Practical Public Health Nutrition E-Book

Roger Hughes

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 366

Veröffentlichungsjahr: 2010

Beschreibung

Providing the reader with a practice-focussed approach to public health nutrition intervention management, Practical Public Health Nutrition is a crucial resource for dietitians, community and public health nutritionists and related health professionals in need of a practical guide to practicing public health nutrition. Internationally recognised experts Hughes and Margetts describe in detail the rationale, processes and tools that can be used to assess population needs, analyse problems and develop effective interventions at a community level. Exercises in each section of the book contribute to a collective PHN intervention plan, providing the reader with the opportunity to demonstrate an outcome of intervention management. Unique in its approach to teaching the practical applications of this increasingly crucial discipline, Practical Public Health Nutrition is a vital purchase for anyone working in the public health arena. * Clearly outlines the practice of PHN intervention management * Covers rationale, processes and tools needed to develop effective interventions at community level * Written by 2 internationally respected authorities on the discipline of Public Health Nutrition * Essential text for dietitians, community and public health nutritions and related health professionals

Leseprobe

Table of Contents

Cover

Table of Contents

Title page

Copyright page

Dedication

Preface

Acknowledgements

Glossary

Part 1: Introduction and context

Chapter 1 The big picture: The context for a textbook on public health nutrition practice

Why develop a public health nutrition textbook?

Malnutrition is still the main game

Innovative solutions are needed

Surely you don’t mean these challenges can be found in rich countries like mine?

Level of influence

Practice informed by a public health approach

First, work to understand the causes, by looking upstream

Practitioners and politics

The philosophy underpinning this book

Building capacity for effective public health nutrition action

Chapter 2 Defining public health nutrition as a field of practice

Introduction

Modes of nutrition practice

Definitions of public health nutrition

An emphasis on the prevention of food and nutrition problems

The core functions of the PHN workforce

Competencies for PHN practice

Professionalism and PHN practice

Chapter 3 A framework for public health nutrition practice

Introduction

A socio-ecological approach to practice

The PHN practice cycle

Recognising the importance of capacity building as a discrete strategy and as an approach to practice

Why make things more complicated and introduce a new framework?

A bi-cyclic framework for public health nutrition practice

Part 2: Intelligence

Chapter 4 Step 1: Community engagement and analysis

Introduction

What is a community?

Why community engagement?

Community development constructs

Community development – a process or an outcome?

Building community capital (and capacity)

Building capacity via ‘bottom-up’ practice

Community analysis

Chapter 5 Step 2: Problem analysis

Introduction

Public health intelligence

What is problem analysis?

Types of need

Conducting a problem analysis

Different methodological approaches to gather intelligence for problem assessment

Applying the intelligence and analysis results

Chapter 6 Step 3: Stakeholder analysis and engagement

Introduction

Why stakeholder engagement?

Stakeholder analysis

Considerations for stakeholder analysis

Conducting the stakeholder analysis

Organising and presenting stakeholder analysis data

Stakeholder engagement

Engaging stakeholders in decision-making

Chapter 7 Step 4: Determinant analysis

Introduction

Analysing determinants

Characterising determinants by their effect

Characterising determinants by the type of causal link

Characterising determinants by level

Determinant interaction and causal pathways

Diagrammatic illustration of determinant analysis

Chapter 8 Step 5: Capacity analysis

Introduction

What is capacity?

A framework for capacity building practice

Capacity assessment for capacity building

Challenges in measuring capacity

Selecting tools for capacity analysis

Tools and strategies for analysing capacity

Presenting capacity analysis data

Chapter 9 Step 6: Mandates for public health nutrition action

Introduction

Mandates for action – the policy context

Policy development – an overview

The challenge of competing policy agendas

National food and nutrition policies

Mandates for action – direct relevance to PHN practice

Chapter 10 Step 7: Intervention research and strategy options

Introduction

Strategic frameworks for health promotion

Determinants as leverage points for intervention

Levels of intervention

Settings as a focus for intervention

Target groups as a focus for intervention

Intervention research: learning from earlier work

Abstracting intelligence from intervention research

Chapter 11 Step 8: Risk assessment and strategy prioritisation

Introduction

Assessing risks and benefits

Types of risks and benefits

Strategy prioritisation

Challenges and dilemmas in strategy prioritisation

Methods for strategy prioritisation

Part 3: Action

Chapter 12 Step 9: Writing action statements

Introduction

Intervention planning

Action statements

Linking problem and determinant analysis to action statements

Writing intervention goals

Writing intervention objectives

Chapter 13 Step 10: Logic modelling

Introduction

What is a logic model?

Types of logic model

Logic model elements

Logic modelling in PHN practice

Developing a logic model

Key questions for reviewing logic models

Chapter 14 Step 11: Implementation and evaluation planning

Introduction

Engaging stakeholders in intervention and evaluation planning

Planning for intervention implementation

Developing work package plans

Work scheduling − developing a Gantt chart

Developing intervention budgets

Evaluation planning

Levels of evaluation

Developing evaluation indicators and plans

Chapter 15 Step 12: Managing implementation

Introduction

Types of PHN intervention implementation

Governance

Managing risk

Partnership satisfaction

Evaluability assessment

Part 4: Evaluation

Chapter 16 Step 13: Process evaluation

Introduction

Evaluation – a brief overview

Linking evaluation to planning

Qualitative and quantitative approaches to evaluation

Levels of evaluation

Process evaluation

Elements of process evaluation

Methods for conducting process evaluation

Process evaluation indicators

Process evaluation in practice – some published examples

Chapter 17 Step 14: Impact and outcome evaluation

Introduction

Impact and outcome evaluation – what is the difference?

When to evaluate?

Key measures of impact and outcome evaluation

Reliability and validity in evaluation

Sampling and data analysis

Evaluation design

Chapter 18 Step 15: Evaluating capacity gains

Introduction

Challenges in measuring capacity

Pre- and post-intervention comparisons

Strategies to enhance the trustworthiness of capacity evaluation

Visual presentations of capacity evaluations

Chapter 19 Step 16: Economic evaluation

Introduction

Costs and consequences in health care

Characteristics of economic evaluation

Types of economic evaluation

Conducting an economic evaluation

Efficiency vs. equity

Chapter 20 Step 17: Reflective practice and valorisation

Introduction

What is reflective practice?

Transformatory learning and reflective practice

Improving practice through reflection

Stages of reflective practice

Methods of reflective practice

Tools for reflective practice

What is valorisation?

Targets of valorisation

Methods of valorisation

Presenting intervention results

Part 5: Appendices

Appendix 1 Intervention plan template

Intervention summary statement

Project partners and governance

Budget

Project schedule – timelines

Risk management

Communication management (valorisation)

References/intelligence sources

Appendix 2 Capacity building analysis tool

References

Index

This edition first published 2011

© 2011 Roger Hughes and Barrie M. Margetts

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Library of Congress Cataloging-in-Publication Data

Hughes, Roger, 1965–

 Practical public health nutrition Roger Hughes and Barrie M. Margetts.

p. ; cm.

 Includes bibliographical references and index.

 ISBN 978-1-4051-8360-4 (pbk. : alk. paper) ISBN 978-1-4443-2922-3 (ebk)

 1. Nutrition policy. 2. Public health. 3. Nutrition. I. Margetts, Barrie M. II. Title.

 [DNLM: 1. Nutrition Policy. 2. Public Health Practice. 3. Health Promotion. 4. Nutritional Physiological Phenomena. QU 145 H894p 2011]

 TX359.H84 2011

 613.2–dc22

2010022796

A catalogue record for this book is available from the British Library.

For our students and practitioner colleagues, past, present and future.

May they have as much positive impact on their populations as they have had on us.

Preface

Public health nutrition as a discipline and as a field of practice is of immense importance to human health and the societies in which we live. It is an area of work that is gathering momentum worldwide. The next few decades will be as challenging, if not more so, than those of the past. This book is a small but practical attempt to support the development of the public health nutrition workforce so that it has the capacity to address these challenges now and into the future. As an aspiring or current practitioner, we hope this book will confirm your current good practice or inform the process of practice improvement we consider so important if we are to have a genuine impact on public health.

The contents of this book have evolved over more than a decade of teaching nutrition and public health students about the practical applications of the principles, theories and processes used to develop population-based nutrition interventions. Over this period, we have come to recognise – albeit slowly – the importance of stepwise, purposive processes that integrate capacity building principles with conventional intervention planning, so that our work as practitioners produces sustainable outcomes (i.e. better nutrition and health) and sustainable activity (i.e. interventions continue beyond our involvement). As authors, our collective experience includes as much failure in practice as it does success. This experience has helped us identify what not to do, as much as it has identified what we must do to be more effective. So we don’t pretend that we have all the answers or that this book in itself is enough to improve practice – that’s ultimately up to you, the practitioner. But we hope that it helps in this process.

This book is called Practical Public Health Nutrition because it intentionally focuses on the principles and processes we believe are required to develop solutions to public health nutrition problems effectively. We introduce a new model to guide the systematic development, implementation and evaluation of interventions in practice. We acknowledge that it has been largely inspired by earlier work by many people and tempered by our own experiences in public health nutrition practice. We accept and emphasise that the practice of public health nutrition is still a work in progress. We hope that students and practitioners alike can use, develop and improve on the model and processes of practice that ultimately add to the effectiveness of public health nutrition effort and enhance public health. After all, that’s what we are all about.

Roger Hughes and Barrie Margetts

Acknowledgements

This book has drawn on the scholarship and wisdom of many others and been tempered by our experiences as practitioners and teachers in this field of public health nutrition. We should, therefore, acknowledge those who have shaped our thinking and continue to question how best to address public health nutrition issues in practice. This includes our many colleagues and students who force us to continually reflect on what and how we practise and teach.

We would like to especially thank Christina Black who reviewed and commented on the whole manuscript, made important preparatory contributions to numerous chapters in this text, argued with us about the bi-cycle model and helped us make it more relevant to actual practice. Her fresh eyes and sharp intelligence, informed by experience as a public health nutrition practitioner, has been much appreciated.

Jenny Davies and Dr Nick Kennedy deserve mention for their collegial contributions to our discussions about this book which has indirectly influenced its content.

To the whole Blackwell team, thank you for your polite professionalism in making this book a reality.

To our respective partners and children, who support our work and careers in public health nutrition, continue to inspire us to do better and keep us grounded in what is important, may your lives continue to be interesting, happy and healthy.

Glossary

Action plans

Also known as strategic plans.

Best buys

Strategy initiatives with the greatest chance of achieving desired outcomes in a given context.

Capacity

The ability of a individual, organisation, community or population to achieve desired objectives (e.g. better health).

Capacity building

The process and practice of enhancing capacity.

Causal pathway

A relationship between exposures or determinants and outcomes that suggests causation.

Community development

A continuous striving to help develop the conditions for people to be inclusive, to share and care, so that they can live healthy, fulfilling lives.

Community engagement

The process of productively interacting with community members and relevant stakeholder groups.

Community organisation

The process of involving and mobilising a variety of agencies, institutions and groups in a community to work together to coordinate services and create programmes for the united purpose of improving the health of a community.

Competencies

The knowledge, skills and attitudes required to perform effectively in the workplace.

Core functions

Those functions that are regarded as absolutely necessary and without which would imply gaps in public health capacity.

Determinant analysis

Analysis of the factors that contribute to the expression of a health problem.

Downstream

Treatment-focused. Refers to the river of prevention analogy.

Economic evaluation

Economic evaluation involves identifying, measuring and valuing the inputs (costs) and outcomes (benefits) of intervention(s).

Effectiveness

The extent to which an intervention achieves the desired outcome in real-world settings/context.

Efficacy

The extent to which an intervention achieves the desired outcome in ideal settings/context.

Evaluability assessment

A process to assess if an intervention is ready to be evaluated.

Formative evaluation

Evaluation conducted to inform strategy development and evaluation planning.

Goal

The overarching change statement of the desired effect of the intervention.

Impact evaluation

Evaluation of intervention effects that relate to defined objectives and/or determinants.

Implementation failure

When interventions are not implemented as planned or inadequately implemented resulting in poor evaluation results.

Indicated prevention

Interventions targeted at high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing the specified health condition, or biological markers indicating a predisposition to it, but who do not currently fulfil diagnostic criteria.

Intelligence

Information from various sources and methods that help inform decision-making about intervention design.

Intervention management

The process and practice of developing, implementing, evaluating interventions, and sharing and applying the learning of this experience.

Intervention plan

A document that details the information required to effectively implement and intervention. An intervention blueprint.

Logic model

Usually a diagrammatic representation of the logic underpinning and intervention, which links identified determinants with intervention strategies and evaluation standards, making assumptions explicit about how the intervention is planned to bring about change.

Malnutrition

The abnormal physiological state associated with insufficient, excessive or imbalanced consumption of nutrients, characterised by an increased risk of morbidity and mortality. It refers to both under- and over-nutrition.

Mandates

Policy statements from organisations and institutions that sanction and prioritise action on nutrition issues.

Mixed-method evaluation

Evaluation that uses numerous methods to collect and analyse data to inform assessments of intervention effects.

Needs assessment

A formative evaluation process of assessing a populations need.

Objective

A statement of desired change in identified determinants of a nutrition problem. Usually written to be specific, measurable, achievable, realistic and time-limited.

Outcome evaluation

Asks the question: Has the intervention goal been achieved?

PEEST analysis

Situational analysis that considers the political, environmental, economic, social and technical dimensions of a health issue.

Primary prevention

Avoiding the onset of ill health and decreasing the number of new cases (the incidence).

Process evaluation

Asks the question: Was the intervention implemented as planned?

Professionalism

A state of mind and behaviour that reflects the mores and expectations of the professional community, often including personal behaviour and presentation, commitment to quality improvement and ethical practice.

Public health nutrition

The art and science of promoting population health status via sustainable improvements in the food and nutrition system. Based on public health principles, it is a set of comprehensive and collaborative activities, ecological in perspective and inter-sectoral in scope, including environmental, educational, economic, technical and legislative measures.

Reflective practice

A process in practice of reflecting on events or practices in order to understand and improve practice.

Reliability

Repeatability of a measure.

Reverse engineering

Deconstructing and backward analysis of strategies and interventions to critically assess the strategy/intervention logic.

Secondary prevention

Preventing the progression if ill health and reducing the rate of established cases in the community (the prevalence).

Stakeholder analysis

Identification, analysis and description of individuals, groups or organisations that have an interest in the issue being addressed.

Strategy portfolio

A mix of strategy options selected to achieve the best possible return on investment given context and available resources/opportunity.

SWOT analysis

Strengths, Weaknesses, Opportunity and Threats analysis.

Targeted prevention

Interventions targeted at individuals or a subgroup of the population whose risk of developing the health problem is significantly higher than average. The risk may be imminent or a lifetime risk.

Tertiary prevention

Stabilising or reducing the amount of disability and number of complications arising from an irreversible condition/disease.

Trial-and-error strategy development

Strategy development based on assumptions rather than by detailed analysis of the determinants of the nutrition issue.

Upstream

Prevention-focused. Referring to the river of prevention analogy.

Universal prevention

Interventions targeted at the general public or a whole population group that has not been identified on the basis of individual risk for the specified health problem. The intervention is desirable for everyone in that group.

Valorisation

The process of disseminating and exploiting the results of projects with a view to optimising their impact, transferring them, integrating them in a sustainable way and using them actively in systems and practices at local, regional, national and global levels.

Work package

A logical sequence or cluster of activities that relate to the development, implementation or evaluation of activities and strategies, reflecting the work required.

Part 1: Introduction and context

This introductory section comprises three chapters which provide the context for consideration of public health nutrition (PHN) as an area of practice. This context is important because it helps lays the foundation of a systematic and thorough approach to practice in public health nutrition discussed in later sections.

Chapter 1 provides a big picture overview of the immense challenges and complexity of PHN as a discipline. It also situates the practitioner in this context, arguing that effective practitioners can indeed make a difference to public health.

Chapter 2 defines PHN and describes its attributes as a practice area. Of equal importance, this chapter articulates what PHN is not, helping to situate it in the health system, with a focus on the protection, maintenance and promotion of health in different populations. This chapter has significant relevance to practitioners as it considers the core functions of the PHN practitioner and the associated competency needs.

Chapter 3 introduces and describes a bi-cycle framework for PHN practice which embeds capacity building with strategic and intelligence-based decision-making at the core of PHN practice. As a stepwise process, it is proposed as a model to assist the application of the rhetoric of health promotion in practice.

Chapter 1

The big picture: The context for a textbook on public health nutrition practice

Why develop a public health nutrition textbook?

This book has been written with the bold aim to help develop competent and effective public health nutrition (PHN) practitioners and to help existing practitioners work more effectively. In this context, the term practitioner refer to individuals or groups with an interest in, responsibility for or mandate to work in the interest of protecting and promoting public health through better nutrition. This can include local health workers, school teachers and hospital dietitians. In much of this book and for most readers it relates more to specialists, such as designated public health nutritionists – a role that is increasingly becoming established in many countries worldwide. It also refers to you, the reader, even if you currently do not have a formal qualification or professional status. We hope that this book, and the processes and principles it describes, will help develop and refine the competencies you require to be effective PHN practitioners. This is important because we contend that:

there are currently many practitioners who aren’t effective in a PHN context; andbeing effective is possible if we follow good practice.

Malnutrition is still the main game

It will come as no surprise that PHN practice is still dominated by considerations of malnutrition in its two-faced manifestations: under-nutrition and over-nutrition. At an international level there is little disagreement about the staggering burden of malnutrition in all its forms. It is now accepted that over a billion people across the world are undernourished, with more now over-nourished and probably as many people with specific micronutrient deficiencies. Many of those who are under- or overweight are also micronutrient-deficient. Whereas in the past the burden of over-nutrition was highest in developed or rich countries, the burden is now spreading to and increasing in poor or developing countries. This trend is now referred to as the double burden of disease. In some countries there is an additional burden associated with high rates of infectious diseases and/or HIV. There is a complex interplay between poverty, food and nutrition insecurity, malnutrition and infection that becomes a downward spiral, with infection adding to the metabolic demands for nutrition, while reducing the capacity to work and earn the money required to address the infection, which further reduces dietary intake. Thus a vicious cycle continues. These complex interactions spiral throughout the life-course, from infants to children, to young women having babies to babies. All this is exacerbated by basic and underlying causes, such as inequality, poverty, conflicts and natural disasters. Despite these enormous challenges, there have been improvements in some countries, but these have been largely offset by setbacks elsewhere.

Is food insecurity due to families being too large or wasting money on ‘junk food’, or are global food prices and the international controls on markets that make life difficult for the poorest in the least wealthy countries more to blame? Per capita food production has kept pace with the rise in population, but the biggest concern is that the rich world is consuming more than its fair share and producing more waste and greenhouse gases, while the poor are told to have fewer children so they can feed them (the same applies with consumption of fossil fuels). Food insecurity is a spectre hovering over humanity worldwide and it ebbs and flows with economic, political and environmental crises. This point was made clear in a recent FAO report on food insecurity in the world.1 The nutrition challenges of today and into the future will continue to be essentially about inequality.

Innovative solutions are needed

The current approach to addressing global nutrition problems, articulated in many policies and resolutions at the international level, such as the Millennium Development Goals, the WHO resolution of diet, physical activity and health, etc., has moved to a model (some use the word paradigm) which relies on a therapeutic/technical approach. This involves giving supplements or fortifying staple foods as a key strategy to address the major micronutrient deficiencies of iron, vitamin A and iodine. In other words, the approach is to say, ‘If we can’t change the causes, we will treat the symptoms by giving what is missing’. Another competing paradigm argues that food is a fundamental human right and that, unless the basic causes of under-nutrition are addressed, until people have control over their lives and are consulted and become part of the solution rather than having solutions imposed on them, we will never fundamentally address health inequalities. So the challenges are enormous, but our work and role as practitioners may never be more important and needed.

Surely you don’t mean these challenges can be found in rich countries like mine?

The challenges for public health nutritionists in developed or rich-economy countries are no less complicated that those of the developing world. What is consistent is the effect of socio-economic inequalities on malnutrition (the poor and uneducated also tend to be the most overweight) and the complex array of determinants that result in disease and disability. Under-nutrition still exists in vulnerable subpopulations and the enormous social burden of preventable disease attributable to over-nutrition makes the role of the public health nutritionist just as important in the developed world as in the developing world.

Level of influence

As a practitioner operating at a national or international level, the options for interventions or approaches to solving problems may be more linked to interventions that aim to improve nutrition by increasing the uptake of supplementation or supporting other attempts to diversify food intake at a national level. Or it may be that your role is to address national priorities, which in many countries are dominated by obesity. Many more of you will be working at a local level, where the policy, goals and objectives have already been set and your role may be to design, plan, implement and evaluate interventions that address the issues mandated in national action plans or priorities. Action by practitioners at all levels is required and important. The level at which you as a current or future practitioner operate will affect how much decision-making and influence you have over the approach to identifying problems and solutions, developing policy and delivering interventions. We argue, however, that at whatever level you operate, there is a practice model that you can work within which will help you be more effective in your practice context. This book outlines the steps in this practice model.

Practice informed by a public health approach

The values, attitudes and the conceptual approaches we apply to practice have a critical influence on our practice behaviours and overall effectiveness. A public health approach (described in more detail in later chapters) is traditionally defined by its focus on prevention rather than treatment, populations rather than individuals and interventions that address the determinants of health rather than the treatment of disease. It is an approach characterised by persistence, recognising that human health requires the right conditions and opportunities to flourish, and that we cannot afford to assume that these conditions will occur or persist without planned effort and attention. Such effort and attention are a key responsibility of the health workforce, policy-makers and community leaders.

First, work to understand the causes, by looking upstream

When we are taking a public health view it is important to step back from the problem and ask, ‘Why did this problem arise?’ In other words, we need to think about the underlying causes (determinants), such as ‘Why did this child not have enough to eat or have diarrhoea? Was it because the household was food insecure or the family was poorly educated and had limited resources and access to education and health care?’ Stepping back further the question is again ‘Why is this so? Why is the family food insecure?’ This is about having reliable and affordable access to nutritious food, as well as clean water and the means to cook. At the basic level the reason many households are food insecure is that the country is poor and has little capacity to generate jobs and provide services because they are dependent on low-yield cash crops as their major source of government revenue. UNICEF described this conceptual framework many years ago, which was updated in 2008 as part of the Lancet series reviewing the evidence around causes and solutions to under-nutrition in the world (see [2–6]).

Practitioners and politics

Turning the focus back to you as a practitioner, you may be asking if the problems are more to do with politics and decisions about fairness and equity, rights, trade and the capacity of countries to look after themselves. You may be wondering what you can possibly do to make a difference. The key point of the discussion in this chapter is to make sure that you consider the wider context in which the problem in front of you arose. If your responsibility is to reduce the prevalence of obesity, telling people to eat less fatty food may not be very effective if they cannot afford or have limited access to alternative, healthier foods. If your responsibility is to operate at a national or advisory level, again it may be helpful to reflect and think about the basic and underlying causes, and not rush in and ‘treat’ what may appear to be the obvious cause. In many countries, governments shy away from addressing these basic and underlying causes because they require them to take an active role – to introduce legislation or regulations that ensure people have enough to live on or that food manufacturers are regulated to optimise the healthfulness of their foods. Very often governments take the view that their role is to supply information and let the people decide, without addressing the real reasons why they are behaving as they do. It is well documented that only well-informed and educated people read food labels and use that information to make decisions about what to buy. This may be one of the reasons for the widening gap! At the same time, the government is often not enthusiastic to regulate, for example, which sugary/fatty snacks can be advertised on television at times when children, the target audience, are most likely to be watching. It may explain why governments are enthusiastic to urge people to be more active, but pay less attention to what industry is doing to the quality of the food supply.

The philosophy underpinning this book

There are two philosophical strands that underpin this book: first, that without well-trained and supported practitioners, even if we have excellent policies and statements of aims/goals and objectives, it is unlikely that effective interventions will be developed, delivered or evaluated; and second, that the approach to developing and addressing problems and the perspective one brings to the approach are critical.

Building capacity for effective public health nutrition action

In most reports on the global or national nutrition situation, few mention the workforce, its role or the skills and support the people doing the work need to be effective. To address this oversight, this book focuses on the practice of public health nutrition and the steps we must take in the development of strategic action and intervention, regardless of level or location in the system. PHN practice is evolving as the workforce of specialists worldwide develops. The UK, Australia and New Zealand have been among the countries that have begun to develop this workforce in recent years. In the US and Canada there is a long tradition of PHN jobs and roles. In all of these workforces, many of these roles are an extension of the treatment clinical model and do not really address a population, public health approach. Practice reorientation is needed if we are to be effective in addressing PHN issues. Be that as it may, we also argue that at whatever level and in whatever organisation you operate, the principles articulated in this book and captured in summary form in the bi-cycle model of PHN practice will help you make sense of where you are and what you need to do, help to explain why things are not working and help you build the evidence (intelligence) to inform your practice now and in the future. The bi-cycle has been developed, based on our own experience, successes, failures and frustrations in trying to develop, deliver and evaluate effective programmes aimed at improving health.

We end this chapter by suggesting 12 golden rules of PHN practice which we shall articulate through this book and which we hope will stay at the forefront of your mind throughout your career as public health nutritionists.

The 12 golden rules of public health nutrition practice1. Know and engage thy community.2. Seek first to understand and define the problem before acting.3. Look upstream to determinants.4. Recognise existing capacity and build, build, build.5. Position activity within existing mandates.6. Check what others have done and learnt, and use this intelligence.7. Think first what can go wrong and manage the risks.8. Pick the best options relative to context.9. Use logic and plan, plan, plan.10. Manage implementation so that your strategies are delivered as planned.11. Evaluate, evaluate, evaluate.12. Share what you learn, particularly your mistakes.

Chapter 2

Defining public health nutrition as a field of practice

Objective

By the end of this chapter you should be able to:

Define public health nutrition as a field of practice distinct from other professional nutrition and broader public health practice, with reference to core work functions and competency requirements.

Introduction

There has been considerable debate over the last decade about what PHN is, how it is defined, what it involves and how it differs from well-established and known types of professional nutrition practice such as dietetics, and broader approaches to public health work evident in issues such as tobacco control, communicable diseases and injury prevention. This debate is important, particularly because PHN practice worldwide suffers from a lack of a public profile about the nature and utility of PHN work and the small number of formally named PHN positions.

PHN is not new, but the use of the title ‘Public Health Nutritionist’ to describe a professional and a recognition of the need for a specialist practitioner who deals with nutrition problems at a population level are increasingly becoming the focus of worldwide effort. The need for a recognised identity for public health nutrition as a specialised field of practice requiring a designated workforce is rooted in the realisation that the public health approach of prevention is likely to be a more cost-effective and sustainable course of action to control the worldwide chronic disease epidemic than traditional curative approaches.7 This recognition has prompted efforts to build workforce capacity in public health nutrition.

Modes of nutrition practice

A simple way of conceptualising PHN is to compare it with the various types of professional nutrition practice that are well known worldwide. In this approach, nutrition services can be considered as a continuum with overlap, delineated by setting, reach, type of prevention, care paradigm, key personnel, determinants of activity and outcome time-frame (see Figure 2.1).

Figure 2.1 Modes of nutrition practice

Source: Adapted from Hughes and Somerset.8

In reality, it is important to note that:

any one practitioner may operate in each of these practice modes on any given day; andthe methodology of community nutrition and public health nutrition is the same; population reach is the key difference.

This book has been designed to help you work in the public health approach to practice and the following case study illustrates how different modes of practice produce different responses, require different resources and often produce different outcomes.

Case study: Comparison between different approaches to managing a communities problem with overweight and obesity

The traditional dietetic approach

Tony* is a dietician employed by the Southampton Community Health Centre. Data produced by the Area Health Epidemiology Unit have identified a recent increase in the prevalence of overweight and obesity in the area population and this finding is supported by an increasing rate of referral of overweight and obese clients to the health centre by general practitioners. Tony’s initial response is to work with the other staff in the Community Health Centre to establish a multidisciplinary weight reduction clinic, linking with the local Division of General Practice. This results in a streamlined service providing services for an average of 60 individuals a week and occupying three days a week of his time. He notices that each individual needs an average of six visits over two to three months to stabilise their weight and sustain changes to related behaviours (the desired outcome), so there are ten outcomes per week. Realising that this method requires significant resources for the limited population reach, he reorganises the service into a group education format, increasing the client service rate to 120 per week for the same time investment and for twice as many outcomes per week (20). At this rate he will achieve about 1,000 outcomes each year.

The public health nutrition approach

Tess* is a public health nutritionist working for the Southampton Area Health Service and has decided to develop a PHN response to the spiralling rates of overweight and obesity in her community. The following account describes how each of the core functions listed in Table 2.4 applies to this scenario. Tess decides to act after analysing recently collected data from her epidemiology unit which show that the rates of overweight and obesity are increasing at an alarming rate, particularly among school children. Her first step is to consult key stakeholders in the community and form a representative taskforce to assist in planning a community-wide intervention to address the problem. At the same time as this taskforce is being established and commencing discussions, Tess lobbies her local public health unit to provide research support and some seed funding for the community taskforce to develop and implement its initial strategies. With the public health epidemiologist, Tess summarises the available public health data about overweight and obesity in a report that is used to inform the taskforce’s deliberations and to communicate this information to the local health workforce. The taskforce then undertakes a determinant analysis (consultation, research and discussion to identify determinants of overweight and obesity in their community) assisted by Tess and staff from the public health unit. Their analysis shows that sedentary lifestyles and increasing reliance on takeaway food are the major direct determinants of increasing adiposity. Indirect determinants include a lack of community facilities for exercise, such as safe pathways, organised sports and affordable gym access. The increasing reliance on takeaway food is considered to be the result of time poverty among working parents, limited cooking skills, the saturation of the local community environment with fast-food advertising and the high number of fast-food outlets.

Table 2.4 Ten core functions for public health nutrition practice

  Core public health nutrition functionResearch & analysis1Monitor, assess and communicate population nutritional health needs and issues.2Develop and communicate intelligence* about determinants of nutrition problems, policy impacts, intervention effectiveness and prioritisation through research and evaluation.Build Capacity3Develop the various tiers of the PHN workforce and its collaborators through education, disseminating intelligence* and ensuring organisational support.4Build community capacity and social capital to engage in, identify and build solutions to nutrition problems and issues.5Build organisational capacity and systems to facilitate and coordinate effective public health nutrition action.Intervention management6Plan, develop, implement and evaluate interventions that address the determinants of priority public health nutrition issues and problems and promote equity.7Enhance and sustain population knowledge and awareness of healthful eating so that dietary choices are informed choices.8Advocate for food and nutrition-related policy and government support to protect and promote health.9Promote, develop and support healthy growth and development throughout all life-stages.10Promote equitable access to safe and healthy food so that healthy choices are easy choices.

*Intelligence refers to information and knowledge from various sources that is used to inform decisions relating to problem resolution in public health nutrition practice.

Source: From Hughes.21

The taskforce develops a community strategy with Tess’s assistance, who informs them about earlier interventions and their effectiveness and other possible options. This strategy forms the basis of a submission for funding from the state government to develop a community-wide obesity prevention strategy. Among other things, the strategy mix includes working with local government to:

develop policies and invest in safe pathways;regulate fast-food outlets through town planning;introduce a train-the-teacher programme in district schools and health centres, so that teachers and health workers can implement a healthy meal preparation skills development programme for students, parents and other community members;develop a community sports organisation to coordinate community-wide physical activity for people of all ages, assisted by the Department of Sport and Recreation.

On receipt of government funding, Tess works with the taskforce and community stakeholders to implement the programme, making a concerted effort to keep stakeholders engaged in and informed about the project. The project team also develops community organisation systems and seeks funding to sustain the project after the government funding ends. On completion of the intervention funding, Tess works with stakeholders to evaluate the intervention and reports widely on its outcomes and lessons.

Comparison of approaches

The difference between these two approaches relates not only to the reach of the interventions, but also to the types of changes achieved, the determinants addressed and the competencies required to successfully implement them.

* The two scenarios in this case study are illustrative, and not based on real people or events.

Definitions of public health nutrition

Understanding what PHN practice involves, how it is performed and what it is trying to achieve is critical for effective action. Having statements that define PHN is important to provide a distinct professional identity, clear understanding and common professional vocabulary that describes and conceptualises PHN practice. Too inflexible a definition of PHN is not necessarily the best approach as a single definition may not fit the reality or needs of the workforce in different countries.

A number of approaches can be used to achieve a common understanding of PHN practice and avoid the constraint of a word-for-word definition. Such approaches include:

exploration of existing definitions and definitional descriptors;exploration of the core functions (the required work) of PHN practice; andreflection on the competency requirements to perform this work.

Across the world various definitions of PHN have been developed over the last decade (Table 2.1).

Table 2.1 Definitions of public health nutrition from the literature

SourceDefinitionRogers & Schlossman (1997, USA)9The term ‘public nutrition’ has been defined as a new field encompassing the range of factors known to influence nutrition in populations, including diet and health, social, cultural and behavioural factors; and the economic and political context. Like public health, public nutrition would focus on problem-solving in a real-world setting, making its definition an applied field of study whose success is measured in terms of effectiveness in improving nutrition situations.Hughes & Somerset (1997, Australia)8Public health nutrition is the art and science of promoting population health status via sustainable improvements in the food and nutrition system. Based on public health principles, it is a set of comprehensive and collaborative activities, ecological in perspective and inter-sectoral in scope, including environmental, educational, economic, technical and legislative measures.Nutrition Society (Landman et al., 1998, United Kingdom10PHN focuses on the promotion of good health through nutrition and the primary prevention of diet-related illness in the population. The emphasis is on the maintenance of wellness in the whole population.Working group for the European Master’s Programme for PHN (Yngve et al., 1999, European Union)11PHN focuses on the promotion of good health through nutrition and physical activity and the prevention of related illness in the population.Johnson (2001, (USA)12PHN practice includes an array of services and activities to assure conditions in which people can achieve and maintain nutritional health, including surveillance and monitoring nutrition-related health status and risk factors, community or population based assessment, programme planning and evaluation, leadership in community/population interventions that collaborate across disciplines, programmes and agencies, and leadership in addressing the access and quality issues around direct nutrition services to populations.Beaudry & Delisle (2005, Canada)13Public[’s] Nutrition applies the population health strategy to the resolution of nutrition problems, Its fundamental goal is to fulfil the human right to adequate food and nutrition. It is in the interest of the public, involves participation of the public and calls for partnership with relevant sectors beyond health.World Public Health Nutrition Association (2007)The promotion and maintenance of nutrition-related health and well-being of populations through the organised efforts and informed choices of society.

From Table 2.1, it is clear that there are some attributes that are consistent among the definitions. The following definitional attributes (Table 2.2) have been identified in an international consensus development study,14 further highlighting the consistently identified attributes of public health nutrition definitions.

Table 2.2 Importance ratings for descriptors of how experts define the field of public health nutrition

Source: From Hughes.14

The launch of New Nutrition Science15 as a paradigm for nutrition sciences closely parallels these attributes of public health nutrition so it is not surprising that public health nutritionists do not consider the New Nutrition Science project as anything new, but see it as an important realisation of the complexity of nutrition as a field of research and practice, beyond the biological emphasis that has preoccupied the development of nutrition over the past century.

An emphasis on the prevention of food and nutrition problems