challenges in nutrition education

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Challenges and opportunities for nutrition education and training in the health care professions: intraprofessional and interprofessional call to action 1, 2, 3, 4

Understanding and applying nutrition knowledge and skills to all aspects of health care are extremely important, and all health care professions need basic training to effectively assess dietary intake and provide appropriate guidance, counseling, and treatment to their patients. With obesity rates at an all-time high and the increasing prevalence of diabetes projected to cost the Federal government billions of dollars, the need for interprofessional nutrition education is paramount. Physicians, physician assistants, nurses, nurse practitioners, pharmacists, dentists, dental hygienists, occupational therapists, physical therapists, speech and language pathologists, and others can positively affect patient care by synchronizing and reinforcing the importance of nutrition across all specialty areas. Although nutrition is a critical component of acute and chronic disease management, as well as health and wellness across the health care professions, each profession must reevaluate its individual nutrition-related professional competencies before the establishment of meaningful interprofessional collaborative nutrition competencies. This article discusses gaps in nutrition education and training within individual health professions (ie, nursing, pharmacy, dentistry, and dietetics) and offers suggestions for educators, clinicians, researchers, and key stakeholders on how to build further capacity within the individual professions for basic and applied nutrition education. This “gaps methodology” can be applied to all health professions, including physician assistants, physical therapists, speech and language pathologists, and occupational therapists.

INTRODUCTION

Nutrition, defined as the process by which one takes in and utilizes nutrients ( 1 ), plays a pivotal role in all aspects of health care including growth and development, health promotion and disease prevention, and acute and chronic disease management. Nutrition is important to the practice of all health care professionals. A working group meeting on “Future Directions for Implementing Nutrition across the Continuum of Medical Education, Training, and Research” was convened by the National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, and cosponsored by the NIH Office of Disease Prevention, Division of Nutrition Research Coordination ( 2 ). The purpose of the meeting was to recommend strategies for implementing nutrition education, research, and training across the continuum of the medical and health care professions ( 2 ). An important outcome of the working group was to disseminate these multidisciplinary deliberations to engage leaders, educators, clinicians, researchers, and key stakeholders to continue the dialogue and implement nutrition across the continuum of medical and health care profession education, training, and research. This article introduces the concept of synchronized interprofessional nutrition competencies and complements the discussions on research priorities in nutrition education ( 3 ), nutrition priorities for medical education ( 4 ), and medical training ( 5 ).

The evolution of health care strategies since the 1972 Institute of Medicine (IOM) 5 report “Future Directions for the National Health Care Quality and Disparities” has shown some progress, but education regarding health care practice per se has not yet motivated overall health care change ( 6 ). Subsequent meetings of the IOM have concluded that, although isolated approaches to the interprofessional training of health care professionals exists, it has yet to become the national norm in our postsecondary institutions and professional training programs ( 7 , 8 ). A key question that is relevant for all institutions considering such reforms is “What is the definition of being interprofessional?”

As elaborated by D'Amour and Oandasan ( 9 ) the concept of “interprofessionalality” is defined as follows: “The process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client, family, and populations. Interprofessionality requires a paradigm shift, since interprofessional practice has unique characteristics in terms of values, codes of conduct, and ways of working.”

To develop an interprofessional approach to implementing nutrition into the health care team, 3 areas of professional competencies need to be addressed ( 10 ). Individual professional competencies remain the distinct domain of each profession, including dentistry, medicine, nursing, nutrition and dietetics, occupational therapy, pharmacy, physician assistant (PA), physical therapy, and speech and language therapy. This article first addresses the competencies relevant to several of these health care professions. Subsequently, competencies in common among these professions and interprofessional collaborative competencies are presented ( 11 ) ( Table 1 ).

Operational definitions of interprofessional concepts 1

INTRAPROFESSIONAL NUTRITION EDUCATION AND TRAINING

Nutrition and scope of practice within nursing.

Nursing is the largest health care occupation in the United States ( 12 ), with >3 million registered nurses (RNs) ( 13 ). Nurses provide holistic care (physical, social, mental, and spiritual needs) to individuals, families, communities, and populations across the care continuum ( 14 ). The scope of nursing practice includes not only curative and palliative care but also health promotion, disease prevention, and coordination of care ( 14 ). Nurses are diagnosticians and formulate “clinical judgments about individual, family, or community experiences/responses to actual or potential health problems” ( 15 ). Nursing diagnoses then “provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability” ( 15 ). Nutrition is 1 of 13 domains in nursing practice and is defined as “the activities of taking in, assimilating, and using nutrients for the purposes of tissue maintenance, tissue repair, and the production of energy” ( 15 ). Approved nursing diagnoses for nutrition focus on imbalances or impaired abilities related to ingestion, metabolism, and hydration (including fluid and electrolytes).

Present state of nutrition education for nurses

Nutrition has been a component of nursing care since Nightingale ( 16 ), the founder of modern nursing, noted nutrition (ie, “taking food”) as the second most important area for nursing. Nurses were initially responsible for preparing and serving food to the sick until the discipline of dietetics was founded ( 17 ). As role differentiation between nurses and dietitians continued during the period of 1950–1970 ( 17 ), the required hours of specific nutrition coursework in nursing curriculum shifted to an “integrated” approach ( 17 ). Even though the mandatory required educational hours in basic nutrition and diet therapy for RN licensure was eliminated ( 17 ), nutrition was and continues to be testable content on the RN licensure examination. Today, the National Council Licensure Examination for Registered Nurses (NCLEX-RN) includes nutrition topics such as nutrition assessment and monitoring, diet therapy, and enteral and parenteral nutrition ( 18 ). Because nutrition is testable content on the NCLEX, the assumption is that nutrition (basic and applied) is included in nursing education programs, even though formal nutrition competencies are not explicated in The Essentials of Baccalaureate Education for Professional Nursing Practice ( 19 ), Similarly, nutrition courses are not required at the graduate level as noted in The Essentials of Master's Education in Nursing ( 20 ) or the Advanced Practice Registered Nurses Consensus Model ( 21 ), but nutrition as a focal area of practice is included in the core competencies ( 3 ).

Didactic approaches for incorporating nutrition content into nursing education include stand-alone nutrition courses, an integrated approach where nutrition is woven throughout nursing courses, and a combination of these 2 (hybrid model). Nutrition content is included in many prelicensure nursing textbooks [eg, fundamentals of practice ( 22 ), clinical skills ( 23 ), adult health ( 24 ), and gerontology ( 25 )]. Furthermore, there are numerous nutrition textbooks written for RNs (eg, a 2013 amazon.com search on “Nutrition Books for Nurses” resulted in 294 nutrition books written for nurses) as well as advanced-practice nurses ( 26 , 27 ). Clinical approaches include nutrition-focused learning during clinical rotations in the laboratory setting and with simulation. Information on nutrition education in US schools of nursing is now outdated. Stotts et al ( 28 ) surveyed US nursing school faculty and course directors in 1987. All 264 Bachelor of Science in Nursing programs that responded included nutrition content (integrated or hybrid), and 54% required at least one stand-alone nutrition course that included, on average, 32 ± 21.5 h of nutrition content ( 28 ). Almost all programs taught nutrition assessment, and most taught enteral and parenteral nutrition therapy and diet counseling ( 28 ). Only 70% of the programs taught nutritional biochemistry. The majority (70%) of the programs did not include a clinical nutrition learning experience ( 28 ). Nurses (57.5%) and dietitians (67%) were primarily responsible for teaching nutrition courses, although a small percentage reported that physicians or pharmacists taught the course ( 28 ). An alarming finding is that only 50% of the graduate program faculty who responded felt that the nutrition content was adequate ( 28 ). Programs that included nutrition focused on dietary assessment and counseling, enteral and parenteral therapy, evaluation of treatment, and differentiation of roles of the health care team ( 28 ). Again, nutritional biochemistry was rarely taught ( 28 ).

Nutrition and the future of nursing: a call to action and building capacity

Nutrition must be integrated throughout a nurse's professional career, including how and when to interact with registered dietitians (RDs) and other nutrition professionals. The IOM's Future of Nursing calls on the nursing profession to “adopt a framework of continuous lifelong learning that includes basic education, residency programs, and continuing competence” ( 14 ). Nutrition competencies should be incorporated into nurse residency programs, as well as annual continuing education. Although nutrition certifications exclusively for nurses do not currently exist, nurses should be encouraged to obtain interdisciplinary certification in nutrition support, diabetes education, or lipid management. Nursing leaders need to consider how nutrition is incorporated into the evolving “milestones for mandated skills, competencies and professional development” ( 14 ). At present, 62.2% of nurses work in hospital settings ( 13 ); however, with the transformation of health care and the aging population, the demand for nurses working in outpatient, ambulatory settings will increase ( 14 ), and so should the approach to incorporating nutrition in these settings.

The critical question moving forward is to what extent, if any, are current nutrition education models preparing nurses to apply nutrition principles in new, transformative, and expanded roles such as care coordinators and health coaches? An informal survey of nurse practitioners conducted by a publishing company in 2011 indicated that nutrition was their number one topic of interest, and they requested that additional content be developed to help them achieve the skills they needed in everyday clinical settings.

Addressing the adequacy of nutrition education needs to be a multipronged effort. A contemporary survey of nutrition education at all levels of nursing education is warranted. As the IOM notes, “nursing schools are grappling with the explosion of research and knowledge to provide health care in complex systems by adding layers of content that requires more instruction—there needs to be a fundamental thinking of this approach” ( 14 ). Adding courses without identification of core nutrition competencies for nurses at all levels (including nursing faculty) is a “Band-Aid” approach. If nurses receive a formal course in nutrition, it is often at the undergraduate level ( 28 ). Recommendations on how to integrate nutrition content across various courses at the graduate level could be highly effective. The key is to identify advanced nutrition competencies that could potentially be threaded into the Direct Care Core 3 P's (advanced physiology/pathophysiology, advanced health assessment, and advanced pharmacology), as well as disease management (acute and chronic) and health prevention courses and clinical learning activities ( 20 ).

Now is the time to revisit the crucial role nurses play in promoting nutritional health and well-being across the life span. Recommendations from The Bipartisan Policy Center's 2012 report entitled “Lots to Lose: How America's Health and Obesity Crisis Threatens Our Economic Future” that are germane to nursing include the following: 1 ) better training of health care professionals to provide care that addresses the issues of diet, physical activity, wellness, and disease prevention; 2 ) the infusion of nutrition and physical activity information and behavioral methodologies in the education, training, and continuing education of all health care professionals; and 3 ) training and credentialing of nurses as health coaches to deliver preventive services to those at high risk of developing chronic conditions ( 29 ). Thought leaders and experts in nursing, along with key stakeholders from the American Association of Colleges of Nursing, the National League for Nursing, the National Council of State Board of Nursing, the American Nurses Credentialing Center, and relevant nursing specialty organizations, need to work together to build such nutrition capacity for nursing. Nursing as a discipline has successfully mobilized intradisciplinary resources in response to calls to action in genetics ( 30 ), end of life ( 31 ), and geriatrics ( 32 , 33 ). Approaches to building nutrition capacity for nursing can be modeled after these. For example, the Hartford Geriatric Nursing Initiative is one of the most extensive movements in nursing and is an exemplar of not only building capacity but sustaining capacity. Key components of the Hartford Geriatric Nursing Initiative model include identification of need, early and sustained buy-in from key stakeholders, primary and secondary sources of funding, identification of key competencies for prelicensure, undergraduate and graduate nursing, coordinated approach to building capacity, quality education and practice resources, and preparation of the next generation of leaders, educators, and researchers in gerontologic nursing ( 34 – 36 ).

Nutrition and scope of practice within pharmacy

Nationally, there are 281,560 pharmacists whose primary purpose is to dispense medications to patients and to offer advice on their safe use ( 37 ). Pharmacists practice in pharmacy and drug stores, hospitals, extended-care facilities/nursing homes, and home care and home infusion. They have managerial, clinical, including both general and specialty, distributional, dispensing, and research roles. The future vision of the Joint Commission of Pharmacy Practitioners describes pharmacists as health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes ( 38 ). Before parenteral nutrition (PN), pharmacist practice in nutrition was in the sale of vitamins and as a resource for drug-nutrient interactions. Although these continue, the development of PN created the role of pharmacists in nutrition. Specific knowledge of pharmaceutical sciences related to solution stability, compatibility, and sterile preparation was essential to translating the science of intravenous nutrition to clinical practice ( 39 ). Safety and efficacy issues with PN required specialized knowledge for optimal provision. This initial need to include pharmacists in PN development and inclusion in patient care evolved into interdisciplinary direct patient care practices that include nutrition assessment, care planning, initiation of therapy, monitoring, management of nutrition services, and advancement of nutrition care as defined by American Society for Parenteral and Enteral Nutrition nutrition support pharmacist standards of practice ( 40 ). This is the primary nutrition practice of pharmacists. As noted in a recent survey, ∼50% of health care system pharmacies provide nutrition consultation services ( 41 ). Other reports suggest that pharmacists play a nutrition role in disease management (diabetes and cardiovascular disease) ( 42 ), obesity ( 43 ), and anorexia-cachexia ( 44 ). An expanded role of consultant pharmacists in nutrition management based on changes in Centers for Medicare and Medicaid Services’ focus on nutrition has been described by Martin ( 45 ).

Present state of nutrition education for pharmacists

Education in pharmacy school after admission is 4 y, with each year depicted as P1, P2, P3, and P4, and includes both didactic and experiential components ( 46 ). There is further training via postgraduate residencies [postgraduate year (PGY)-1 and PGY-2] for more specific direct patient care and advanced operations of pharmacies accredited by the American Society of Health-System Pharmacists ( 47 , 48 ). Didactic curricula for pharmacy schools have been described ( 38 ). Nutrition components of the curricula include the following:

• • Nutrition, essential nutrients: tier 1A
• • Nutrition assessment: tier 1B
• • PN: tier 1B
• • Enteral nutrition: tier II
• • Formula intolerance: tier II

Tier 1 components must be covered by all institutions of higher education; in tier 1A the graduate should receive extensive instruction and be proficient in providing care, and in tier 1B the graduate should be exposed to the disease state. Tier II should be covered in pharmacy school. Unfortunately, opinions of faculty and practitioners express the reality that this only occurs if there is faculty available to instruct pharmacy students.

Nutrition and pharmacy: a call to action and building capacity

Although there is no specific mention of nutrition functions in PGY-1 ( 47 ) or PGY-2 ( 48 ) residency training, there are 3 specialty residencies available for nutrition, of which only 2 were filled in 2012 ( 49 ). A noted concern is that pharmacy leaders feel that PN is a less commonly used therapy and so there is less interest and fewer resources allocated to this area of study. There is, however, the ability to become board-certified in nutrition support therapy; the Board of Pharmaceutical Specialties now has 523 board-certified pharmacists in nutrition support (designated as BCNSP) ( 50 ), and the National Board of Nutrition Support Certification has recently offered their examination to pharmacists (based on a professional practice audit that found interdisciplinary roles in nutrition were similar) ( 51 ). The Board of Pharmaceutical Specialties examination is based on several domains such as develop and implement a therapeutic plan of care, management of nutrition support operations, patient care management, compounding operations, and advancement of nutrition support practices ( 50 ).

Nutrition practice in pharmacy is very specific to the advanced practices involved with enteral nutrition and PN in which a pharmacist's unique knowledge and practice are clearly delineated. This overshadows the potential and necessary role pharmacists may have in health and promotion and disease management. As a health care provider, pharmacists must play a role in nutrition care. Approximately 250 million Americans walk into a pharmacy weekly ( 37 ), so pharmacists have extraordinary access to the public and to provide nutrition education. As more diseases become redefined with broader definitions, such as prehypertension and prediabetes, pharmacists are left on the sidelines as others attempt to influence behavior, nutrition, and physical activity to improve the health of our nation and to hopefully avoid the development of disease. The Joint Commission of Pharmacy Practitioners’ vision assigns this responsibility to pharmacists: “promotion of wellness, health improvement, and disease prevention” ( 52 ). At present, the practice is specific and at an advanced level whereby the need is elsewhere and the preparation of pharmacists is inconsistent. There is a need to address nutrition in practice ( 53 ), including how and when to interact with RDs and other certified nutrition professionals, and in pharmacy curricula to successfully meet the need of patients for disease prevention and chronic and acute management.

Dentistry and dental hygiene

Nutrition and scope of practice in dentistry and dental hygiene.

Nutrition is recognized as an important component of oral care. The major oral problems (dental caries, periodontal disease, and oral infections) all have nutritional/dietary implications. The oral cavity is the pathway for nutrition, so any problems in the oral cavity (missing teeth, pain, infections, etc) can affect desire and ability to eat and can affect subsequent nutritional status. Conversely, dietary and nutritional factors can play major roles in initiation and/or extension of oral disease or promotion of oral health. Dietary and nutritional factors can influence the oral flora, the salivary flow rate, oral structure development, and tooth mineralization, remineralization, and maturation. Dietary patterns of carbohydrate intake are directly related to dental caries risk. Undernutrition can lower resistance to oral infections. Dietary supplement excesses can have temporary or permanent effects on oral hard and soft tissue.

A variety of dental professional organizations, including the American Dental Association (ADA) ( 54 ), the American Dental Hygienists Association ( 55 ), the Academy of Nutrition and Dietetics (AND) ( 56 ), and the American Academy of Pediatric Dentistry ( 57 ), publish nutrition guidelines for dental practice. Although there is wide recognition of the importance of nutrition in dental practice, a major disconnect exists between the acknowledgment of the importance of nutrition and the implementation of clinical strategies to diagnose nutritional issues and provide meaningful interventions in clinical practice. When surveyed, practitioners acknowledge the importance of nutrition for patient care, but admit that they feel inadequately trained, and thus uncomfortable, providing nutrition interventions ( 58 ). Rarely are RDs readily available as resources to dental teams, so team members are usually on their own in this regard.

For this reason, efforts have been made starting in the 1960s to develop model programs to train dentists, dental students, and dental hygiene students in applied nutrition strategies for clinical practice ( 59 , 60 ). There are many challenges to accomplishing this goal. Most important, if the faculty member assigned to teaching nutrition in a dental school does not have applied clinical nutrition expertise, the clinical applications will not be taught (and more importantly, modeled), so nutrition will not be seen by students as applicable to patient care ( 60 ). Often, a basic science faculty member, such as a biochemist, is assigned to teach nutrition. In such cases, unless the professor joins with a clinician to teach clinical implication strategies, the essential link from science to practice is lost. Other issues such as lack of curriculum time, conflicting values of decision makers, etc, are similar to other disciplines. For these reasons, nutrition educators in dental and dental hygiene education have been striving to improve the nutrition education of dental and dental hygiene students that will meet the needs of contemporary clinical practice.

Present state of nutrition education for dental and dental hygiene students

Although the dentist is the primary dental care provider and sets the standards for the practice, he or she may not be the principal dental nutrition care provider. That role is usually assigned to the dental hygienist as a component of preventive care (or disease prevention and health promotion). Dental hygienists are considered allied health care professionals and work closely with dentists or independently (as determined by the scope of practice at the state level).

The Commission on Dental Accreditation of the ADA is the accrediting body for dental schools and dental hygiene schools ( 61 ). The American Dental Education Association (ADEA) ( 62 ), the professional association for dental education, works closely with the ADA in policy development. Although there is no accreditation requirement for nutrition education per se for dental students, it is implied by requiring competency “in the application of biomedical science knowledge in the delivery of patient care” and competency in “health promotion and disease prevention” ( 63 ). The ADEA does emphasize nutrition specifically in its “Foundation Knowledge and Skills for the New Dentist,” which lists, under Health Promotion, “the ability to provide intervention, motivation, and nutrition as essential health promotion/disease prevention strategies” ( 63 ).

Dental hygiene accreditation standards for dental hygiene education specifically state nutrition as a biomedical science requirement (ie, ADEA Hygiene 2-10 Biomedical Science content must include content in anatomy, physiology, chemistry, biochemistry, microbiology, immunology, general pathology and/or pathophysiology, nutrition, and pharmacology), but there is no stated competency in applied nutrition. The spectrum of nutrition education in dentistry focuses on nutrition as foundation knowledge, applied nutrition basics, and the translation to patient care.

The number of hours devoted to nutrition has remained fairly consistent and is low compared with other curriculum areas ( 61 ). A 2001 survey of US and Canadian dental schools found that only 41% of schools reported that students provided diet counseling for patients, and only 28% of schools had an RD on the faculty to provide clinical nutrition education ( 64 ). Another study found that although dentists were motivated to include nutrition in their clinical care, most felt unqualified to provide dietary guidance and thus shied away from doing so ( 65 ). A survey conducted by the ADEA in 2011 ( 66 ) found that of 24 US dental schools reporting, there was an average of 15.9 h of didactic nutrition taught with a range of 7–40 h, and no clinical hours reported. In contrast, dental hygiene programs not only included didactic nutrition content (on average, 32.7 h) but also an average of 4.9 h of laboratory and 9.3 clinical hours for a total of 46.9 h. This likely reflects the acknowledged role of the dental hygienist as the clinical prevention educator. All of the dental schools surveyed reported teaching nutrition in their curricula. The majority of faculty were biochemists and those from “nutrition-related disciplines,” followed by RDs and those with graduate coursework in applied nutrition. Some dentists were also teaching nutrition. In most cases, nutrition was taught as part of the biochemistry course or as part of a preclinical course. Some schools did have stand-alone nutrition courses, and the fewest number included nutrition as part of a clinical course. Less than half of respondents reported changes in their nutrition programs resulting from curriculum changes, but those who did reported nutrition being redistributed through other courses rather than being stand-alone courses. This may reflect the move to systems-based curricula currently influencing current curricular changes.

Nutrition teaching in dental and dental hygiene schools has always had to fight to maintain a baseline presence and has never achieved optimal integration. Many barriers conspire to undermine efforts to develop better nutrition curricula in dental education. Traditionally, people trained in applied nutrition are not employed in dental schools. If they are, it is often on a part-time or ad hoc basis, which does not allow time for developing the crucial allegiances needed to move visions forward. Thus, the science of nutrition is more likely to be taught by scientists already teaching subjects other than the clinical applications and models. Consequently, the broad spread of hours for nutrition in dental curricula likely reflects the varied levels of commitment to nutrition of the people making the programming and scheduling decisions rather than purposeful programmatic planning. This is further undermined by the lack of a consensus core curriculum that can serve as a benchmark. The dearth of evidence-based research on the efficacy of clinical nutrition interventions in practice is also a barrier to the implementation of nutrition strategies.

Nutrition and dentistry: a call to action and building capacity

Despite the limitations of past efforts to improve nutrition curricula in dental education, many models for applied nutrition do exist ( 61 , 67 ) and several current trends may support forward movement in this area. There has been a burst of interest and activity in the area of interprofessional education. Strategic planning initiatives for dentistry (as well as for all other health care professionals) have pinpointed the need for competency in working successfully with other health care professions as a major curricular requirement for the dentist of the future. Developing alliances between RDs, other clinical nutrition professionals, and dentists around patient care is a natural opportunity in this area. Dentists have also allied with other health care professionals around areas of mutual concern and interest such as childhood obesity and type 2 diabetes. Such collaborations can foster increased interest in nutrition as it relates to these pressing issues as well. Contemporary technology has also provided an opportunity for developing resource for nutrition/dental collaborations. For example, MedEdPortal ( https://www.mededportal.org/ ) is a valuable resource for medical and dental educational models and could provide dental nutrition models as well.

What we need going forward

Better synergy between dentistry, dental hygiene, and nutrition will be best served by focusing on the following several areas of current weakness:

• • Research on clinical outcomes. More research is needed on the value of nutrition interventions in clinical dental practice.
• • Curricular guidelines to assist in curriculum design. The movement in dentistry has been away from subject-specific curricular guidelines [although they did exist in the past ( 68 )]. However, this has left a void for those attempting to develop or improve nutrition curricula. Thus, new curriculum guidelines or consensus statements for nutrition in dental education need to be developed and promulgated by professional associations to assist in curriculum design and implementation.
• • Better dissemination of effective models. Good models of nutrition/dental curricula need to be made more readily available via MedEdPortal and other professional venues.
• • Consensus on highest impact messages to impart to the public and dental patients ( 69 ).
• • More accessible training in clinical applications. Avenues need to be developed to train the workforce that will be teaching nutrition in dental and dental hygiene schools in areas they may be lacking. This may mean educating dentists and/or dental hygienists in applied nutrition, teaching basic scientists applied nutrition in dentistry, teaching nutritionists about nutrition in dentistry, or some combination of these.

Only when we have educators who can make nutrition relevant to dentistry, will we move forward.

NUTRITION AND DIETETICS

Nutrition and scope of practice within dietetics.

An RD or a registered dietitian nutritionist is a food and nutrition expert who has met the minimum academic and professional requirements to qualify for the credential “RD” by the AND ( 70 ). As of 2013, there were ∼86,967 RDs in the United States and the majority work in the treatment and prevention of disease in hospitals, health maintenance organizations, private practice, or other health care facilities ( 70 ). In addition, a large number of RDs continue to work in community and public health settings and academia and research. A growing number of RDs work in the food and nutrition industry, in business, journalism, sports nutrition, and corporate wellness programs ( 70 ).

Undergraduate programs specific to dietetics always encompass education and training related to the science and application of nutrition. Achievement of an undergraduate degree, usually a Bachelor of Science degree in nutrition and dietetics, followed by a certified dietetic internship, entitles an individual to take a registration examination to become an RD.

According to the AND, an RD must fulfill the following minimum requirements:

• • Earning a bachelor's degree with coursework approved by AND's Commission on Accreditation for Dietetics Education. Coursework typically includes food and nutrition sciences, foodservice systems management, business, economics, computer science, sociology, biochemistry, physiology, microbiology, and chemistry.
• • Completing an accredited, supervised practice program at a health care facility, community agency, or foodservice corporation.
• • Passing a national examination administered by the Commission on Dietetic Registration (CDR).
• • Completing continuing professional educational requirements to maintain registration.
• • Students must complete a 1200-h internship to sit for the RD examination.

Although all RDs are nutritionists, the reverse is not necessarily true. Graduate programs in nutrition leading to the master's- or doctoral-level degree represent advanced knowledge and understanding of nutrition and may accompany an RD credential as well as other clinical or health care professional degrees, including the medical doctor (MD), RN, or other clinical specialties. Thus, depending on the course or curriculum being taught, any number of professionals trained in nutrition and/or dietetics may be involved in medical nutrition education and in educating other health care specialties, but the training of RDs is specialized, in-depth nutrition science, research, and education, which distinguishes it from other disciplines.

Present state of nutrition and dietetics

Teaching programs in nutrition and dietetics were initially offered in the Department of Home Economics within the School of Agriculture in many universities as early as 1904. Departments of Foods and Nutrition, Biochemistry, and Nutritional Sciences were created, and faculty with expertise in nutrition science, food and dietetics, food science, and foodservice management were hired. In keeping with the natural direction in dietetics education, a formal Didactic Dietetics Program (called “plan IV”), recognized by the AND, was instituted in 1974 ( www.eatright.org ). A Coordinated Program, incorporating the supervised practice component of dietetics education, was instituted in 1976 with 2 major options: General Dietetics and Food Service Administration. With the Coordinated Program came annual review and evaluation by the AND, not only of the clinical components but also of the didactic components of the dietetics education programs. At the present time, ∼50% of RDs hold advanced degrees. Some RDs also hold additional certifications in specialized areas of practice, such as pediatric or renal nutrition, nutrition support, and diabetes education.

In 1969, the AND developed a voluntary system of credentialing to help ensure the competency of dietetics professionals through a standardized, quality-controlled process administered by the CDR ( 71 ).

The purpose of CDR is to serve the public by establishing and enforcing standards for certification and by issuing credentials to individuals who meet these standards. The CDR has sole and independent authority in all matters pertaining to certification including, but not limited to, standard setting, establishment of fees, finances, and administration. The CDR offers certification as dietetic technicians, RDs, and board-certified specialists in pediatric nutrition, renal nutrition, gerontologic nutrition, and sports dietetics ( 71 ).

The registration examination assesses only a cross-section of the knowledge and skills needed for entry-level competence, including principles of dietetics, nutrition care for individuals and groups, and management of nutrition programs and services and foodservice systems. Included within the principles of dietetics are a wide range of nutrition topics including food science, human physiology, biochemistry, and more recently, behavioral applications. The American Dietetic Association became the AND in 2012, and these and other evidence-based components remain integral to the fundamental training of RDs. The new name complements the focus of the organization to improve the nutritional well-being of the public while communicating the academic expertise of Academy members and supporting the organization's history as a food- and science-based profession.

Nutrition Care Process

In 2003, the American Dietetic Association adopted the Nutrition Care Process and model in the interest of achieving the high-quality nutrition care needed to help achieve the “desired health services consistent with current professional knowledge,” as specified by the IOM ( 72 , 73 ). The Nutrition Care Process is a standardized process rather than standardized care because it emphasizes the relation between the patient, client, or group and the dietetics professional by using state-of-science, evidence-based dietetics practice to meet individualized needs ( 74 ). The Nutrition Care Process defines common language, terms, key components, critical thinking characteristics, documentation elements, and other considerations related to standards of nutrition care. Essentials of the Nutrition Care Process include the following:

• Step 1: nutrition assessment to determine nutrient adequacy, health function, and behavioral status
• Step 2: nutrition diagnosis to determine the etiology, cause, and contributing risk factors
• Step 3: nutrition intervention to implement the evidence-based action or medical nutrition therapy appropriate to the condition
• Step 4: nutrition monitoring and evaluation to review and measure ongoing progress related to the established goals of intervention

NUTRITION AND OTHER HEALTH CARE PROFESSIONS

Nutrition is also an important component of education, training, practice, and research for PAs, physical therapists (PTs), occupational therapists (OTs), and speech and language pathologists (SLPs). These graduates are ideally positioned to serve as health coaches promoting lifestyle modifications, especially during the rehabilitative continuum. As nursing, pharmacy, and dentistry search inward for nutrition competencies within their professions and placement of nutrition in the curriculum, so must PAs, PTs, OTs, and SLPs and embrace a similar call to action. Advancing nutrition in these disciplines is best accomplished by identifying resources, champions, expert leaders, and key stakeholders (professional associations, regulatory bodies, and specialty societies) to mobilize efforts for health promotion and disease prevention. It is only through this inward reflection can we move toward interprofessional competencies.

THE INTERPROFESSIONAL NATURE OF NUTRITION

It is noteworthy that, in addition to dentistry, the American Association of Colleges of Nursing, The Association of American Medical Colleges, The American Association of Colleges of Pharmacy, and the Association of Schools of Public Health all provide language to support the collaborative and interprofessional development of nutritional approaches to address health care needs ( 8 ). Thus, the challenge at hand remains not in the support of the constituent societies but more so in the lack of institutional implementation of interprofessionalism into the educational environment. A part of this difficulty lies within the challenge of defining and fully understanding “What is interprofessionalism?” Understanding the concept of “collaborative competencies” aids greatly in making the transition toward full implementation of interprofessional educational initiatives. Interprofessional collaborative competencies help to more clearly delineate how interprofessional strategies differ from those of individual constituent societies and traditional scientific organizations. These competencies are the domain of those practices or organizations of societies that seek to define “interprofessionalism.” These concepts focus most importantly on the teamwork required to accomplish a patient-centered approach and toward developing the nature of the relation between the team members and the competency development for interprofessional collaborative practice. Within this third domain of “interprofessionalism” there are operative definitions essential to understanding how interprofessional approaches differ from the typically discipline-specific concepts that constitute the historic practices of professional societies. These include interprofessional domains of education, collaborative practice, teamwork, team-based care, competencies in health care, and competency-based domains ( Table 1 ). Note that these definitions center more on how care is delivered and less on the traditional professional alignment of what care is delivered. These definitions are centered on deliberate practice models and focus on how care is delivered. By doing so, the interprofessional approach to the health sciences honors and respects individual professional competencies, it builds on common competencies, and seeks to establish interprofessional collaborative competencies for the benefit of the patients and communities we serve. With proper discovery, planning, coordination, and implementation, nutrition and dietetics can become uniquely poised to address today's health care needs with our professional allies, through innovative and collaborative development of interprofessional deliberate-practice nutrition approaches.

Interprofessional models of nutrition in action

Increasingly, innovative approaches to interprofessional models of education, training, and practice are being implemented and evaluated ( 75 ). Examples of current interprofessional models of nutrition in action include programs supported by the Health Resources Services Administration (HRSA), formal and informal interprofessional education initiatives in the university settings, and models to address adult hospital malnutrition.

HRSA programs

The HRSA is a division of the Department of Health and Human Services, and its mission is to improve health and to achieve health equity through access to quality services, a skilled health workforce, and innovative programs. The HRSA supports the training of the health care workforce with a focus on interprofessional training for team-based care. The Bureau of Health Professions (BHPr) programs train health care professionals and place them where they are needed most. Grants support scholarship and loan repayment programs at colleges and universities to meet critical workforce shortages and to promote diversity within the health care professions. BHPr programs tackle a range of current health care workforce challenges. There are numerous reports of shortages of primary care physicians, nurses, and public health and allied health care professionals. The Health Professions Training programs make grants to health professions schools and training programs, which use the funds to develop, expand, and enhance their efforts to train the health care workforce America needs. At this time, nutrition has a limited focus for the BHPr.

The Maternal and Child Health (MCH) Bureau's Division of MCH Workforce Development provides national leadership and direction in educating and training the nation's future leaders in maternal and child health. Special emphasis is placed on the development and implementation of interprofessional, family-centered, community-based, and culturally competent systems of care across the entire life course with experiences in one life stage shaping health in later stages.

There is an emphasis on leadership education and promoting interdisciplinary training, practice, and interorganizational collaboration to enhance systems of care for MCH populations. The graduate and postgraduate education programs train several disciplines in interdisciplinary settings: for example, medicine, nursing, psychology, nutrition, dentists, and social work. Some of the interdisciplinary programs are Leadership Education in Adolescent Health, Leadership Education in Neurodevelopmental and Related Disabilities, Pediatric Pulmonary Centers, Schools of Public Health, and Public Health Nutrition graduate education. This training is especially important for the MCH populations—prenatal, neonatal, high-risk infants, pediatrics, children with special health care needs and/or developmental disabilities, adolescence, and families—as it relates to the prevention of chronic diseases in a life course perspective.

Jefferson's Center for Interprofessional Education

Jefferson's Center for Interprofessional Education (JCIPE) was founded in 2007 at the Thomas Jefferson University in Philadelphia. JCIPE is dedicated to improving interprofessional care by implementing and evaluating patient-centered education throughout the Thomas Jefferson University curriculum ( 76 ). JCIPE aims to define the future of interprofessional care by creating a culture of collaborative educational practice and setting the standards for patient-centered care and team-based training. The JCIPE Health Mentors Program offers students from Jefferson Medical College and the Schools of Nursing, Pharmacy, and Health Professions (occupational, physical, and couples’ and family therapy) to learn first-hand from a patient about things that really matter to patients living with health conditions and/or impairments. Students work in teams to meet with their health mentor and are required to create wellness plans and safety assessments and to develop behavior change strategies over a 2-y period, considering the patients chronic medical conditions. Teams present during small group sessions to 2 faculty members who facilitate discussion and provide feedback. This program is an excellent example of how nutrition can be formally and informally woven into interprofessional education by using health mentor sessions, cases, lectures, as well as during small group sessions. However, if a school does not have a formal nutrition and dietetics program in place, nutrition students may not be part of the interprofessional education process. Therefore, it is very important that clinical dietitians are invited to the table for interprofessional education curriculum development and preceptor opportunities.

Drexel's interprofessional nutrition research initiatives

Interprofessional research initiatives related to nutrition topics are another way to model the transdisciplinary approach to nutrition. Health and wellness is the overarching research theme at Drexel University's College of Nursing and Health Professions. Researchers and students in nursing, nutrition, rehabilitation sciences, creative arts therapy, and couples’ and family therapy collaborate on several research projects that have a nutrition component. For example, one of the authors (RAD-G) is a site investigator for the annual Nutrition Day screening program at Hahnemann University Hospital. Nursing, nutrition, creative arts therapy and pre-med students work as a team with faculty and clinical mentors to collect and analyze the data on a yearly basis. Students learn valuable lessons in hospital-based nutrition screening.

Alliance to Advance Patient Nutrition

The Alliance to Advance Patient Nutrition, an interdisciplinary group of professional organizations (Academy of Medical-Surgical Nurses, AND, American Society for Parenteral and Enteral Nutrition, and Society of Hospital Medicine) and industry (Abbott Nutrition), was recently created to address adult hospital malnutrition. In their interdisciplinary call to action paper, the Alliance presents a novel care model to address hospital malnutrition based on 6 principles that can be used by all members of the health care team ( 77 ).

CONCLUSIONS

Understanding and applying nutrition knowledge and skills to all aspects of health care are extremely important, and all health care professions need basic training to effectively assess dietary intake and provide appropriate guidance, counseling, and treatment to their patients. With obesity rates at an all-time high and the increasing prevalence of diabetes projected to cost the federal government billions of dollars, the need for interprofessional nutrition education is paramount. Physicians, PAs, nurses, nurse practitioners, pharmacists, dentists, dental hygienists, OTs, PTs, SLPs, and others can positively affect patient care by synchronizing and reinforcing the importance of nutrition across all specialty areas. Although nutrition is a critical component of acute and chronic disease management, as well as health and wellness across the health care professions, each profession must first reevaluate its individual nutrition-related professional competencies to establish meaningful interprofessional collaborative nutrition competencies.

Acknowledgments

We thank Denise Sofka, Maternal and Child Health Bureau, HRSA, for her assistance in the preparation of the manuscript.

The authors’ responsibilities were as follows—All of the authors contributed to writing of the manuscript. None of the authors declared a conflict of interest.

5 Abbreviations used: ADA, American Dental Association; ADEA, American Dental Education Association; AND, Academy of Nutrition and Dietetics; BHPr, Bureau of Health Professions; CDR, Commission on Dietetic Registration; HRSA, Health Resources Services Administration; IOM, Institute of Medicine; JCIPE, Jefferson's Center for Interprofessional Education; MCH, Maternal and Child Health; OT, occupational therapist; PA, physician assistant; PGY, postgraduate year; PN, parenteral nutrition; PT, physical therapist; RD, registered dietitian; RN, registered nurse; SLP, speech and language pathologist.

Healthy Eating Learning Opportunities and Nutrition Education

Healthy eating learning opportunities includes nutrition education  and other activities integrated into the school day that can give children knowledge and skills to help choose and consume healthy foods and beverages. 1 Nutrition education is a vital part of a comprehensive health education program and empowers children with knowledge and skills to make healthy food and beverage choices. 2-8 

US students receive less than 8 hours of required nutrition education each school year, 9  far below the 40 to 50 hours that are needed to affect behavior change. 10,11  Additionally, the percentage of schools providing required instruction on nutrition and dietary behaviors decreased from 84.6% to 74.1% between 2000 and 2014. 9

Given the important role that diet plays in preventing chronic diseases and supporting good health, schools would ideally provide students with more hours of nutrition education instruction and engage teachers and parents in nutrition education activities. 5, 12  Research shows that nutrition education can teach students to recognize how healthy diet influences emotional well-being  and how emotions may influence eating habits. However, because schools face many demands, school staff can consider ways to add nutrition education into the existing schedule. 11

Nutrition education can be incorporated throughout the school day and in various locations within a school. This provides flexibility allowing schools to use strategies that work with their settings, daily schedule, and resources.

In the Classroom

Nutrition education can take place in the classroom, either through a stand-alone health education class or combined into other subjects including 2,5 :

• Counting with pictures of fruits and vegetables.
• Learning fractions by measuring ingredients for a recipe.
• Examining how plants grow.
• Learning about cultural food traditions.

Nutrition education should align with the National Health Education Standards and incorporate the characteristics of an effective health education curriculum .

Farm to School

Farm-to-school programs vary in each school or district, but often include one or more of the following strategies:

• Purchasing and serving local or regionally produced foods in the school meal programs.
• Educating students about agriculture, food, health, and nutrition.
• Engaging students in hands-on learning opportunities through gardening, cooking lessons, or farm field trips.

Students who participate in farm-to-school activities have increased knowledge about nutrition and agriculture, are more willing to try new foods, and consume more fruits and vegetables. 14-17

School Gardens

School garden programs can increase students’ nutrition knowledge, willingness to try fruit and vegetables, and positive attitudes about fruits and vegetables. 18-22 School gardens vary in size and purpose. Schools may have window sill gardens, raised beds, greenhouses, or planted fields.

Students can prepare the soil for the garden, plant seeds, harvest the fruits and vegetables, and taste the food from the garden. Produce from school gardens can be incorporated into school meals or taste tests. Classroom teachers can teach lessons in math, science, history, and language arts using the school garden.

In the Cafeteria

Cafeterias are learning labs where students are exposed to new foods through the school meal program, see what balanced meals look like, and may be encouraged to try new foods through verbal prompts from school nutrition staff, 23 or taste tests. 24-25 Cafeterias may also be decorated with nutrition promotion posters or student artwork promoting healthy eating. 24

Other Opportunities

Schools can add messages about nutrition and healthy eating into the following:

• Morning announcements.
• School assemblies.
• Materials sent home to parents and guardians. 24
• Staff meetings.
• Parent-teacher group meetings.

These strategies can help reinforce messages about good nutrition and help ensure that students see and hear consistent information about healthy eating across the school campus and at home. 2 

Shared use agreements can extend healthy eating learning opportunities. As an example, an after-school STEM club  could gain access to school gardens as learning labs.

CDC Parents for Healthy Schools: Ideas for Parents

Nutrition: Gardening Interventions | The Community Guide

Dietary Guidelines for Americans, 2020–2025

Introduction to School Gardens

Learning Through the Garden

National Farm-to-School Network

National Farm to School Network Resource Database

National Health Education Standards

Team Nutrition Curricula

USDA Farm to School

USDA Team Nutrition

• Centers for Disease Control and Prevention. School health guidelines to promote healthy eating and physical activity. MMWR Morb Mortal Wkly Rep . 2011;60(RR-5):1–76.
• Joint Committee on National Health Education Standards. National Health Education Standards: Achieving Excellence. 2nd ed. Atlanta, GA: American Cancer Society; 2007.
• Centers for Disease Control and Prevention. Health Education Curriculum Analysis Tool, 2012, Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2012. Available at http://www.cdc.gov/healthyyouth/hecat/index.htm. Accessed April 9, 2019.
• Price C, Cohen D, Pribis P, Cerami J. Nutrition education and body mass index in grades K–12: a systematic review. J Sch Health. 2017;87:715–720.
• Meiklejohn S, Ryan L, Palermo C. A systematic review of the impact of multi-strategy nutrition education programs on health and nutrition of adolescents. J Nutr Educ Behav . 2016;48:631–646.
• Silveira JA, Taddei JA, Guerra PH, Nobre MR. The effect of participation in school-based nutrition education interventions on body mass index: A meta-analysis of randomized controlled community trials. Prev Med . 2013;56:237–243.
• County Health Rankings and Roadmaps. School-based Nutrition Education Programs website. http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/school-based-nutrition-education-programs . Accessed on April 9, 2019.
• Results from the School Health Policies and Practices Study 2014 . Atlanta, GA: Centers for Disease Control and Prevention; 2014.
• Connell DB, Turner RR, Mason EF. Results of the school health education evaluation: health promotion effectiveness, implementation, and costs . J Sch Health . 1985;55(8):316–321.
• Institute of Medicine. Nutrition Education in the K–12 Curriculum: The Role of National Standards: Workshop Summary. Washington, DC: The National Academies Press; 2014.
• Murimi MW, Moyeda-Carabaza AF, Nguyen B, Saha S, Amin R, Njike V. Factors that contribute to effective nutrition education interventions in children: a systematic review. Nutr Rev . 2018;76(8):553–580.
• Hayes D, Contento IR, Weekly C. Position of the American Dietetic Association, School Nutrition Association, and Society for Nutrition Education: comprehensive school nutrition services. J Acad Nutr Diet . 2018; 118:913–919.
• Joshi A, Misako Azuma A, Feenstra G. Do farm-to-school programs make a difference? Findings and future research needs . J Hunger Environ Nutr . 2008;3:229–246.
• Moss A, Smith S, Null D, Long Roth S, Tragoudas U. Farm to school and nutrition education: Positively affecting elementary school-aged children’s nutrition knowledge and consumption behavior. Child Obes . 2013;9(1):51–6.
• Bontrager Yoder AB, Liebhart JL, McCarty DJ, Meinen A, Schoeller D, Vargas C, LaRowe T. Farm to elementary school programming increases access to fruits and vegetables and increases their consumption among those with low intake . J Nutr Educ Behav . 2014;46(5):341–9.
• The National Farm to School Network. The Benefits of Farm to School website. http://www.farmtoschool.org/Resources/BenefitsFactSheet.pdf . Accessed on June 14, 2019.
• Berezowitz CK, Bontrager Yoder AB, Schoeller DA. School gardens enhance academic performance and dietary outcomes in children. J Sch Health . 2015;85:508–518.
• Davis JN, Spaniol MR, Somerset S. Sustenance and sustainability: maximizing the impact of school gardens on health outcomes. Public Health Nutr . 2014;18(13):2358–2367.
• Langellotto GA, Gupta A. Gardening increases vegetable consumption in school-aged children: A meta-analytical synthesis. Horttechnology . 2012;22(4):430–445.
• Community Preventative Services Task Force. Nutrition: Gardening Interventions to Increase Fruit and Vegetable Consumption Among Children. Finding and Rationale Statement .. https://www.thecommunityguide.org/sites/default/files/assets/Nutrition-Gardening-Fruit-Vegetable-Consumption-Children-508.pdf . Accessed on May 16, 2019.
• Savoie-Roskos MR, Wengreen H, Durward C. Increasing Fruit and Vegetable Intake among Children and Youth through Gardening-Based Interventions: A Systematic Review. Journal of the Academy of Nutrition and Dietetics 2017;11(2):240–50.
• Schwartz M. The influence of a verbal prompt on school lunch fruit consumption: a pilot study. Int J Behav Nutr Phys Act. 2007;4:6.
• Fulkerson JA, French SA, Story M, Nelson H, Hannan PJ. Promotions to increase lower-fat food choices among students in secondary schools: description and outcomes of TACOS (Trying Alternative Cafeteria Options in Schools). Public Health Nutr. 2003 ;7(5):665–674.
• Action for Healthy Kids. Tips for Hosting a Successful Taste Test website. http://www.actionforhealthykids.org/tools-for-schools/find-challenges/classroom-challenges/701-tips-for-hosting-a-successful-taste-test . Accessed on May 19, 2019.

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New NSLP Guidelines: Challenges and Opportunities for Nutrition Education Practitioners and Researchers

• Carmen J. Byker, PhD Carmen J. Byker Correspondence Address for correspondence: Carmen J. Byker, PhD, Department of Health and Human Development, Montana State University, 222 Romney Gym, Bozeman, MT 59717; Phone: (406) 994-1952; Fax: (406) 994-6314 Contact Affiliations Department of Health and Human Development, Montana State University, Bozeman, MT Search for articles by this author
• Courtney A. Pinard, PhD Courtney A. Pinard Affiliations Gretchen Swanson Center for Nutrition, Omaha, NE Search for articles by this author
• Amy L. Yaroch, PhD Amy L. Yaroch Affiliations Gretchen Swanson Center for Nutrition, Omaha, NE Search for articles by this author
• Elena L. Serrano, PhD Elena L. Serrano Affiliations Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, VA Search for articles by this author
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School health and nutrition

Good health and nutrition are foundations for learning and a crucial investment for more sustainable, inclusive and peaceful futures – they can improve education outcomes, empower learners to thrive and promote inclusion and equity in education and health.

What is the state of school health and nutrition around the world?

The good news is that:

• 9 in 10 countries globally invest in school health and nutrition programmes.
• More than 100 countries have school vaccination programmes.
• One in two primary school children receives school meals
• Almost every country includes education for health and well-being in its curriculum.

And yet many children, in particular girls, are missing out especially in the poorest countries.

• 73 million of the most marginalized children are not reached by school feeding, undermining their ability to benefit from education.
• Over 246 million learners experience violence in and around school every year.
• 1 in 3 schools do not have basic drinking water and adequate sanitation.

Developed by UNESCO and five UN partners (UNICEF, WFP, FAO, GPE, and WHO), in collaboration with the World Bank, the Research Consortium for School Health and Nutrition and the UN-Nutrition Secretariat,  Ready to learn and thrive  takes stock of countries’ policies and programmes around health and nutrition, and underscores school health and nutrition as an effective and affordable way to ensure learners learn and thrive throughout their education pathway and beyond. 

What does health and nutrition mean for learners and schools?

School health and nutrition is about investing both in learners’ education  and  their health, with benefits extending to homes and communities. Ensuring the health and well-being of learners is one of the most transformative ways to improve education outcomes, promote inclusion and equity and to rebuild the education system, especially following the COVID-19 pandemic.

The report shows that healthy, well-nourished and happy children and adolescents learn better and are more likely to lead healthy and fulfilling lives. For example, learners are 50% less likely to skip school when the learning environment is free from violence; absenteeism is reduced in low-income countries when promoting handwashing in particular for girls during menstruation when water, sanitation and hygiene is improved, and enrolment rates increase when school meals are provided to learners.

What are some of the key challenges?

Despite significant progress on school health and nutrition, more work must be done to ensure that the programmes in place are comprehensive, meet the needs of  all  learners and can be sustained. Many children are still missing out, especially in the poorest countries and most marginalized communities.

While the multisectoral nature of school health and nutrition is a strength, it can also lead to diffused action and scattered interventions. More attention needs to be paid to the quality of progammes, the synergies with existing efforts and the monitoring and evaluating of actions’ delivery and impact.

As the world is facing a global food crisis and struggling with the devastating effects of the COVID-19 pandemic, school health and nutrition must be integral to the daily mission of education systems across the globe.

What can we do about it?

To transform education and the lives of children and adolescents, this publication urges governments and development partners to put learners’ health and well-being at the core of the education agenda and to improve the quality and reach of school health and nutrition programmes.

We need comprehensive policies and programmes that address  all  learners’ needs holistically, are relevant and responsive to contexts and evolving needs, coordinated across sectors and sustained by increased policy and financial commitments.

There are many ways in which schools can promote physical and mental health and well-being. This starts by including health and well-being in curriculum, providing nutritious school meals and ensuring access to health services. It also means ensuring that school environments are free from violence and conducive to good health, nutrition, development and learning. Greater efforts to engage learners and communities and to ensure school staff and teachers have the necessary knowledge, tools and support are also needed.

School health and nutrition actions are a cost-effective investment. They can help reach marginalized learners and advance inclusion and equity, while benefitting multiple sectors including education, health, social protection and agriculture.

How does UNESCO work to advance school health and nutrition?

At UNESCO, school health and nutrition are core parts of its education mandate. We know that children and youth learn better when they are happy, healthy and thriving in school. This means that their learning environment must feel safe, offer healthy meals and promote physical and mental health.

Guided by its  Strategy on education for health and well-being , UNESCO offers technical advice and resources, and fosters resilient and health-promoting education systems. The  Global Standards for Health-Promoting Schools  by UNESCO and WHO, for example, supports countries to adopt and institutionalize a holistic approach that promotes the physical and mental health and well-being of all learners.

The COVID-19 pandemic has demonstrated the interlinkages between education and health and the urgent need to work together across sectors. This is especially the case around the mental health of learners post-COVID. In Chile for example, UNESCO provided technical advice to the  Seamos Comunidad  programme which addresses the effects of the pandemic through a focus on improved relations and infrastructures, and better mental health and learning in school.

Through its work with governments, partners and civil society, UNESCO seeks to create and support education and school systems that foster a safe and healthy learning environment, enabling learners to thrive and get the most benefits out of their education. A series of guidance and tools were produced by UNESCO to help countries respond to  school violence and bullying ,  school-related gender-based violence , and other forms of violence in and around school.

School health and nutrition for every learner

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• Download  the global report  and the  highlights  from the report
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Please note you do not have access to teaching notes, school-based nutrition education: features and challenges for success.

Nutrition & Food Science

ISSN : 0034-6659

Article publication date: 10 November 2014

The aim of this review is to critically assess published articles on school-based nutrition education (NE) intervention to identify factors hindering or contributing to the success of interventions. School-based NE possesses the capacity to influence learners’ nutrition behaviours.

Design/methodology/approach

An electronic search of articles was conducted in Medline, PubMed, the Cumulative Index to Nursing and Allied Health Literature databases, Google and snowballing. Included in the review were school-based studies with classroom NE with or without nutrition services and studies published between 2000 and 2013. School-based non-intervention studies and interventions that did not include a nutrition teaching component were excluded in the review.

Thirty-nine studies met the inclusion criteria. Features of successful NE interventions included the use of behavioural theories, especially the social cognitive theory and the involvement of trained teachers in the implementation of interventions. Capacity development for teachers, time constraints, school policies and implementation problems of multicomponent interventions were some of the identified challenges encountered in the studies reviewed.

Originality/value

Trained teachers are invaluable assets in interventions to improve nutrition behaviours of learners. Challenges associated with teacher-oriented school-based NE intervention can be overcome by properly designed and implemented interventions based on behavioural theory.

• School-based
• Nutrition education
• Nutrition behaviours

Acknowledgements

The authors acknowledge financial support from the Institute for Food, Nutrition and Well-being (IFNuW) of the University of Pretoria.

Kupolati, M.D. , MacIntyre, U.E. and Gericke, G.J. (2014), "School-based nutrition education: features and challenges for success", Nutrition & Food Science , Vol. 44 No. 6, pp. 520-535. https://doi.org/10.1108/NFS-01-2014-0001

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Copyright © 2014, Emerald Group Publishing Limited

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The internet and nutrition education: challenges and opportunities

• A Oenema 1 ,
• W Kroeze 1 &

European Journal of Clinical Nutrition volume  59 ,  pages S130–S139 ( 2005 ) Cite this article

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To review the possibilities of using the Internet and especially the World Wide Web (WWW) in nutrition education.

A healthy existence is partly dependent on dietary behaviours. One way to promote health-promoting dietary habits is nutrition education. In the last decades several potentially important new channels for health communication and nutrition education have emerged, with the Internet and its WWW as the most striking example. The introduction and growth of the WWW has enabled swift and inexpensive distribution of nutrition education expertise and materials. Furthermore, the WWW has also been used for tailoring nutrition education to the personal characteristics of the user. Only few studies have investigated the effects of generic web-based nutrition education, while web-based computer-tailored nutrition education has been studied in randomised controlled trials, with promising but mixed results. Two important challenges for web-based nutrition education interventions are to realise sufficient exposure and to ensure sufficient source reliability and credibility.

Conclusions:

Next to the great opportunities, there are many challenges for web-based nutrition education. Some evidence for effects of web-based computer-tailored nutrition education has been reported, but more research is needed to obtain evidence for the effectiveness in real-life situations.

Sponsorship:

The contribution of WK was made possible by a grant from ZonMw, The Netherlands Organisation for Health Research and Development; the contribution of AO was made possible by a grant from the Netherlands Heart Foundation.

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Contributors : JB coordinated the writing of the paper and wrote the first draft. AO, WK and HR all provided comments on this first draft. AO wrote the paragraph on the effectiveness of web-based nutrition education. WK especially contributed to the paragraphs on tailored nutrition education. HR contributed especially to the paragraph on on-line research.

Discussion after Brug

Becker : Thinking about my role as a GP with my patients, I completely agree how ineffective we are, we try to give people information, but we know that they forget most of what we tell them even before they leave. It is a very inefficient way of doing the things that you can do very efficiently. However, at the same time your previous slide of all the gaps and the things that you want to be able to do, getting people to the website, building social support and making it an ongoing process, giving people skills, these are things that GPs can approach. There is a system; when someone calls your office they are directly appointed to your website with a task to do some of that work. Then somehow you get some feedback from what they have done so that during the visit I no longer have to rely on my instincts about their stage of change, I already assessed it. I have some information and we have a plan that we can work on. Has anybody looked at that type of plan?

Brug : I think that is a really good point, that we can try to combine the authority of the GP with the expertise that has been documented in a computer program. And indeed some of the first studies did computer tailoring with GP-offices. So people who visited the GP got the screening questionnaire, and they also got feedback that was signed by the GP; although he did not really write the feedback letter it was still under his authority. One of the things that we are now developing is computer-tailored intervention for parents of really young children who visit the baby clinic, and we encourage the parents to complete the computer tailoring; the feedback goes to their doctor, to the clinic and to themselves, and this is used as a preparation for interpersonal communication.

Helman : If we look at it in terms of input and output I think you are on the right track in terms of input. We find that the most popular thing people are looking for on the Internet is dietary analysis. People love to put in data about what they eat…. What I find a little bit striking is how primitive our outputs are….

Brug : Yes, although we have to be really careful with the output side. I was at a workshop in Boston a couple of weeks ago, that was on dialogue systems, in which they used talking animations that gave the feedback, and their research showed that the more their animation tried to look like a human the more irritating it became. There have been some good studies on what people prefer for the feedback. It was the paper and pen feedback that was preferred; the more the feedback looked like a personalized letter, with ‘Dear Hans’ above it, and signed by some kind of expert, the more the people liked it. It had more authority, the credibility was higher. One of the people in Boston told me that they did some research on what people preferred their websites to look like; they came up with a website looking very similar to the Google site, so very simple, no pop-up screens, not too many animations, but just text they can easily read. So we have to think about the output, but the more complicated and nice it looks does not mean that it is more effective.

Helman : If you assume that the output is information, it could vary. It could be a reminder, a graph and so on.

Brug : Certainly. And what you suggested, a combination with text messaging or e-mails, that is going on at the moment too, also with hand held computers and the wireless applications that we nowadays have. Part of the problem is that technology goes much faster than research. So we study things that are old, and in the meantime a lot of new applications have popped up.

Pavlekovic : My question is: I imagine myself as a layperson sitting at the computer and trying to find a reliable website. But there is a huge number of commercial ones. How can I find, in this jungle, professionally and ethically right websites. I always need some kind of advise.

Brug : How do you find the right website? In the Google search the first ten hits were one from the American Dietetic Association and eight from a university; while the tenth was from a consumer organisation. So if you do a Google search you will find more credible and reliable sources. That might help. And I think we should combine it with community-based approaches or with family-doctor-based approaches; they can refer people to go to that website. Also, the printout should be brought to the consultation so that we can discuss it together. The combination of the expertise you can put in a computer program, being the pooled expertise of many experts, much more than one GP can have, with the interaction of the GP, might be a really fruitful approach.

Helman : Can I put in a plea for Tufts Nutrition Navigator? Very reliable, very independent assessment of lay nutrition information available on the internet.

Brug : And if you do it in Dutch, and you search for ‘voeding’ and ‘gezondheid’, the Dutch words for nutrition and health, you do not get the Netherlands Bureau for Nutrition Education in the first 15 or 20 hits. They have to work on that to get there.

Reeves : GPs get money in the UK for bringing people to screening, but not a word about possible harms.

Brug : Here in The Netherlands we have a good example, about 5–10 y of focus on total fat. We needed to bring the total fat consumption down. And I must admit that I was involved in that campaign, doing at least an evaluation of the campaign. Nowadays there are data showing that the industry took it up rather nicely and took out a lot of the fat and put in other calories, and maybe saturated fat did not go down enough while unsaturated fat did; we were afraid to tell the complicated message so we talked about total fat. And now it is not really sure that the message was right. What about fruits and vegetables? Should we still promote them?

Lodge : It seems to me that this model is a build-up of useful things that we can do with the Internet, the internet being a source of health information for the public, and evidence-based health research information for the practitioners. Then the practitioners can recommend their patients to go to this website. ‘I will only talk to you for seven minutes, but go to this website, it has good information’. There is also the necessity to encourage a more informed patient base. The relationship between patient and doctors has changed, and will change further. Also because of the Internet. We have to use the Internet to reestablish a new dynamic between the patient and the practitioner. The patient should also do some homework before he comes in; then the numbers are already there. When we take on a new patient we ask their name, address, date of birth, history, telephone number, but what we should also ask them is, do you have e-mail and do you have Internet access?

Brug : I agree very much; just like we discussed yesterday, we should register their BMI as a standard procedure.

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Brug, J., Oenema, A., Kroeze, W. et al. The internet and nutrition education: challenges and opportunities. Eur J Clin Nutr 59 (Suppl 1), S130–S139 (2005). https://doi.org/10.1038/sj.ejcn.1602186

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Challenges and issues in nutrition education

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The paper takes into account problems experienced by countries affected by food insecurity and undernutrition while facing challenges of overweight, obesity and diet-related chronic diseases that can negatively affect social and economic development.

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Power imbalances and equity in the day-to-day functioning of a north plus multi-south higher education institutions partnership: a case study

• Silondile Luthuli 1 , 2 ,
• Marguerite Daniel 1 &
• J. Hope Corbin 1 , 3  

International Journal for Equity in Health volume  23 , Article number:  59 ( 2024 ) Cite this article

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Partnerships between Higher Education Institutions (HEIs) in the global north and south have commonly been used as a vehicle to drive global health research and initiatives. Among these initiatives, include health system strengthening, research capacity building, and human resource training in developing countries. However, the partnership functioning of many global north-south partnerships still carry legacies of colonialism through unrecognized behavior patterns, attitudes, and belief systems in how they function. Even with research literature calling for a shift from equality to equity in the functioning of these partnerships, many still struggle with issues of complex and unspoken power dynamics. To understand the successes and challenges of north-south partnerships, this paper explored partnership development and functioning of a northern and multi-southern HEIs partnership focused on nutrition education and research.

A qualitative research approach was used; data were collected through in-depth interviews (IDIs) with questions developed from the Bergen Model of Collective Functioning (BMCF). Thirteen IDIs were conducted with partners from all institutions including stakeholders.

The partnership was built on the foundation of experiences and lessons of a previous partnership. Partners used these experiences and lessons to devise strategies to improve partnership inputs, communication, leadership, roles and structures, and maintenance and communication tasks. However, these strategies had an impact on partnership functioning giving rise to issues of inequitable power dynamics. The northern partner had two roles: one as an equal partner and another as distributor of project funds; this caused a conflict in roles for this partner. The partners distinguished themselves according to partner resources – two partners were named implementing partners and two named supportive partners. Roles and partner resources were the greatest contributors to power imbalances and caused delays in project activities.

Using the BMCF to examine partnership dynamics illuminated that power imbalances caused a hierarchical stance in the partnership with northern partners having overall control and power of decision-making in the partnership. This could impact the effectiveness and sustainability of project in the southern institutions going forward.

Partnerships between countries in the global north and global south have been recognized as crucial and beneficial to southern countries in addressing health-related challenges and promoting global health for all [ 1 , 2 , 3 ]. Countries in the global south often face health-related challenges such as high rates of infectious diseases, non-communicable diseases, inadequate healthcare infrastructure, and limited access to healthcare services [ 4 , 5 , 6 , 7 ], leading to poor health indicators and outcomes. Many of these health challenges can be argued to be products of systematic deprivation through colonialism and unfavorable economic policies and programs at the country level [ 8 ].

Partnerships with governments and health and education institutions in High-Income Countries (HICs) have assisted low-middle-income countries (LMICs) in combating health-related challenges and developing relevant interventions and policies for health [ 9 , 10 , 11 , 12 ]. Moreover, partnerships between Higher Education Institutions (HEIs) in the global north and global south have commonly been used as a vehicle to drive global health initiatives and research between HICs and LMICs. These partnerships are often focused on health systems strengthening, research capacity building, and human resource training to improve health through human resources [ 9 , 13 , 14 , 15 , 16 , 17 , 18 ]. However, Khan et al. [ 19 ] and Whitehead et al. [ 20 ] argue that many of the north-south partnerships still carry legacies of colonialism through unrecognized behavior patterns, attitudes, and belief systems that are adopted by these partnerships.

The success of north-south partnerships between HEIs for Global health and health research in achieving their outcomes has been documented [ 21 , 22 , 23 , 24 ] but literature reports on the operation and functioning of these partnerships are scarce [ 25 ]. Key characteristics of the success of global health partnerships include a common understanding of vision and mission, mutual respect and benefits, trust, good communication, and clear partner role distribution and expectations [ 21 , 26 ]. Even with these key characteristics in place, many global health partnerships still face challenges with power dynamics and these are often rooted in colonial legacies that perpetuate the paternalistic approach of HICs on LMICs [ 1 , 27 , 28 , 29 ].

Crane [ 1 ] and Geissler [ 27 ] further mention that the conceptualization of global health exacerbates power dynamics because it often pairs countries that are unequal to improve or promote health. Over the years there has been a shift toward equity in global health research between HICs and LMICs [ 30 , 31 , 32 , 33 ], with researchers recognizing that inequalities do exist in global health partnerships but strategies need to be implemented to mitigate power dynamics. Key areas of improvement to flatten power dynamics include recognizing ethical issues within partnership functioning [ 32 ], research should focus on local health priorities [ 34 , 35 , 36 ], acknowledge capacities and limitations to contribution in partnership [ 32 ], recognize different skill sets, training background, resources, and funding [ 32 , 37 ], recognize local expertise [ 38 ], build trust between funders and southern partners [ 32 , 36 ], and transparent communication from beginning of partnership [ 39 ]. Even with these key strategies to flatten power dynamics in partnerships, and characteristics of successful partnerships mentioned above, many global health partnerships between HICs and LMICs still experience challenging power dynamics, therefore, more research is needed to understand the functioning of north-south partnerships between HEIs, perhaps from the standpoint of day-to-day operation of these partnerships.

Having identified issues raised in the literature, a case study using categories from the Bergen Model of Collaborative Functioning (BMCF) will be helpful to trace the pathway to understand partnership successes and negative processes that impact partnership functioning. The BMCF framework has been used in some global health partnerships with power dynamics rising as key issues [ 39 , 40 , 41 ]. However, literature that focuses on the day-to-day functioning of these partnerships is scarce. This paper describes a study investigating the partnership development and functioning of a northern and multi-southern partnership focused on nutrition education and research by exploring how different partners understood and contributed to: (1) mission, partner resources, and financial resources (2) Leadership and roles and structures (3) input interaction and communication (4) production and maintenance tasks.

PROJECT-2 is a North-multi-South partnership between Higher Education Institutions (HEIs) focused on nutrition education, research, and capacity building. Four institutions are collaborating on PROJECT-2. The partners comprise ‘supporting’ partners – Northern partner (N1) Footnote 1 and one Southern partner (S1) – and ‘implementing’ partners – the remaining Southern partners (S2 & S3). The terms ‘supporting’ and ‘implementing’ were informally developed by the partners based on how they perceived their roles in the partnership. PROJECT-2 is an extension of a former project, PROJECT-1, with a new partner (S3) joining the partnership. The project is funded by a Northern government funding agency referred to as FUNDER in the paper. The aim of FUNDER agency is to support projects that promote global development, green living, and ending world poverty. Much like the project, the funding agency has funding programs – FUNDING-1 refers to funding for previous partnership, and FUNDING-2 funding for the new project, PROJECT-2. The FUNDING program aims to strengthen the capacity of higher education institution in developing countries to produce higher-quality graduates, higher-quality research, and inclusive higher education. According to FUNDING, the projects must be based on partner institutions’ identified needs and contextual needs.

PROJECT-2 is built upon learnings and experiences from PROJECT-1. The main aim of the partnership is to address the shortage of research capacity to inform the development of locally relevant evidence-based policies in two low-income countries (where S2 and S3 are based), using nutrition as the vehicle for capacity building. The objectives of the partnership are (1) to develop and implement a master’s and PhD Nutrition program (2) to establish research capacity building (3) to inform the development of locally relevant nutrition policies. The countries S2 and S3 were chosen as research sites because they were among countries on the FUNDING-2 list as potential collaborating countries according to FUNDER country’s development policy and they presented poor nutrition health indicators. At the core of PROJECT-2 was to build a partnership that was mutually beneficial to all partners and founded upon the health and nutrition needs of S2 and S3 at the forefront of the partnership.

Conceptual framework

The study used the Bergen Model of Collaborative Functioning (BMCF). Most details about the model were drawn from Corbin and Mittlemark [ 42 ] and used as a reference in this section. The systems model provides an input-throughput-output analytical frame to examine partnerships. The inputs and throughputs interact and function together to produce outputs that feedback to the partnership positively or negatively, all of this happens within a context (Fig.  1 ). The inputs to the partnership are the mission, partner resources, and financial resources. The mission is the vision and objectives of the partnership in how the project will function. Partner resources refer to the skills, knowledge, commitment, connections, and other attributes that humans contribute to the partnership. Financial resources are all the monetary and material investments in the partnership.

The bergen model of collaborative functioning [ 44 ]

The throughput is the collaborative context, the inputs enter the context and interact positively or negatively with elements in the collaborative context as they work on the production tasks (related to the mission) and the maintenance tasks (related to administrative duties). There are four elements within the collaborative context – input interaction, leadership, roles/structure, and communication. These elements create dynamics and reinforce cycles within the collaborative context through their interactions.

The outputs of the collaborative context may be additive, synergy or antagony. Synergy is the intended product of partnership, all the partners bring resources, skills, etc. to bring forth a product bigger than their individual effort. Antagony is not only the failure to reach synergy in the partnership but also the wasting of partner and financial resources so that more is consumed in the partnership process than produced in the partnership. Antagony is any tension in the interaction between collaborative partners that causes interferences, tension, and counter-productivity [ 43 ].

The model was appropriate for the current study because it allowed the researchers to explore various aspects and characteristics of the PROJECT-2 partnership. The model has also been successfully used in many health research partnerships with countries in the global north and south [ 39 , 40 , 41 , 43 , 44 ]. In this paper, only the input and throughput sections of the model were used during the analysis of the data.

A qualitative research approach using in-depth interviews (IDIs) was used in the study to explore the partners’ understanding of the mission and the functioning of the PROJECT-2 partnership. Interviews were conducted with partners and stakeholders involved in the project.

Participants and recruitment

The study population included participants from all the partner institutions and stakeholders from the relevant Government Departments in the research site countries. Participants included Principal Investigators (PIs), administrators, professors, researchers, PhD candidates, and representatives at country level in research site. A purposive sampling strategy was employed in which participants were selected based on their expertise on the subject matter [ 45 ]. Using purposive sampling enabled the researcher to select participants who had extensive knowledge and experience of the project – this was determined by the participants’ involvement in the following project activities: (1) involvement in proposal development (2) engaged in daily activities of the project at individual institution (3) Attending monthly and annual partner meetings, and (4) administrative duties of the project. Recruitment began with the first author attending all the partner virtual monthly meetings to take note of key members from each institution and their involvement in the project. The first author was part of the list of people attending project activities, this included the first annual in-person workshop with the partners. In the annual meeting, the first author introduced the study and invited all participants to participate. Partner representatives who did not attend any monthly meetings or the physical annual meetings were excluded from the study.

Data collection

Semi-structured IDIs were conducted with participants over a period of five months, between February and June 2022. A total of 13 interviews were conducted by the first author. These were three IDIs with members from N1 institution, three IDIs with members from S1, three IDIs with members from S2 and three IDIs with members from S3, and one stakeholder representing country level department in S3. One partner representative was unavailable for an interview and was therefore excluded from the study. An interview guide was developed using the BMCF model to structure topics to be included in the interviews. Topics included in the guide were the partners’ understanding of the mission, contribution of each institution to the partnership, project funding, distribution of roles, views on project leadership, and expected outcomes from the project. Seven interviews were conducted in-person, of these five were done during the partner’s annual meeting. Five interviews were conducted virtually using ZOOM, and one participant requested to provide written answers to interview questions due to the language barrier. All interviews were done in English language.

Data analysis

All interviews were either audio or digitally recorded, using audio recording device for in-person interviews and digital recording through Zoom during virtual interviews. The interviews were 13 to 64 min long. Interviews were transcribed verbatim using a transcribing software Amberscript and Zoom transcribing. All interviews were quality checked by the first author to ensure that everything was accurately captured during transcribing process. The first author listened to audios and read transcripts and made necessary corrections. Analysis was conducted by the first and second authors. The steps of thematic network analysis were followed to analyze the data [ 46 ] and NVIVO v12 was used to manage the data. A hybrid approach, using both inductive and deductive approaches, was employed to guide the analysis process. The inductive approach was used in the initial stages of coding and analysis, followed by deductive approach during the process of developing organizing and global themes (see Table  1 ). The authors (SL, MD) read all the transcripts to familiarize themselves with the data and met frequently virtually and physically to discuss coding process, develop codebook, and themes coming from the data. The final global themes that emerged are structured according to the BMCF model: context, input, and throughput.

Ethical considerations

This study’s data management plan was approved by the [name of institution] for Research Data. Signed informed consent was obtained from all participants before each interview and all identifying information was removed to ensure confidentiality.

The findings are presented according to the structure of BMCF. Elements of the model used are context, inputs, and throughputs which became the global themes of the findings with basic and organizing themes reflecting the initial experiences of participants in developing and establishing the partnership.

Partnership background

Building from project-1:.

coming to the new partnership, the participants expressed that PROJECT-2 is founded on experiences and relationships, achievements, and challenges learned from PROJECT-1. This had an influence on changes that were planned for this second round of the project. Participants presented mixed views about their experiences of being involved in PROJECT-1. Some participants commented on the functioning of the first project and how that might impact the new partnership. Mentioning that “ what is good, is that most of the partners are the ones that were involved in PROJECT-1. So we already know each other and I know how we work, I know we had no problem like collaborating” (Participant 7, IP Footnote 2 ). Another participant mentioned the operation of the first project being poorly managed, commenting specifically that:

a lot of things in PROJECT-1 were done on a fairly ad hoc basis… we had meetings here and there quite often, but people didn’t always turn up… It was… sort of normalized that if you have something else to do, then you would not go to the PROJECT meeting (Participant 8, SP).

In some cases, the outcomes of the first project were perceived to have benefited one partner more than others in the whole project.

… S2 received an extension budget to develop a e-Learning system. And we did just before Covid pandemic and the system helped the school to continue with delivering teaching and courses remotely (Participant 10, IP).

PROJECT-1 achieved several other positive outcomes, for example “… they managed to kind of get out with 40 out of the 41 students that got their masters in the partnership… there will be four PhD candidates also” (Participant 3, SP). The participant also commented on the good relationships between the partners on which the second project was built. However, the participants also expressed that there were numerous challenges that affected the functioning of PROJECT-1. These included issues with security in Country S2 “ … where it was not possible to travel because of conflict” (Participant 3, SP) , language barriers which had an impact on communication between partners and students, communication with the funders, and relationships with institutional boards.

Language as barrier to communication:

PROJECT-1 was operated in English, which meant all communication between partners, and students was done in English. However, there were misunderstandings between partners, students, and institutional boards about the requirements of the project and that of the institution for academic programs. As a requirement of the project, the students had to write and defend their theses in English to pass the program. However, S2 institution only accepted work done in French. “ We learnt that in PROJECT-1, we forced the students to write their thesis in English, and just yesterday we learnt that many of those theses were back translated into French and defended in French” (Participant 3, SP). The participant went on to explain that had the country steering committee told them at that time, they could have come up with alternative solutions. Communication between funders and institution in Country S2 was another challenge expressed by one of the participants. The institution in Country S2 experienced issues with reports to funders that were embedded in language barrier between the partners.

“ … since our accountant, is not that strong in the English, it was a bit complicated and we had to write rewrites [of reports]… we had some troubles like spending some of the money that we requested” (Participant 7, IP).

Going into PROJECT-2 partnership, there were changes implemented by the funders and by partners . The funders made the northern partners in charge of distribution of funds to the other partners and the coordination of the overall project.

Before in PROJECT-1, they gave the responsibility to each south partner, but now they have given it to the N1 partner to coordinate everything that happens in the project when it comes to administration, like the money transfer and all of these things (Participant 1, SP).

Some of the participants found the change implemented by the funders frustrating because they introduced uncertainties and delays with project activities “ … instead of us as project, me as project manager relating to FUNDER directly, we have to now go through the N1 Secretariat. And they have a quite unclear role… but we know we have to wait” (Participant 3, SP).

Another change implemented in the project is the exchange of students from the northern partners to the southern partner institutions; whereas previously only southern partner students had opportunity of attending courses in northern institution. Participant 3, SP explained the introduction of a new practice:

“ … a set of N1 students will come and join students in Country S3 and Country S2 to see what learning opportunities are there from that process, it will be quite interesting” .

Expanding structure:

the partnership brought changes in the form of a new partner joining the project. The participants mentioned that “ … bringing in [a] new partner has strengthened the program…” (Participant 3, SP). The participant went on to say “ … the new partner has shown to be, I think, very strong and fitted extremely well into the program and taking responsibility and has been a very positive addition to the program”. Bringing in a new partner has also brought a sense of commitment from the old partners.

“ And as I see the old participants who have been working, they are committed. Each site wants to make sure that they attain their goals” (Participant 4, IP).

Involving stakeholders in the partnership activities was an important aspect of expanding the structure and developing context-relevant research agenda, focused on the health priorities of the southern partners. The partners were in communication with representatives from various departments at country level to get support and a list of research priorities in the research site countries.

The stakeholder in one of the sites went on to say that they will be working closely with the institution as research hub to provide access to data that students can use in their studies.

I have research ongoing, I have platforms that can give access to data via other government sources and… they can access the information they need for their research projects (Participant 12, IP).

Going into PROJECT-2, the context (background of PROJECT-1) became the foundation of the collaborative context for PROJECT-2. The partners made changes and developed strategies to mitigate the challenges that were previously experienced. The program was set to continue to operate in English with planned strategies to enhance communication and engagements between students and partners.

Inputs emerged as a global theme that was pivotal in the development and functioning of PROJECT-2 partnership.

Understanding the mission of the project:

the participants had different understandings about the mission of the project. For the majority of the participants, the mission of the project was related to developing human resources and building strong collaborations between countries. As highlighted by one participant who mentioned that PROJECT-2 mission is similar to PROJECT-1 mission, and stated that the mission is.

… to establish a strong collaboration for improving nutritional epidemiology, research and education in nutritional epidemiology in Country S2 and Country S3… so improving nutritional epidemiology research and education in both countries (Participant 10, IP).

For another participant, the mission of the project was to establish a master’s and PhD program in nutrition research in Country S2 and Country S3.

And I think, looking back to the kind of call from the donors, it’s that building, that the higher education, which is the main objective of, of FUNDING. And by that I think we have succeeded in PROJECT-1, and the hope that we can succeed in PROJECT-2 in kind of building this master, and PhD capacity (Participant 3, SP).

The participant continued, highlighting the importance of research, “ where the big challenges is on the research,… because you can’t have research-based master’s program and PhD programs without having a good research project”.

In contrast, some participants had uncertainties about what is the mission of the project. Participant 8 (SP), mentioned she could not remember what the mission was about “ … participatory research and education to develop to develop skills, something like that was what we wrote… but I think it’s empowering”. Whereas, participant 5 (IP), was convinced that the project “ … does not have the mission yet. We have objectives… to address the human resource shortages… creating evidence that can also support the challenges of nutrition related conditions”.

Vision of the project:

the participants also expressed different views about the vision of the project. One of the participants explained the vision of the project is working together towards a common goal and working well together based on relationships built in the previous project.

… we all want the project to do well, and that we all do have a fairly common vision into as to where we’re going and that we’ve worked together for all this time, not Country S3, but the other people without any conflict, really (Participant 8, SP).

Another participant, expressed that like the mission, the vision is not yet set (Participant 5, IP).

Institution gains from the project:

when asked about the gains of each institution in the project, the participants found it easy to articulate the gains of the two southern partners where the project will be implemented but difficult to describe the institution gains of the northern partner and the other southern partner. By the end of the project the partners in institution S2 and institution S3 would have gained master’s and PhD graduates in the field of nutrition, an opportunity for staff and students to develop careers and broaden horizons, facilitation and teaching skills, distance learning skills and materials, and sound research. The stakeholder in one institution made it clear that the government department at the country level will also benefit from the project in different ways.

… my gains are two-fold… I do have a lot of data, some are redundant, that are sitting here, then that would benefit a lot from having somebody manipulate, model, and give us more information on it, so that’s one. I will have hands on local information on what is happening on the ground in terms of nutrition (Participant 12, IP).

The participant went on to say that once the project starts producing graduates there will be “… a bigger pool of employees who are competent in manipulating and analyzing and even collecting data but more importantly, conceptualizing the design of different research projects”.

For partners in Country N1 and Country S1, the institution gains were unclear. One participant mentioned that there is nothing that the N1 partners are expecting to gain in the project, he explained that working in north-south partnerships “… is our mission. So, if we are able to complete our mission to train staff members in lower-middle-income countries, we are just happy” (Participant 2, SP). The participant expanded to say that the institution gains of the Country S1 partner “ … will be expanding the horizons of the Centre, knowing more about Africa outside Country S1”.

Expected outputs:

the participants were asked about their expectations in working on the project to understand the outputs. Much like institution gains, some partners were expecting to get graduates and researchers in nutrition research by the end of the project. Other outputs mentioned by the participants are divided into short-term and long-term outputs. For short-term outputs, participants mentioned getting started with the program in Country S3, the partners being focused, structured, and output orientated, large research studies for students, and getting students’ research proposals in good English and through N1 ethics processes. The students in S2 and S3 institutions had to submit their research proposals for ethical approval to northern institution as part of their PROJECT-2 requirement.

The participants in institution S2 also mentioned that there were changes in the curriculum due to a new teaching strategy that was implemented by the institution. As an outcome, the participants, are anticipating a smooth transition that will honor expectations from both project partners and institution. Long-term, the participants mentioned that they expect to see research publications coming from the project, more partnerships and other funding opportunities, and improvement in nutrition and food indicators in both research site countries.

Personal learning and goals:

the participants were asked what they would hope to have personally gained by the end of the project. These included improving language communication, new skills in financial management and administration, writing skills, communication skills, use of technology for blended learning, online teaching and assessment skills, development of online/distance learning courses skills, research skills, teaching skills, staff development, and opportunities to exploring other cultures. A common skill mentioned by the partners was the management skill in relation to leading organisations and multinational projects.

Partner resources

The participants distinguished themselves according to implementing partners and supporting partners in the project. These labels are according to the role distribution and resources that each institution is bringing into the partnership. The supporting partners, Country N1, they are “… the one who like funds the project… they also have this rich contribution on the management of the whole project” (Participant 10, IP) and also provide support in supervision, teaching, and research. The institution in Country S1 team brings skills related to training and research to the partnership.

I think the Country S1 team brings with it, strength in the development of training materials and development of research proposals, development of tools, and those kind of aspects within the research (Participant 11, SP).

With the implementing partners, the resources they bring to the partnership were related to skills in teaching and curriculum development of the program. “ I understand that the [role] of S3 and S2 will be more into the teaching of the curriculum that we have developed” (Participant 6, IP).

Financial resources

Funders and funding:.

with the changes introduced by the funders in PROJECT-2, this presented mixed views from the participants. For the northern partners, this was an added administrative duty that caused frustration and delays in the progress of project activities for all the institutions.

… because FUNDER… have changed the way they organize the structure… there was more than half a year delay because of the contractor issues… and think it will maybe take even maybe half a year or a year to have a full circle in (Participant 1, SP).

The collaborative context (throughput)

Input interaction.

In the study, this was understood as the participants’ understanding of their own personal contribution and the different institutions’ contribution in fulfilling the mission . Many of the participants made a link between the roles they play in the partnership as a key contribution they are making in fulfilling the mission of partnership. One participant felt his role in the partnership was not clear and was not sure how he will individually contribute to fulfil the partnership mission.

When describing the contributions of each partner institution to the mission of the partnership, the participants had clear understandings of what the supporting partners were contributing. For example, this particular participant explained that N1 institution’s contribution to the partnership was “… to improve the opportunities for training and pushing the knowledge agenda forward in Country S3 and… Country S2” (Participant 2, SP). Other participants had a clear understanding that S1 was contributing through providing research skills, training, teaching, and supervision; as highlighted in the resources sub-theme.

The participants were not so clear in describing the role of the implementing institutions in fulfilling the partnership mission. The implementing partners themselves and some other partners kept referring to the roles of teaching and supervision as key contributions to the fulfilment of mission.

The supporting partners often had comparative and competitive descriptions of the individual contributions of the implementing institutions, as seen in the leadership theme. Participant two in particular, felt that one specific partner was not contributing much resources into the partnership but needed the most support to fulfil mission in institution, see below.

… with Country S2, I think it will be like the small brother in the group, who is contributing the least, and needs the most guidance, and the local issues I talked about earlier is, adding to this… (Participant 2, SP).

Production and maintenance tasks

Even though the main focus of the paper/data collection was to understand the initial stages of partnership development and implementation, however, the partners did have plans and activities for production and maintenance tasks. In this section, we present findings of how different activities had a positive and negative interaction with each other during the early stages of partnership development and implementation.

Production tasks

Production tasks include activities that are undertaken for the purpose of achieving the mission in a partnership. Two characteristics (roles and leadership) are important in understanding how production tasks are conducted to produce the intended outcomes in the partnership.

Roles and responsibilities:

All the partners were aware of the various roles that they individually play in the partnership and there was an awareness of the various roles and responsibilities that institutions play in fulfilling the mission of the project. One of the partners highlighted that there was a fair distribution of responsibilities with regard to project activities, this helped “… everyone know what is expected of them” (Participant 7, IP). The roles mentioned by participants include administrative and financial management roles, project manager/coordinator, principal investigators in each site responsible for overseeing the implementation of objectives and research activities in institutions, being a teacher and co-supervisor in the project, coordinating the development of curriculum in the institution, being a stakeholder and research hub, and being PhD candidates in the project. One of the participants expressed that coming from a northern partner, their role was conflicting because the partnership is structured to be equal “ … where we are on the very egalitarian basis, but in the same time, the N1 plays a role as a controller of the others, because we are the ones that are report to the donors” (Participant 3, SP) , they felt that they have more power to control roles and responsibilities in the partnership.

Leadership:

the partnership has leaders in each institution but there is also an overall leader/manager in the project, the PI from Country N1. The project manager’s role in the partnership is to organize partner meetings (virtual and physical), facilitate the meetings, take notes during meetings, and liaise with the funders. When asked about leadership style in the partnership, some of the partners expressed that leadership is good, encourages shared decision-making among partners, there is openness to share the leadership role, and the project manager does “ … not try to control the way things are going and gives everybody the floor and let everybody speak…” (Participant 8, SP) , and this was perceived as a good model of leadership and an improved leadership style from the previous, PROJECT-1 partnership, leaning towards a more collaborative orientated project.

However, some of the N1 partners were concerned about the power dynamics in the partnership. They felt the northern side of the partnership was “… imposing a lot of things on the partners…” (Participant 1, SP) because of their dual role and multiple responsibilities in the partnership. The northern partners felt that some of these responsibilities needed to be shared among partners in order to flatten out the power dynamics. One of the participants explained that a platform to share some of the project administrative duties with the project manager was opened in the first partner meeting but none of the other partners took up the offer.

When describing the leadership in the implementing institutions , the partners often compared the leadership styles of these two leaders in implementing institutions. The participants spoke of one leader as driven, clearly understanding the mission, committed, wanting to build a future and career, and bringing wealth of knowledge and experience to the partnership. Whereas, when speaking about leadership in the other institution, some participants alluded to underlying issues in leadership that affect the functioning of project in that institution.

Teaching and supervision tasks:

one of the main production tasks in PROJECT-2 was the development and implementation of the nutrition research program (curriculum) in S3 institution and continued support at S2 institution. Other teaching and supervision tasks in the partnership included finding strategies for blended learning in the implementation institutions.

In PROJECT-1 we had made the recommendation that we move to mixed methods teaching platform, where one would not teach only face-to-face… but rather use multiple methodologies for teaching and I think that from the workshop its very clear that that’s the way they want to go (Participant 11, SP).

Research tasks:

building a research agenda that addresses nutrition priorities and policy at country level was important for the project. Research studies that would be conducted by the students in the project had to link to country priorities, and this was done through working in collaboration with government departments in each implementing country and they provided a list of research priorities in nutrition for the country. Ensuring that research studies conducted in the project address policy change and the need for evidence for interventions or publication in the implementing countries was important for the partners. As highlighted by participant 5 who explained that project would be.

… generating evidence that can address the dearth of evidence, in these countries for policymaking processes to address the nutrition challenges, and together we can also address issues with regard to health and welfare of the society (Participant 5, IP).

However, in developing plans and strategies about the research agenda, the partners had agreed that having “ … bigger research projects that involve both master’s students and PhD students around a few projects… instead of… very small studies” (Participant 3, SP) would work best for the project. This would allow the partners and project at large to get an in-depth understanding of the topic under investigation.

Maintenance tasks

Maintenance tasks are activities that keep the partnership functioning, these include administration duties, meetings, grant writing, and writing reports. Communication is an important characteristic of maintenance tasks. Maintenance tasks do not affect the mission of the project directly but play a significant supportive role in its achievement.

Team meetings:

the partners had regular virtual meetings to discuss project progress in each site and updates on project activities. As highlighted by Participant 4, who mentioned that the meetings were important in getting an understanding of activities they have to do as an institution and “… reporting what we have been doing and what has been done and what needs to be done”. The partners had their first in-person meeting/workshop and this provided partners an opportunity to engage with one another better. The workshop also provided partners “… clarity in terms of what are the expectations from the project” (Participant 5, IP). During discussions in the workshop, a decision was made that principal investigators (PIs) from all the institutions should have their own meetings to discuss “ … issues that need to be really interrogated that not everybody is agreeing with or if there is issues where one partner is lagging a bit behind…” (Participant 11, SP).

Admin tasks:

the partners had to prepare budgets and reports for the funders about the first period of the project. One of the partners had delayed submitting the budget because they were unaware of the procedures. This particular partner explained that being part of the monthly meetings assisted in getting clarity about what is expected of them during reporting.

I had some delays in submitting reports… but from being a member of those meetings, then I was becoming aware that I was supposed to do this and this… there is a budget, but we were required to prepare some six-month budgets for supporting some of the activities that are being done (Participant 4, SP).

The same participant continued to express dissatisfaction about how administrators in the partnership have limited chance to interact amongst each other and learn from one another. The participant suggested that administrators should have their own workshops or maybe zoom meetings where they can learn from each other.

New administrative role in northern institution:

the overall administrative role and management of the project were operated by the northern partner and this caused frustration in the N1 partners because there was a lack of clarity of what is expected of them from the funders and there was concern that the role adds another dimension in the power dynamics. There was also concern that the shift in financial management duties may limit opportunities for capacity building for the south partners. Participant 3 (SP) explained that FUNDING-1 experienced numerous admin challenges in the previous project which led to moving all project management duties to northern partners. However, the shift in administrative duties was welcomed with gladness for one of the south partners because this meant they do not have to interact directly with the funders. This made their work easy as they were often unfamiliar with funder’s procedures of reporting.

We were like directly responsible over all the things are related to financing, with FUNDER. But now we have to pass through the N1 [institution] which is a very good like way of doing things because actually, they are more accustomed to working with FUNDER agency and it makes things very easy for us (Participant 7, IP).

Practical and contextual challenges in communication:

in the first year of PROJECT-2, the partners communicated mostly virtually through emails and Zoom meetings due to travel restrictions caused by COVID-19 pandemic. During that time, the partners were writing a funding proposal virtually and a lot of challenges related to communication were experience; some of these issues transferred to physical communication when the partners eventually met. There were concerns about misunderstandings when everything was done via text or zoom in a partnership and also there was often confusion on who was to be invited into zoom meetings. Some partners felt that communication was clear and structured with everyone knowing what is expected of them in the partnership. Other partners expressed a view that more physical meetings would strengthen relationships in the partnership and perhaps smaller groups within the partnership would be beneficial for better communication and shared experiences among different roles in the partnership. Participant 1 (SP) highlighted that perhaps it would be better “ … to arrange in these workshops to get more in smaller groups that is maybe easier to talk and to communicate and share experiences when you’re in that small group” and separate these groups according to different roles in the partnership.

Culture and language were also an added layer of dynamics in the partnership that had an impact on communication. The partners come from diverse cultural backgrounds and speak different languages, an incident that happened during the first partner meeting brought awareness to the partners on the need to be considerate and respectful of different cultural contexts in the partnership. In this incident, one partner spoke harshly to another partner during a team meeting sending waves of shock among partners.

I think it… speaks to a lack of understanding of culture and norms. And I think that working in a diverse cultural background, diversity of cultural backgrounds, we need to be mindful (Participant 11, SP).

Using the Bergen Model of Collaborative Functioning (BMCF), this paper explored partnership development and functioning of PROJECT-2 as well as partners’ understanding and experiences of partnership. In this study, we found that PROJECT-2 was built on an existing partnership among the majority of the participants plus one new partner. Many of the participants alluded to the previous partnership experiences, PROJECT-1, having a significant impact on the establishment and overall functioning of the current partnership. These experiences were both positive and negative during PROJECT-1. Negative experiences in PROJECT-1 included poor management of the project, skewed benefit ratio between the partners, and poor communication between partners, funders, and institutions. These became the backbone of key changes intended in PROJECT-2, including the expansion of the nutrition program by introducing a new partner and involving stakeholders to influence the development of a context-relevant research agenda. The positive experiences included good working relationships, successfully developing and implementing master’s and PhD programs, and producing graduates from the program.

As a way to increase the chances of success in north-south partnerships, many authors have suggested that partnerships should be anchored on a shared understanding of vision or mission, shared resources and skills, mutual benefits, and good management practices [ 47 ]. In their study, Dean et al. [ 25 ] found good working relationships from previous partnerships as a contributor to effectiveness and sustainability in north-south partnerships. Going into PROJECT-2, the participants incorporated many of the experiences and lessons learned from PROJECT-1 into establishing PROJECT-2, including some of the characteristics highlighted by Buse and Tanaka [ 47 ] and Dean et al. [ 25 ], it seemed the partners understood and recognized their strengths and weaknesses going into PROJECT-2 and planned strategies to improve the functioning of the partnership.

Mission for sustainability – a house divided cannot stand

The establishment of a clear mission and vision for partnership is important not only for role and resource distribution but also has an impact on the sustainability of projects even long after funding has ceased. An understanding of the purpose of coming together into partnership with end goals clearly understood by all partners involved is key. This includes the alignment of project mission to that of institution for sustainability. John, Ayodo, and Musoke [ 21 ] also included the same moral values as an important characteristic to effective global partnerships, this promotes trust among the partners. Even though the partners understood the importance of establishing a vision and mission for the effectiveness of the partnership prior to establishing PROJECT-2, during the interviews the participants struggled to articulate a collective understanding of the vision and mission of the partnership. The participants were pulling apart different aspects of the project objectives without a clear understanding of the overall partnership aim. However, what was interesting in their definitions of partnership mission was how the partners were linking the mission to the outputs of the project, but what was missing was the partners’ understanding of project outcomes and linking those to the institution needs and mission. Using the Theory of Change (ToC) concepts to distinguish outputs and outcomes, mission connects to overall goals linked to context and is future-orientated, whereas outputs connect to shorter term goals that contribute to fulfilment of outcomes in partnership [ 48 , 49 ]. In the interviews, only one participant (Participant 10, IP) gave a definition of the mission that focused outcomes rather than outputs, moving beyond institution and partnership but also national level objectives. A clear understanding of project outcomes has an impact on sustainability which in turn influences mission and functioning of partnerships. In PROJECT-2 the partners stated that they were intentional about developing a partnership that is driven by the needs of southern partners. Working closely with stakeholders at the country level in developing a research agenda focused on nutrition priorities was a strategy implemented by the partners in ensuring sustainability of project. This also increases the chances of project impact and sustainability in the country; and long-standing challenges of global north and south partnerships [ 50 , 51 ].

Communication breakdown impacts transparency

Effective communication among the partners not only has an impact on partnership functioning but can also promote transparency in the partnership. Good work relationships established from the PROJECT-1 project were perceived as a strength to establish PROJECT-2. However, it is interesting that these good work relationships were mentioned only by the supporting partners. These perceived good work relationships should be questioned for their genuineness and relevance in PROJECT-2. The communication and working together between the partners in PROJECT-1 are seen as not transparent. When the partners in S2 institution experienced language barriers and translation issues within the institution, they did not communicate with the partners about changes implemented at the institutional level. This then undermined the view of good work relationships and brings to question what could have led S2 to implement changes in the partnership without informing the rest of the partners and funders. During the in-person meeting, an explanation was asked for and given for the changes that were implemented in S2 but the issue was not followed up post the in-person meeting to make relevant changes in the functioning of the program in S2 institution. Transparency as highlighted by Monetta et al. [ 26 ] and Nakanjako et al. [ 18 ] goes beyond financial transparency but also to challenges experienced at an institution level and the openness of partners to welcome contextual knowledge to improve partnership functioning. This means going to the root of issues at the institute level and finding contextually appropriate solutions without following stringent partnership legacies that are not beneficial to all partners.

The power of language in communication between partners is equally important in promoting respect, knowledge value, fairness, and transparency in north-south partnerships. In the interviews, one participant referred to one of the southern institutions as a “little brother” in the partnership, alluding to the partner’s contribution and distribution of resources. Using such language in north-south partnerships is paternalistic and continues the legacy of colonialism [ 52 ] and diminishes the value and knowledge value of southern partners. This could be argued to explain the reasons the southern partners did not tell the partners about changes at institution level, tied to value of partners in the partnership and knowledge value.

Unclear role distribution and resource contributions give rise to power dynamics

Role distributions and resource contributions in partnerships can be a birthplace for inequitable power dynamics if partners do not understand the inequalities that exist within them in the partnership. These can often lead to frustrations and unmet expectations – antagony in partnerships. The changes in administrative duties and communication with funders implemented in PROJECT-2 raised issues of power dynamics within the partnership functioning. This is nothing new to global health partnerships. Historically, issues of power dynamics and equality have been and continue to be an ongoing challenge of partnerships with countries in the global north and south [ 32 , 36 , 53 ]; with updates in literature calling for a shift from equality (sameness) to equity (fairness) in global north-south partnerships [ 33 ]. Although many partners in PROJECT-2 believed that there was equality in the partnership, there were concerns expressed by some participants about control and power. These were implied in control and the overall decision-making power of PROJECT-2 held by the northern partners. Even then, with these concerns of power dynamics expressed by some participants, the partners did not have any effective strategies to flatten the power dynamics. Such dynamics further raises questions on collaborations with local expertise in these partnerships, the people who have better understanding of context and who are able to make decisions aligning with true needs of southern partners.

Even though there has been a shift over the years, with developments of approaches and models for engagements in north-south partnerships, issues of inequitable power dynamics and control persist in these partnerships. These are often rooted in who has control over decision-making. In as much as the PROJECT-2 partnership approached the development of the partnership from the model that puts Southern partners at the forefront of decisions about the research agenda, the partnership was at risk of falling victim to many pitfalls of global health partnerships due to overall decision-making power held by Northern partner. There have been many approaches and models developed to improve global health partnerships over the years [ 54 , 55 ], in practice, many of these partnerships still struggle with challenges of power dynamics and these are often rooted in the mismatch in research priorities and research context, unclear role distributions, resources, communication, funding, and a lack of clear understanding of the research agenda [ 15 , 54 , 56 , 57 ]. All of these could be summed up as ‘control’ and can be attributed to the power of decision-making in many of these partnerships.

Control is further highlighted in the partnership by how the partners understand each other’s resource contributions and benefits in the project. In defining contributions and benefits, the partners created a divide in the partnership by calling themselves implementing and supporting partners. Using these labels created hierarchy in the partnership with the supporting seen as experts and the implementing seen as beneficiaries of the partnership; potentially exacerbating ‘the little brother effect’ attached to global north-south partnerships [ 33 , 52 ]. However, the focus should be shifted to understanding what are the hidden or unacknowledged benefits of the partners who are considered experts in partnerships between countries in the global north and south. In their study, Syed et al. [ 58 ] found that benefits for HICs in these partnerships included deeper contextual understanding of working in LMICs for future research and transferring research learnings and innovations to their countries. Dean et al. [ 25 ] further state that having a clear understanding of benefits for all partners is important, this has an impact on the effectiveness and sustainability of partnerships.

In PROJECT-2, the supporting partners see their main role as providing support in the partnership with minimal benefits directly linked to the partnership. This is an interesting perspective from the supporting partners whereas they view the partnership as an equal partnership. By definition, an equal partnership connotes that all partners contribute and benefit equally [ 59 ]. According to Crane [ 1 ] and Geissler [ 27 ] partnerships steered towards ‘global health’ should not be considered ‘partnerships’ or ‘collaborations’ because of their intrinsic nature of inequality. As stated above, literature has seen a shift in global health partnerships towards equity (fairness) instead of equality (sameness) emphasizing differences in contributions and benefits of partners [ 33 , 60 , 61 ]; these are fixed according to the needs of the partners.

Study limitations

Firstly, the PROJECT-2 partnership has a small membership, so maintaining anonymity and confidentiality in the data was difficult as participants knew each other very well. Anonymity also made it difficult in presenting the research findings in this paper, we could not contextualize the quotes and certain quotes had to be removed from presentation of findings to preserve anonymity and confidentiality of participants. Secondly, the researcher (SL) was well acquainted with the research participants as she worked on the PROJECT-1 and works on PROJECT-2 as a researcher. This could have caused response bias from the participants. Thirdly, language was a barrier to communicating with one participant. For this particular participant, an interview guide was sent to answer the questions. Lastly, the use of digital platforms to conduct interviews was a challenge, the internet connection was a problem at times, and getting participants available was a challenge at times.

Using the Bergen Model of Collaborative Functioning (BMCF), the study explored the development and functioning of a northern and multi-south partnership in global health. Even though the study was conducted during the initial stages of partnership development, the partners seemed to be aware of some of the underlying issues in the partnership and their potential to influence functioning. Roles and structures were experienced by the partners as possibly the main contributor to complex power dynamics. Tied to roles and structure are financial resources, partner resources, and leadership which also had an impact on distribution of roles. Lessons from the previous partnership included lack of agreement on mission and vision for the partnership, and poor communication with students, among partners, and with institutions. Even though the partners had an intention of developing vision and mission and communication strategies, these seemed to be ineffective as participants did not have a common mission and vision and the partners still maintained functioning of partnership and teaching and learning to be in English without effective solutions to mitigate those issues. A key feature usually missing in global north-south health partnerships is positioning projects based on southern needs, not only on paper but actually finding research priorities that are rooted in context and allowing southern partners to lead projects as members with the most contextual understanding. Such changes in the functioning of global health partnerships would mitigate and solidify the shift from equality to equity, therefore promoting sustainability of these projects even after funding ceases.

Data availability

No datasets were generated or analysed during the current study.

All country names and institutions have been concealed in the paper to maintain anonymity and confidentiality of the partnership.

IP = Implementing Partner.

SP = Supporting Partner.

Abbreviations

Bergen Model of Collaborative Functioning

Higher Education Institutions

High Income Countries

In–depth Interviews

Low–and–middle income countries

Principal Investigator

Theory of Change

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Acknowledgements

The authors would like to thank all the participants of this research who made the production of this paper possible.

Open access funding provided by University of Bergen. The study received funding from the PROJECT-2 partnership. However, the partnership had no role in the study design, data analysis, and preparation of the manuscript or the decision to publish.

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S.L. designed and carried out the research, analyzed and interpreted the findings, and drafted the manuscript. M.D. advised in the design of the research and guided in the analysis and interpretation of the findings, recommended literature, and edited the manuscript up to the final version. J.H.C. advised on the theoretical background of the study, and the interpretation findings, and provided editing of the final paper. All authors read and approved the final manuscript.

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The study’s data management plan was approved by the [name of institution] for Research Data (494646). Signed informed consent was obtained from all the participants for the interview and audio recording session. All identifiable information was removed from the transcripts.

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S.L. studies at one of the partner institutions and is also employed by another partner institution in the partnership. The research study was also funded by the partnership under investigation. However, it should be noted that the funder and the partners had no influence or contributions to the analysis of data and writing of the manuscript.

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Luthuli, S., Daniel, M. & Corbin, J. Power imbalances and equity in the day-to-day functioning of a north plus multi-south higher education institutions partnership: a case study. Int J Equity Health 23 , 59 (2024). https://doi.org/10.1186/s12939-024-02139-x

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I Am Public Health: Victoria Adebiyi

April 1, 2023  | Erin Bluvas,  [email protected]

Victoria Adebiyi has big goals. The Ph.D. in Health Promotion Education and Behavior (HPEB) candidate plans to improve maternal and child nutrition and health in low- and middle-income countries after her 2025 graduation – continuing the path she began a decade ago in Nigeria.

As an undergraduate at the University of Ibadan, Adebiyi became interested in public health nutrition when one of her courses introduced the various related challenges her country faced. After graduating with a bachelor's degree in human nutrition, she completed a hospital-based internship to become a registered dietitian.

“The burden of preventable diet-related chronic diseases that I encountered during my dietetics training only fueled my passion to study public health nutrition to understand how to prevent such diseases on a broader scale, beyond the individual level,” Adebiyi says.

With a scholarship from the Mastercard Foundation, she enrolled in a master of public health program at the University of California, Berkeley. During this time, she became involved with the School of Law’s Health and Human Rights Program and interned with Save the Children International over a summer back in Nigeria.

The burden of preventable diet-related chronic diseases that I encountered during my dietetics training only fueled my passion to study public health nutrition to understand how to prevent such diseases on a broader scale, beyond the individual level.

When looking for doctoral programs. Adebiyi sought a setting with researchers involved in global nutrition work where she could explore her growing interests in maternal and child nutrition and health. The Arnold School’s HPEB department hit the mark, and she found mentors in faculty members Leila Larson and Edward Frongillo .

“I am grateful for the immense academic and professional support I have received from my mentors since the beginning of my program at USC,” Adebiyi says. “Under their supervision, I have been able to study the determinants and consequences of food insecurity and anemia among women and children globally, especially in limited-income contexts, and co-author peer-reviewed publications.”

She credits their support in her successful procurement of funding for her dissertation research. With a training grant from the Nestlé Foundation, Adebiyi is researching how mothers in urban Nigeria make breastfeeding decisions upon returning to work after childbirth.

“This is a very competitive award, and Victoria worked hard to earn it,” says Larson. “As part of her dissertation, she is conducting her own mixed methods research in Nigeria, interviewing postpartum women and their social networks. The World Health Organization recommends exclusively breastfeeding children until six months of age, but for many working women, whether it be urban Nigeria or Columbia, South Carolina, this is a personal and often hidden struggle.”

Adebiyi plans to continue this type of research after completing her degree. Working with a research institute, international non-governmental organization or in academia, her goal is to design and implement evidence-based interventions to improve maternal and child nutrition and health in Sub-Saharan Africa and other low- and middle-income settings. She is also interested in working with governments in the Global South to scale up existing evidence-based interventions and develop food policies to combat malnutrition.

At USC, Adebiyi has taken on leadership positions with the Maternal and Child Health Student Association, where she coordinated a student-faculty event, and the International Student and Global Health Forum, where members share their cultures, health systems and visions for their countries. At the national level, Adebiyi is student representative for the Global Nutrition Council of the American Society of Nutrition. She has enjoyed living in SC's capital city and the supportive campus community. 

“I have been exposed to and learned a lot from students from different cultures both in and out of classes,” says Adebiyi, who also has advice for academic success. “Find and connect with professors whose research interests align with yours and who will propel you to think critically and support you all through your program. There is a plethora of such professors who are very supportive of students’ progress in the HPEB department, so consider applying!”

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