Public Health Nutrition: 25(8), 2084–2098 doi:10.1017/S1368980022000866 Values and preferences influencing willingness to change red and processed meat consumption in response to evidence-based information: a mixed methods study Anna Prokop-Dorner1,* , Aleksandra Piłat-Kobla1, Joanna Zając2, Michalina Luśtyk1, Claudia Valli3,4, Aneta Łapczuk1, Monika Brzyska1, Bradley Johnston5,6, Dena Zera7,8, Gordon Guyatt8,9, Pablo Alonso-Coello4,10 and Malgorzata M Bala2 1 Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, 31-034 Krakow, Poland: 2Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland: 3Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain: 4Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain: 5College of Agriculture and Life Scinces, Texas A&M University, College Station, TX, USA: 6Department of Epidemiology & Biostatistics, School of Public Health, Texas A&M University, College Station, TX, USA: 7Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA: 8Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada: 9Department of Medicine, McMaster University, Hamilton, ON, Canada: 10CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain Submitted 11 October 2021: Final revision received 9 March 2022: Accepted 1 April 2022: First published online 8 April 2022 Abstract Objectives: The aim of the study is (1) to assess the extent to which omnivores are willing to stop or reduce their consumption of red and processed meat in response to evidence-based information regarding the possible reduction of cancer mortality and incidence achieved by dietary modification; (2) to identify socio-demographic categories associated with higher willingness to change meat consumption and (3) to understand the motives facilitating and hindering such a change. Design: During an initial computer-assisted web interview, respondents were presented with scenarios containing the estimates of the absolute risk reduction in overall cancer incidence and mortality tailored to their declared level of red and processed meat consumption. Respondents were asked whether they would stop or reduce their average meat consumption based on the information provided. Their dietary choices were assessed at 6-month follow-up. Additionally, we conducted semi-structured interviews to better understand the rationale for dietary practices and the perception of health information. Participants: The study was conducted among students and staff of three univer- sities in Krakow, Poland. Results: Most of the 513 respondents were unwilling to change their consumption habits. We found gender to be a significant predictor of the willingness. Finally, we identified four themes reflecting key motives that determined meat consumption Keywords preferences: the importance of taste and texture, health consciousness, the Values and preferences habitual nature of cooking and persistence of omnivorous habits. Meat consumption Conclusions: When faced with health information about the uncertain reduction in Evidence-based health information the risk of cancer mortality and incidence, the vast majority of study participants Cancer health risk were unwilling to introduce changes in their consumption habits. Mixed methods Over the past decades, medical and media discourse have influencers(4–6), promote particular nutrients, food products popularised various nutrients, foods and dietary patterns. or dietary habits as either beneficial or harmful to one’s Different social factors, such as national(1) and international health. This includes the consumption of red and processed health agencies(2), medical associations(3) and media meat, which is the focus of this paper. Recently, critics have *Corresponding author: Email anna.prokop@uj.edu.pl © The Author(s), 2022. Published by Cambridge University Press on behalf of The Nutrition Society. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. Values and preferences about meat consumption 2085 questioned the evidence informing recommendations and The socio-cultural context and dietary patterns the extent to which they reflect the values and preferences in Poland of the population targets(7,8). Firstly, political pressures from Despite disadvantageous health indicators (45·7 % of food companies influence both nutritional studies(9) and women and 62·2 % of men in Poland are overweight, dietary guidelines and governmental policies regarding as compared with the average for the European Union nutrition(10). Secondly, while there is a consensus that countries of 42·7 % and 57·1 %, respectively)(23), most dietary guidelines—like any other guidelines—should Poles (80 %) are convinced about their dietary habits being reflect the highest-quality available evidence(7,11), evidence healthy or very healthy and only fewer than one-fifth regarding the impact of diet on long-term health outcomes describes own diet as unhealthy (17 %)(24). Poles are among is typically of low or very low quality. This is certainly true the six least physically active nations in the European for data on the association of red meat consumption with Union(24). Polish dietary patterns studied in the last two cancer and cardiovascular risk(12–15). decades revealed changes with regard to increased meat At the other end of dietary recommendations, guidelines intake(25) and reproducing traditional culinary practices have typically neglected the impact of well-established associated with Eastern Europe(26). A comparison of dietary eating habits. They have also taken for granted changes patterns in three countries carried out in the HAPIEE study in consumption that well-informed individuals would be revealed that a high adherence to the traditional Eastern willing to make in response to possible health benefits(16). European diet, consisting of (1) bread and grain products, While the significance of values and preferences is often (2) potato, (3) legumes, (4) storable vegetables, (5) minimised when developing dietary recommendations, preserved fruits and vegetables, (6) dairy products and they are crucial when the evidence is uncertain and when egg, (7) poultry, (8) processed meat products and (9) lard effect estimates are small. The practice of evidence-based for cooking, was considerably higher in the Polish sample nutrition should involve not only awareness of the best compared with the Russian and Czech samples(26). A Polish available evidence and guidance to certainty in estimates daily menu includes bread at least once a day (90 % of of test properties, patients’ prognosis or treatment effects Poles) and fresh and frozen vegetables and fruits (62 % but also acknowledging individual and societal values and 61 %, respectively), meat and meat products (36 %) and preferences(17–19). We define them as the collection and fish (1 %)(24). In 2018, the consumption of meat per of goals, expectations, predispositions, beliefs, and abilities capita in Poland (62·4 kg in total)(27) was somewhat higher and resources to make the changes that individuals have than in other European countries, such as Germany for certain decisions that may influence their outcomes (61·3 kg), Italy (58·6 kg), Spain (59 kg) and the United [17:196]. In social sciences, values are conceptualised as Kingdom (54·5 kg)(28). Reduction in the consumption of a key component of culture and defined as abstract some products has been declared by three in ten adult concepts acquired through the process of primary and Poles, of whom 11 % excluded meat. The most crucial secondary socialisation, which guides individuals’ beliefs reasons for Poles for being on diet were willingness to hone and behaviours(20). Taken for granted conceptions about nutrition habits (35 %), illness (34 %), weight loss (32 %) or food, taste and health, as well as practices of satisfying doctor’s recommendations (23 %). Those motivated by hunger, celebrating festive occasions or marking social medical doctors mentioned having CVD (28 %), diabetes identity define lifestyle and impact health behaviours and (25 %) and alimentary tract disorders (21 %). Women more may therefore impede introducing changes thereinto(10). often than men followed some diets (31 % and 26 %, The authors of a systematic review on values and pref- respectively), and female consumers were typically more erences concluded that omnivores are attached to their consistent with their diet (18 % v. 15 %). Dieting was more meat consumption habits and are unwilling to change even common among individuals with higher education (38 %) when faced with potentially undesirable health effects; and younger respondents aged 18–34 years (36–38 %)(24). however, the available evidence was of low quality(21). The research question of this study was addressed in the Nevertheless, given that this constituted the highest quality context of the Polish culinary culture. of evidence available, it played a key role in developing a weak recommendation for continuing the current levels of red and processed meat consumption(22), a recommenda- Methods tion that proved controversial. The primary reason for the low-quality evidence is that no study had directly The aims of this cross-sectional mixed methods study(29) addressed the question at hand: When informed of the were as follows: (1) to assess the extent to which omnivores possible health benefits of reducing meat consumption, are willing to reduce their consumption of red and proc- to what extent would individuals currently regularly eating essed meat in response to evidence-based information meat be willing to modify their diet? Therefore, we under- regarding the reduction of cancer mortality and incidence took this mixed methods study to directly address the they might achieve by dietary modification; (2) to identify above question and explore peoples’ motivation for their which socio-demographic categories are associated with dietary choices. higher willingness to change their meat consumption 2086 A Prokop-Dorner et al. QUANTITATIVE PHASE QUALITATIVE PHASE QUALITATIVE PHASE MAIN SURVEY FACE-TO-FACE FOLLOW-UP SURVEY (computer-assisted INTERVIEWS (computer-assisted web interview) (in-depth interview) web interview) October 2019 December 2019 March 2020 - link to the online questionnaire - interviewees selected from the - link to the online questionnaire send via university mailing list respondents of the Main Survey send via e-mail to the Main Survey - invitation to participate in who consented to be interviewed respondents who consented to be subsequent phases of the study and provided contact data followed-up and provided contact (face-to-face interview) data Fig. 1 Study phases and general information on the recruitment of participants and (3) to understand the motives facilitating and hindering any of the following: active cancer, severe CVD or pregnancy, such a dietary change. We combined quantitative data unwillingness or inability to provide informed consent(31). collected during an online survey (computer-assisted At the stage of the analysis, we excluded professionally web interview) among students, staff and faculty members inactive individuals (eight respondents). of three universities in Krakow, Poland, with qualitative The invitation to participate in the survey, together with data from in-depth interviews carried out among a purpos- the background study and contact information as well as a ively selected sample of survey respondents (Fig. 1). link to the questionnaire, was sent to scientific and admin- The choice of the population was based on the assumption istrative employees and students via the electronic mailing that individuals with a higher educational status demon- systems of the three universities. strate the highest levels of health literacy(30) and more At the end of the main survey’s questionnaire, we asked often declare healthy dietary habits(24). To diversify the respondents to participate in subsequent parts of the study, sample, the study involved three universities, including including an in-depth interview and/or a brief follow-up both general and technical universities. The quantitative survey. Individuals who positively responded to the invita- measurement, conducted twice at an interval of 6 months, tion were contacted via phone or email. Participants were enabled us to describe the dominant preferences regarding not offered any incentives. meat consumption, while the qualitative study facilitated the understanding of the reasons and beliefs underlying Research instrument willingness or unwillingness to change diet. The questionnaires employed in the main and follow-up The study protocol(31) was developed as part of phases were developed by an interdisciplinary research an international cooperation within the framework of team previously involved in the systematic review on NutriRECS(22). The study was piloted with thirty-two values and preferences related to meat consumption(21). individuals from two Canadian provinces(32). All study The questionnaire used in the main survey explained the participants provided informed consent for inclusion in types of meat addressed in the survey. It was divided into the study. three parts: 1. Socio-demographic: it consisted of twenty-two items addressing respondents’ sex, age, education level, marital Quantitative phase status, religion, ethnicity, weight, height, physical activity, chronic illnesses and a family history of cancer. Recruitment of respondents 2. Meat consumption beliefs and behaviour: it consisted According to the domestic deliveries and consumption of twenty-three questions regarding red and processed report in Poland, the average intake of both unprocessed meat consumption. Respondents specified how many and processed meat in 2017 was 115 g/d (9 portions/week)(33). portions of each type of meat they ate in a week and which Based on these data, we defined the lower threshold for products from each type they ate the most. The question- the average intake of both red and processed meat as three naire provided a detailed description of the portions of portions/week and included only those respondents who unprocessed red meat(31). It also contained pictures illus- consumed at least three portions of either type of meat. trating both types of meat and portion sizes (see Furthermore, prior to completing the questionnaire, we veri- Supplementary Material 1). Next, respondents selected fied respondents’ eligibility for the study. The online question- three main reasons determining their decision about meat naire was completed only by individuals who did not declare consumption out of eleven categories, including price, Values and preferences about meat consumption 2087 health issues, taste, availability, family preferences, tradi- to plot the percentage frequency of score occurrences. tion, religion, preparation time, social context, animal Moreover, we conducted an exploratory logistic regression welfare, environmental issues and others. The subsequent analysis using the above variables as categorical variables: six items asked about food buying practices and another willingness (≥ 5 points on the 7-point scale) and unwilling- four items referred to satisfaction with the current diet. ness (≤ 4 points on the 7-point scale) to change meat 3. Direct choice exercise: it assessed willingness to consumption and calculated the OR and the associated reduce or eliminate red and processed meat consumption 95 % CI for willingness to eliminate or reduce meat when faced with information about the possible health consumption. The frequency and proportion of partici- effects related to the change in meat consumption habits. pants from the follow-up sample who introduced any This section included a description of each outcome changes in their meat consumption habits at 6 months (cancer mortality and incidence, see Supplementary was calculated. The data were analysed using IBM SPSS Material 3 Part Three) as well as absolute risk reductions Statistics (Version 26) predictive analytics software(36). for overall cancer mortality and incidence if respondents eliminated or reduced their meat consumption. The latter was based on absolute reductions visually displayed per Qualitative phase 1000 people using the MagicApp software derived from Research instrument a systematic review with dose-response meta-analysis(15,34) The semi-structured interviews were carried out by two (see Supplementary Material 2). It also included a video qualitative researchers according to an interview guide and a written explanation of how respondents should inter- (see Supplementary material 4) developed within the pret the data as well as a 7-point scale assessing respon- international cooperation(31). The interview guide covered dents’ willingness to change meat consumption (see questions on the key motives determining red and proc- Supplementary 3 Part Three). We also presented the corre- essed meat consumption and the evaluation of the health sponding certainty of evidence for potential health bene- information presented in the survey. The interview guide fits. When the respondent expressed unwillingness to was translated into Polish and piloted on a small sample. eliminate meat consumption after being presented with During the face-to-face interviews, interviewees were evidence for potential absolute risk reduction in adverse reminded their responses regarding their reasons for meat health outcomes, we asked about their willingness to consumption given in the questionnaire and encouraged to reduce consumption. We provided respondents with the elaborate on them. The cultural context of shaping individ- scenario of reduction in health risk tailored to their level uals’ beliefs and their related dietary practices typically of consumption declared in questionnaire Part One. results in people taking them for granted. For instance, The questionnaire used during the follow-up stage many of the individuals’ culinary and consumption was aimed to establish whether respondents had made practices are habitual. Such culturally acquired values any changes in meat consumption since participation in and preferences linked to dietary habits are challenging the main survey(31). Those who had introduced any to study. Therefore, asking indirect questions and probing changes to their meat intake pattern were presented with participants about what may be taken for granted is the four further questions regarding the reasons for such a most optimal qualitative research strategy to learn about change, including health outcome information provided people’s values and preferences. Talking about their previously. dietary habits and asking participants about the reasons The original English language version of the question- why they consume as well as maintain or change them naire and additional materials were translated into provided insight into the cultural norms underlying Polish and piloted on a sample of fifteen employees. The those values and preferences. The interviewers were self-administered questionnaires were distributed elec- probing the study participants to provide examples of their tronically via university mailing lists (main survey) or particular dietary practices and social situations involving directly to respondents’ email addresses (follow-up meat consumption. Interviewees were asked about their survey). Both quantitative phases were carried out using impression on the information on possible health benefits the LimeSurvey application dedicated to online surveys(35). related to the change in meat consumption presented in the main survey. Finally, they were encouraged to establish what kind of data could encourage any potential change Quantitative data analysis in their meat consumption. Frequencies of participants’ characteristics were described. The distribution of the continuous variables ‘willingness to Sampling reduce meat consumption in the face of undesirable cancer From among those who agreed to participate in health risks’ and ‘willingness to eliminate meat consump- the subsequent phases of the study, we purposefully tion in the face of undesirable cancer health risks’ was selected individuals based on their socio-demographic described using median and IQR. Histograms were used characteristics (i.e. sex) and declared meat consumption. 2088 A Prokop-Dorner et al. We made efforts to gather a heterogeneous sample of Table 1 Socio-demographic characteristics of the respondents participating in the main survey in October 2019 and in a follow-up women and men with low (a less than average number study in March 2020 of portions of red and processed meat) and high meat consumption (an average number of portions of red and Follow-up processed meat or more). Of the individuals with whom Main survey survey the interviews were arranged, two cancelled the appoint- n % n % ments without providing a reason. The recruitment process Sex was discontinued when data saturation was reached (i.e. Male 204 39·8 65 36·9 researchers provided repeated evidence for their concep- Female 309 60·2 111 63·1 tual categories, and further data collection would not Age 0–25 202 39·5 62 35·2 generate any new conceptual insights)(37). 26–40 174 34·0 68 38·6 ≥41 136 26·6 46 26·1 Qualitative data analysis Education The interviews were audio-recorded and transcribed Elementary/secondary 62 12·1 17 9·7 Post-secondary 73 14·2 20 11·4 verbatim. The analysis was conducted in an ongoing Higher 378 73·7 139 79·0 manner. We applied the analytical approach of thematic Occupational status analysis by Boyatzis(38). Both researchers kept their obser- Employee 318 62·0 113 64·2 Student 195 38·0 63 35·8 vations in a logbook throughout the process of data collec- Religion tion and analysis. The purpose of the qualitative analysis is Christianity 381 74·3 127 72·2 to emphasise how data fit together as a whole and bring Other 9 1·8 5 2·8 None 123 24·0 44 25·0 together the context and meaning(39). It requires starting Family history of cancer with data immersion and leads to familiarity with the Yes 253 49·3 content of the transcripts and enables noticing common No/I don’t know 260 50·7 themes. Next, we coded the gathered material using a mixed approach. We developed the codebook partly deductively and partly inductively, when reading through the data and Patterns of unprocessed and processed meat identifying emergent themes expanding the preformulated consumption list. In the next step, we focused on working through code As shown in Table 2, processed meat was more often reports aggregating segments of transcripts coded with the consumed than red meat. Meat consumption was signifi- same code. We displayed data to capture the variations of cantly lower in women compared with men (P < 0·001). themes. We also applied some visual tools to overview Every tenth woman (11·6 %) and every third man how many segments from each interview were assigned (30·4 %) declared eating more than four portions of red specific codes and to distinguish nuances of the themes. It meat per week, while 29·1 % (3/10) of women and enabled us to describe the individual values and preferences 44·1 % (4/10) of men declared consuming more than four of the interviewees and to identify broader patterns. We portions of processed meat per week. applied the constant comparison method to understand rela- The main factors determining the decision about tions between themes. Throughout the analysis, we wrote red and processed meat consumption were similar: summaries and memos to develop a deeper understanding taste (76·2 % and 74·5 % for red and processed meat, respec- of the patterns, form hypothesis and interpretations, as well tively), family preferences (35·5 % and 32·6 %, respectively), as document our insights. The MAXQDA2018 software was price (28·1 % and 34·3 %, respectively), availability (25·9 % used in all analytical procedures(40). and 38·2 %, respectively), health (23·2 % and 13·3 %, respec- tively) and preparation time (20·1 % and 35·5 % respectively). The taste of red meat was significantly more important for men than for women, while the preparation time was more Results important for women than for men. For both red and proc- essed meat, the preferences of family members were more Quantitative phase important for women than for men (P < 0·001 and P = 0·01, respectively), and for red meat, they were more important Response rate and socio-demographic characteristics for older respondents than for younger ones (P = 0·001). of participants Easy availability and short preparation time of processed meat The link to the survey was accessed by 3932 individuals, were more important for the youngest respondents than for and 2097 (53 %) respondents filled out the questionnaire. the other age groups (Table 3). We included 513 respondents in the main survey (mean age, 32·91 ± 12·63 years), and 333 respondents consented Willingness to eliminate or reduce meat consumption to participate in the follow-up. Of these, 176 (52·85 %) The results concerning the willingness to eliminate or responded to the follow-up survey (Table 1). reduce meat consumption were checked for normal Values and preferences about meat consumption 2089 Table 2 Self-reported consumption of red and processed meat per week (P < 0·001), n 513 Unprocessed red meat* Processed meat** Men n 204 Women n 309 Men n 205 Women n 311 Meat consumption per week n % n % n % n % < 3 portions 75 36·8 185 59·9 52 25·5 121 39·2 3–4 portions 67 32·8 88 28·5 62 30·4 98 31·7 5–8 portions 51 25·0 35 11·3 59 28·9 72 23·3 9–12 portions 9 4·4 1 0·3 16 7·8 10 3·2 > 13 portions 2 1·0 0 0·0 15 7·4 8 2·6 Data are presented as number (percentage). *P < 0·001 (Fisher’s exact test). **P < 0·001. distribution using the Kolmogorov–Smirnov test. None of of cancer incidence risk (P = 0·03) and cancer mortality risk these variables were found to have normal distribution (P = 0·02), as compared with male sex (Table 6). (P < 0·001) and are presented in Table 4. The percentage The multivariate logistic model analysis for willingness frequency of score occurrences is shown in Fig. 2. to reduce processed meat and for willingness to reduce Most respondents were unwilling to eliminate meat or eliminate red meat revealed no significant associations. consumption in the face of cancer incidence risk for both red (84 %) and processed (84·9 %) meat. Similarly, partici- Change in meat consumption at 6 months pants were reluctant to eliminate meat consumption in the Among the 176 participants in the follow-up phase, 74 face of cancer mortality risk for both red (86·6 %) and proc- (42 %) declared a change in their eating habits regarding essed (81·6 %) meat. The majority of respondents to the the consumption of red or processed meat since their question about the willingness to reduce the number of participation in the main survey. Of the respondents, portions of red and processed meat remained unwilling forty-nine ate less portions of red meat and three consumed to do so in the face of cancer incidence risk (91·3 % for more portions of red meat 6 months after the first survey. red meat and 94·6 % for processed meat). In the face of Similarly, for processed meat consumption, forty-six cancer mortality risk, the percentage of negative responses people declared eating fewer portions, while eleven was similar: 94·2 % for red meat and 95·2 % for proc- people ate more portions than reported in the main survey. essed meat. The most frequent reasons given as the key motivation to We performed preliminary analyses using the Pearson change red or processed meat consumption were health chi-squared test to identify associations between individual (56·8 % and 52·7 %, respectively), environmental issues variables and willingness to change meat consumption (24·3 % and 27 %, respectively), animal welfare (24·3 % habits. The only significant relationships were shown for and 27 %, respectively), preparation time (24·3 % and processed meat (Table 5). The willingness to eliminate in 18·9 %, respectively) and availability (12·1 % and 18·9 %, the face of cancer incidence risk was associated with respectively). About one-fifth of participants (21·6 %) gender and occupational status. Women were more willing declared that the change was definitely or possibly moti- to eliminate meat than men (P = 0·01). Students showed vated by the information provided during the main survey. lower willingness to reduce consumption compared with university employees (P = 0·045). Women were also more Qualitative phase likely to show willingness to eliminate when faced with the risk of cancer-related death (P = 0·006). Characteristics of participants A multivariate analysis for willingness to eliminate proc- Of the 347 individuals who agreed to participate in a face- essed meat in the face of cancer incidence risk was to-face interview, we included eleven individuals, of whom conducted using a logistic regression model with sex, six were under the age of 35, three were male and seven age, education, occupational status, religion and family reported a family history of cancer. The sampled individ- history of oncological diseases as independent variables. uals represented various meat consumption (Table 7). It confirmed the significance of gender; however, occupa- The qualitative material reflects a dominant significance tional status was found to be nonsignificant when these of daily dietary habits, well-established eating patterns, as variables were included in the model (Table 6). A similar well as health- and food-related convictions and compe- analysis conducted for willingness to eliminate processed tences. While meat is a common day-to-day and festive meat in the face of cancer mortality risk also confirmed food, plant-based food options were considered relatively the significance of gender. Female sex was associated with more demanding to prepare. On the other hand, many more than 2-fold higher odds of eliminating meat in the face interviewees were conscious about the recommendation 2090 Table 3 Key reasons for meat consumption by socio-demographic category Socio-demographic categories Sex, n (%) Occupation, n (%) Age group, n (%) Reasons for red meat consumption Male Female P value Employee Student P value 0–25 26–40 ≥41 P value Price 53 26·0 91 29·4 0·45 69 21·7 75 38·5 <0·001* 77 38·1 42 24·1 24 17·6 <0·001* Health issues 48 23·5 71 23·0 0·97 83 26·1 36 18·5 0·06 39 19·3 43 24·7 37 27·2 0·21 Taste 170 83·3 221 71·5 0·003* 233 73·3 158 81·0 0·06 163 80·7 131 75·3 96 70·6 0·10 Availability 55 27·0 78 25·2 0·74 74 23·3 59 30·3 0·10 60 29·7 45 25·9 28 20·6 0·17 Family preferences 52 25·5 130 42·1 <0·001* 120 37·7 62 31·8 0·20 64 31·7 60 34·5 58 42·6 0·11 Tradition 29 14·2 39 12·6 0·70 45 14·2 23 11·8 0·53 23 11·4 25 14·4 20 14·7 0·59 Religion 2 1·0 0 0·0 0·16† 1 0·3 1 0·5 0·99† 1 0·5 0 0·0 1 0·7 0·73† Preparation time 30 14·7 73 23·6 0·02* 64 20·1 39 20·0 0·99 41 20·3 30 17·2 32 23·5 0·39 Social context 30 14·7 40 12·9 0·66 46 14·5 24 12·3 0·58 25 12·4 27 15·5 17 12·5 0·62 Animal welfare 9 4·4 16 5·2 0·85 13 4·1 12 6·2 0·40 12 5·9 8 4·6 5 3·7 0·62 Environmental issues 6 2·9 14 4·5 0·50 15 4·7 5 2·6 0·32 6 3·0 8 4·6 6 4·4 0·68 Other 3 1·5 6 1·9 0·99† 4 1·3 5 2·6 0·31† 5 2·5 2 1·1 2 1·5 0·70 Sociodemographic categories Sex, n (%) Occupation, n (%) Age group, n (%) Reasons for processed meat consumption Male Female P value Employee Student P value 0–25 26–40 ≥41 P value Price 64 31·4 112 36·2 0·30 72 22·6 104 53·3 <0·001* 110 54·5 42 24·1 23 16·9 <0·001* Health issues 23 11·3 45 14·6 0·35 52 16·4 16 8·2 0·01* 19 9·4 28 16·1 21 15·4 0·11 Taste 152 74·5 230 74·4 0·99 241 75·8 141 72·3 0·44 143 70·8 135 77·6 103 75·7 0·30 Availability 73 35·8 123 39·8 0·41 103 32·4 93 47·7 0·001* 102 50·5 56 32·2 38 27·9 <0·001* Family preferences 53 26·0 114 36·9 0·01* 119 37·4 48 24·6 0·004* 47 23·3 62 35·6 58 42·6 0·001* Tradition 10 4·9 10 3·2 0·47 15 4·7 5 2·6 0·32 5 2·5 8 4·6 7 5·1 0·39 Religion 1 0·5 0 0·0 0·40† 1 0·3 0 0·0 0·99† 0 0·0 0 0·0 1 0·7 0·27† Preparation time 82 40·2 100 32·4 0·09 98 30·8 84 43·1 0·006* 86 42·6 61 35·1 35 25·7 0·006* Social context 11 5·4 26 8·4 0·26 29 9·1 8 4·1 0·05 7 3·5 17 9·8 12 8·8 0·04* Animal welfare 6 2·9 12 3·9 0·75 12 3·8 6 3·1 0·87 6 3·0 8 4·6 4 2·9 0·69† Environmental issues 4 2·0 7 2·3 0·99† 6 1·9 5 2·6 0·76† 5 2·5 1 0·6 5 3·7 0·16† Other 2 1·0 7 2·3 0·33 7 2·2 2 1·0 0·49† 2 1·0 5 2·9 2 1·5 0·40† A Prokop-Dorner et al. *Significant differences. †P value for the Fisher’s exact test of independence. Values and preferences about meat consumption 2091 Table 4 Willingness to reduce or eliminate red meat or processed meat consumption in the face of undesirable cancer health risk (7-point scale) Willingness to change meat consumption in Willingness to change meat consumption in the face of cancer incidence risk the face of cancer mortality risk Meat consumption n Median IQR n Median IQR Red meat Willingness to eliminate 156 2·00 1·00–4·00 157 2·00 1·00–4·00 Willingness to reduce 104 2·00 1·00–3·00 104 2·00 1·00–3·00 Processed meat Willingness to eliminate 312 2·00 1·00–4·00 315 3·00 1·00–4·00 Willingness to reduce 222 2·00 1·00–3·00 208 2·00 1·25–3·00 to reduce meat consumption due to health issues and point. Well, you can, of course, cheat and probably talked about their efforts to minimise the amount of make the same taste somehow different, but some- consumed meat or to buy meat products of good quality. thing is missing, [maybe it’s] that flavor called The significance of the various rationales discussed by ‘umami’, but I guess that’s the point. (Interviewee_9) the interviewees is depicted in Fig. 3. Besides taste, the texture of meat was discussed, The subsequent analysis of the relations between the a distinguishing mark of dishes containing meat: coded segments enabled us to identify four themes reflecting the key motives determining the preferences Well, every food has its own specific texture and if we connected to meat consumption and one overarching make a dish, it’s nice if each of its elements has its theme capturing the relation between them. own individual character : : : and I think it would be difficult to find a substitute for meat that would The importance of taste and texture accurately reflect what the texture of the meat really When talking about own meat consumption, all of our is like. Well, this is just a characteristic, I would say, interviewees referred to the senses, and some of them used that makes eating pleasant when you can differen- very sensual language to describe their attitudes toward tiate the ingredients of the meal through their own textures. (Interviewee_11) meat consumption. A few individuals referred to meat dishes as an object of ‘temptation’ or ‘a culinary delight’ that These hedonistic motives were presented by some of the they could not resist: interviewees as indisputable reasons that cannot be further negotiated or questioned. Researcher: What would help you to completely stop [eating meat]? Interviewee: I don’t know if I’d be able Partial health consciousness to stop. Sometimes I have to, I just have to taste it. As far as the impact of meat consumption on health is (Interviewee_2) concerned, the interviewees talked about two issues. I: [ : : : ] Yes, I feel like I’m addicted to meat [I. and Firstly, they tended to take a stand in the discussion on R. laugh]. Therefore, it’s a problem that meat is so whether meat is healthy or unhealthy. To support their appealing to me. Very much so. (Interviewee_4) thesis, most of them mentioned various microelements, I am a meat eater : : : and I’d rather not for example, proteins, vitamins, micronutrients and stop eating meat. Despite my love for animals, purines. The interviewees’ knowledge in this regard, I wouldn’t be able to abstain from consuming meat. however, seemed incomplete. Their convictions were (Interviewee_6) more consistent regarding meat quality. They talked a lot An attachment to meat-based dishes was discussed by most about the disadvantageous ingredients of meat products, of our interviewees in connection with meat’s unique char- such as additives and preservatives. They were critical acteristics, mainly with regard to its taste and texture. about the mass production and the quality of meat products Despite current discussions promoting plant-based diets, sold in supermarket chains. Most of the interviewees due to the uniqueness of the taste of meat, most of the inter- shared their own strategy of coping with the threat of viewees refused to completely eliminate meat from their low-quality meat products, for example, reading product diet. One of them discussed: etiquette or travelling long distances to buy meat only from R: What does meat have that you do not see in vegan known sources, often out of the city and in the countryside. or vegetarian dishes? I: Well, that’s a difficult ques- A 44-year-old study participant drives 300 km each month tion. I mean, it seems to me that a well-prepared meat to buy meat from a known source. She said: dish can do that : : : Meat easily absorbs the flavours When we return from shopping [in that particular of seasoning. Thus, for example, if you, let’s say, place], half of the freezer gets filled. And there is such prepare some ribs, and roast them properly, then a good sausage that my son likes very much. And we these herbs and spices are very noticeable at this buy everything there. Ham with no preservatives, but 2092 A Prokop-Dorner et al. Willingness to introduce changes to red meat consumption In the face of cancer incidence risk In the face of cancer incidence risk 40 30 30 Percentage Percentage 20 20 10 10 0 0 1·00 2·00 3·00 4·00 5·00 6·00 7·00 1·00 2·00 3·00 4·00 5·00 6·00 7·00 Willingness to eliminate RM Willingness to reduce RM In the face of cancer mortality risk In the face of cancer mortality risk 40 30 30 Percentage 20 Percentage 20 10 10 0 0 1·00 2·00 3·00 4·00 5·00 6·00 7·00 1·00 2·00 3·00 4·00 5·00 6·00 7·00 Willingness to eliminate RM Willingness to reduce RM Willingness to introduce changes to processed meat consumption In the face of cancer incidence risk In the face of cancer incidence risk 30 30 Percentage Percentage 20 20 10 10 0 0 1·00 2·00 3·00 4·00 5·00 6·00 7·00 1·00 2·00 3·00 4·00 5·00 6·00 Willingness to eliminate PM Willingness to reduce PM In the face of cancer mortality risk In the face of cancer mortality risk 30 40 Percentage Percentage 30 20 20 10 10 1·00 2·00 3·00 4·00 5·00 6·00 7·00 1·00 2·00 3·00 4·00 5·00 6·00 7·00 Willingness to eliminate PM Willingness to reduce PM Fig. 2 Percentage frequencies of respondents willing and unwilling to introduce any changes in meat consumption in the face of the undesirable cancer health risk Values and preferences about meat consumption 2093 Table 5 Willingness to eliminate processed meat in the face of cancer health risks according to socio-demographic categories Willingness to eliminate Willingness to eliminate processed meat in the face processed meat in the face of cancer incidence risk of cancer mortality risk No Yes No Yes Parameter n % n % P value n % n % P value Male 194 95·1 10 4·9 191 93·6 13 6·4 Sex 0·01* 0·006* Female 272 88·0 37 12·0 264 85·4 45 14·6 Age 0–25 190 94·1 12 5·9 0·12 183 90·6 19 9·4 0·54 26–40 155 89·1 19 10·9 152 87·4 22 12·6 ≥41 120 88·2 16 11·8 119 87·5 17 12·5 Education higher 340 89·9 38 10·1 0·22 331 87·6 47 12·4 0·10 elementary/secondary 60 96·8 2 3·2 60 96·8 2 3·2 post-secondary 66 90·4 7 9·6 64 87·7 9 12·3 Occupational status employee 282 88·7 36 11·3 0·045* 277 87·1 41 12·9 0·19 student 184 94·4 11 5·6 178 91·3 17 8·7 Religion Christianity 340 89·2 41 10·8 0·11† 334 87·7 47 12·3 0·48† other 9 100·0 0 0·0 9 100·0 0 0·0 none 117 95·1 6 4·9 112 91·1 11 8·9 Family history of oncological diseases no 241 92·7 19 7·3 0·19 234 90·0 26 10·0 0·42 yes 225 88·9 28 11·1 221 87·4 32 12·6 *Significant differences. †P value for the Fisher’s exact test of independence. Table 6 Willingness to eliminate processed meat: logistic regression models Willingness to eliminate processed Willingness to eliminate processed meat in the face of cancer incidence meat in the face of cancer mortality risk risk Parameter OR 95 % CI P value OR 95 % CI P value Sex (female) 2·24 1·07, 4·71 0·03* 2·25 1·16, 4·36 0·02* Age (0–25) 1 (ref.) – 1(ref.) – Age (26–40) 1·21 0·31, 4·68 0·78 0·79 0·26, 2·36 0·67 Age (≥ 41) 1·26 0·31, 5·13 0·75 0·79 0·24, 2·53 0·69 Education (higher) 1(ref.) – 1 (ref.) – Education (elementary/secondary) 0·64 0·12, 3·29 0·59 0·30 0·06, 1·45 0·14 Education (post-secondary) 1·89 0·57, 6·22 0·29 1·15 0·42, 3·13 0·78 Occupational status (student) 0·49 0·12, 2·00 0·32 0·64 0·20, 2·02 0·45 Religion (Christianity) 1(ref.) – 1(ref.) – Religion (other) NA† – NA† – Religion (none) 0·47 0·19, 1·17 0·10 0·76 0·38, 1·55 0·46 Family history of oncological diseases (yes) 1·47 0·78, 2·76 0·23 1·20 0·68, 2·12 0·53 *Significant differences. †Has not been calculated due to 0 cell count (category ‘yes’). you have to queue for an hour there as there are so R: So, does that mean that if the results indicated that many people shopping there. Well, this is an old some 90 fewer people would get cancer that would proverb—my mother always told me: ‘if you don’t convince you? I: Exactly. Because then it’s more pay a baker, you will have to pay a doctor’. likely that you could find yourself in one of these (Interviewee_4) groups. Yes. R: And if it weren’t 50 %, just let’s say When reminded of evidence-based information about the 40 %, that is, 60-something fewer people would get cancer, would that convince you? I: [pause] It’s hard health effects of meat reduction or elimination tailored to to say. I suppose that it wouldn’t convince me to stop the level of meat consumption they had declared in the completely because I already eat meat and it’d be main survey, the interviewees remained rather sceptical hard to stop. (Interviewee_3) of introducing any dietary changes. Most of them declared that only a more spectacular effect could convince them. For some interviewees, the overall certainty of evidence One of the interviewees outlined his view: was more important than the size of the effect itself. The interviewees deliberated that a high or very high certainty R: And what effect would convince you to reduce of evidence would convince them. For some however, the or eliminate meat consumption? I: Let’s say 50 %. change would not come without a price: 2094 A Prokop-Dorner et al. Table 7 Characteristics of the study participants of the qualitative interviews Meat consumption (portions/week) Satisfaction Willingness to Willingness to with dietary Age Health status/family Red Processed eliminate/reduce eliminate/reduce habits ID Sex (years) Education level cancer history meat meat red meat processed meat (1–7) 1 F 29 Higher ?/Y 1–2 3–4 – 4/- 4 2 F 43 Higher Hashimoto disease/Y >1 3–4 – 7/- 2 3 M 43 Higher not þ/N 3–4 1–2 2/3 – 4 completed 4 F 44 Higher -/? >1 5–6 – 2/2 3 5 F 60 Scientific degree Asthma/Y 3–4 3–4 3/4 6/- 5 6 F 63 Higher þ/Y 3–4 3–4 3/5 5/- 4 7 M 35 Scientific title þ/Y 5–6 7–8 -/- 1/1 4 8 F 32 Higher þ/Y 3–4 3–4 1/1 1/1 5 9 M 20 Higher þ/N 7–8 3–4 2/6 -/- 7 10 F 33 Scientific title Allergy/Y 1–2 5–6 -/- 4/- 5 11 F 22 Post-secondary -/? 1–2 >1 -/- -/- 3 ‘þ’: no health problems reported; ‘-‘ some health problems reported; ‘Y’- family history of cancer; ‘N’: no family history of cancer; ‘?’: I don’t know. INTERVIEWEES CODES 1 2 3 4 5 6 7 8 9 10 11 RATIONALES FOR MEAT CONSUMPTION TASTE HEALTH FAMILY PREFERENCES CULINARY COMPETENCES PREPARATION TIME MEAT SOURCE TRADITION PRICE AVAILABILITY SOCIAL OCCASIONS ANIMAL WELFARE RELIGION ENVIRONMENT Fig. 3 Overview of the rationales for meat consumption discussed during qualitative interviews. Circles represent the coding frequency, and the calculation of the circle size refers to the column. The larger the circle, the more central the rationale was to the interviewee’s individual preferences R: And if you thought about the certainty of Habitual nature of meat consumption evidence? I: ( : : : ) If it was a higher certainty as to A clear pattern blocking the study participants’ willingness the probability of these studies, then maybe I would to change their omnivorous habits is their cooking compe- decide to, even with this effect size. R: We assess the tence and socialisation in a particular culinary culture. certainty on a 4-point scale. How high on this scale One of the interviewees, when asked what would help should it be? ( : : : ) I: Certain or very certain. ( : : : ) her to reduce your level of consumption of meat, said: R: If the evidence were of a third or fourth degree of certainty, do I understand correctly that it’d be I: : : : I think it’d have to be a re-evaluation of my enough to convince you? I: I might take it into consid- cookbook. What I mean is that, if you’ve been taught eration. Then I’d be able to eat meat once a day : : : since being a child that meat was always there, and Once a week at home [laughs] R: And if the effect of there are many recipes with meat and few vegetarian reducing or stopping meat consumption was even ones : : : For me, at the moment, trying more greater? With a high degree of certainty, would vegetarian recipes : : : is a bit of a pain in the neck. you be ready to stop? D: I would but with a heavy Because I have to try to cook something that, after heart. (Interviewee_6) reading the recipe, I am aware that I might like Values and preferences about meat consumption 2095 it—and this is also not obvious—but you know, since For some interviewees, meat during social gatherings is asso- childhood you get used to certain flavours : : : so you ciated with delicacy, being festive and pampering oneself: won’t always like new dishes that you try. When meeting friends, as one would say, meat (Interviewee_8) rules : : : . When you enjoy yourself in good A key barrier here seems the conviction that cooking company, then culinary pleasure is also important. without meat is difficult. Well-known recipes seem And it all seems cumulative, right? Because one quick and simple as opposed to plant-based dishes pleasure is combined with another. Ham rules as associated with creativity, sophisticated ingredients and a sandwich ingredient and meat for dinner is time-consuming culinary procedures. Both female and [obvious] : : : Few people consciously give up meat. male interviewees talked about the practical advantages Well, because meat is more expensive, when you of an omnivorous diet: are a guest. It was always the meat that was the right choice, at least among my friends. (Interviewee_4) [I like preparing meals with meat], they’re so quick. It only depends on what form I decide to use for Many interviewees took a cold meat platter on a party cooking. And : : : well, I often roast or grill meat in menu for granted and perceived that being fussy about the oven. It’s so easy too, and it does the job quickly. meat-based dishes when being a guest as socially inappro- (Interviewee_5) priate. As hosts, on the other hand, the interviewees tended Meat is easy to season—you just sprinkle on some to willingly follow this pattern or adjust to omnivores’ pref- pepper and salt and that’s it. However, for plant- erences, for example, due to the preference of male guests based dishes there are various possibilities, and I to have a fatty snack with alcoholic drinks. Efforts made to have the impression that preparing a vegetarian introduce vegetarian dishes at barbecues are perceived as a dish requires more creativity and more ingredients minority preference uniting non-omnivores into a separate are combined. Some kind of pepper, curry, herbs, category. Restricting the consumption of meat is practised spices, or whatever : : : . Those kinds of thing. Meat by some interviewees mainly in a religious context. Four doesn’t necessarily require this, which, in this interviewees conformed to religious practices of meatless respect, makes it easier to prepare a meat dish. It’s Fridays or avoided meat as part of a resolution for the fail-safe. (Interviewee_7) fasting period of Lent in the 6 weeks running up to Easter. Another cognitive barrier to going beyond our own culi- nary habits is the belief that vegetarian meals are not stodgy The value conflict: healthy v. familiar and would not be accepted by members of the household. Finally, we found that the practices connected to meat Our interviewees often mentioned their closest relatives, preparation and consumption are contextualised by a when explaining their meat consumption habits. Some conflict of two dominant values: what people believe is specific practices, reoccurring meat dishes, are often attrib- healthy and what they are familiar with. Valuing well-being uted to the child’s or spouse’s liking: and health on the one hand, and being attached to and being bound to practical and sensory preferences rooted Usually I make stew or spaghetti, which [my son] loves in early socialisation, on the other hand, leads to a disso- and sometimes stewed pork chops. ( : : : ) In our nance. However, this value conflict does not appear to household my son determines what is cooked. be strong enough to clearly motivate efforts to follow health If it wasn’t for my son, I wouldn’t eat meat. information and introduce change in meat consumption (Interviewee_2) habits. Persistence of meat-eating rituals We observed strong conformism toward including meat dishes in a festive menu. Most of the interviewees took Discussion meat as a component of social gatherings for granted. For family meetings, let us say, we go to my parents or When faced with health information about the uncertain my in-laws, they prepare a plate, let us say of reduction in the risk of cancer mortality and incidence, charcuterie, usually this includes kabanos sausage, the vast majority of study participants were unwilling to ham : : : . They are cut up into bite-size pieces and introduce any changes in their consumption habits. you are sitting there, so, you know, you just eat it. Small differences were observed in regard to the type of (Interviewee_3) meat (red v. processed), the health risks reductions (cancer Going out, meeting someone or visiting somebody mortality risk v. cancer incidence risk) or the extent of the as a guest, we step out of line if we strive to avoid meat consumption change (stop v. reduce). Gender was the dishes. It is hard because it seems to me that it is so significant predictor of the willingness. Women not only ever-present that wherever you socialize with tend to be more willing to eliminate and reduce meat when someone, you will find meat. (Interviewee_11) faced with evidence-based information, but also more 2096 A Prokop-Dorner et al. frequently prioritise practical and less frequently hedonistic their diet. Instead, they have adopted their shopping strat- reasons to consume meat than men. Moreover, occupa- egies to minimise the risk of consuming low-quality prod- tional status determined the differences in regard to the ucts. A similar tendency was observed in a Danish study(42). willingness to eliminate processed meat in the face of Furthermore, the participants of our study, similarly to city cancer incidence risk. The division between the male dwellers surveyed on the determinants of food choices in and female preferences regarding meat consumption the central region of Poland(43), did not talk about the envi- cannot be interpreted without considering the impact that ronmental consequences of their consumption. The results gender norms have on the health-related practices. Our of the survey by Rejman et al.(43) revealed that environ- data suggest that women not only consume less portions mental factors gave way to other determinants such as of meat weekly and significantly more often organise taste, food quality, healthy ingredients and supporting local weekly menu than men but they are also more reflective food producers. The discourse on the environmental about their dietary habits. Despite being rooted in a consequences of meat consumption impacted the dietary particular cultural context, our findings correspond with practices of Poles to a smaller extent than the beliefs and the studies conducted according to the same main habits of Europeans in other countries. From twenty-five protocol(31). The significance of gender as a key correlate nations surveyed in 2005(41), Poles (68 %) together with of dietary habits and of the preferences related to meat Czechs (74 %), Slovaks (73 %) and Estonians (69 %) were consumption that we observed is in line with the recent the least concerned about the welfare of the animals from systematic review(21). which the meat they buy is sourced, in comparison to Moreover, we observed that meat consumption was Swedes (29 %), Greeks (29 %) Luxembourgers (32 %) and closely related to the respondents’ lifestyle. Easy access Danes (35 %), who most often reported paying attention to meat-based dishes is more important for students than to the welfare of farmed animals(41). Ten years later, for employees while family preferences determine food attitudes toward animal welfare in Poland were still less choices of people in the older age groups to a greater extent clear than in other countries. Every eighth Pole was not able than of those in the younger age group. to relate to any of the four statements describing animal Furthermore, we identified four themes reflecting key welfare. While almost every respondent in Sweden motives determining meat consumption preferences: the (99 %), Finland (99 %) and Portugal (99 %) considered importance of taste and texture, health consciousness, animal welfare to be ‘important’, Poles (86 %), Hungarians the habitual nature of cooking and persistence of omnivo- (86 %) and Croatians (86 %) were the most sceptical rous habits. The qualitative material reflects also the clash about it(44). of two conflicting values: health- and food-related convic- Similar to the findings from a systematic review(21) as tions and well-established eating habits and sensory and well as from another study(45), the majority of our partici- practical preferences. While meat is taken for granted not pants were reluctant to change their meat consumption only as the component of festive menus but also daily food habits. The evidence-based information about the health product, plant-based diet appears to be too demanding or effect of reducing or eliminating meat consumption was not satisfying. not convincing enough to make any changes. Even the An international comparative study from 2005 revealed interviewees who appreciated the information were not that Poles found it more difficult to eat a healthy diet than interested in changing their habits. people in other European countries. While less than a quarter of Dutchmen (20 %), Swedes and Spaniards (21 %), Maltese (23 %), Germans and British people Strengths and limitations (24 %) indicated that following a healthy diet is difficult, Our study addressed the overlooked dimension of devel- around half of Latvians (48 %), Poles (49 %), Czechs oping nutritional recommendations, and its findings can (51 %), Slovaks and Bulgarians (52 %), Hungarians (54 %) inform nutritional guidelines regarding meat consumption. and Croatians (57 %) also found it challenging. Among However, the collected material was limited to presenting those Poles who found it difficult to eat a healthy diet, health benefits related to two cancer-related outcomes 34 % were convinced that preparing a healthy diet takes and omitted the possible concomitant benefits on cardio- too much time, 21 % lacked control over what they ate vascular risk reduction. and 20 % lacked information about the food they eat. Moreover, the mixed methods approach applied here About 19 % of those who found healthy diet difficult to can be used in analogous inquiries aiming at gaining under- follow found information about healthy eating contradic- standing of culturally determined values and preferences tory and confusing(41). toward other key products. Moreover, further studies are Moreover, our interviewees were very conscious about needed to determine the preferences of individuals without the poor quality of mass-produced meat; nevertheless, they the academic background and those consuming less than were rather not willing to exclude meat completely from three servings of meat per week. 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