Importance–Performance Analysis (IPA) of Foodservice Operation, Dietary Life Education, and Nutrition Counseling Tasks of Nutrition Teachers and Dietitians in Jeju, Korea

The purpose of this study was to analyze foodservice operation, dietary life education, and nutrition counseling tasks of nutrition teachers and dietitians in elementary, middle, and high schools in Jeju, Korea, and to provide effective ways to implement dietary life education and nutrition counseling in schools. This study surveyed 94 nutrition teachers and 46 dietitians working at elementary, middle, and high schools in Jeju during 7–14 May 2015. The importance and performance of 16 tasks of nutrition teachers and dietitians were measured using questionnaires. The data was analyzed by using the SPSS software and Importance–Performance Analysis (IPA). Importance was ranked in the order of foodservice operation (4.72), dietary life education (4.37), and nutrition counseling (4.24); and performance was ranked in the order of foodservice operation (4.48), dietary life education (3.70), and nutrition counseling (3.22). The importance–performance matrix showed that in Quadrant 4, the “Concentrate Here” item was “nutrition and dietary life education for students”, while in Quadrant 2, the “Possible Overkill” item was “cost control and office management”. These findings suggest that it is important to reduce unnecessary administrative and office management tasks in order for nutrition teachers and dietitians to implement effective nutrition education, dietary life education, and nutrition counseling programs.


Introduction
Jeju Island is located in the south part of Korea and it is the largest island in Korea [1]. The Jeju Special Self-governing Provincial Office of Education decided to focus on school meal nutrition management and the strengthening of dietary life education as priority issues to manage. The "Operational Plan for School Education" includes items related to the safety and nutrition of children's favorite foods, elimination of unhealthy foods, food safety, and nutrition and dietary life education.
It is important to develop good dietary habits during childhood and adolescence because dietary habits affect growth and are difficult to change. Nutrition and dietary life education advances the nutritional knowledge and dietary behaviors of children and positively affects their overall nutritional The questionnaires were distributed to the nutrition teachers and dietitians in Jeju who responded by email that they would participate in the survey. The survey was conducted through face-to-face survey, e-documents, and emails from 7 May 2015 to 14 May 2015. A total of 160 questionnaires were distributed, and 140 were collected (87.5%), which were used in the analysis. The Institutional Review Board approval number is JJNU-IRB-2015-016, and it was granted by the Jeju National University Institutional Review Board.

Contents of the Questionnaire
The questionnaire used for this study was developed by revising and complementing the Basic Direction of School Meals, 2015 [12] and other previous studies [20][21][22][23][24]. The questionnaire was composed of 10 questions on demographic and workplace characteristics, as well as 16 questions on the importance and performance of work tasks of nutrition teachers and dietitians. The scale items for importance-performance analysis were presented in Table A1.
With regard to demographic characteristics of the research targets, age, number of years at the job, employment type, and level of education were identified. For workplace characteristics, school establishment type, school type, school meal type, school meal operations, number of students eating school meals, and number of meals were identified.
The main jobs of nutrition teachers and dietitians were foodservice operation, nutrition and dietary life education, and nutrition counseling. The eight items on foodservice operation included menu planning, purchase management, cooking and serving, facility management, sanitation management, human resource management, quality management, and cost control and office management. The five items on nutrition and dietary life education included nutrition and dietary life education planning, nutrition and dietary life educational materials development, nutrition and dietary life education for students, nutrition and dietary life education for teachers to guide students, and nutrition and dietary life education for parents to guide students. The three items on nutrition counseling included nutrition counseling for students, nutrition counseling for teachers of students requiring special attention, and nutrition counseling for parents of students requiring special attention.
Each item was scored on a 5-point Likert scale, with the measurement of task importance ranging from 1 (very unimportant) to 5 (very important), and the measurement of task performance ranging from 1 (very dissatisfied) to 5 (very satisfied).

Statistical Analysis
In this study, the final data from 140 questionnaires was analyzed using SPSS 18.0 (SPSS, Inc. Chicago, IL, USA). A paired-sample t-test was used to compare the mean of importance and performance data. An independent t-test and ANOVA were conducted to observe differences according to demographic and workplace characteristics. Duncan's multiple-range test was performed as a post hoc test of ANOVA.
To construct the importance-performance matrix, the means of the performance and importance ratings of each attribute were calculated. The attributes in Quadrant 1 are high-importance and high-performance and are labelled "Keep Up the Good Work". The attributes in Quadrant 2 are low-importance and high-performance and are labelled "Possible Overkill". The attributes in Quadrant 3 are low-importance and low-performance and they are "Low Priority". The attributes in Quadrant 4 are high-importance and low-performance and are labelled "Concentrate Here" [14,25].

Demographic and Workplace Characteristics
The demographic and workplace characteristics are shown in Table 1. The participants were generally aged between 40 and 49 years (57.9%), followed by 30-39 years old (17.1%), over 50 (14.3%), and below 30 (10.7%). The number of years at the job was in the order of from 10 to 20 years (37.9%), Nutrients 2017, 9,1157 4 of 13 below 10 years (35.0%), and more than 20 years (27.1%). Employment type showed that there were more nutrition teachers (67.2%) compared to dietitians (32.8%). More participants had attained their highest education level from a university (67.9%), compared to post-graduate schools (32.1%). The analysis of workplace characteristics indicated that the school establishment type was generally skewed towards national/public (89.3%) rather than private (10.7%). The school types were led by elementary schools (55.0%), followed by middle school (22.1%), high school (17.9%), and then others (5.0%). The type of school meals was skewed towards urban (55.7%) rather than rural and islandic styles (44.3%). School meal operations were led by individual management of meals (90.7%) rather than joint management and cooking (9.3%). The number of students eating school meals was led by the less than 500 group (57.1%), followed by the less than 1000 group (22.9%), and the more than 1000 group (20.0%). In terms of number of meals, the 1 meal per day (84.3%) selection was more than that of 2 or 3 meals per day (15.7%).

Difference between Nutrition Teachers and Dietitians According to Demographic and Workplace Characteristics
An analysis of the demographic characteristics and differences in the work environment among nutrition teachers and dietitians indicated that there were statistically significant differences according to age (p < 0.01), job experience (p < 0.001), level of education (p < 0.001), school establishment type (p < 0.001) and school meal operation (p < 0.01) ( Table 2). It was found that nutrition teachers were generally older than dietitians. Nutrition teachers also had longer job experiences than dietitians. However, dietitians were found to have higher levels of education. In terms of school establishment type, nutrition teachers worked generally in national and public schools, while dietitians worked in not only national and public schools but also in private schools. In terms of school meal operation types, nutrition teachers had engaged in individual cooking and in joint management and cooking, while all dietitians had engaged in individual cooking.

Difference between the Importance and Performance of Nutrition Teachers' and Dietitians' Tasks
The tasks of the nutrition teachers and dietitians were divided into three categories-foodservice operation, dietary life education, and nutrition-in order to analyze their importance and performance ( Table 3). The results of the analysis indicated that the importance ratings of all categories were significantly higher than the performance ratings (p < 0.05). Foodservice operation showed the highest importance score, followed by nutrition and dietary life education, then nutrition counseling. Foodservice operation also had the highest performance score, followed by nutrition and dietary life education, then nutrition counseling. In the foodservice operation part, sanitation management was of highest importance, while purchase management had the highest performance. In the dietary life education part, importance was highest for education for students, while nutrition & dietary life education planning had the highest performance. In the nutrition counseling part, the highest importance was ranked in the order of nutrition counseling for students, nutrition counseling for parents of students requiring special attention, then nutrition counseling for teachers of students requiring special attention; on the other hand, highest performance was in the order of nutrition counseling for students, nutrition counseling for teachers of students requiring special attention, and nutrition counseling for parents of students requiring special attention.

Importance-Performance Analysis (IPA) of Nutrition Teachers' and Dietitians' Tasks
There were statistically significant differences between performance and importance in all 16 task items for nutrition teachers and dietitians (Table 3). Therefore, there was room for improvement on all items. As such, this study has conducted the Importance-Performance Analysis (IPA) to set long-and short-term operational improvement strategies by identifying priorities depending on the needs of the consumers and presenting them on a grid (Figure 1). They were divided into 4 quadrants with the base of 4.53 importance points and 4.00 performance points on average.   Quadrant 1 can be termed as "Keep Up the Good Work" as it has high importance and performance, wherein the work items are carried out in accordance to the perception of importance by the consumer; this includes (1) menu planning; (2) purchase management; (3) cooking and serving; (4) facility management; (5) sanitation management; (6) human resource management; and (7) quality management. Items in Quadrant 1 generally cater to foodservice operation; their current level of performance should be maintained and continuously improved. According to Table 3, the importance perceived by the consumer and the perceived level of performance were different in all items; hence, methods to decrease the gap between performance and importance should continuously be sought, even though this is the quadrant where maintaining present levels is sufficient. Quadrant 2 has a high level of performance despite a low level of importance and can be termed "Possible Overkill". This quadrant includes (8) cost control and office management, and relates to  Quadrant 1 can be termed as "Keep Up the Good Work" as it has high importance and performance, wherein the work items are carried out in accordance to the perception of importance by the consumer; this includes (1) menu planning; (2) purchase management; (3) cooking and serving; (4) facility management; (5) sanitation management; (6) human resource management; and (7) quality management. Items in Quadrant 1 generally cater to foodservice operation; their current level of  Quadrant 1 can be termed as "Keep Up the Good Work" as it has high importance and performance, wherein the work items are carried out in accordance to the perception of importance by the consumer; this includes (1) menu planning; (2) purchase management; (3) cooking and serving; (4) facility management; (5) sanitation management; (6) human resource management; and (7) quality management. Items in Quadrant 1 generally cater to foodservice operation; their current level of performance should be maintained and continuously improved. According to Table 3, the importance perceived by the consumer and the perceived level of performance were different in all items; hence, methods to decrease the gap between performance and importance should continuously be sought, even though this is the quadrant where maintaining present levels is sufficient. Quadrant 2 has a high level of performance despite a low level of importance and can be termed "Possible Overkill". This quadrant includes (8) cost control and office management, and relates to administrative tasks in meal management that are carried out more frequently than is required for their level of importance.
Quadrant 3 is a zone of "Low Priority" with low importance and low performance, and includes (9) nutrition and dietary life education planning; (10) nutrition and dietary life educational materials development; (12) nutrition and dietary life education for teachers to guide students; (13) nutrition and dietary life education for parents to guide students; (14) nutrition counseling for students; (15) nutrition counseling for teachers of students requiring special attention; and (16) nutrition counseling for parents of students requiring special attention. Items relating to Quadrant 3 generally relate to nutrition and dietary life education and nutrition counseling, and were not perceived as important as tasks relating to foodservice operation in Jeju, Korea.
Quadrant 4 is termed "Concentrate Here" with high importance but comparatively low performance, resulting in dissatisfied consumers; items belonging here need to be prioritized in the short term. This quadrant includes (11) nutrition and dietary life education for students, and this item requires focus and execution in the near future.

Discussion
This study examined the tasks of nutrition teachers and dietitians in elementary, middle, and high schools in the three categories of foodservice operation, nutrition and dietary life education, and nutrition counseling. Their importance and performance were also analyzed to identify key areas requiring management among the tasks of nutrition teachers in Jeju. Through these steps, this study aimed to identify methodologies for comprehensive and practical dietary life education and nutrition counseling.
Nutrition teachers were generally found to be older than dietitians, and with longer work experience, although dietitians had a higher level of education. Han [11] also stated that nutrition teachers were generally older than dietitians. In terms of school establishment type, nutrition teachers generally worked in national and public schools, whereas dietitians worked in national, public, and private schools. In terms of foodservice operations, nutrition teachers generally cooked individually with some joint management and cooking, while dietitians only cooked individually.
Under the Enforcement Decree of the Elementary and Secondary Education Act amended in 2003, when a school cannot hire a nutrition teacher due to reasons such as a high demand for teachers, the school must hire a licensed dietitian [26,27]. Following the School Meals Act amended in 2006, a school dietitian is considered a public official for hygiene from 2007, and is generally changed to a nutrition teacher upon passing the teacher certification exams. While nutrition teachers are full-time school nutritionists, dietitians often share the same work as nutrition teachers but are not treated like them and tend to be on contract [8,27].
Moreover, a study indicated that there were more than twice the number of dietitians with degrees higher than Master's compared to nutrition teachers, which was in line with the findings of this study. The problem was that dietitians with no education degree had gone to graduate schools, which certified them as nutrition teachers; however, there were very few new-hires for nutrition teachers.
In analyzing the importance and performance of the work of nutrition teachers and dietitians, divided into the three categories of foodservice operation, dietary life education, and nutrition counseling, the importance of all three categories was significantly higher than their performance. Moreover, compared to the tasks relating to foodservice operation, the importance and performance of dietary life education and nutrition counseling were ranked lower. In a study on nutrition teachers in Seoul by Park [20], tasks relating to nutrition education and counseling had lower performance and perceptions of importance compared to foodservice operations, and this was also in line with the results of this study.
The results of the IPA have included mainly foodservice operation items in Quadrant 1, "Keep up the Good Work". Their current level of performance should be maintained and continuously improved. Quadrant 2, "Possible Overkill", included "cost and administrative management," and the indicated that this item was being carried out more frequently than is required for its level of perceived importance. Yang [28] and You et al. [29] also indicated that the administrative tasks of nutrition teachers and dietitians were excessive, which are in line with this study. According to Yang [28], among the tasks that require job improvement and reduction, "simplification of administrative documents" was highest at 37.9%, "reducing official documents on school meals" was at 25.0%, and "transferring other tasks" was at 19.7%, revealing a high demand for reducing administrative work. Regarding tasks with work transfer and reduction, You et al. [29] indicated high response rates of 109 (35.1%) for "support for school meal costs and milk", 83 (26.7%) for "reporting and reconciling budgets", and 75 (24.1%) for "various requested and reporting documents". It was clear that nutrition teachers were concerned and stressed with overwork and wanted work transfer and reduction to effectively manage it. Thus, it is important to reduce cost and administrative work such as office management, and strengthen the original work function of nutrition teachers and dietitians.
Items in Quadrant 3 generally relate to nutrition and dietary life education and nutrition counseling, and were not perceived as important as tasks relating to foodservice operation in Jeju. Han [11] also indicated that nutrition counseling had low work performance and was perceived as low importance by nutrition teachers and dietitians, regardless of rank. Such results indicate that school nutrition teachers and dietitians perceive the setting of nutrition education plans, nutrition education execution, and nutrition counseling to be important but difficult; difficulties associated with nutrition education and counseling due to low levels of knowledge and confidence and low perceptions of school management were in line with other studies [17,[30][31][32][33]. Hence, there must be institutional support and education for school nutritionists to become proficient in nutrition education and counseling.
Quadrant 4 includes "nutrition and dietary life education for students", and this quadrant requires focused management. While there are legal foundations of placing nutrition teachers in schools, there is weak institutional support to help these nutrition teachers carry out their duties within schools. They are typically unable to engage in their original role of providing nutrition education, and focus instead on the existing foodservice operations. According to existing studies on nutrition education [17,34], more than 95% of principals, parents, and teachers indicated that nutrition education was required, and more than 85% believed that nutrition education should be delivered by nutrition teachers. However, despite the high perceived necessity of nutrition education, the actual level of execution was low. While elementary schools saw more active execution of nutrition education compared to middle and high schools [35,36], the direct delivery of nutrition education in Seoul and Gyeonggi regions was 36.8%, 26.6% in Gangwon Province [37], and less than 10% in Jeonbuk [38].
Kim [39] asserted that the job satisfaction levels of nutrition teachers were lower than the expected levels before they became nutrition teachers. This results from the high expectations from authority and independence on nutrition counseling and education, and its discrepancy with the reality where they are perceived simply as managers of school meals.
You et al. [29] identified the perception and level of necessity on the items that require supplementation relating to the tasks and institutions for nutrition teachers. In school, dietary life education is carried out through Practical Education, Technology and Home, and Physical Education. Moreover, dietary life education by nutrition teachers and dietitians is being carried out through topics such as obesity education, dietary life and cultures, managing picky eating, cooking practicums, experiencing kitchens, meal etiquettes, nutrition, and practicing tradition. However, due to the excessive amount of work expected of nutrition teachers and dietitians, the burden of operating a class, and the lack of independent educational curricula, the dietary life education offered in schools faces various obstacles [40].
Moreover, there are various guidelines such as the guidelines for nutrition and dietary life by the Ministry of Food and Drug Safety, Children's Dietary Lifestyles Guide [41], and Guidelines for Green Dietary Lifestyle [42]. However, they remain insufficient to meet the diverse level of educational demands and skill levels of students [43]. According to Park et al. [16], 59.5% of dietitians engaged in nutrition education and its methods; however, majority of the education is carried out using handouts and is indirect in nature. Among the reasons for not engaging in nutrition education, excessive amount of work was the most cited (75.8%). After the introduction of nutrition teachers, Jun [19] indicated that 80% of the research targets engaged in indirect nutrition education, and the reasons for not being able to engage in direct education were the lack of educational opportunities (36.9%) and excessive work relating to foodservice operation (33.3%). In a study of the status of nutrition education in the Gyeongnam region [18], the reason for being unable to engage in direct nutrition education was mainly the excessive work relating to foodservice operation (34.2%). In a study focusing on elementary schools nationwide [17], the reasons for the same were ranked in the order of institutional reasons (62.5%) and lack of time due to excessive amounts of work (62%), similar to the results of this study. The study by Yoon [35] indicated that institutional problems must be addressed as nutrition education was generally indirect (72.4%); methods of improving and introducing direct education included a comprehensive education process, diversification of educational programs, and allotment of time for education and perceptions of school management. Kim et al. [22] indicated that to invigorate the dietary life education for elementary schools in Chungbuk, introduction of an independent class for dietary life education was found to be the most important (44.2%). In a study by Jung and Lee [13], the development of learning materials by school year (4.28) and regularity of education (4.26) were presented as potential solutions.
Based on the results of this study, we provide recommendations for achieving practical and comprehensive nutrition and dietary life education and nutrition counseling, whose performance was found to be much lower than foodservice operation. Nutrition teachers and dietitians face difficulties in offering education and counseling on nutrition due to the excessive work relating to school meals and administrative tasks, resulting in a lack of time for the education and counseling. Hence, there must be methods to decrease the unnecessary administrative work so that nutrition and dietary life education and counseling can be executed effectively. Moreover, it should be granted independent class time, settling eventually as a regular class by itself. The development of various educational materials on nutrition and dietary life is also critical to ensure that the classes meet the various educational needs and skill levels of students.

Conclusions
Among the tasks of nutrition teachers and dietitians, nutrition and dietary life education for students is the most important to concentrate on, while cost control and office management tasks should be reduced. In order for nutrition teachers and dietitians to implement effective nutrition and dietary education, it is important to reduce unnecessary administrative and office management tasks.
Author Contributions: Eun A Park was responsible for data collection and drafting the manuscript. Mi Na Jo analyzed the data and revised the manuscript. In Sook Chae supervised the overall research and critically revised the manuscript. All authors read and approved the final manuscript for submission.

Conflicts of Interest:
The authors declare no conflict of interest.