Pilot Study: The Training of Health Professionals about Geneticalle Modified Foods from the Perspective of the Science, Technology and Society

In the last two decades, the social controversy over the benefits
and harms in health and the environment about transgenic food
(TF) [1], as well as concerns about the monopoly of world trade...


Introduction
In the last two decades, the social controversy over the benefits and harms in health and the environment about transgenic food (TF) [1], as well as concerns about the monopoly of world trade, the reliability of public institutions, the integrity of regulatory agencies, the loss of both individual and ethical choice, and the future of food supply, have kept the national and international public discussion alive [2]. It is in this context of technological complexity that the role of health professionals gains an unexpected significance. In spite of officially guaranteeing legal criteria and, until now, despite the fact that negative impacts on health or the environment are controversial [3], the process of authorization and commercialization of TF cannot prevent the possibility of unforeseen (by definition) surprises, which puts health professionals at a critical point in providing information and reliably advising patients, answering questions and maximizing safety and wise behaviors.
The TF topic presents several challenges, related to thought fragmentation and to the proliferation of knowledge that quickly changes, dividing itself in isolated areas. In order to understand TF, more integrated analyses are needed, including diverse perspectives and scientific and professional experiences. A new model of attention and training concerning TF for health professionals is needed in order to update and broaden these professionals' thought.
The objective of this work was to set and assess a training module for Nutrition Sciences and Medical Sciences in relation to TF, in addition to contributing to the construction of a comprehensive learning concept connected to scientific, technological and social knowledge.

Evaluation of the Module's Structure
Instruments: Three instruments were designed to evaluate the module's structure. Instrument 1 consisted of a survey (i) that was created using closed questions with a 5-level Likert scale to assess agreement (1-strongly disagree, 2-disagree, 3-neither disagree nor disagree, 4-agree, 5-strongly agree) and importance Participants: Participants in this study include: 14 health professionals, of whom 7 were nutritionists and the other 7 physicians, including academic and professional representatives working as nutritionists or physicians. The inclusion criterion for instruments 1 and 2 was to be a professor affiliated with a university.
The sample consisted of 5 representatives from medical schools and 5 from faculties with degrees in Nutrition Sciences. For instrument 3, sampling was carried out in the private sector. Physicians and nutritionists who practiced the profession were contacted. Four professionals (2 doctors and 2 nutritionists) participated.
Data collection: Data collection took place from September to December of 2018 through three activities. The objective of each action was previously highlighted, and the confidentiality of the information collected was guaranteed. The first activity consisted in disseminating instrument 1 online. Subsequently, semi-structured interviews were carried out in person at the participants' universities (instrument 2). Training was carried with a duration of 4 hours, focusing on the contents of Table 1. Subsequently, presented as a lecture, the module was evaluated with regard to the agreement and importance of contents and opinions about the knowledge acquired (tool 3).

Data Analysis:
The results of the interviews (instrument 2) were analyzed in the program Nvivo® version 11.4.2 (QSR International, Pty Ltd.) using the techniques of content analysis according to Bardin [16], through three chronological segments:

Surveys
The degree of agreement was evaluated in relation to the twelve topics related to TF (Table 1). It has been found that both physicians and nutritionists agree or strongly agree with most of the topics to be included in TF training (mean score for response score greater than 4). Only in item 10, and for both professionals, the average was slightly below a score of 4. For both nutritionists and physicians, topics with a greater level agreement were related to "Health" and the lowest level of agreement lies in the "Stakeholders' insight". In terms of the topics' relevance, physicians considered all of them important or very important. Only the "Controversies" topic had a lower average rating, with a score of 3.8. Nutritionists also classified most of the topics as important or very important, but the topics "Genetics", "Concerns", "Controversies" and "Stakeholders' insight" obtained a lower average score, classified as neither important nor important by this group of health professionals.
For both nutritionists and physicians, "Health" was the topic that had the least variation (assessed by the standard deviation) of answers concerning agreement and importance.
The "Precautionary Principle" was the topic that presented less variation in responses of importance for nutritionists. In order to measure the reliability of the surveys' items, the Cronbach Alpha test was applied. The numbers obtained were 0.94 for agreement and 0.97 for significance, revealing high internal consistency.

Physicians' and nutritionists' agreement and importance responses
were independent (p> 0.05) of all characterization data (gender, age, place of work and / or profession) ( Table 1).

Interviews
In the interviews, there were questions that sought to achieve a variety of impressions and perceptions that the various individuals have in relation to the training module on TF. These perceptions were reorganized into secondary groups (Table 2), with transcription of some of the respondents' comments (in the sections below). In general, health professionals have made an important contribution in all aspects. Table 2: Groups of answers given by nutritionists and physicians who were interviewed.

Main Group Secondary Groups
Nutritionists Physicians

Contents
The module is very comprehensive. x corresponds to a response attributed by health professionals *corresponds to the absence of response by health professionals.

Group I -Contents
With regard to content, what would you change, add or remove?
For the interviewees, the module's contents are well structured, comprehensive, well explained and arranged by topics. On the other hand, based on the destination degree of the training offer, they consider some more important topics and other less important ones. They raise concerns about the relevance of each content because, being health professionals, they already consider having some knowledge foundations in specific areas. They also express concerns about the training's duration, which may be short and, finally, about the module's operationalization, since moments of discussion during the learning process would be necessary.

Do you think it is feasible to manage the module with multiple topics?
In relation to the module structure, which is multidisciplinary and focused on the STS approach, health professionals agree that it is feasible and expected, fundamental, desirable and essential, as the new challenges in the food field require more sustainable production. On the other hand, TF is on the market and tend to increase. A structure that depends on trainers and targets students is pointed out, so as to pass on the information and increase receptivity to the topic, the attendance of this kind of training at the academic level being important.

Group 3 -Emerging Topics
Does the degree structure follow the emerging topics?
The answers related to this group demonstrated the interest of curricular units' coordinators in keeping updated contents, depending on each professor and curricular unit that is taught, and fulfilling requirements stipulated by accrediting entities.

Group 4 -Inclusion in the Degree Plan
If it were to include the module of TF training in the curricular plans of the degrees in Medicine and Nutrition Sciences, in which curricular unit (s) would it be feasible?
They consider it important to include the module in the health portion. There are, however, differences in the approach between the Nutrition Sciences degree and the Medical degree. In Nutrition Sciences, it is stated that it can be taught as a nuclear or optional subject. In Medicine, since there is no nutrition subject, they refer to it as continuing training.

Group 5 -Difficulties
Which difficulties do you foresee with the module introduction?
The interviewees report lack of materials / information on TF, lack of skills and difficulties in the multidisciplinary approach involving the module. There are doubts about the curricular units where the module can be integrated. There are also concerns about the receptivity of students and of health professionals and teachers, who are accustomed to a traditional teaching format and are resistant to changes in the structure of existing curricular units.
They also anticipate difficulties in attracting interest.

Is there any topic related to TF in the curricular plans of Medicine and Nutrition Sciences degrees?
Professionals report that there is not a single curricular unit that addresses TF; however, this topic may have been mentioned in genetics, either in the food context or in the human context. They consider that topics related to TF may also have been addressed in ethics, toxicology, food technology, community nutrition and public health. In the Medical degree, there is no curricular unit concerning nutrition and only contents related to risk factors of diseases are approached. There is a general absence of issues related to food quality and / or production.

Group 7 -Skills Acquired
What are the skills and competences to be acquired / developed with training?
Those interested, after training in TF, should have the competence to impartially inform and advise users on TF. If patients consume TF, monitoring is important for studies on the impact of TF on health. They also point out that individuals who have been trained should be able to filter and synthesize information and be able to give a reasoned opinion, this critical analysis being a major challenge. However, only those interested can acquire more knowledge.

Discussion
Studies with a multidisciplinary approach and / or CTS are in the literature, especially in the health and food areas, and so they report positive results. However, there is no similar work in the literature as proposed in this investigation, allowing only comparisons by analogy.

Feasibility of Teaching a Module with Multiple Subtopics
The results of this work are similar with the findings of Alonge et al. [18], where feasibility in teaching a module with several subtopics is stated, that is, with transfer of knowledge from several perspectives. The work of Alonge et al. [18] was conducted in the USA in the format of a module for postgraduate students, using multiple approaches concerning "implementing research and practice in public health." The potential of this method is the ability to demonstrate the diffusion and transfer of knowledge from various perspectives. This teaching approach can potentially influence the method of teaching at the postgraduate level in health professions, where various subjects intersect.

Difficulties in Applying the Module
It was possible to detect fears in the receptivity of teachers who are possibly used to the traditional format. Similar opinions were presented in the studies of Gehlert et al. [19], Reme et al. [20], Daniel Stokols [21]. Other difficulties reported in this research come from getting interested students. Studies by Abubakari [22], Kartens and O´Connor [23], Gero [24], corroborate these findings. It is corroborated by Daniel Stokols [21], that overcoming these challenges would require strategic training and experience, along with encouraging the development of interpersonal skills. Therefore, in general managing a module for multiple themes depends on who and whom one works with.

Degree Plan
The inclusion of the TF module in the Nutrition Sciences degree plan was more indicated in nuclear and / or elective subjects, such as: genetics, ethics, food toxicology, food technology and human nutrition. For the degree in Medicine, the prevalence was in optional subjects and / or activities at the end of the course.
Possibly this difference comes due to the nature of the courses, as nutrition science is more related to food issues and medicine congruent with health. On the other hand, some studies point out and, therefore, corroborate, the importance of physicians knowing more about nutrition, given the constant need for them to approach this topic in patient care [26]. In view of this, there appears to be a growing demand for inclusion of emerging issues in the curricula [27], and the need to improve the nutritional education of health professionals [28].
These demands come from changing views on health and disease. There are an increasing number of studies about food production, nutrition, health and interrelations in the context of climate change, increasing populations and urbanization [29]; such as: studies in the field of public health, since there are countries that face food shortages, water, as well as socio-demographic and diet-related changes [30,31]; as well as studies on transgenic foods, which involve food supply issues [32]. In response, higher education is increasingly being asked to train students who are able to deal with emerging and complex issues [33], such as the TF topic. Complex issues are often shrouded in scientific uncertainties and concerns and therefore generate divergences and require a well-rounded approach that is simultaneously ethical and social, economic and even political [5]. Therefore, I conjecture that the discussion of emerging issues should be managed in a formation that incorporates all these conflicting and ambiguous aspects, in which the TF are undoubtedly inserted. We hope that the training through this module can support the understanding of TF and significantly improve patient care.

Conclusion
With unanimity, the individuals involved in this study agree and consider the themes presented in the module structure to be important, although there is a difference between the courses of nutrition science and medicine regarding the way in which training is offered and in some content. They point there are difficulties in implementing a module in this format, however, will not be impossible. They positively believe that the module will contribute to students' proactive skill development. In view of this, our research corroborated the findings that the training proposed for a medical and nutritionist audience will provide a comprehensive understanding of the complexity of the TF topic.