Planetary health is an emerging field that focusses on ‘analysing and addressing the impacts of human disruptions to Earth’s natural systems on human health and all life on earth’(1). The public health nutrition workforce has the capacity to promote planetary health in a diverse range of settings and population groups; therefore, it plays a critical role in addressing the triple planetary health crises of climate change, pollution and biodiversity loss(Reference Whitmee, Haines and Beyrer2–Reference Bell4). However, the window for transformative action is rapidly closing(Reference Whitmee, Haines and Beyrer2,Reference Lee, Calvin and Dasgupta5) . Our future health workforce will be at the coalface required to address these major public health challenges. However, they are not receiving sufficient fit-for-purpose education during their tertiary public health nutrition training to prepare them adequately(Reference Shaw, Walpole and McLean6,Reference Brand, Collins and Bedi7) . Evidence suggests that educators agree this should be part of health professions’ training; however, they themselves do not feel prepared to facilitate planetary health education(Reference Brand, Collins and Bedi7–Reference Oisin Brady, Aisling and Debbi9).
Research has explored the degree to which various health disciplines are embedding planetary health education in their training, and theoretically how this is being done(Reference Best, Tutticci and Heart10–Reference Oudbier, Sperna Weiland and Boerboom12), including public health(Reference Arora, Comrie and Ernst13) and nutrition and dietetics(Reference Nuttman, Patrick and Townsend14–Reference Wegener, Fong and Rocha16). However, to our knowledge, the peer-reviewed literature is lacking practical examples of planetary health education interventions amongst public health nutrition learners that include an embedded evaluation to assess efficacy. This research examines the responses of nutrition and dietetics students engaged in a planetary health education workshop, co-designed by students and their educator, as part of their tertiary public health nutrition training.
Methods
Setting and population
A 3-hour planetary health workshop was facilitated face to face on campus at an Australian university with students enrolled in a Public Health Nutrition module as part of their Bachelor of Nutrition Science and Master of Nutrition and Dietetics degrees. The lesson plan and teaching materials (Table 1: Workshop learning objectives and outline) were co-designed by students (n 5) and educators (n 1). The authors of this paper were all involved in this process including three students (shared first-authorship).
Table 1. Workshop learning objectives and outline co-designed with students
Study design
This study is part of a Faculty-wide intervention to increase the quantity and quality of planetary health curricula offered within health professions’ degrees at the University. A co-design approach was adopted with educators and students from twelve disciplines(Reference Barbour17), which will be examined and published elsewhere.
This research utilised both qualitative and quantitative methods to examine (i) students’ attitudes, self-efficacy and self-perceived knowledge regarding planetary health, (ii) students’ word association with the term ‘planetary health’, (iii) students’ self-perception of the term ‘planetary health’ and (iv) students’ prioritisation of core values to apply in practice. This study was approved by the Monash University Human Research Ethics Committee (ID: 38428)
Data collection and analysis
Data were collected from students through interactive tasks during the facilitated workshop and align with the four study aims outlined previously.
Students’ attitudes, self-efficacy and self-perceived knowledge regarding planetary health
Workshop attendance was self-recorded by students using Moodle, an e-learning platform. Students were invited to complete both a pre- and post-workshop poll, containing 5 identical questions. These questions were based on a previously administered survey exploring healthcare professionals’ attitudes, self-efficacy and self-perceived knowledge regarding planetary health(Reference Brand, Collins and Bedi7). All poll questions prompted a Likert scale response, with a four-point rating allocated for analysis purposes from strongly disagree, disagree, agree and strongly agree. These quantitative results were analysed using an online statistical software GraphPad, whereby an independent sample t-test was performed to compare pre- and post-poll data, as data were collected anonymously so students were not matched.
Students’ word association with the term ‘planetary health’
In addition to the pre-post polls, students were encouraged to participate in a number of interactive tasks throughout the workshop. To seek the students’ immediate associations, they were asked ‘What words come to mind when you think about “Planetary Health”?’ at the beginning of the workshop using an online polling software. A word cloud was generated using student responses, illustrating the frequency of words, with the size of each word corresponding to how frequently that term appeared in the analysed text(Reference Atenstaedt18). The utilisation of word clouds is growing in academic and educational settings due to their capacity to stimulate critical thinking and student engagement(Reference DeNoyelles and Reyes-Foster19).
Students’ perception of the term ‘planetary health’
The question: ‘What does planetary health mean to you?’ was also asked at the beginning of the workshop and answers were recorded using online polling software. Content analysis was used to interpret the poll responses. Content analysis enables the reduction of broad descriptions to refined concepts that are situated within the context of the overarching research question(Reference Cole20,Reference Bengtsson21) . The content analysis procedure used for this study was adapted from several papers(Reference Bengtsson21–Reference Elo and Kyngäs23) and involved transferring the poll results to a spreadsheet, identifying keywords within the responses (code words), creating subcategories by grouping similar code words together and finally grouping these subcategories into main concepts. This process was implemented by three co-authors (BC, LB and RL) who worked together to consider decisions regarding categorisation and concept descriptions collaboratively.
Students’ prioritisation of core values to apply in practice
The main workshop activity involved the presentation of five scenarios of typical work roles for practicing nutritionists and dietitians. This activity encouraged students to reflect on the personal qualities and values required in their future roles as nutrition professionals. Prior to the activity, the students reviewed a list of values created by Brene Brown(Reference Brown24), along with a visual prompt that included three example values considered fundamental to the promotion of planetary health. Students then worked in groups to write down the values they felt were associated with each of the five scenarios and consider how these values relate to planetary health. To encourage dialogue, a ‘world cafe’ approach was utilised as a participatory method of data collection from the large group of student participants(Reference Löhr, Weinhardt and Sieber25). This involved each student group rotating between all five scenarios and contributing to a collective butcher’s paper list of relevant values. Frequency analysis was conducted to review which core values students prioritised.
Results
Research findings are presented here, to address each of the four key study aims.
Students’ attitudes, self-efficacy and self-perceived knowledge regarding planetary health
Of all students in attendance at the workshop (n 44), 40 participants completed the pre-workshop poll (response rate 90·9 %) and 30 completed the post-workshop poll (response rate 68·2 %). Poll results demonstrated statistically significant improvements in four of the five questions (see online supplementary material, Supplemental Material 1: Pre- and Post-workshop Poll Results). Students reported an increased ability to explain the term ‘planetary health’ (P< 0·0001), describe how health professionals in their field can address the causes and consequences of climate change (P= 0·001), advocate for change to promote planetary health within their field (P< 0·0001) and believe their training had prepared them to address the causes and consequences of climate change (P= 0·0001). Students reported an increase in agreement that planetary health is core business for healthcare professionals; however; this result was not statistically significant when compared before and after the workshop (P= 0·0668).
Students’ word association with the term ‘planetary health’
Among the responses (n 29) (Figure 1: Word Cloud of responses to ‘What words come to mind when you think about “Planetary Health”?’), the term ‘sustainability’ was the most prevailing within the word cloud (n 9), followed by ‘environment’ (n 5). Other frequently submitted words were ‘climate change’, ‘climate action’ and ‘environmentally friendly’.
Figure 1. Word Cloud of responses to ‘What words come to mind when you think about “Planetary Health”?’.
Students’ perception of the term ‘planetary health’
Content analysis of the responses (n 29) (Figure 2: Responses to ‘What does planetary health mean to you?’) resulted in 10 subcategories derived from the de-contextualisation of several codes developed from passages of text as the unit of analysis (see online supplementary material, Supplemental Material 2: Content analysis of responses to: What does planetary health mean to you?). The subcategories were then abstracted into higher order and classified into three main concepts as a means to re-contextualise and interpret the data. Exemplar quotes display the exact wording from students to illustrate the inferences drawn from the main concepts.
Figure 2. Content analysis of responses ‘What does planetary health mean to you?’.
Students’ prioritisation of core values to apply in practice
The world café activity yielded a total of 123 values documented by students across the five scenarios (see online supplementary material, Supplemental Material 3: Frequency analysis of ‘Value’). Of the ten butchers’ paper, with two assigned to each scenario, students documented ‘collaboration’ on six, making it the most frequently written value. This finding aligns with workshop content delivered prior to this activity (see online supplementary material, Supplemental Material 4: Visual prompt prior to World Café activity) that highlighted the need for interdisciplinary collaboration to address emerging planetary health crises(Reference Lerner and Berg26,Reference Gilbertson, Craft and Potter27) . ‘Respect’ was identified as a core quality required by nutritionists and dietitians within all five of the scenarios. This observation also aligns with workshop content that emphasised the critical role of respecting planetary boundaries and Indigenous knowledge, perspectives and values systems in addressing planetary health challenges. While ‘sustainability’ and ‘environment’ are recognised in the literature as crucial values to addressing planetary health issues(Reference MacNeill, McGain and Sherman28), these only appeared once on the butchers’ paper, suggesting a lower priority.
Discussion
This study demonstrated that a co-designed in-person workshop can effectively increase self-perceived knowledge and self-efficacy scores regarding planetary health action amongst nutrition and dietetics tertiary students studying public health nutrition. Students reported higher levels of self-perceived knowledge about planetary health as a concept and taking action to promote planetary health within their future professional roles. Interestingly, students’ descriptions of what planetary health means to them were focused on humans’ role in protecting and preserving the ecosystem, the responsible and sustainable use of natural resources and a need to sustain a healthy life for future generations, all of which are reflected in Guzman et al.’s (2021) best practice framework for facilitating planetary health education(Reference Guzmán, Aguirre and Astle29). Students prioritised the values of collaboration and respect, as being critical for nutritionists and dietitians to draw upon in their personal and professional practice to promote planetary health. Both values are broadly referenced as being fundamental to transformative action in the health sector and beyond to achieve sustainable development targets and the desired planetary health outcomes(Reference Lawrence, Burlingame and Caraher3,Reference Guzmán, Aguirre and Astle29) . Further exploration of students’ perceptions about why certain personal and professional values are critical in applying planetary health principles in practice, and how these values can be nurtured amongst the current and future workforce, is needed.
The learning and teaching activities developed by, and for, public health nutrition learners are described in this study, together with an analysis of student responses to each task. These learning and teaching activities can be used to assist health professions educators as they strive to embed more planetary health education in their curricula. There is broad agreement that this curriculum shift must happen(Reference Shaw, Walpole and McLean6,Reference Guzmán, Aguirre and Astle29–Reference Abbasi, Ali and Barbour31) , and evidence that educators are seeking practical examples of what this looks like in practice for the various health disciplines including public health(Reference Wegener, Fong and Rocha16). While some case examples of tertiary-level sustainable food systems education in the public health nutrition field are available(Reference Carino, McCartan and Barbour32), to our knowledge no studies have published their efficacy amongst public health nutrition learners. It is a limitation that pre-post poll data is not matched and that the post-poll data reflects a lower response rate (68 %), likely missing students who were less engaged with the workshop material which would have impacted the statistical significance of this data. Another limitation of this present study is that it is a small intervention involving one single discipline, it offers a unique evaluation of curricula that has be co-designed with, and for, public health nutrition students on the emerging topic of planetary health.
Conclusion
It is well established that public health outcomes are dependent on the health of the natural living systems that humans are part of. However, those responsible for training the future public health workforce to address contemporary food-related environmental challenges have limited capacity and guidance to offer effective, evidence-informed planetary health education. More practical case studies of how planetary health education can be facilitated in the tertiary setting are required, particularly those that have been evaluated. This study demonstrated that an interactive workshop for public health nutrition students can effectively increase self-perceived knowledge about what planetary health is, how our future workforce can address the causes and consequences of climate change in practice and how they can advocate for change to promote planetary health. Our results show that incorporating planetary health curricula designed by, and for, tertiary learners could be a feasible and effective way to prepare future healthcare professionals to face planetary health challenges.
Supplementary material
For supplementary material accompanying this paper visit https://doi.org/10.1017/S1368980024002611
Acknowledgements
The authors would like to acknowledge Adel Nazeer and Tharini Ganegodage who were student champions on this project and contributed to the development and facilitation of the intervention.
Authorship
Study design and ethics (L.B. and B.C.), intervention development and implementation (K.P.C., W.C., R.L. and J.McC.), data collection (K.P.C., W.C. and R.L.), data analysis (K.P.C., W.C., R.L., B.C. and L.B.), manuscript preparation and review (all) and manuscript finalisation (L.B.).
Financial support
The senior author (L.B.) received funding from the Faculty of Medicine, Nursing and Health Sciences at Monash University to lead the multi-disciplinary project, of which this paper represents one component.
Competing interests
There are conflicts of interest.
Ethics of human subject participation
This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Monash University Human Research Ethics Committee (Project ID: 38428). Participant consent was implied through participation in the intervention activities as per the approved ethics application.
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