our work or if you really want to help people, it’s usually like you need to work with different disciplines to achieve larger goals’ (E13).

The second connection value expressed by almost all nutrition health professionals (n = 27) was relationships, which reflected the relations between the professionals and SDPs. As one professional explained: ‘We don’t have to be friends with the participants but building a relationship in order to understand more of their day-to-day life and their lived experience is quite important’ (E07). In addition, professionals valued relatedness, or being on the same level and being able to relate to one other. In line with this, some professionals valued the involvement of SDPs in the development of strategies.

Perseverance

Finally, values that fell under the group perseverance represented the determination to improve healthy eating among SDPs. Most nutrition health professionals (n = 26) valued commitment, reflecting dedication to their work and goals: ‘I’m persistent in reaching the goals that I set’ (E11). The second perseverance value expressed by more than half of the nutrition professionals (n = 17) was willpower, which reflected the drive that the professional had to improve on healthy eating or health in general. As one professional explained: ‘If you don’t have that, I don’t think you can improve anything because the motivation is not there’ (E02).

Discussion

This study identified the key values of nutrition health professionals and was the first to apply Schwartz’s (2012) theory of basic human values to health promotion. The Values Wheel of Nutrition Health Professionals (VWNHP) (Figure 1) was developed based on the key values identified in this study. The wheel consists of six main groups of values subdivided into a total of 16 values. Four of the groups of values identified – self-transcendence, self-enhancement, openness to change, and conservation – correspond with value groups from Schwartz’s (2012) theory of basic human values. However, two value groups – connection and perseverance – are unique for this research. All values that comprise the value groups – apart from universalism and hedonism – are also unique for this research.

Figure 1. Values Wheel of Nutrition Health Professionals (VWNHP).

Contrary to the theory of basic human values of Schwartz (2012), the VWNHP contains a set of complementary values with little to no opposing values. For example, a link was often made between self-enhancement and self-transcendence values as professionals reported getting satisfaction or pride out of their job by contributing to and improving the health of others. In addition to complementing one another, the values in the VWNHP strengthen one other. For instance, nutrition health professionals were motivated to undertake action to improve healthy eating in SDPs due to their value of universalism which reflected considerations of fairness, equality, and equity. This is in line with the findings of Towe et al. (2021), who concluded that the perceived unfairness or injustice embedded in health care systems contribute to policy makers’ motivations to adjust policy. These values are complemented and strengthened by the strong equity lens required to reduce socioeconomic health disparities within a highly complex food and health system, requiring dedicated professionals who are willing to take on all challenges (Baum 2007; Mozaffarian et al. 2018).

The VWNHP provides a common vocabulary for professionals in different institutions and organizations and, as such, can assist nutrition health professionals in thinking and talking about values (Wills and Woodhead 2004). In practice, the VWNHP may be used to promote individual and collective awareness of values through critical reflection. Critical reflection is one way of identifying the values that shape the foundation on practices, decisions, and goals in public health. Critical reflection can help nutrition health professionals to understand one another’s value priorities as well as uncover potential value conflicts to facilitate improvements in practice (Moyo et al. 2016). For example, if universalism is identified as a key value among different nutrition health professionals, this should be uniformly reflected in public health and health promotion strategies to ensure an inclusive and equal treatment of all population groups.

The values represented in the VWNHP have been developed based on data from the SDP context. While these values might very well apply to other groups, meeting these values may require more effort from health professionals (e.g. to understand the position of SDPs or to empathize with SDPs). In this way, the VWNHP could encourage professionals to step outside their usual way of thinking and provide alternative lines of thought. For example, valuing conservation – a common finding among nutrition health professionals – runs the risk of professionals maintaining conventional health promotion values in which chronic diseases are portrayed as an outcome of poor individual ‘lifestyle’ choices (Baum and Fisher 2014; Kesberg and Keller 2021). Implementing strategies solely targeting individual factors (e.g. education and dietary counseling) is likely to widen socioeconomic health disparities as SDPs experience more difficulties related to a lack of access to resources as time, finance, and coping skills (Berg, Harting, and Stronks 2021; McGill et al. 2015). Encouraging nutrition health professionals to reflect on their values and consider new healthy eating strategies may reduce reliance on these individual-level strategies and thus facilitate more equitable health promotion strategies.

Although the VWNHP has been developed using data collected from nutrition health professionals, it may be used among other stakeholders including SDPs. Critical reflection among and between stakeholders will be of added value, as in the last few decades there has been a shift towards greater collaboration and participation in research and practice (Aldridge 2015). The complexity of current public health challenges requires the involvement of a large variety of disciplines, as many of the determinants of health and healthy eating lay outside the formal health sector (Baum 2007; DiClemente et al. 2019). Professionals’ values that represent growth positively relates to engagement in outgroup contact, which will often be required of higher educated nutrition health professionals engaged with SDPs (Kesberg and Keller 2021). The involvement of SDPs themselves may reveal different conceptualizations of health behaviors and prevent the mismatch and rejection of behavioral messages (Berg, Harting, and Stronks 2021). Overall, critical reflection enabled by the VWNHP is promising to create a mutual understanding of one another’s value priorities and uncover potential value conflicts to facilitate improvements in practice and collaboration.

Strengths and limitations

The results of this study should be interpreted within the context of its strengths and limitations. When conducting qualitative research – particularly when researching values – one should consider the influence of the researcher. In recognition of this, a reflexive approach to data analysis has been taken through which the researchers have actively reflected upon their own personal beliefs, assumptions, and biases throughout the research process and inductive coding was performed to stay as close as possible to the participants´ words. The broad range of professionals included could be regarded as a strength as it provides a more complete understanding of all the values present among a diverse group with a role in promoting healthy eating among SDPs. However, policymakers from the National Institute for Public Health should also be involved to ensure that a complete overview of values from relevant professionals. Finally, the conceptual model bears cultural limitations as it has been developed based on data collected in the Netherlands. Differences in values exist within and between Western and non-Western countries and, as such, the VWNHP may be less applicable in other contexts. Future research is needed to determine how the VWNHP can be applied in critical reflection and to what extent it is effective in raising awareness about values and changing public health and health promotion practice. For instance, a number of statements for each value included in the VWNHP could be composed followed by in-depth questions and discussion to stimulate critical reflection (Herens and Wagemakers 2017; Tretheway et al. 2015).

Conclusion

The knowledge gained in this study contributes to an increased understanding of and awareness about nutrition health professionals’ values in the Netherlands. The ‘Values Wheel of Nutrition Health Professionals’ (VWNHP) developed in this study provides a common vocabulary for different professionals which can be useful to organize discussion about values in various settings, not prescriptively or as a guide, but as a shared language to reflect on personal and collective experiences. Critical reflection has the potential to address inequities by facilitating transparency and accountability among nutrition health professionals and to ensure that shared values are purposefully reflected in public health research, policy, and practice. This process will form an important step towards the improvement of healthy eating in SDPs and elimination of socioeconomic health disparities.

Acknowledgments

The authors wish to thank the participants as well as Merle Boontje for her assistance in recruiting participants and collecting data.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed here

Additional information

Funding

The study was supported by the Edema-Steernberg Foundation (Wageningen, The Netherlands) [N/A]