Community Dietitians Research Articles

An exploration of knowledge, attitudes and advice given by health professionals to parents in Ireland about the introduction of solid foods. A pilot study

BackgroundFor the purposes of this paper "weaning is defined as the introduction of the first solid foods to infants". Global recommendations by the World Health Organisation (WHO) recommend that all infants be exclusively breast-fed for the first six months of life. No global recommendations have been made for formula fed infants. In Europe it is recommended that weaning foods should be introduced between 18 weeks and 26 weeks regardless of whether infants are breast or formula fed. In the United Kingdom it is recommended that solids be introduced at around six-months for both breast and formula fed infants. In Ireland official guidelines recommend that breast fed infants should be introduced solids at 6 months of age while for formula fed infants the recommendation is for 4 months. The disparity between these global, European, UK and local recommendations may be a source of confusion for parents and health care professional based in Ireland. Emerging evidence suggests that babies in Ireland are given solid foods before the recommended age but there has been little investigation of the weaning advice provided by health professionals. Since community health professionals have routine parent interactions in the pre-weaning and early-weaning period and hence are in a unique position to positively influence parental weaning decisions, this study aimed to explore their knowledge, attitudes and advice practices about weaning.MethodsA mixed-methods approach was used for the research, commencing with a multi-disciplinary focus group to guide and develop a questionnaire. Questionnaires were then distributed in a postal survey to General Practitioners (GPs) (n 179), Practice Nurses (PNs) (n 121), Public Health Nurses (PHNs) (n 107) and Community Dieticians (CDs) (n 8).ResultsThe results indicate varying levels of knowledge of official weaning recommendations and a variety of advice practices. CDs and PHNs acknowledged a clear role in providing weaning advice while demonstrating high confidence levels in providing this advice. However, 19% of PNs and 7% of GP respondents did not acknowledge that they have a role in providing weaning advice to parents; even though Health Service Executive (HSE) written literature given to parents states that they should seek information from PNs and GPs.ConclusionSmall pockets of misinformation about the introduction of solid foods persist amongst health professionals which may lead to inconsistent advice for parents. Further research is needed.

A role for community health care providers in neonatal follow-up

It is imperative that community health care providers are adequately informed of the nursery course and the individualized follow-up plan of each baby sent back to his community for convalescent and postdischarge care. Community hospital-based physiotherapists, occupational therapists, dietitians and public health nurses can cooperate with their counterparts in tertiary care centres to assist the primary care physician in providing quality services to ensure optimal support, stimulation and development of these preterm infants. Well-organized follow-up appointments can greatly alleviate the stress and anxiety of parents faced with the challenges involved in the care of their ‘special’ newborns. The role of community health care providers in post-NICU care is of paramount importance to tertiary care centres, which need to keep their beds available for high-level care, and to parents, who appreciate being closer to home and family as early as is safely possible. Lastly, one can be sure that compliance with follow-up will be better if the primary care team is ‘in the loop’ and sees its role in neonatal follow-up as a vital part of the patient’s care.

Parents' perceptions of health professionals' responses when seeking help for their overweight children

Childhood obesity continues to worsen and so more parents of overweight children are likely to seek help from health professionals. Attitudes and practices of primary care personnel have been sought about adult obesity, but rarely about overweight children. Parents' views in this respect have not been explored. This paper addresses that omission. The aim was to explore parents' perceptions of help-seeking experiences with health professionals. This study was a qualitative investigation with parents, conducted in central and south-west England using semi-structured interviews and body shapes used as prompts. Sampling was purposive to ensure an age range of children (4-15 years). Parents of 40 children with concerns about their child's weight were interviewed in their homes. Analysis was thematic and iterative. Parents went through a complex process of monitoring and self-help approaches before seeking professional help. The responses they received from GPs included: being sympathetic, offering tests and further referrals, general advice which parents were already following, mothers were blamed, or dismissed as "making a fuss", and many showed a lack of interest. Health visitors offered practical advice and paediatric dietitians were very supportive. Experiences with community dietitians were less constructive. Professional responses ranged from positive, but not very helpful, to negative and dismissive. Health professionals may benefit from a better understanding of parents' plight and childhood obesity in general. This in turn may improve their attitudes and practices and encourage parents to seek help at an earlier stage of their child's overweight.

Weight management in primary care: how can it be made more effective?

Obesity is often difficult to tackle in primary care. Pressure of time in the consultation, a lack of appropriately-trained primary care staff, a shortage of community dietitians or nutritionists, the potentially enormous caseload, language or cultural barriers and the sheer intractability of patients' eating habits, exercise behaviour and their clinical condition, all conspire to make general practitioners, other team members and often the patients themselves lose heart and stop even trying. However, there are ways of overcoming these difficulties. Examples of changes that evidence suggests are able to support and enhance basic one-to-one interventions in general practice include: improved clinical guidelines; better training of primary care staff; at-risk patient registers; smarter database search tools; new quality incentives; closer working with dietitians, counsellors and pharmacists; more hospital outreach clinics; designated general practitioner specialists and practice clustering; expanded exercise referral schemes and links with leisure providers; subsidised referral to commercial slimming groups; better use of patient groups and voluntary and community workers. The present paper describes a proposed 'triple-tier' pathway for weight management incorporating most of the elements mentioned earlier. With a more joined-up and creative approach to the development and organisation of primary care, more comprehensive training and workforce planning, and better integration with social care, voluntary groups and the commercial sector, weight management in general practice has the potential to be much more effective.

Focus-group interview and data analysis

In recent years focus-group interviews, as a means of qualitative data collection, have gained popularity amongst professionals within the health and social care arena. Despite this popularity, analysing qualitative data, particularly focus-group interviews, poses a challenge to most practitioner researchers. The present paper responds to the needs expressed by public health nutritionists, community dietitians and health development specialists following two training sessions organised collaboratively by the Health Development Agency, the Nutrition Society and the British Dietetic Association in 2003. The focus of the present paper is on the concepts and application of framework analysis, especially the use of Krueger's framework. It provides some practical steps for the analysis of individual data, as well as focus-group data using examples from the author's own research, in such a way as to assist the newcomer to qualitative research to engage with the methodology. Thus, it complements the papers by Draper (2004) and Fade (2004) that discuss in detail the complementary role of qualitative data in researching human behaviours, feelings and attitudes. Draper (2004) has provided theoretical and philosophical bases for qualitative data analysis. Fade (2004) has described interpretative phenomenology analysis as a method of analysing individual interview data. The present paper, using framework analysis concentrating on focus-group interviews, provides another approach to qualitative data analysis.

Tackling undernutrition through appropriate supplement prescribing.

Undernutrition has significant implications for patients' clinical condition and economical consequences for the NHS. However, due to continually increasing prescribing costs for sip feeds, treating undernutrition is often seen as very costly. An audit project in Lothian was undertaken to look at the appropriateness of sip feeds being prescribed. The project found there was a significant level of inappropriate prescribing with 30% of patients having their prescriptions for supplements stopped as they were deemed unnecessary. In view of this, the community dietitians involved developed and introduced a nutritional care pathway to allow a systematic and evidence-based approach to the identification and treatment of undernutrition.

Dietetic helpers in the community: the Bolton Community Nutrition Assistants Project

Summary Study objective: To explore the role of ‘Community Nutrition Assistants’ (CNAs) in helping to increase coverage, by increasing access to local community dietetic services, and to bring about positive changes in the determinants of healthy eating, within low‐income areas of Bolton, UK. Study design: A descriptive evaluation of programme development and field‐testing (1995–97) in the community. Nonexperimental design. Setting: Community, less affluent neighbourhoods in Bolton, North West England. Subjects: 1272 people in total, individuals and members of community groups, recorded as CNA contacts during two discreet monitoring periods; an opportunistic or purposive sampling strategy was used; subjects were randomly selected for group interview (n=8) and telephone interviews (n=41) out of a traceable sample of contacts (n=94) over a randomly selected 1‐month collection period. Findings: Compared with professional‐only service, CNAs efforts resulted in a four‐fold increase in coverage of community nutrition services in the local community. CNAs demonstrated unique attributes, which positively influence their ability to work well with local people, but particularly those considered hard to reach. At least half the subjects interviewed reported positive behaviour changes such as changes to foods bought, cooking methods or foods eaten in the home. Conclusions: This study has shown some benefits in training local people to work alongside existing community dietitians. This may help to reduce inequalities in health, address barriers to healthy eating experienced by low‐income families and improve cost effectiveness. Before expansion continues on an ad hoc basis, further research is needed to test its application in general, to assess health outcomes and to quantify the value of using local people. The findings here are useful in guiding further developments.

Chicago Dietetic Association Salary Survey

In the summer of 1996, the Chicago Dietetic Association sent 1490 salary surveys to Chicagoland area dietitians. 493 surveys were returned yielding a 33% response rate and of those 84% were available for analysis. 99% of the respondents were female and 1% male. 58.6% had a BS or BA degree as their highest degree. Although there were only six men in the sample, there was a statistically significant difference between their salaries and those of the women in the sample (p=.010). No statistically significant differences were found between whites, Asians, or African Americans with respect to salary (p=.82). A statistically significant difference was found between primary job roles with respect to salary (p<.0005). Dietitians in business/industry or management practice were found to be the highest paid followed by education/research or food service. Lower paid were clinical and consulting/private practice. Lowest paid were community dietitians. Only weak correlations (Spearman's rho 2-21} were found between salary and age group, highest degree earned, years as a practicing dietitian and years in primary job role/position. A statistically significant difference was found between primary job roles and satisfaction with pay (p=.006). The percentages who felt that they were paid adequately for the primary job roles are: business/industry(70%), food service(55%), community dietetics(51%), management(45%), clinical dietetics(43%), consulting/private practice(57%) and education research(30%). As expected, respondents who felt that they were paid adequately had higher salaries than those who did not feel that they were paid adequately (p=.001).

A New Name For Dietitians? Attitudes Of Registered Dietitians Toward Three Possible Titles

This study tested the null hypotheses that registered dietitians would report significantly different attitudes toward the titles dietitian, nutritionist and medical nutrition therapist, that there would be differences in attitudes among dietitians from different areas of practice, and that age and years of practice would be correlated with the attitudes. The titles medical nutrition therapist and nutritionist were selected on the basis of their having been frequently mentioned in the literature as alternative titles for dietitians. The sample was one thousand RDs randomly selected from a list purchased from ADA; 45% of the mailed surveys were completed and returned. Most respondents were clinical dietitians in practice 16-20 years and between 41 and 45 years of age. The attitude section of the survey used a semantic differential instrument, with four pairs of adjectives applied to each title from three perspectives: the respondent's own, patients’, and health care professionals’. The respondent indicated how (on a five point scale) each adjective pair would be applied from each perspective to each of the three titles. The three perspectives were combined to yield a total score (15 possible points) for each title. Analysis of variance (ANOVA), repeated measures of analysis of covariance (ANCOVA), Pearson correlations and means comparisons were calculated using SPSS statistical software. Using repeated measures of ANCOVA with age as the covariate, neither interaction of age, nor main effect of title or area of practice was found. Neither was there an interaction of title and area of practice. Mean attitude scores revealed that all areas of practice, except for community dietitians, gave their highest scores to medical nutrition therapist, while community dietitians showed the highest mean score for nutritionist. However, the fact that the differences were not significant and that the mean scores were all in the range of 7.9–9.5 (of 15 possible points) indicate that no title was highly regarded and that the level of support for the three names was approximately equal. Based on the data obtained there is no indication that there is a commitment to change the professional title of dietitian.

Shopping for health ‐ food for thought: a programme in public health promotion

Outlines a health promotion programme run in conjunction with a local Asda supermarket in Ayr. The event focused on the store itself. Community dietitians were available for specific advice, and a team of student dietitians conducted evaluations, circulated special discount coupons, and handed out health promotion material. Throughout the store there were specific health messages following NACNE and COMA report guidelines. A treasure hunt and food pyramid both acted as additional activities for customers. Publicity prior to the event included local radio and press advertising. The event was evaluated as a success and shoppers said they would like more such events.

Research and evaluation: the involvement of community dietitians

The recent document Dietitians in the Community: Opportunities for the Future (BDA, 1993) highlighted the importance of strengthening the evaluation and research base of the practice of dietitians working in the community. Members of the Community Nutrition Group of the BDA were surveyed by postal questionnaire in March 1992 to gather information to facilitate implementation of the report's recommendations. Thirty-six per cent of the members (n = 125) responded. Over half (56%) reported recent involvement in a research project and 97% expressed a need for better training and support in one or more aspects of the research process. Information was also gathered about the types of projects undertaken, preferred forms of support, previous training, evaluation and research, collaborative links and perceptions of the role of the BDA Research Committee and Metabolic Research Groups. This information is presented and discussed. In conclusion, relatively few community dietitians are actively involved in evaluation and research. Various modes of support are necessary to increase the number of dietitians engaged in this area, if the stated commitment of professional managers and the British Dietetic Association is to be fulfilled.

Job satisfaction of Texas dietitians

The purpose of this study was to assess the current level of job satisfaction of Texas Dietitians. Two hundred nineteen Texas Dietitians from the areas of management, clinical, community, and consultant/private practice returned completed questionnaires assessing their job satisfaction. The Job Descriptive Index (JDI) and the Job In General (JIG) were used to obtain responses. The JDI measured five determinants of job satisfaction including: co-workers, supervision, pay, promotion, and the work itself. The JIG measured attitudes about the job in general. A one-way analysis of variance was used to determine significant differences between the four groups of dietitians, the categories of the JDI and JIG, and the demographics of the sample at a significance level of p≤.05. Student Newman-Keuls test was used to compare means among the four groups, JDI and JIG categories and demographics to determine where differences existed. Overall, Texas dietitians were most satisfied with the job in general and least satisfied with promotion. Clinical dietitians were least satisfied with the work itself and management and consultant/private practice dietitians are more satisfied than clinicals and community dietitians with pay. Dietitians earning larger salaries were more satisfied with pay; those who were living with someone were more satisfied with promotion than those divorced, single or married; and those in sales were more satisfied with promotion.

Dietitians' knowledge structure relative to fat and cholesterol

The objectives of this study were to quantitatively and qualitatively assess community and clinical dietitians' (RD) knowledge structure related to fat and cholesterol through a recall method. RDs' knowledge has usually been assessed using recognition methods, which tend to overestimate accessible knowledge compared to recall methods for which respondents must generate their own answers. Thirty clinical and community dietitians were interviewed and concept maps were drawn for each transcribed interview. The maps were scored based on the number of major concepts and crosslinks (indicative of a more complex, integrated knowledge structure) mentioned; points were subtracted for misconceptions. Student’s t-tests revealed that the community and clinical dietitians' concept, crosslink, and total map scores were not significantly different. While years as a dietitian was not significantly related to the total map score, an inverse trend was noted. However, knowledge was limited; the RDs only recalled 50% of the total possible information and had low crosslink scores, indicating a lack of knowledge integration that could adversely affect how RDs learn new information or present information to clients. Therefore, information from this study has implications for the teaching and assessment of knowledge in baccalaureate and continuing education programs.

Management activities in community dietetics practice ,

Information on the management activities of community dietitians was obtained through a mail survey of 350 randomly selected community dietitians. Subjects provided information on their management level, the importance to their job performance of 83 management activity statements, and the percent of time they spent performing management activities in each of nine categories. Twenty-nine percent of the respondents indicated job responsibilities in lower-level management; 45% had mid-level and 26% had upper-level management responsibilities. Numbers of activities rated essential or very important increased as management levels increased. Kinds of activities changed from technical to human to conceptual as management levels increased. Mid-level management subjects, while still spending time working with clients, reported spending considerable time on coordinating, investigating, and evaluating, often reporting as much time spent on those activities as did upper-level management subjects. Definitions provided by respondents indicated great diversity in job requirements and settings.

Evaluating the evidence for nutrition interventions: Two algorithms

Community and clinical dietitians are increasingly involved in choosing interventions to alleviate problems and in evaluating programs for their effectiveness. Two decision trees have been developed to assist program planners in this process. The first addresses whether or not a pilot project should be recommended. It deals with determining whether a sufficient problem exists to warrant an intervention, and whether an appropriate intervention that will make a difference can be provided. The second algorithm is directed at the question of whether an existing program should be continued or expanded. It is concerned not only with the outcome of the program but also with its cost-effectiveness.

A personal view of teaching nutrition

Isabel Cole‐Hamilton, BSc, SRD, describes ways in which community dietitians are contributing towards nutrition education by providing resources and in‐service training for teachers, as well as going into schools to give talks and organise activities based on food and sensible eating

Dietitians at work‐at home

For the dietitian community health work means promoting health and helping to prevent disease by working with other people in the health and educational fields. The involvement of dietitians in this way came about via a number of different routes. One of the earliest posts of this kind dates from 1949 and was for a Health Education Officer (Nutrition) and the post was associated with a Health Education Department. Towards the end of the 1960's and early '70's, a number of Community Dietitians were appointed. Some of these were employed by the Health Departments and responsible to the County Medical Officers of Health. One or two were employed by Social Services Departments, and were answerable to the Director for Social Services of their local authority. Their advice would be sought primarily by staff of residential homes on matters of catering and in helping to plan new buildings. In some instances, hospital dietitians worked in the community on a voluntary basis, or were encouraged to do so by a community‐oriented hospital physician. Such local initiative and enthusiasm resulted in several official posts being established in this way. With reorganisation of the health service in view, quite a number of Community Health Dietitians were appointed. Their distribution in 1972‐3 can be seen from the map.