Integrating the sustainable development goals into health professions’ curricula: using the nominal group technique to guide their contextualisation

Abstract

Background

To embed the Sustainable Development Goals in health profession education, educators must contextualise them to their profession and geographical region. This study used the nominal group technique to contextualise the SDGs for Australian nutrition and dietetics tertiary education programs by determining the specific knowledge, skills, and values required for graduating dietitians to practise sustainably.

Methods

In 2022, 23 experts in food and sustainability attended a group session that employed the nominal group technique to discuss the Sustainable Development Goals knowledge, skills, and values Australian dietetic students should develop. After the group session, participants ranked the Sustainable Development Goals according to their perceived level of importance for student dietitians. These data were analysed using multi-methods, including a summation of the rankings, directed qualitative content analysis and reflexive thematic analysis.

Results

The three highest-priority Sustainable Development Goals identified were (1) Zero Hunger, (2) Good Health and Well-Being, and (3) Responsible Consumption and Production, which were then considered with the qualitative findings. The main categories that were generated from the content analysis reflected the broad knowledge, skills, and values student dietitians should develop. The preliminary codes provided specific details for each of the main categories. The thematic analysis generated two additional themes: the importance of Indigenous ways of knowing, being and doing, and authentic experiential learning activities.

Conclusions

The method employed for this study provides a useful framework for health professions to contextualise the Sustainable Development Goals to their profession and geographical region. For this study, the ranking process and the qualitative data analysis enabled the Sustainable Development Goals to be reframed in a way that would be meaningful for dietetic educators and students and demonstrate the interrelatedness of the goals. The direct qualitative content analysis and reflexive thematic analysis identified the knowledge, skills, and values student dietitians should develop.

Introduction

The 2030 Agenda for Sustainable Development was accepted by all countries in the United Nations in 2015, [1] and outlines the 17 Sustainable Development Goals (SDGs) and their targets and indicators. These goals, while widely recognised as being ambitious, [1, 2] require urgent action to achieve them. One of the goals, SDG 13 (Climate Action), highlights the need to address climate change. [1] The adverse impact of climate change on human health has been well documented [3,4,5,6,7]. Globally, the healthcare sector is responsible for 4.4% of greenhouse gas emissions and consequently is contributing to the climate crisis [8]. This bi-directional relationship between healthcare and the climate crisis supports the need for universities and their health profession educators (HPE) to develop health students’ capabilities to address both population and planetary health [9,10,11]. Planetary health is a paradigm that acknowledges the interconnectedness between human health and the environment, as well as the social, economic and political systems that support equity [11, 12]. The SDGs support planetary health, however, health professionals and students are currently unprepared to meet the complex challenges they will face due to climate change, [10, 13] despite health professions being acknowledged as key change agents to achieve the SDGs [9,10,11].

To date, the literature has focused on sustainable healthcare education. The SDGs have been used to validate the importance of educating the current and future health workforce on how to respond to the climate crisis and create environmentally sustainable ways to practice [10, 13,14,15,16,17,18]. Reducing the impact of healthcare on the environment is critically important, however the environment directly relates to only four of the 17 SDGs [1]. While interrelated, the SDGs can be grouped into three pillars; the environment, society, and the economy, with SDG17 (Partnerships for the Goals) transcending all three pillars [1]. Given the interrelated nature of the SDGs, for health professionals to maximise their contribution to the SDGs, including Goal 13 (Climate Action), HPE must develop their students’ knowledge, skills, and values across all three pillars [2, 19].

Education for Sustainable Development (ESD) is a well-established concept that aims to develop competencies that empower individuals to take informed, responsible actions that align with the SDGs [20,21,22]. Several frameworks exist that provide guidance specifically for HPE to integrate sustainable development into curricula [15]. The United Nations Educational, Scientific and Cultural Organization’s (UNESCO) framework for ESD details eight cross-cutting key competencies and includes learning objectives, topics and activities for each SDG for educators to adapt to their specific profession and learning context [2]. The ‘Association for Medical Education in Europe (AMEE) Consensus Statement: Planetary health and education for sustainable healthcare’ has also detailed learning activities, opportunities, and assessment approaches for HPE to integrate sustainable healthcare education into their curricula [10]. While it addresses the SDGs across the three pillars, their recommendations are not specific to particular health professions [10]. Recently, 17 frameworks that inform planetary health education for health professions were found via a rapid review of the literature, [10, 23] including the AMEE Consensus Statement [10]. These frameworks were pitched at a high conceptual level with the majority focusing on environmental sustainability rather than the interplay between the environment, the economy and social sustainability [10, 23, 24]. While there are conceptual frameworks, [23, 24] HPE still need to make sense of the SDGs and contextualise them to their profession and the geographical region in which their programs are enacted to maximise their impact [25]. Furthermore, there is a paucity of literature describing how to contextualise the SDGs for HPE.

Customising the SDGs and embedding them into different health professions’ curricula is complex and multifaceted [15]. For instance, within universities, organisational, structural and policy-level change is required in addition to upskilling HPE, who will likely need to develop their own knowledge, skills, and values to design and integrate new requirements into what is often an overcrowded curriculum [25,26,27]. One way to address overcrowding in curricula is to not consider knowledge, skills, and values as separate ‘knowledge’ entities. Instead, Billett (2015) offered an approach that focuses on the interdependence between these three types of knowledge (Fig. 1) [28]. For students to engage meaningfully with learning experiences, Billet (2015) suggested that first, they must demonstrate dispositional readiness, i.e., “the attitudes, values, interests, and intentions that direct and guide an individual’s conscious thinking and acting”.^{28(p. 369)} More simply, the students must value economic, social, and environmental sustainability first, for them to then engage with the knowledge (conceptual knowledge), develop the skills (procedural knowledge), and further develop the values required. Due to the interdependence of these three knowledges, ‘knowledge, skills and values’ will herein simply be referred to as knowledge [28].

Fig. 1

Interdependence amongst conceptual, procedural and dispositional knowledge [28]

While both ambitious and broad, the SDGs must be urgently integrated into health professions curricula if these goals and their associated targets are to be met. Universities and HPE must identify how to do this in a way that is impactful and makes sense in the context of their profession and region [10]. While universities must evolve their curricula to address the SDGs, the knowledge that students are required to develop to prepare them for the future workforce may not yet be clear [15].

To identify the knowledge that health profession students should acquire, this study employed the Nominal Group Technique (NGT). The NGT is “a group process model for identifying strategic problems and developing appropriate and innovative programs to solve them”([29], (p467)). Since it was published in 1971, it has frequently been used to explore healthcare priorities [29, 30]. The NGT was therefore identified as a data collection method that may elicit the knowledge health profession students should develop to prepare them for the future workforce.

To utilise the NGT to contextualise the SDGs, one profession in one geographical region was the focus, i.e., Nutrition and Dietetics in Australia. Specifically, we sought to identify the knowledge that should be developed in Australian nutrition and dietetics tertiary education programs in relation to the SDGs. Australia was chosen as the region, as while it is geographically diverse, the professional standards and competencies are nationwide and determined by Dietitians Australia [31]. This means that irrespective of where in Australia the program is delivered, the same professional competencies must be developed.

For educators of dietitians, the SDGs have broad applicability. As dietitians work primarily with food, and the food system is responsible for 19–29% of total global greenhouse gas emissions in addition to other adverse impacts on planetary health, [32,33,34,35,36] it is essential to understand the relationship between the food system, the SDGs, and a dietitian’s role. Much like healthcare, the impact of the climate crisis on the food system is expected to be complex and widespread [37]. The bi-directional relationship between planetary health and food production means that dietetic students should graduate with knowledge that supports both sustainable healthcare and a sustainable food system if dietitians are to positively contribute to achieving the SDGs [38,39,40]. The criticality of the food system on the health of the planet, and therefore human health, has meant that it is an emerging area of interest in the profession. Globally, dietitians have been clarifying their role in the broader food system through the development of summary resources such as role statements and standards [38, 41,42,43].

Despite the increasing volume of literature and resources supporting a dietitian’s role in transforming the food and healthcare system to be more sustainable, [2, 10, 38, 41,42,43] dietetic educators, like all HPE, are challenged with contextualising the SDGs to their profession and region, and identifying the knowledge required to develop students who demonstrate readiness to engage productively and sustainably at work. Therefore, to determine the knowledge (i.e., the knowledge, skills and values) required for students to practise through the lens of sustainable development when they enter the workforce, this study aims to contextualise the SDGs for Australian nutrition and dietetics tertiary education programs by determining the specific knowledge required for graduating dietitians to practise through the lens of sustainability.

Methods

Informed by pragmatism, [44] the goals of this research were to present a research method that was practical, effective, and useful for HPE broadly, and to provide an example in the context of Australian nutrition and dietetics tertiary education programs. To align with this methodological approach to the research, content analysis was used as the theoretical framework underpinning the study. One approach to qualitative content analysis is directed qualitative content analysis (QCA) [45]. This was used to analyse the data due to its rigour and its focus on yielding practical results [46]. In the context of this study, practical results was interpreted as applying the SDGs to concepts that may already be familiar to, or could be applied by, Australian nutrition and dietetic academics through describing those concepts through the lens of sustainability. To report on this study, the consolidated criteria for reporting qualitative studies (COREQ) was used to improve the rigour, comprehensiveness, and credibility of the qualitative component of this study [47]. This study was approved by the Griffith University Human Research Ethics Committee (GU Ref no. 2022/185) and all participants provided their consent to participate prior to collection of data.

As the data collection was conducted during May and June of 2022, the results of this study should be interpreted through the lens of the global situation at that time. The COVID-19 pandemic was impacting our daily lives, and geo-political conflict had erupted between Russia and Ukraine. Locally, in Australia, the climate crisis was impacting people across the country with devasting fires and floods. Australia’s complex food supply chains are vulnerable to geopolitical, environmental, economic and societal shocks, and consequently food shortages were experienced during this time [48]. These shocks resulted in individuals across Australia, who had never experienced food insecurity before, finding themselves in need of food relief [49].

Research team and reflexivity

Our multi-disciplinary research team included five female health care professionals, four with Ph.D. qualifications and one a Ph.D. candidate. All researchers in the team were teaching researchers and understand curriculum development within the context of Australian universities, and each of the researchers have completed post graduate training in curriculum design and development.

Two of the researchers lead programs of research in health professions education (AB and CN); SR is a public health expert and has an established research program in environmental sustainability with a focus on climate; and LR is a dietitian with an interest in the prevention of chronic disease. The lead investigator is a Ph.D. candidate (JM) who is a dietitian with an 11-year history of working in academia. She conducted each of the group discussions and, as per the recommendations of Braun and Clarke, kept a reflexive research journal to document her own position within the research [50]. As the participants included other dietitians working in the same field, the lead researcher knew six of the participants prior to commencing the study, however there were no identified conflicts of interest. Each of the participants was informed that the study formed part of a program of research for a Ph.D. Through regular discussions and peer review, the perspectives of the team were considered when analysing the group discussions which resulted in a focus on the semantics rather than the meaning of individual words and phrases for a more holistic interpretation of the interviews. The research team resolved any discrepant views through group discussions and consensus.

Study design

To address our research aim, this study used a multiple methods research design (Fig. 2). The nominal group technique (NGT) was employed to garner descriptions of the knowledge that should be embedded into Australian nutrition and dietetics tertiary education programs on the SDGs, and to rank their importance to dietetics curricula [51]. The NGT was employed as it is a structured group decision-making research technique that facilitates equal participation by allowing each participant to brainstorm and then communicate their ideas and knowledge without interruption through a round-robin style session. [51] Then the qualitative data were analysed primarily using directed QCA [46, 52].

Fig. 2

Research design for nominal group procedures and analysis

Participants

Purposive sampling was used to identify participants. To be included in the study, participants needed to be considered an expert in the field, i.e., a member of Dietitian Australia’s national Food and Environment Interest Group leadership team or had published literature on food and environment/sustainability in Australia. Thirty-three experts were identified and invited via email to participate in this study and a total of four nominal groups were conducted.

Procedure

The participants were allocated to their preferred time for the NGT sessions and were sent an invitation to attend the online group session using Microsoft Teams (Microsoft Corporation, Version 1.0.1), which allowed them to participate in the study in an environment where they were comfortable. Prior to participating in the group session, the participants were provided with supporting materials to focus the conversation on the SDGs, and a link to a pre-study survey that asked the participants when, across a dietitian’s career (from student to practitioner) they felt each SDG should be learnt. Each group session was then recorded and transcribed using Microsoft Teams (Microsoft Corporation, Version 1.0.1). Transcripts were produced in Microsoft Word (Microsoft^® Word for Microsoft 365 MSO, version 2311) and checked for accuracy by the lead author. The transcripts were then used to complete the directed QCA and thematic analysis.

The classic NGT was adapted to include three round-robins, with each round-robin addressing one of the three pillars of the SDGs (social, economic, and environmental sustainability). A visual presentation was provided to the participants, including the question: “What knowledge, skills and values should be taught to Australian student dietitians?”, and the aggregated results from the pre-study survey. The presentation remained on-screen as a prompt while participants had five minutes of silence to generate their response to the question. Each participant was provided with uninterrupted time to share their ideas in response to the question. This was considered important to create an environment where everyone had an equal opportunity to contribute. At the end of the round-robin, the participants and the group facilitator had opportunity to clarify any points from the discussion. At the conclusion of the three round-robins, a note-taker provided the participants and the facilitator with a summary of the discussion and participants were asked to verify its accuracy. They were requested to prioritise the SDGs based on their perception of each SDG’s importance or relatedness to Australian nutrition and dietetics tertiary education programs. Each nominal group session was recorded and transcribed using Microsoft Teams technology, and then checked for accuracy by the lead author.

Analyses

The quantitative and qualitative data were analysed in three phases: (1) summation of the nominal group ranking, [51] (2) a directed QCA on the transcripts, [46] and (3) reflexive thematic analysis on the transcripts [50]. This approach allowed the research team to organise the data in a way that would be meaningful for dietetic educators, while also reflecting on the rich qualitative themes not classified within the SDG framework.

Nominal group rankings of the SDGs

The participants’ rankings of the importance of the SDGs were summed, with lower scores indicating greater importance.

Directed qualitative content analysis

Directed QCA was used to synthesise the qualitative data gained from the NGT sessions and to re-frame the SDGs into meaningful concepts for dietitians [45, 46]. Directed QCA has historically been used in healthcare research for data analysis of interviews, [53] to develop knowledge and understanding of a phenomenon; in this case, the SDGs [46]. The data from each nominal group session were separated into the three SDG pillars (social, economic, and environmental sustainability) and each pillar, across the four nominal groups, were merged. Deductive and inductive content analysis were used to gain an understanding of the knowledge that should be embedded in nutrition and dietetics tertiary education programs in Australia for each of the SDGs. Assarroudi et al’s (2018) 16-step process for directed QCA was used for the analyses [46]. This process involved analysing the data to identify ‘preliminary codes’, which were then logically grouped into ‘generic categories’. Using these generic categories and comparing them to the SDGs resulted in the development of new ‘main categories’ to describe the key knowledge to be embedded into Australian nutrition and dietetics tertiary education programs.

The data analysis was completed independently by the lead author (JM) and discussed with two co-authors (SR and LR) as per the recommendations by Assarroudi et al. (2018) [46]. The lead author’s reflexive research journal facilitated this discussion, which enhanced the rigour of the interpretation of data, and the appropriate coding and generation of categories. Each step of the analyses was individually documented, from analysing the raw data to the inductive abstraction of the main categories generated, providing an audit trail. Once the directed QCA was completed, the results were integrated with the SDG rankings. As the data were analysed, the rich insights shared by the participants related to the complexities of readying students for a sustainable future were recognised, resulting in a third phase of analysis.

Reflexive thematic analysis

Reflexive thematic analysis was employed using the data and the reflexive research journal maintained by the lead author (JM) throughout this study [50]. This allowed meaning to be drawn from data not directly aligned with the SDGs [50]. The lead author was guided by Braun and Clarke’s (2022) six phases of reflexive thematic analysis:1) Familiarisation with the dataset, 2) Coding, 3) Generating initial themes, 4) Developing and reviewing themes, 5) Refining, defining and naming themes, and 6) Writing up [50]. To enhance rigour of the thematic analysis, regular peer-debriefing between the lead author and the research team occurred during this phase of the analysis, including the sharing of initial observations and insights, reviewing the coding and themes generated, and ongoing review of the theme write-up.

Results

Of the 33 experts invited, 27 consented to participate in the online group session. Of those who did not agree to participate, four were unable to attend at the times allocated due to work commitments, and two did not respond to the invitation. Four participants withdrew on the day of the study due to work commitments (2), technology issues (1) or personal reasons related to the working-from-home environment (1), resulting in 23 participants who contributed to the data collection. Of these, 3 were male and 20 were female. Each NGT session consisted of five to seven participants. Eight participants were recruited from Dietitian Australia’s Food and Environment Interest Group leadership team, twelve were identified from published literature on the topic of food and environment, and three were both in the Food and Environment Interest Group and had published on the topic of food and environment. Each of the group discussions lasted between 90 and 120 min, and no new concepts were introduced during the fourth and final group discussion.

SDG ranking

Zero Hunger (SDG 2), Good Health and Well-Being (SDG 3), and Responsible Consumption and Production (SDG 12) were considered the most important priorities for the Australian Dietetics curricula.

Directed qualitative content analysis

The data were assigned preliminary codes that were generated during the analysis. This then informed the inductive abstraction of generic categories and new main categories. The ‘preliminary codes’ described the specific knowledge or skills the food and environment experts believe should be embedded into Australian nutrition and dietetics tertiary education programs,, the ‘generic categories’ described the content areas that should be addressed in curriculum, and the new ‘main categories’ generated from the data represented the key values and topics that Australian nutrition and dietetics tertiary education programs should include. This addressed the aim of the study; to contextualise the SDGs for Australian nutrition and dietetics tertiary education programs by determining the specific knowledge required for graduating dietitians to practise through the lens of sustainability. When integrating the directed QCA results with the nominal group ranking of the SDGs, ‘zero hunger’ was merged with ‘good health and well-being’ due to their interdependence. The interrelated nature of the SDGs was emphasised when discussing SDG 12 (Responsible consumption and production). One participant commented “I can’t emphasize enough that…almost all of that (sic. Health) is irrelevant if we don’t embed it all in a sustainable food system.” This quote clearly articulated the two sustainability concepts that are meaningful for dietitians: 1) health, and 2) a sustainable food system through responsible consumption and production. Therefore, to present these results in a meaningful way for dietetic educators, the preliminary codes, and the generic and new main categories were reframed and considered through the lens of “Good Health and Well-being” and “Responsible Consumption and Production”. The new ‘main categories’, or ‘key knowledge’, generated from the groups are summarised below followed by quotes for each of them. The supplementary file provides further details of the codes and categories.

Good Health and Well-being, and responsible consumption and production

A strong social justice lens lies at the heart of population and planetary health

Good health and well-being (SDG 3) and zero hunger (SDG 1) are the primary goals of dietitians in all current areas of dietetic practice. However, participants indicated that student dietitians should learn that ‘good health and well-being’ includes mental health. Health is largely influenced by the social determinants of health and other events which are often beyond the control of the individual. To address health inequities in the population, student dietitians should first value social justice, to then appreciate how hunger, poverty, poor education, poor food access, and food insecurity impacts people’s health.

Participants collectively agreed that a sustainable food system addresses many of the social determinants of health, providing affordable and healthy food while being ecologically and environmentally sustainable. Furthermore, it positively impacts on planetary health, which then influences an individual’s health and well-being. Given health and well-being is a primary goal of dietitians, every student should value a socially just and sustainable food system and understand its impact on population and planetary health.

“Dietitians [should] understand that in our food system – cheap food can contribute to poverty. … A very concrete example is … the cocoa supply chain and utilizing child slavery. … it’s one of the touchpoints that dietitians can …in the food system by encouraging ethical food choices and fair-trade products.” – Participant A5^*

Think global, act local

¹As global citizens who value social justice, student dietitians need to think morally and ethically about food and how the current food system exploits workers, both domestically and internationally. The global food system is influenced by the global financial system, which exacerbates inequalities through the demand for low-cost food. Simultaneously, responsibly produced food needs to be affordable and accessible for everyone. Economic, social and nutrition inequalities negatively impact on the social determinants of health and student dietitians should learn how to advocate for reducing inequality both in Australia and internationally.

“I think what we’re doing is challenging people to think morally and ethically. … if you look at it globally… it just consistently shows that the people who are least responsible for the problems we’re facing are those who are going to probably suffer the most”. – Participant A6.

There is a strong relationship between the profession and global land and water systems, and dietitians have a moral obligation to protect and nurture those systems

Dietitians in all areas of practice work with food, so student dietitians should value the relationship between the profession and global land and water systems, and all that those systems provide. Our food system has a bi-directional relationship with the climate and has a significant impact on land and water systems; dietitians, as global citizens, should therefore have a moral obligation to protect and nurture these systems.

“Dietitians trained in Australia – we’ve got a moral imperative to take action. We need to take responsibility because Australia is one of the worst offenders in that global context, and so dietitians, being an important part of their food system – we need to step up and take action.” – Participant A6.

Collaboration and a ‘whole of food system approach’ is needed for the betterment of sustainability and human health

To facilitate the transition to a sustainable food system, student dietitians should understand the whole food system and be able to identify processes within the system that can be improved to enhance sustainability. Student dietitians should cultivate strong communication and advocacy skills to develop and enhance partnerships with industry, government, and non-traditional partners with the view to improving the sustainability of the food system. Locally, students should learn to critically analyse geographical areas for sustainability, to improve both population and planetary health.

A participant refers to a project which demonstrates this theme:

“They went into the fringe communities … that were really impoverished, and they worked with … professionals and … the lowest caste of individuals in these societies, which was women, and they taught them how to farm using indigenous techniques, … then they pooled their seeds at the end of their harvest season. [The project has] grown and grown and grown. And now [impacts] … 3500 families across 50 villages. They’ve opened restaurants… so that people from the city will come and eat local and indigenous produce.” – Participant A4.

A healthy and sustainable diet should be accessible to everyone, and primarily driven by a sustainable food system

A healthy and sustainability diet is beneficial for the population and the planet; however, a healthy and sustainable diet will be unique to the individual. Food provides more than macro- and micronutrients; food, and customs around food, are major contributors to both our physical and mental health. Therefore, student dietitians should appreciate that advising clients to consume a wide variety of in-season, minimally packaged foods, that is not beyond their needs, is advice that will look different for everyone. Currently, when student dietitians graduate they mostly work with consumers, [54] and therefore may inadvertently place the responsibility of sustainable food choices onto them. Students should develop their knowledge and advocacy skills to also work within the food system and support the transition to a sustainable food system.

“Dietitians need to understand what it’s going to take to create a healthy and sustainable food system.” – Participant D4.

Understanding economics and the political economy, and advocacy skills, are critical for sustainable food and healthcare systems

Understanding economics and the financial reasons that drive decision-making by businesses, organisations, and governments, allows dietitians to engage with key stakeholders and align the benefits of transforming the food system with the desired outcomes for the stakeholders. Student dietitians should develop these skills to advocate for improved infrastructure and reduce inequality in the community.

“Our current economic system is actually designed to produce excessive amounts of … food, to get people to consume excessive amounts of … food, and also produces excessive waste.” – Participant C1.

Clean water and sanitation are essential for safe food, the environment, and health

The food system is reliant on clean, safe water to produce fresh and healthy food, while individual health is also highly dependent on clean water and sanitation. Student dietitians should appreciate that outside of natural disasters, city-dwellers have ready access to clean and safe water, however this often does not occur in rural and remote communities.

“I suggest that clean water and sanitation is possibly the (the) most important because we know that people can’t survive more than about 24 hours without clean water.” – Participant B3.

As an evidence-based profession, student dietitians should understand environmental science for the betterment of the food system

As an evidenced-based profession that is driven to improving the sustainability of the food system, student dietitians should have a foundational understanding of environmental science, including climate science, environmental metrics, water scarcity metrics, the management of topsoil, Life Cycle Assessments (a method used to assess the environmental impact of food items) across the entire food chain, and planetary boundaries. This ensures they have a solid understanding of environmentally sustainable agricultural practices, which when combined with environmentally-sound production methods, can improve Australia’s ecosystems, biodiversity and food supply.

“What would be useful is just understanding what different environmental metrics are out there. So being aware that greenhouse gas emissions are not the be all and end all. That there’s water footprints, pesticide footprints etc.” – Participant B5.

Systems-thinking skills enable change-makers in the food and healthcare systems

The development of systems thinking skills should be scaffolded across the curriculum and applied to the food system to identify key touch points where dietitians can facilitate positive change. To be change-makers, dietitians across all areas of practice should be advocates and activists for climate action and the environment, including in both the food and healthcare systems. By influencing consumer demand for healthy and sustainable food, dietitians can impact production processes. Dietitians can also progress climate action by advocating for and improving energy usage and advocating for better waste management practices across the entire food system.

“(Know) what are the key touch points, like where are some of the really like big ticket items that dietitians can put our energy into understanding those.” – Participant D1.

Reflexive thematic analysis

Indigenous ways of knowing, being and doing was a strong theme that was generated from the data, however as only four indicators that underpin the SDGs specifically mention indigenous peoples, it was not reflected in the directed QCA due to the use of the SDGs as the initial framework. [1] Another theme that was generated was ‘how’ the identified knowledge should be taught to students to ensure it is meaningful and develops their values and readiness to learn and practise.

Indigenous ways of knowing, being and doing

Valuing indigenous ways of knowing, being and doing, and integrating that across the curriculum, was a theme that was generated from the analysis. The interconnectedness between humans and planetary ecosystems is fundamental to indigenous ways of ‘knowing, being and doing’, [48] and should be the lens through which student dietitians learn, with one participant saying: “we can’t train our future workforce without a fundamental knowledge and respect for that concept, and so to ignore this would be incredibly remiss of us as educators.” - Participant C2.

The interconnectedness between people, the planet, and the food system was further highlighted when discussing the Murray Darling Basin, and the recent mass death of thousands, potentially millions, of fish due to the depletion of water from irrigation. [55] This example and the disastrous effect that can occur if people dismiss indigenous knowledge on water and land management was discussed across multiple groups. Furthermore, it was identified that a culturally capable dietetic workforce was important for reducing inequality in Australia: “I think intrinsic in this [sic reducing inequality] is Aboriginal reconciliation and looking at reducing the gap here.”- Participant B1.

Authentic experiential learning

The value of authentic, experiential learning opportunities being embedded into courses across all areas of practise, was expressed by all groups. This theme arose from two different perspectives. First, participants discussed how students learn through active engagement. For example, one participant suggested: “expose students to scenario’s where clients may not have electricity in the homes or may not be able to afford it” - Participant C5. Another participant commented on how their university engages students in active learning: “we have an assignment which is focused on local governments, and we get students to choose the local government area and complete an audit of the local government area … and then they provide three recommendations for improving health equity and sustainability of the local food system.” - Participant A4.

Second, participants discussed how they, themselves, had continued to develop their knowledge through experiential, “on-the-job” learning, sometimes years after graduating from university. One participant, when referring to Life Cycle Assessments of food, said: “What is [environmentally] sustainable food? Because I know I’ve learned a lot over the last year about how it’s measured”- Participant A3. Another dietitian, when referring more broadly to the SDGs and sustainable food systems, said: “I’ve only really learned about it in the past couple of years by virtue of my policy work and personal interest.” - Participant A5.

Discussion

Globally, the need to integrate the SDGs into higher education is well accepted by universities. [56] While literature has thus far focused on embedding sustainable healthcare into curricula, [10, 13,14,15,16,17,18] it has been recommended that the SDGs need to be contextualised to the health profession and geographical region [10]. Profession-specific knowledge of the SDGs is required to promote population and planetary health and are important attributes that students should develop before graduation [1, 2, 10]. Despite several frameworks and resources being available, the SDGs still need to be contextualised to the specific health professions and the geographical region within which they can work using their qualifications [2, 10, 38, 41].

The current frameworks available to facilitate HPE embedding planetary health into curricula are high-level conceptual frameworks that mostly focus on environmental sustainability [23]. The results of this study differ from these frameworks by grouping knowledge according to values and concepts familiar to the profession rather than the three pillars of the SDGs, and by describing specific knowledge to be embedded in curricula. Given the urgency of embedding the SDGs into curricula and the importance of developing dispositional readiness (i.e., values) first to enhance knowledge development, [1, 28] HPE may find a values-based framework useful as it applies the SDGs to concepts they may already be familiar with but describes those concepts through the lens of sustainability [1, 28]. Therefore, the application of this method may assist other health professions develop a framework that is specific to their health profession.

The frameworks currently available for practising dietitians to integrate sustainability into their work focus on concepts such as sustainable food systems and healthy and sustainable diets [38, 41,42,43, 57]. The results of this study focused on curricula for Australian nutrition and dietetics tertiary education programs and determined the specific knowledge required for graduating dietitians to practise through the lens of sustainability, including knowledge of sustainable food systems, healthy and sustainable diets, and sustainable healthcare. It is intended that the information presented in this framework be used by all academics, from those who may identify as ‘novice’ to those more experienced. The embedding of SDGs into Australian nutrition and dietetics tertiary education programs may be expedited by using concepts dietetic educators are already familiar with and applying SDG knowledge and competencies to those concepts.

This is the first known study that uses a method that contextualises the SDGs to a specific health profession and region and provides concrete recommendations regarding how to frame the curriculum. By experts ranking the SDGs after the NGT sessions and considering this information with the results from the directed QCA and TA, this study framed the knowledge in a way that was meaningful for the profession. Therefore, the results of this study indicate that this method was successful in contextualising the SDGs for Australian nutrition and dietetics tertiary education programs. The NG method may be useful for other health professions due to the broad participant eligibility criteria, i.e., an expert in sustainability within a profession. It is recommended that participants include experts across the three pillars of sustainability i.e., environmental, social and economic sustainability, and the results may be enhanced by including an SDG expert. The research team had a focus on recruiting experts in food and environmental sustainability which may have excluded experts across the other pillars of the SDGs. Moreover, the eligibility criteria may have excluded some experts who have not published peer-reviewed papers or engaged in Dietitian Australia’s national Interest Group. Therefore, the research team recommends a diverse sample of experts are recruited to future studies to ensure that different views are heard and represented during the NGT sessions. Furthermore, the method of analyses allows the content to be framed in a way that is most useful to the profession. For professions contemplating how to embed the SDGs into curricula, the research team recommends replicating this method to accelerate the identification of the essential knowledge required to be embedded to produce work-ready graduates.

Many HPE will need to upskill to enhance their knowledge of sustainability and their confidence to facilitate student learning to urgently embed the SDGs into curricula. [28] The results of this study indicated that the method employed may overcome this barrier by articulating the specific knowledge that educators should develop, to then be confident to facilitate student learning. To enhance HPE developing this knowledge, the concepts of readiness discussed by Billett (2015) can be equally applied to HPE as it can to students. [28]

To the best of our knowledge, this is the first study that robustly examines the SDG knowledge that should be embedded in Australian nutrition and dietetic tertiary education programs. The two SDGs that were prioritised as part of the NGT ranking process, SDG 3 (Good Health and Well-Being), and SDG 12 (Responsible Consumption and Production), may assist dietetic educators to reframe curricula in a way that is meaningful for themselves and their students, and demonstrates the interrelated nature of the SDGs. The thematic analysis generated a further two themes, including incorporating Indigenous ways of ‘knowing, being and doing’ into the curriculum, and using authentic experiential learning activities. The strong emphasis of these themes across the four groups of experts highlights the important role these themes have, or should have, in dietetics education and aligns with contemporary education practices. [2] The supplementary file provided has been designed as a framework for dietetic educators. This framework can assist dietetic educators in identifying both the alignment and the gaps between the current curricula and the relevant knowledge students should develop in relation to the SDGs.

The focus of this study was on the knowledge that should be embedded in health profession tertiary education programs in relation to the SDGs; however, this approach does have some limitations. While the thematic analysis identified the Indigenous way of ‘knowing, being and doing’ as important for curricula, it did not specifically identify the conceptual and procedural knowledge to be embedded in Australian nutrition and dietetic tertiary education programs. To encourage the respectful addition of indigenous knowledge, the research team recommends that educators work with local indigenous elders and experts. This study did not explore the barriers to implementation, i.e., a ‘perfect world’ scenario was assumed. However, barriers to embedding sustainability into curricula exist and will differ depending on the profession and geographical region [10, 15]. It is, therefore, recommended that the barriers and enablers are identified and either addressed or utilised to support the urgent uptake of this study’s findings into curricula. When considering the limitations of the methods, it is important to consider that the four participants who consented to the study, but were unable to attend, may have had differing views than those discussed in the group sessions and presented here. Also worth noting, is the high percentage of female participants, which is reflective of the high percentage of females in the profession. While this is reflective of the profession, males may have considered the topic differently. To add further rigour and to enhance the transferability of the method to other health professions, including SDG experts as participants may have beneficial.

This study set out to employ the NGT to contextualise the SDGs to specific health professions and their region. The data collection and analysis methods used in this study have reframed the SDGs so that they are meaningful for dietetic educators in Australia. Due to the urgency needed to achieve the SDGs, the research team strongly recommends other health professions use this as a method to contextualise the SDGs to their profession and curricula. The barriers and enablers to embedding this content into curricula should be examined simultaneously, if possible, to support the urgent uptake of this content into higher education.