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ORIGINAL RESEARCH
published: 02 February 2022
doi: 10.3389/fnut.2022.821016
Frontiers in Nutrition | www.frontiersin.org 1February 2022 | Volume 9 | Article 821016
Edited by:
Garmt Bernard Dijksterhuis,
Wageningen University and
Research, Netherlands
Reviewed by:
Monique Vingerhoeds,
Wageningen University and
Research, Netherlands
Siet Sijtsema,
Wageningen University and
Research, Netherlands
*Correspondence:
Giovanni Sogari
giovanni.sogari@unipr.it
Specialty section:
This article was submitted to
Eating Behavior,
a section of the journal
Frontiers in Nutrition
Received: 23 November 2021
Accepted: 10 January 2022
Published: 02 February 2022
Citation:
Wongprawmas R, Sogari G,
Menozzi D and Mora C (2022)
Strategies to Promote Healthy Eating
Among University Students: A
Qualitative Study Using the Nominal
Group Technique.
Front. Nutr. 9:821016.
doi: 10.3389/fnut.2022.821016
Strategies to Promote Healthy Eating
Among University Students: A
Qualitative Study Using the Nominal
Group Technique
Rungsaran Wongprawmas, Giovanni Sogari*, Davide Menozzi and Cristina Mora
Department of Food and Drug, University of Parma, Parma, Italy
Introduction: The years spent at university are critical in terms of altering people’s dietary
patterns. This study aimed to: (1) understand the main dietary changes that students
experience after starting university; (2) determine the personal and objective factors that
hinder healthy eating, and (3) define possible strategies to facilitate healthier diets among
university students.
Methods: The nominal group technique (NGT) was used to elicit ideas from 39
students from the University of Parma, Italy. The sample comprised 16 freshmen and 23
non-freshmen. Participants prioritized and weighed their top five ideas regarding dietary
changes, barriers to healthy eating, and possible strategies to maintain a healthy diet. A
thematic analysis was conducted to compare the priorities across groups.
Results: Forty-three themes were elected as the most significant changes related to
diet, 39 themes related to personal barriers, 43 themes related to objective barriers,
and 55 themes related to strategies. A lack of time for cooking, low financial availability,
consumption of unvaried food or junk food, and gaining knowledge about food were
identified as the main changes. Personal barriers to eating healthy were intrinsic (i.e.,
lack of willpower, personal gluttony, and little effort in cooking preparation), poor dietary
information, and a busy lifestyle. Market and financial factors (i.e., the high price of healthy
products and low financial availability), as well as social factors (i.e., the negative influence
of social networks, childhood food education, and origin/tradition), emerged as objective
barriers. Possible strategies that could encourage students to adopt a healthy diet include
varying the food products offered in university canteens, including organizing spaces
where students who prepare meals from home can warm up and eat their food. Student
discounts at supermarkets and information on nutrition and a healthy diet were also
identified as important ways of supporting students.
Conclusion and Implication for Practice: In order to make students part of the
solution, the NGT provided them with the opportunity to equally contribute their ideas
and opinions about having a healthy diet in a university context. This could potentially
lead to tailor-made solutions for policymakers, educators, and foodservice providers in
promoting healthy eating habits.
Keywords: nominal group technique (NGT), focus group, university students, canteen, healthy food, diet, young
adult, Italy
Wongprawmas et al. Strategies to Promote Healthy Eating
INTRODUCTION
For many young adults, leaving the parental home to go to
university is a critical transition period, which includes new
challenges such as taking charge of their own eating habits (1–
3). During this time, several personal (intrinsic factors such
as will, taste, and perception) and objective (extrinsic factors
such as the environment or culture) factors (4) may discourage
university students from following nutritional advice. As a result,
many young people can go from being a normal weight to being
overweight, which puts them at high risk for chronic disease
(2,3,5).
Efforts to eat healthy foods are often overcome by certain
perceived or encountered barriers, such as culinary traditions,
social pressure, habits, and a lack of availability or the high
price of healthy foods (3,6,7). In addition, a lack of knowledge
or information, as well as a general lack of interest in making
a change to one’s diet may also prevent people from having
a healthy diet (8). However, providing technical and detailed
nutritional information is not always a successful strategy (9,10).
The reason is that healthy-eating guidelines have primarily been
derived on an epidemiological basis (8), without considering
consumers’ personal and objective barriers.
The Health Belief Model (HBM) was developed in 1974 by
Rosenstock (11). The HBM is an expectancy-value model that has
been successfully used to predict healthy behaviors (12). Among
the several factors included, the HBM postulates that individuals
will engage in healthy behaviors when they perceive themselves as
susceptible (e.g., eating changes occurring as a university student)
and believe that the benefits of healthy behaviors exceed the
costs (i.e., the perceived barriers). As a result, individuals are
more likely to take preventive actions, such as maintaining a
healthy diet (13). The HBM considers that cues to action (i.e.,
tools and strategies) can modify behavior-influencing variables by
prompting actions.
In the past, several qualitative studies (some of which used
focus groups) have been conducted on healthy eating perceptions
and practices among young adults (3,14–16). However, there
is a lack of structural design to provide concrete and feasible
implications based on the targeted group. To address this issue,
the use of a nominal group technique (NGT) provides tailored
suggestions that could be applied in a particular context.
NGT is a structured multi-step group technique that is used
to generate and prioritize consensus responses to a carefully
articulated question, which is intended to address specific issues
(17–20). This technique has been used in a number of different
contexts to generate ideas or allow a group to reach consensus
(6,20–22). The advantage of NGT over a traditional focus group
is that it encourages equal contributions from everyone and
facilitates discussion and prioritization, which leads participants
to come to an agreement on an issue (1,19,23,24). Therefore,
the issues that are deemed important could be addressed first.
The purpose of this study is to better understand the factors
that impede healthy eating behaviors among young adults. We
utilized the NGT to elicit information from a group of Italian
students and determine what changes occur in eating behavior
after starting university, as well as the barriers associated with
embracing a healthy diet. During the analysis, the sample was
grouped by gender and year of enrollment (freshmen and non-
freshmen) to provide variety and an in-depth interpretation of
the results. The policy and managerial implications for campus
settings are then provided and discussed.
MATERIALS AND METHODS
In our study, the NGT was applied to generate and prioritize
participants’ ideas about the perceived barriers of adopting
healthy eating habits, as well as possible solutions. The NGT is
a qualitative method of data collection that may be considered
a highly structured focus group, which can guide face-to-face
meetings (25). The NGT format is useful in that it allows
participants to disclose creative and meaningful responses to a
carefully articulated question that is intended to address specific
information needs, as in the case of studies on healthy behavior
(1,19), including healthy diet (6,26). It also allows for priorities
between different groups of participants to be compared (19,27).
Participants
The sample consisted of 39 Italian university students (both
male and female) that were recruited using advertisements that
were handed out in and around the campus of the University of
Parma, Italy. Snowball sampling was used to recruit participants.
To be eligible, participants had to be enrolled as undergraduate
or graduate students at the university. Written consent forms
were provided to and approved by all participants at the
beginning of the study, as well as an information sheet, which
established the ground rules around confidentiality, respect, and
protecting participants’ identities. The study was approved by the
Institutional Review Board (IRB) of the Ethical Committee of the
University of Parma (Protocol ID: 41959, 17th November 2017).
Data Collection
Seven NGT sessions were held at the university campus between
January and April 2018. Each group was comprised of 3–8
individuals. The criteria of a maximum of seven NGTs and a
group size of 2–14 participants was recommended by McMillan
(19). The participants were full-time students aged 19–26 years.
Two NGTs were made up of only freshmen students, three
NGTs were only non-freshmen students, and the remaining
NGT groups were made up of a mixture. Four NGTs were
mixed genders, two were made up of only females, and one
was exclusively male. All the sessions were conducted in Italian
language, and each NGT session lasted approximately 90 min.
The sessions were all initially videotaped, and the discussions
were later transcribed and quality checked.
The structured questionnaire contained four questions
adapted from the HBM (11) and was developed by a group
of consumer researchers with expertise in attitudinal research
within the field of nutrition. Based on this framework we
developed the following questions:
1. What personal barriers can impede university students from
eating healthily?
Frontiers in Nutrition | www.frontiersin.org 2February 2022 | Volume 9 | Article 821016
Wongprawmas et al. Strategies to Promote Healthy Eating
2. What objective barriers can impede university students from
eating healthily?
3. When attending university, what changes occur to one’s
eating habits?
4. What are some techniques, strategies, or tools that might
motivate university students to maintain a healthy diet?
Three researchers (one moderator and two facilitators) were
trained to organize and facilitate the sessions. All sessions
followed the same structure and procedures as those suggested
by McMillan et al. (19).
Each focus group began with the first step in the NGT model,
which involves the moderator providing a brief explanation
of the purpose of the study and each participant introducing
themselves. Each participant was then provided a pen and a
worksheet with a specific question at the top of each page (for
example, what personal barriers can impede university students
from eating healthily?), which they worked on individually
for 5 minto generate written responses. This second step of
the protocol is the so-called silent generation of ideas during
which time participants are not allowed to consult with each
other or discuss their ideas (19,28). After this step, we asked
each participant to share their answers with the rest of the
group using a “Round-robin” technique. While the responses
were being shared, they were also verbatim recorded by the
facilitators on a flip-chart, using the exact words spoken by
the participants. Once all the responses were listed, the group
discussion and clarification steps of the process began. The
moderator discussed the responses to ensure that participants
understood, thus enabling them to make informed decisions
in the next step of selecting and ranking. In addition, through
consensus, similar responses were combined with agreement
from all participants (e.g., price, high price, high cost of
healthy food products were combined as “high price of healthy
products”). During the discussion process, participants could
come up with new ideas that would then be added to the list in
the flipchart.
The final step in the protocol is to select the top five themes
from the generated list (flipchart) and prioritize (rank) the
recorded ideas. Based on previous literature (19), we asked
participants to rank the top five items that were most relevant
to them (i.e., where one was the most salient idea and five was
the least salient idea). It is important to note that even though
participants’ identities were not anonymous during the group
discussion stage, the responses collected in the worksheet on the
individual ranking were confidential.
All the steps of the NGT process were repeated for
each question.
Data Analysis
The data analysis of NGT combines both qualitative and
quantitative methods. It involved coding the material
of each session and constructing conceptual categories
from the emerging codes, including calculating scores and
prioritizing themes. Furthermore, individual comments from
the transcription were cross-checked against the response sheets
(i.e., the written comments) and information on the flipcharts (as
recorded by the facilitator). As a result, this approach improved
the clarity and depth of the results.
All the responses (themes) generated by each group were
entered into Excel spreadsheets, along with the ranking of the
responses. An initial review of the raw data in the spreadsheets
(i.e., the original participant data) were used to identify any
anomalies or nuances within the data. Then, the ranking was
converted into scores, ranging from the least salient idea (1) to
the most salient idea (5).
Responses from the seven NGT sessions that addressed
the same questions were aggregated. Specifically, very similar
themes were combined to create a new list of distinctive (non-
overlapping) themes. Two authors (RW & GS) reviewed and
discussed these aggregations to determine the final themes.
The total score for each distinctive theme was computed by
summing up the scores received from each participant and were
combined across groups as the “sum of scores.” The relative
importance of each theme was calculated as the proportion (%)
of the total score for the theme on the maximum possible score
(Participant number x 15). The priority list (“ranked priority”)
was determined by considering the relative importance of the
theme. If themes had equal relative importance, the voting
frequency was then used to decide the ranking priority, whereby
the higher the frequency of voting, the higher the priority.
The tables presented in the results section show the themes
that were ranked in the top 10 for each question. A complete list
of the responses is available in Supplementary File 1.
RESULTS
The demographic characteristics of the overall sample are
shown in (Table 1). Thirty-nine university students (19–26
years old) participated in seven NGT sessions. The majority of
the participants were female (56%) and had a normal weight
(71%). The average age was 22 ±2.2 years old with a mean
body mass index (BMI) of 22.8 ±3.2. Fifty-four percent of
the participants were graduate students, and the rest were
undergraduate students, of which freshmen made up the majority
(89% of undergraduate students). Most participants (69%) lived
with friends or flat mates.
Most Common Changes Related to Diet
A total of 43 themes related to dietary changes when attending
university were generated; further details can be found in
Supplementary Table S1. The aggregated responses that were
ranked highly across all seven NGTs are presented in Table 2.
“Lack of time for cooking,” “low financial availability,” “not
having a varied diet” and “consumption of junk food” emerged as
the responses with the greatest number of votes and frequencies
across the seven groups. “Gaining knowledge about food”
(selection and preparation of food) was also identified as an
important theme.
Themes varied slightly by gender and depending on
whether participants were freshmen or non-freshmen. The most
important change for the total sample non-freshmen and female
participants was “lack of time for cooking”; for freshmen, it was
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Wongprawmas et al. Strategies to Promote Healthy Eating
TABLE 1 | Participants’ characteristics (n=39).
Characteristics n(%)
Female 22 (56%)
Age mean (SD) 22 (2.2)
BMI mean (SD) 22.8 (3.2)
BMI categories (n=38)
Underweight (BMI<18.50) 2 (5%)
Normal weight (18.50 ≤BMI ≤24.99) 27 (69%)
Overweight (25.00 ≤BMI ≤29.99) 8 (20%)
Obese (BMI ≥30.00) 1 (3%)
No response 1 (3%)
Study
Undergraduate 18 (46%)
Graduate 21 (54%)
Freshmen 16 (41%)
Living condition
With parents 7 (18%)
With friend/flat mate 27 (69%)
With partner 3 (8%)
Alone 2 (5%)
“low financial availability”; and for males it was “not having a
varied diet.”
Personal Barriers to Maintaining a Healthy
Diet
Overall, 39 themes were generated (see
Supplementary Table S2). Table 3 presents the aggregated
categories of personal barriers to following a healthy diet across
all seven NGTs. Key personal barriers to eating healthy food were
“lack of willpower,” “personal gluttony,” “little effort in cooking
and preparation,” “poor dietary information,” and “lack of time
during the day.”
The primarily personal barrier for the total sample, non-
freshmen and male participants was a “lack of willpower,”
whereas for freshmen and female participants it was
“personal gluttony.”
Objective Barriers to Maintaining a Healthy
Diet
The total number of themes generated was 43. Table 4 outlines
the aggregated categories of objective barriers to maintaining
a healthy diet across all seven NGTs. Further can be found in
Supplementary Table S3. “High price of healthy products,” “low
financial availability,” “negative influence of social networks,”
“poor childhood food education,” and “origin and tradition”
emerged as key objective barriers to eating healthy food among
the university students.
The main objective barrier for the total sample, non-freshmen
and male was the “high price of healthy products”; for freshmen
participants it was the “negative influence of social networks”;
and for female participants it was “low financial availability.”
Strategies to Maintain a Healthy Diet
A total of 55 themes were generated (see
Supplementary Table S4). The aggregated responses that
ranked highly and could encourage students to adopt a healthy
diet across all seven NGTs are presented in Table 5. “Varying
food products offered in university canteens,” “student discount
at supermarkets,” “better organization of university canteen
areas” (so that students who prepare meal from home can warm
up their food and eat it there), and “dissemination of information
about healthy diet through seminars or courses” were identified
as top strategies. “Reduce prices of sport facilities” was also
mentioned as a crucial strategy though it was not directly related
to healthy eating. This reflects the fact that students consider
sport to be an important part of a healthy lifestyle.
The top strategy for the total sample, freshmen and female
participants was “varying food products offered in university
canteens,” whereas this strategy was not deemed to be important
by male participants (it ranked 9th). For males, “limited
consumption of junk food in university canteens” was more
important, while “better organization of university canteen areas”
was the most important for non-freshmen participants.
DISCUSSION
The aim of this qualitative study was to provide in-depth insight
into university students’ dietary changes, barriers, and possible
strategies that could encourage them to embrace a healthy diet.
The differences in participants’ responses by year of enrollment
(freshmen vs. non-freshmen) and gender were also explored.
The dominant changes in eating habits included a lack of
time to cook, limited budget, and consumption of unvaried
food or junk food. On the other hand, gaining knowledge about
food selection and preparation has also been identified as an
important change. The results are in line with previous studies
(3,5,15,16,29) that suggested time constraints, budgets, and
consumption of unhealthy food are crucial changes that young
adults experience when they go to university. Note that for
non-freshmen students, gaining knowledge and experience in
food decision and preparation are positive changes that could
potentially lead to self-efficacy when it comes to having a healthy
lifestyle (30). Time constraint and unbalanced or unvaried diet
are crucial changes that are relevant to all participants.
Many studies have cited time constraints (3,15) as a barrier
to healthy eating. The participants highlighted that their hectic
schedule did not allow them to have time to cook and eat
properly. Since university students tend to prioritize studying
and being accepted as peers, they tend to spend more time and
resources on these issues compared to things like healthy eating
(14,16). Hence, they tend to eat fast and ready-to-eat foods,
which might be high in calories and not very nutritious. In
addition, our sample of participants were young and is in their
peak physical stage; therefore, the effect of bad eating habits
might not be visible at present, but will emerge later in their
lives (5). To cope with these issues, attitudes and perceptions of
healthy eating should be established by family and schools before
enrolling in university. Time management is also a crucial skill
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Wongprawmas et al. Strategies to Promote Healthy Eating
TABLE 2 | Aggregated results across the 7 groups on the main dietary changes since attending university.
Idea Total (n=39) Freshmen (n=16) Non-freshmen (n=23) Female (n=22) Male (n=17)
SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank
Lack of time for cooking 50 8.55 15 117 7.08 6 533 9.57 9 139 11.82 11 111 4.31 4 8
Low financial availability 48 8.21 15 225 10.42 7 123 6.67 8 326 7.88 8 222 8.63 7 2
Not having a varied diet 40 6.84 16 318 7.50 5 422 6.38 11 417 5.15 9 523 9.02 7 1
Consumption of junk food 36 6.15 11 421 8.75 7 215 4.35 4 917 5.15 5 619 7.45 6 4
Gaining knowledge about
food (e.g.,
choosing/preparing food)
28 4.79 8 511 4.58 3 917 4.93 5 67 2.12 2 19 21 8.24 6 3
Change of daily routine 27 4.62 7 60 0.00 0 28 27 7.83 7 211 3.33 3 13 16 6.27 4 6
Exclusion of many healthy
foods
22 3.76 6 70 0.00 0 28 22 6.38 6 58 2.42 2 15 14 5.49 4 7
Consuming cheaper foods 21 3.59 9 86 2.50 2 17 15 4.35 7 818 5.45 7 33 1.18 2 21
Low availability of healthy
foods
18 3.08 6 918 7.50 6 30 0.00 0 32 18 5.45 6 40 0.00 0 31
Irregular meal times 17 2.91 5 10 7 2.92 3 14 10 2.90 2 15 15 4.55 4 92 0.78 1 27
High consumption of coffee 17 2.91 5 10 13 5.42 4 84 1.16 1 24 17 5.15 5 60 0.00 0 31
Study-related stress 17 2.91 5 10 0 0.00 0 28 17 4.93 5 617 5.15 5 60 0.00 0 31
Imbalanced diet due to lack
of time
17 2.91 4 13 14 5.83 3 73 0.87 1 25 0 0.00 0 35 17 6.67 4 5
Careless shopping 14 2.39 5 14 0 0.00 0 28 14 4.06 5 10 11 3.33 4 12 3 1.18 1 22
Unhealthy lunch box 14 2.39 4 15 14 5.83 4 60 0.00 0 32 14 4.24 4 10 0 0.00 0 31
Little desire to cook 13 2.22 5 17 0 0.00 0 28 13 3.77 5 11 3 0.91 1 26 10 3.92 4 9
Consumption of
ready-to-eat foods
12 2.05 5 20 10 4.17 4 10 2 0.58 1 28 7 2.12 3 18 5 1.96 2 17
Less healthy food regime 10 1.71 3 22 0 0.00 0 28 10 2.90 3 14 1 0.30 1 30 9 3.53 2 10
SS, sum of scores; RI, relative importance; Freq, frequency of voting; Rank, ranked priority. The bold value is to highlight the ranked priorities of the themes.
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Wongprawmas et al. Strategies to Promote Healthy Eating
TABLE 3 | Aggregated results across the 7 groups on personal barriers to maintaining a healthy diet.
Idea Total (n=39) Freshmen (n=16) Non-freshmen (n=23) Female (n=22) Male (n=17)
SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank
Lack of willpower 62 10.60 17 119 7.92 5 343 12.46 12 128 8.48 8 234 13.33 9 1
Personal gluttony 60 10.26 22 232 13.33 11 128 8.12 11 336 10.91 14 124 9.41 8 3
Poor dietary information 44 7.52 12 324 10.00 5 220 5.80 7 613 3.94 3 10 31 12.16 9 2
Little effort in cooking and
preparation
40 6.84 11 45 2.08 2 16 35 10.14 9 228 8.48 7 312 4.71 4 6
Lack of time during the day 34 5.81 9 510 4.17 2 924 6.96 7 424 7.27 6 410 3.92 3 9
Low financial availability 32 5.47 13 612 5.00 6 720 5.80 7 618 5.45 7 614 5.49 6 5
Lack of time for cooking 32 5.47 11 715 6.25 4 417 4.93 7 823 6.97 8 59 3.53 3 10
Lack of physical activity 27 4.62 10 85 2.08 1 19 22 6.38 9 516 4.85 7 711 4.31 3 8
Hectic daily routine 21 3.59 8 99 3.75 3 10 12 3.48 5 12 4 1.21 2 22 17 6.67 6 4
Challenge of following a
balanced and varied diet
16 2.74 4 10 0 0.00 0 29 16 4.64 4 911 3.33 3 12 5 1.96 1 19
Individual laziness 15 2.56 4 11 15 6.25 4 40 0.00 0 29 15 4.55 4 80 0.00 0 27
Junk food consumption 14 2.39 4 12 14 5.83 4 60 0.00 0 29 14 4.24 4 90 0.00 0 27
Lack of
willpower/self-control to
maintain a healthy diet and
lifestyle
13 2.22 4 13 0 0.00 0 29 13 3.77 4 10 5 1.52 2 19 8 3.14 2 13
Poor knowledge of food 13 2.22 4 13 0 0.00 0 29 13 3.77 4 10 4 1.21 1 24 9 3.53 3 10
Lack of interest in a healthy
diet
12 2.05 3 15 0 0.00 0 29 12 3.48 3 13 0 0.00 0 32 12 4.71 3 7
Lack of time to eat 11 1.88 4 18 11 4.58 4 80 0.00 0 29 3 0.91 1 27 8 3.14 3 12
SS, sum of scores; RI, relative importance; Freq, frequency of voting; Rank, ranked priority. The bold value is to highlight the ranked priorities of the themes.
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Wongprawmas et al. Strategies to Promote Healthy Eating
TABLE 4 | Aggregated results across the 7 groups on objective barriers to maintaining a healthy diet.
Idea Total (n=39) Freshmen (n=16) Non-freshmen (n=23) Female (n=22) Male (n=17)
SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank
High price of healthy
products
69 11.79 20 128 11.67 8 241 11.88 12 130 9.09 9 239 15.29 11 1
Low financial availability 49 8.38 13 212 5.00 3 637 10.72 10 233 10.00 8 116 6.27 5 4
Negative influence of social
networks
43 7.35 16 331 12.92 11 112 3.48 5 923 6.97 9 320 7.84 7 2
Poor childhood food
education
36 6.15 10 40 0.00 0 27 36 10.43 10 321 6.36 6 515 5.88 4 5
Origin and tradition 35 5.98 12 522 9.17 7 413 3.77 5 723 6.97 8 412 4.71 4 7
Lack of time for cooking 34 5.81 8 626 10.83 6 38 2.32 2 18 20 6.06 5 614 5.49 3 6
Little information on healthy
diet
23 3.93 9 79 3.75 3 914 4.06 6 63 0.91 3 25 20 7.84 6 3
Bad influence from friends,
partners, and other people
23 3.93 8 86 2.50 3 13 17 4.93 5 418 5.45 6 75 1.96 2 16
Unhealthy family habits 21 3.59 7 914 5.83 4 57 2.03 3 19 17 5.15 5 84 1.57 2 20
Availability of unhealthy food 20 3.42 7 10 8 3.33 3 10 12 3.48 4 10 15 4.55 59 5 1.96 2 16
Unhealthy traditional food
and habits
19 3.25 8 11 9 3.75 4 710 2.90 4 13 12 3.64 4 11 7 2.75 4 12
Lack of interest in a healthy
diet
16 2.74 5 12 0 0.00 0 27 16 4.64 5 59 2.73 2 15 7 2.75 3 13
Misleading advertisements 15 2.56 4 13 5 2.08 1 15 10 2.90 3 14 15 4.55 4 10 0 0.00 0 31
Lack of time to maintain a
healthy diet
13 2.22 5 14 0 0.00 0 27 13 3.77 5 71 0.30 1 29 12 4.71 4 7
External stimuli 12 2.05 4 15 0 0.00 0 27 12 3.48 4 10 2 0.61 1 26 10 3.92 3 10
Lack of organization during
the day
11 1.88 3 17 0 0.00 0 27 11 3.19 3 12 0 0.00 0 34 11 4.31 3 9
Seasonal and local habits 9 1.54 4 20 9 3.75 4 70 0.00 0 34 9 2.73 4 13 0 0.00 0 31
SS, sum of scores; RI, relative importance; Freq, frequency of voting; Rank, ranked priority. The bold value is to highlight the ranked priorities of the themes.
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TABLE 5 | Aggregated results across the 7 groups for strategies to maintain a healthy diet.
Idea Total (n=39) Freshmen (n=16) Non-freshmen (n=23) Female (n=22) Male (n=17)
SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank SS RI Freq. Rank
Varying food products offered in
university canteens
53 9.06 14 126 10.83 7 127 7.83 7 242 12.73 11 111 4.31 3 9
Student discounts in
supermarkets
36 6.15 10 221 8.75 6 215 4.35 4 726 7.88 6 210 3.92 4 10
Better organization of university
canteen areas
33 5.64 10 30 0.00 0 37 33 9.57 10 117 5.15 5 516 6.27 5 2
Reduce prices of sport facilities 28 4.79 9 411 4.58 5 617 4.93 4 614 4.24 5 914 5.49 4 3
Dissemination of information
about healthy diets through
seminars or courses
24 4.10 8 50 0.00 0 37 24 6.96 8 315 4.55 5 79 3.53 3 11
Better organization of the day 24 4.10 7 611 4.58 3 713 3.77 4 10 20 6.06 6 34 1.57 1 24
Limit consumption of junk food in
university canteens
23 3.93 5 70 0.00 0 37 23 6.67 5 45 1.52 1 21 18 7.06 4 1
Distribute appropriate information
about correct diet
18 3.08 10 80 0.00 0 37 18 5.22 10 514 4.24 7 84 1.57 3 22
Discounted fruits and vegetables
for university students
18 3.08 5 918 7.50 5 30 0.00 0 34 18 5.45 5 40 0.00 0 37
Greater economic availability 16 2.74 4 10 16 6.67 4 40 0.00 0 34 16 4.85 4 60 0.00 0 37
Availability of a broad range of
healthy products
15 2.56 4 11 0 0.00 0 37 15 4.35 4 712 3.64 3 11 3 1.18 1 27
Attention to food labels 14 2.39 4 12 10 4.17 3 84 1.16 1 24 2 0.61 1 37 12 4.71 3 8
Discounted meals in university
canteens
13 2.22 5 14 0 0.00 0 37 13 3.77 5 94 1.21 2 25 9 3.53 3 11
Varying the consumption of
healthy products
13 2.22 3 15 8 3.33 2 11 5 1.45 1 22 0 0.00 0 42 13 5.10 3 4
Reduce prices of healthy foods 13 2.22 3 15 4 1.67 1 22 9 2.61 2 15 0 0.00 0 42 13 5.10 3 4
Prepare meals the day before 12 2.05 5 17 4 1.67 2 20 8 2.32 3 16 12 3.64 5 10 0 0.00 0 37
Advertising a healthy diet 12 2.05 4 18 12 5.00 4 50 0.00 0 34 0 0.00 0 42 12 4.71 4 6
Good food education from
parents
12 2.05 4 18 8 3.33 3 94 1.16 1 24 0 0.00 0 42 12 4.71 4 6
Water delivering services 8 1.37 3 23 8 3.33 3 90 0.00 0 34 8 2.42 3 12 0 0.00 0 37
SS, sum of scores; RI, relative importance; Freq, frequency of voting; Rank, ranked priority. The bold value is to highlight the ranked priorities of the themes.
Frontiers in Nutrition | www.frontiersin.org 8February 2022 | Volume 9 | Article 821016
Wongprawmas et al. Strategies to Promote Healthy Eating
that students should acquire before starting university to organize
priorities during the study period.
Before attending university, most of the participants lived
with their parents or guardians and were not used to doing
food shopping or cooking by themselves. As a result, freshmen
students might not know the importance of food prices,
purchasing decisions, and cooking preparation. Since “poor
childhood food education” and “origin and tradition” were
reported among the most important objective barriers, we
believe that these two aspects should be handled before starting
university. For example, families could play an important role in
encouraging their children to be self-sufficient in terms of diet—
e.g., knowledge of food ingredients, awareness of healthy eating
habits, and ability to cook basic dishes. Additionally, middle
or high schools could offer courses on healthy cooking (e.g.,
simple recipes) and budget organizations to teach students the
relevant skills. Off-campus social groups (e.g., club, unions) can
also contribute by sharing places where cheap fruit and vegetables
can be bought and by sharing quick and easy recipes with each
other (31).
Our findings align with the conclusions of previous studies
(29,32) that identified differences between freshmen and non-
freshmen students; this study found that freshmen students had
less cooking skills than non-freshmen. Hence, financial and food
availability are the main issues for freshmen students. At the same
time, these aspects are less prominent for non-freshmen students,
which indicates that they were able to gain these skills over time.
Comparing by gender, junk food and fast food consumption
was more prominent among males (29,33), although females
reported eating cheaper food. Participants reported that healthy
food options, such as fruits and vegetables, are available and
accessible in university canteens, but also mentioned that they are
not varied enough and sold at higher prices compared to other
food options.
The leading personal or subjective barriers to healthy eating
identified by the participants included personal and intrinsic
barriers, a lack of dietary information, and time constraints.
Among the intrinsic barriers, the lack of willpower to adopt
healthy eating patterns was the most frequently mentioned
response, which is well-aligned with previous studies (7,34,35).
Furthermore, we found that women perceived personal gluttony
as the primary personal barrier. This might be because females
tend to be more stressed than males; hence, they are more likely
to eat sweet foods as a coping strategy (29,36). A lack of physical
activity was the fifth key barrier for non-freshmen students, while
this issue was less important for other participant groups. Other
studies have highlighted possible synergies of integrated public
interventions aimed at improving young adults’ health behaviors,
such as physical activity and healthy food consumption (37).
A nutrition knowledge deficit was also mentioned as a
personal barrier (14). Although this ranked second for freshmen
participants, it ranked sixth among non-freshmen participants.
This could imply that nutrition information was acquired
after years of studying, since non-freshmen participants had
completed at least one course on nutrition within the curricula.
The key objective barriers to healthy eating were market
and financial factors (high price of healthy products, low
financial availability), social factors (negative influence of social
networks), childhood food education, and origin and tradition.
The perception that healthy products have high prices was the top
barrier for participants, which is in accordance with the findings
of previous studies (3,31). In other college food environments,
such as in the US, most freshmen students are required to live
on campus and eat every meal in the canteen, which includes a
planned meal and an all-you-can-eat buffet. Therefore, the prices
of healthy or unhealthy options are not the main factors affecting
food choices. However, for non-freshmen students in the US,
who tend to live off-campus, prices do play a role (1). In Italy,
there is no such difference among freshmen and non-freshmen
students since living on campus is not as common; therefore,
students tend to either cook or go to canteens/restaurants/bars
for meals.
Social and peer networks were cited as both barriers to, and
facilitators of, healthy eating in other studies (14,16,31,38).
The influence of social media (i.e., Instagram, Facebook) was
perceived as having a negative effect on the participants in this
study. This highlights that social effects, especially from peers
(including friends, acquaintances, and partners) are important
in real-life or virtual social platforms (e.g., Instagram followings,
Facebook friends).
Furthermore, childhood food education and family food
habits are crucial since participants who grow up in a family that
prioritizes healthy eating make better food choices at university
(3,14,16). These results also indicate that participants who grew
up with unhealthy family habits or traditions are unlikely to
change, even though they know that they are unhealthy.
Individual places of origin and food traditions were also
discussed as objective barriers to a healthy diet. For example,
some participants mentioned that they consume a high amount
of food during holidays or festivities at home (e.g., Christmas and
Easter holidays). As a result, the high intake of traditional foods
(appetizers, first course, second course, side dish, dessert, etc.)
could contribute to a high caloric intake. Some students reported
that during these festivities or other family reunion occasions
they tend to eat unhealthy food (e.g., fried food) due to tradition
and habits.
While there are differences between personal (intrinsic) and
objective (extrinsic) factors (barriers), the results show that
participants themselves did not clearly distinguish between these
two types of barriers. In particular, a lack of time for cooking and
a lack of information were considered to be both personal and
objective barriers. This may hinder healthy eating habits even
further, if people believe these are not personal issues that can
be self-managed.
As suggested in previous literature (5,14,16,37), changing
the food environment (university canteen) was cited by students
as the most promising strategy to encourage healthy eating. The
changes included offering a variety of healthy food products
in the canteen, offering discounted fruits and vegetables, and
organizing spaces in canteens for students who bring food
from home to be able to warm and consume food there.
Additionally, offering healthy products throughout the university
(for example, distributing healthy snacks like nuts, pre-cut fruits,
and vegetables instead of high-calorie ones in vending machines)
Frontiers in Nutrition | www.frontiersin.org 9February 2022 | Volume 9 | Article 821016
Wongprawmas et al. Strategies to Promote Healthy Eating
was also mentioned, although it was not ranked in the top
five strategies.
Another frequently mentioned strategy was the dissemination
of information on healthy diets through seminars and courses,
which links to the previously mentioned belief that a lack of
knowledge and information is a significant personal barrier. This
finding is in accordance with the findings of previous studies,
which held that improving knowledge could enable university
students to eat more healthily (3,14,16,31,35). Therefore,
offering a health class or seminar at the university (either on-
site and online) is one way in which nutrition education can be
improved. Nevertheless, students differ in terms of their personal
characteristics and levels of nutrition-related knowledge, and
more research regarding tailoring classes to address diverse
groups of students (e.g., freshmen vs. non-freshmen) is required.
To overcome budget constraints, student discounts at
supermarkets and lower prices of healthy food have also been
proposed (16). Reducing the prices of sports facilities was
brought up as a highly-ranked strategy, as found in previous
studies (1,15). This highlights the fact that eating nutritious
food and performing physical activities are inseparable in most
people’s concept of healthy living, which therefore implies
relevant strategies for university governing bodies (37).
Practical Implications
For policy makers, universities, and teachers, providing tailored
courses and seminars on knowledge of nutrition, cooking skills,
budget organization, and time management for students with
different characteristics and backgrounds is crucial. Furthermore,
social networks could be useful tools for promoting knowledge
and information about healthy eating; for example, this can
be used to create social support groups among students who
are seeking a healthier lifestyle. However, knowledge and
information alone are not sufficient if the various healthy food
options are unavailable. There is also a need for interventions
that can promote convenient and healthy food options at the
university in order to help students overcome time constraints
and the perception that healthy food is labor-intensive (14).
There are opportunities for the industry and university
canteens to provide healthy ready-to-eat foods that target young
people who do not have much time but want to have a
healthy lifestyle. For managers of university canteens, offering
various healthy dishes and products could improve students’
eating habits.
Limitations
The NGTs were conducted with a non-probabilistic, purposively
selected sample in a specific context; hence, it cannot be
generalized to university students in other contexts. Nevertheless,
it could form a basis for future studies that seek to find strategies
and interventions to mitigate barriers and encourage students to
eat healthily.
Future Research
Further research should use the themes identified in this
study to create and evaluate tailored intervention programs to
promote healthy eating in the university. Future research might
consider using the health belief model or the ecological model
of health to design questions in the NGT study. Larger and
more representative samples of university students (e.g., students
from different disciplines or diverse geographical locations and
contexts) should be included in future studies.
CONCLUSION
This study identified barriers and strategies to facilitate healthy
eating among university students. The most significant barriers
included intrinsic factors (i.e., lack of willpower, personal
gluttony, and lack of knowledge and information), busy
lifestyle (i.e., lack of time), market and financial factors
(i.e., high price of healthy products, and low financial
availability), and social factors (i.e., influence of social networks,
childhood food education, and food origin and tradition). The
results of this study identify potential areas of intervention,
such as offering healthier and various options of food in
university canteens and vending machines, reducing prices
of healthy food and sports facilities, and offering courses
and seminars about healthy diets to students. The protocol
of the NGT as an information-generating tool provides an
opportunity for participants to share and contribute their
ideas about having a healthy diet in a university context,
thereby allowing them to feel that they were part of the
solution. This highlights the importance of listening to
students’ opinions and experiences before designing and
implementing interventions.
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/Supplementary Material, further inquiries can be
directed to the corresponding author.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by the Ethical Committee of the University of Parma
(Protocol ID: 41959). The participants provided their written
informed consent to participate in this study.
AUTHOR CONTRIBUTIONS
GS wrote the grant proposal, assisted with data analysis, and
ran the NGT sessions. CM managed funding acquisition. GS,
DM, and RW contributed to the conception and design of the
study. DM and CM recruited the participants and contributed
to manuscript revision. GS and CM prepared data collection
material. RW performed the statistical analysis. RW and GS
wrote the first draft of the manuscript. All authors read and
approved the submitted version.
FUNDING
This study was part of a wider project called CONSUMEHealth.
Using consumer science to improve healthy eating habits and
had received funding from the European Union’s Horizon
Frontiers in Nutrition | www.frontiersin.org 10 February 2022 | Volume 9 | Article 821016
Wongprawmas et al. Strategies to Promote Healthy Eating
2020 Research and Innovation Programme under the Marie
Sklodowska-Curie Grant Agreement No. 749514.
ACKNOWLEDGMENTS
The authors would like to thank Silvia Turani, Umberto
Massa Saluzzo, Gaia Martina Meneghetti, and Chiara Pirolo for
supporting the organization of the NGT sessions. The authors
would also like to acknowledge Filippo Di Tommaso for data
preparation and management.
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fnut.2022.
821016/full#supplementary-material
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Conflict of Interest: The authors declare that the research was conducted in the
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