Public Health Nutrition Practice Research Articles

Strengthening public health nutrition: findings from a situational assessment to inform system-wide capacity building in Ontario, Canada.

To assess public health nutrition practice within the public health system in Ontario, Canada to identify provincial-wide needs for scientific and technical support. A qualitative descriptive study was conducted to identify activities, strengths, challenges and opportunities in public health nutrition practice using semi-structured key informant interviews (n 21) and focus groups (n 10). Recorded notes were analysed concurrently with data generation using content analysis. System needs were prioritised through a survey. Public health units. Eighty-nine practitioners, managers, directors, medical officers of health, researchers and other stakeholders were purposively recruited through snowball and extreme case sampling. Five themes were generated: (i) current public health nutrition practice was broad, complex, in transition and collaborative; (ii) data/evidence/research relevant to public health needs were insufficiently available and accessible; (iii) the amount and specificity of guidance/leadership was perceived to be mismatched with strong evidence that diet is a risk factor for poor health; (iv) resources/capacity were varied but insufficient and (v) understanding of nutrition expertise in public health among colleagues, leadership and other organisations can be improved. Top ranked needs were increased understanding, visibility and prioritisation of healthy eating and food environments; improved access to data and evidence; improved collaboration and coordination; and increased alignment of activities and goals. Collective capacity in the public health nutrition can be improved through strategic system-wide capacity-building interventions. Research is needed to explore how improvements in data, evidence and local contexts can bridge research and practice to effectively and efficiently improve population diets and health.

Developing and Pilot Testing a Population-focused Nutrition Screen Incorporating Social Determinants of Health

Introduction: Given that nutrition status is directly related to a variety of health outcomes, nutrition screening is a prime focus of public health nutrition practice. 
 Objectives: The purposes of this pilot study were to develop and pilot test a Rural Adult Nutrition Screen (RANS) that includes criteria addressing social determinants of health and to explore possible applications of the screen development methodology in other settings.
 Methods: Mixed-methods research including interviews and survey dissemination was conducted among a rural southern Appalachian population in the United States. Themes identified in the research were used to construct a preliminary rural adult nutrition screen (RANS-1). The RANS-1 was pilot-tested among a sample of community-dwelling rural residents (n = 83), and was revised based on participant, administrator, and nutrition practitioner comments. The revised screen, the RANS, was pilot-tested among a sample of attendees of a free community medical clinic (n = 37). Nutrition risk as determined by the RANS was compared with the Nutrition Triage Score of the Patient-Generated Subjective Global Assessment (PG-SGA), the United States Department of Agriculture 6-item Household Food Security Survey Module (USDA-6), and nutrition assessment performed by a Registered Dietitian Nutritionist who was also credentialed as a Physician Assistant (RDN, PA). Non-parametric statistical tests were used to compare the results of the PG-SGA NTS and the USDA-6 with the RANS regarding “at risk” and “low risk” status.
 Results: In this small pilot study, no statistically significant differences were found among either comparative instrument and the RANS in determination of “at risk” and “low risk” status. The RDN, PA’s agreement with the RANS was 100%. 
 Conclusion: This pilot study provides some evidence that the RANS may be used to screen rural, community-dwelling adults for nutrition needs in light of social determinants of health common in rural settings. Further research and formal validation of the RANS are needed in order to establish this tool as a valid nutrition screen for use in the rural community setting. Procedures used to develop the RANS may be applicable to the development of population-specific nutrition screens in other rural and urban global populations.

The politics of food in the Pacific: coherence and tension in regional policies on nutrition, the food environment and non-communicable diseases.

Our study analysed evolving regional commitments on food policy in the Pacific. Our aim was to understand regional priorities and the context of policy development, to identify opportunities for progress. We analysed documentation from a decade of regional meetings in order to map regional policy commitments relevant to healthy diets. We focused on agriculture, education, finance, health, and trade sectors, and Heads of State forums. Drawing on relevant political science methodologies, we looked at how these sectors 'frame' the drivers of and solutions to non-communicable diseases (NCD), their policy priorities, and identified areas of coherence and tension. The Pacific has among the highest rates of non-communicable diseases in the world, but also boasts an innovative and proactive response. Heads of State have declared NCD a 'crisis' and countries have committed to specific prevention activities set out in a regional 'Roadmap'. Yet, diet-related NCD risk-factors remain stubbornly high and many countries face challenges in establishing a healthy food environment. Policies to improve food environments and prevent NCD are a stated priority across regional policy forums, with clear agreement on the need for a multi-sectoral response. However, we identified challenges in sustaining these priorities as political attention fluctuated. We found examples of inconsistencies and tension in sectoral responses to the NCD epidemic that may restrict implementation of the multi-sectoral action. Understanding the priorities and positions underpinning sectoral responses can help drive a more coherent NCD response, and lessons from the Pacific are relevant to public health nutrition policy and practice globally.

Ethnography in Nutrition and Dietetics Research: A Systematic Review

Ethnography is a qualitative research approach used to learn about people and their culture. There is a need to explore the application and use of ethnographic methodology in nutrition and dietetics research to inform future research and practice. Our aim was to examine the extent, range, nature, and contribution of ethnographic methodology in nutrition and dietetics research. Eight electronic databases were searched using a defined search strategy until November 2017. No restrictions were placed on language, date, or study design of original research. Two authors independently assessed titles and abstracts, then full-text records, against inclusion criteria. Hand-searching of reviews identified in the database search was undertaken. Quality assessment was conducted using the Critical Appraisal Skills Programme checklist. Data were described narratively. A total of 2,185 records were identified, with 92 studies from public health nutrition (n=72), clinical nutrition (n=13), and foodservice (n=7) practice areas meeting inclusion criteria. Common research areas included infant/child feeding, food choice, diabetes, nutrition in schools and food insecurity. In addition to observation, frequently reported data collection techniques were interview (n=85), focus groups (n=17), and document analysis (n=10). Ethnographic research was most often reported from North America (n=31), Europe (n=16), and Australia/Oceania (n=13). This research approach was shown to inform dietetic research and practice by illuminating sociocultural factors that influence dietary beliefs and practices, practitioner training opportunities, evaluating nutrition education methods, informing programs and interventions, identifying nutrition policy and guideline focus areas, and the need for new approaches and communication strategies. Ethnography can increase understanding of complex food and nutrition–related health issues and their contributing factors across public health nutrition, foodservice, and clinical dietetic practice. It can be used to explain health inequalities, direct policy, and inform more effective intervention design and delivery. Wider uptake of this research approach as a stand-alone or complementary study design will advance efforts to improve health and wellbeing through food and nutrition.

Workforce capacity to address obesity: a Western Australian cross-sectional study identifies the gap between health priority and human resources needed.

BackgroundThe disease burden due to poor nutrition, physical inactivity and obesity is high and increasing. An adequately sized and skilled workforce is required to respond to this issue. This study describes the public health nutrition and physical activity (NAPA) practice priorities and explores health managers and practitioner’s beliefs regarding workforce capacity to deliver on these priorities.MethodsA workforce audit was conducted including a telephone survey of all managers and a postal survey of practitioners working in the area of NAPA promotion in Western Australia in 2004. Managers gave their perspective on workforce priorities, current competencies and future needs, with a 70 % response rate. Practitioners reported on public health workforce priorities, qualifications and needs, with a 56 % response rate.ResultsThe top practice priorities for managers were diabetes (35 %), alcohol and other drugs (33 %), and cardiovascular disease (27 %). Obesity (19 %), poor nutrition (15 %) and inadequate physical activity (10 %) were of lower priority. For nutrition, managers identified lack of staff (60.4 %), organisational and management factors (39.5 %) and insufficient financial resources (30.2 %) as the major barriers to adequate service delivery. For physical activity services, insufficient financial resources (41.7 %) and staffing (35.4 %) and a lack of specific physical activity service specifications (25.0 %) were the main barriers. Practitioners identified inadequate staffing as the main barrier to service delivery for nutrition (42.3 %) and physical activity (23.3 %). Ideally, managers said they required 152 % more specialist nutritionists in the workforce and 131 % specialists for physical activity services to meet health outcomes in addition to other generalist staff.ConclusionHuman and financial resources and organisational factors were the main barriers to meeting obesity, and public health nutrition and physical activity outcomes. Services were being delivered by generalists rather than specialists, which may reduce service effectiveness. Although conclusions from this research need to take into account the fact that the audit was conducted in 2004, the findings suggest that there was a need to equip health services with an adequately skilled workforce of sufficient capacity to deliver an effective public health response to the obesity epidemic, particularly addressing poor nutrition and physical inactivity.

The importance of stories in understanding people's relationship to food: narrative inquiry methodology has much to offer the public health nutrition researcher and practitioner.

Despite the usefulness of quantitative research, qualitative research methodologies are equally needed to allow researchers to better understand the important social and environmental factors affecting food choice and eating habits. The present paper contributes insights from narrative inquiry, a well-established qualitative methodology, to a food-related doctoral research study. The connections between food shoppers and the producer, family, friends and others in the food system, between eaters and the earth, and how these connections affect people's meaning-making of food and pathways to food citizenship, were explored in the research. The research used narrative inquiry methodology and focus groups for data collection. Five different food-ways in the Canberra region of Australia were selected for the present research; that is, community gardens, community-supported agriculture, farmers' markets, fresh food markets and supermarkets. Fifty-two people voluntarily attended eight focus groups with four to nine participants in each. From a practical perspective, the present paper offers a guide to the way in which narrative inquiry has been applied to one research project. The paper describes the application of narrative inquiry methodology, revealing the important place of narratives in generating new knowledge. The paper further outlines how phased narrative analysis can lead to a defensible and rigorous interpretive framework grounded in the data generated from people's stories and meaning-making. We argue that individual, social and system change will not be possible without further rigorous qualitative studies to inform and complement the empirical basis of public health nutrition practice.

Practitioner consensus on the determinants of capacity building practice in high-income countries.

To assess and develop consensus among experienced public health nutrition practitioners from high-income countries regarding conceptualisation of capacity building in practice, and to test the content validity of a previously published conceptual framework for capacity building in public health nutrition practice. A Delphi study involving three iterations of email-delivered questionnaires testing a range of capacity determinants derived from the literature. Consensus was set at >50% of panellists ranking items as 'very important' on a five-point Likert scale across three survey rounds. Public health nutrition practice in Australia, the UK, Canada and the USA. Public health nutrition practitioners and academics. Result A total of thirty expert panellists (68% of an initial panel of forty-four participants) completed all three rounds of Delphi questionnaires. Consensus identified determinants of capacity building in practice including partnerships, resourcing, community development, leadership, workforce development, intelligence and quality of project management. The findings from the study suggest there is broad agreement among public health nutritionists from high-income countries about how they conceptualise capacity building in public health nutrition practice. This agreement suggests considerable content validity for a capacity building conceptual framework proposed by Baillie et al. (Public Health Nutr 12, 1031-1038). More research is needed to apply the conceptual framework to the implementation and evaluation of strategies that enhance the practice of capacity building approaches by public health nutrition professionals.

Consensus development on the essential competencies for Iranian public health nutritionists.

To assess key experts' opinion regarding essential competencies required for effective public health nutrition practice within the health-care system of Iran. Qualitative study using the modified Delphi technique through an email-delivered questionnaire. Iran. Fifty-five experts were contacted through email. The inclusion criterion for the study panel was being in a relevant senior-level position in nutrition science or public health nutrition in Iran. In the first round, forty-two out of fifty-five experts responded to the questionnaire (response rate=76 %). A sixty-five-item questionnaire was designed with nine competency areas, including 'nutrition science', 'planning and implementing nutritional interventions', 'health and nutrition services', 'advocacy and communication', 'assessment and analysis', 'evaluation', 'cultural, social and political aspects', 'using technology' and 'leadership and management'. All experts who had participated in the first round completed a modified version of the questionnaire with seventy-seven items in the second round. The experts scored 'nutrition science' as the most essential competency area, while more applied areas such as 'management and leadership' were less emphasized. In both rounds, the mean difference between the opinions of the necessity of each area was 5.6 %. The Iranian experts had general agreement on most of the core competency areas of public health nutritionists. The results indicated the need for capacity building and revisions to educational curricula for public health nutritionist programmes, with more emphasis on skill-based competency development.

Aspirational competency expectations for public health nutritionists in Australia: A consensus study

AbstractAimTo assess consensus among public health nutrition (PHN) workforce development stakeholders on the competencies required for effective PHN practice in the Australian workforce context.MethodsA modified Delphi study involving two iterative survey rounds among an expert panel of 33 Australian PHN workforce development stakeholders. Surveys tested panellist ratings (essential, useful, irrelevant) of a listing of 143 competency elements derived from the literature and existing competency standards, across two survey rounds, with feedback between rounds. An arbitrary consensus cut‐off of 67% was applied with <10% change between rounds or 100% agreement interpreted as agreement stability.ResultsA total of 109 competency elements from the total list of 143 were rated as essential above the consensus cut‐off, representing 76% of the original list. Thirty‐three (33) elements were rated as essential by 100% of panellists. Approximately 90% or more of the competency elements tested were retained using the 67% cut‐off across nutrition science, nutrition communication, professional communication, capacity building and intervention management competency units. Competency elements rated as essential beyond the consensus cut‐off concentrated in the practice competency units of nutrition assessment, monitoring and surveillance, capacity building, and intervention management.ConclusionsThe results provide an empirical basis for future nutrition curriculum renewal and workforce development innovations and challenge the assumption that existing dietetic workforce preparation based on meeting entry‐level competencies is adequate for community and PHN practice.

Core functions for the public health nutrition workforce in Europe: a consensus study.

To assess and develop a consensus among a European panel of public health nutrition workforce stakeholders (academics and employers) regarding core functions required for effective public health nutrition practice. A modified Delphi study involving data from two rounds of questionnaires administered among a panel of public health nutrition workforce stakeholders. Europe. A panel of fifty-three public health nutrition development stakeholders, including thirty-three academics and twenty employers, sampled from eighteen European countries. Panellists rated 50 % (19/38) of the initially listed functions as core (i.e. without which public health capacity is limited), using a majority cut-off (>50 %). Out of the nineteen core functions seven were categorised under the heading Intervention management, emphasising high agreement on the importance of managing interventions in public health nutrition work. Only one of the identified core public health nutrition functions was rated differently between academics and employers, suggesting consistent identification of core functions between stakeholder groups. This consensus on core functions of the public health nutrition workforce in Europe can be used to promote a consistent understanding of the role and value of public health nutritionists as a discrete disciplinary sub-specialty of the public health workforce. The convergence of opinions of academics and employers, as well as comparison with previous international studies, indicates that there is a set of core public health nutrition functions transferable between countries that can be used as a benchmark to guide further development of the public health nutrition workforce in Europe.

The public health nutrition intervention management bi-cycle: a model for training and practice improvement.

The present paper describes a model for public health nutrition practice designed to facilitate practice improvement and provide a step-wise approach to assist with workforce development. The bi-cycle model for public health nutrition practice has been developed based on existing cyclical models for intervention management but modified to integrate discrete capacity-building practices. Education and practice settings. This model will have applications for educators and practitioners. Modifications to existing models have been informed by the authors' observations and experiences as practitioners and educators, and reflect a conceptual framework with applications in workforce development and practice improvement. From a workforce development and educational perspective, the model is designed to reflect adult learning principles, exposing students to experiential, problem-solving and practical learning experiences that reflect the realities of work as a public health nutritionist. In doing so, it assists the development of competency beyond knowing to knowing how, showing how and doing. This progression of learning from knowledge to performance is critical to effective competency development for effective practice. Public health nutrition practice is dynamic and varied, and models need to be adaptable and applicable to practice context to have utility. The paper serves to stimulate debate in the public health nutrition community, to encourage critical feedback about the validity, applicability and utility of this model in different practice contexts.

Consensus on the competencies required for public health nutrition workforce development in Europe – the JobNut project

To assess and develop consensus among a European panel of public health nutrition stakeholders regarding the competencies required for effective public health nutrition practice and the level of proficiency required in different practice contexts. A modified Delphi study involving three rounds of questionnaires. European Union. Public health nutrition workforce development stakeholders, including academics, practitioners and employers, from twenty European countries. A total of fifty-two expert panellists (84 % of an initial panel of sixty-two Delphi participants) completed all three rounds of the Delphi study. The panellists rated the importance of fifty-seven competency units possibly required of a public health nutritionist to effectively practice (Essential competencies). Twenty-nine of the fifty-seven competency units (51 %) met the consensus criteria (≥66·7 % agreement) at the second round of the Delphi survey, with the highest agreement for competencies clustered within the Nutrition science, Professional, Analytical and Public health services competency domains. Ratings of the level of competencies required for different levels in the workforce indicated that for a public health nutrition specialist, advanced-level competency was required across almost all the twenty-nine competencies rated as essential. There were limited differences in rating responses between academics and employer panellists throughout the Delphi study. Competencies identified as essential can be used to review current public health nutrition practices and provide the basis for curriculum design and re-development, continuing education and workforce quality assurance systems in Europe. These are all important tools for systematic and strategic workforce development.

A capacity-building conceptual framework for public health nutrition practice

To describe a conceptual framework to assist in the application of capacity-building principles to public health nutrition practice. A review of the literature and consideration of the determinants of effective public health nutrition practice has been used to inform the development of a conceptual framework for capacity building in the context of public health nutrition practice. The limited literature supports a greater integration and application of capacity-building strategies and principles in public health nutrition practice, and that this application should be overt and strategic. A framework is proposed that identifies a number of determinants of capacity for effective public health nutrition action. The framework represents the key foundations for building capacity including leadership, resourcing and intelligence. Five key strategic domains supported by these foundation elements, including partnerships, organisational development, project management quality, workforce development and community development, are proposed. This framework can be used to assist the systematic assessment, development and evaluation of capacity-building activity within public health nutrition practice. Capacity building is a strategy within public health nutrition practice that needs to be central to public health nutrition intervention management. The present paper defines, contextualises and outlines a framework for integrating and making explicit the importance of capacity building within public health nutrition practice at many levels.

Genetic and Epigenetic Contributions to Human Nutrition and Health: Managing Genome–Diet Interactions

The Institute of Medicine recently convened a workshop to review the state of the various domains of nutritional genomics research and policy and to provide guidance for further development and translation of this knowledge into nutrition practice and policy. Nutritional genomics holds the promise to revolutionize both clinical and public health nutrition practice and facilitate the establishment of (a) genome-informed nutrient and food-based dietary guidelines for disease prevention and healthful aging, (b) individualized medical nutrition therapy for disease management, and (c) better targeted public health nutrition interventions (including micronutrient fortification and supplementation) that maximize benefit and minimize adverse outcomes within genetically diverse human populations. As the field of nutritional genomics matures, which will include filling fundamental gaps in knowledge of nutrient–genome interactions in health and disease and demonstrating the potential benefits of customizing nutrition prescriptions based on genetics, registered dietitians will be faced with the opportunity of making genetically driven dietary recommendations aimed at improving human health.

Public health nutrition practice in Canada: a situational assessment

Renewed focus on public health has brought about considerable interest in workforce development among public health nutrition professionals in Canada. The present article describes a situational assessment of public health nutrition practice in Canada that will be used to guide future workforce development efforts. A situational assessment is a planning approach that considers strengths and opportunities as well as needs and challenges, and emphasizes stakeholder participation. This situational assessment consisted of four components: a systematic review of literature on public health nutrition workforce issues; key informant interviews; a PEEST (political, economic, environmental, social, technological) factor analysis; and a consensus meeting. Information gathered from these sources identified key nutrition and health concerns of the population; the need to define public health nutrition practice, roles and functions; demand for increased training, education and leadership opportunities; inconsistent qualification requirements across the country; and the desire for a common vision among practitioners. Findings of the situational assessment were used to create a three-year public health nutrition workforce development strategy. Specific objectives of the strategy are to define public health nutrition practice in Canada, develop competencies, collaborate with other disciplines, and begin to establish a new professional group or leadership structure to promote and enhance public health nutrition practice. The process of conducting the situational assessment not only provided valuable information for planning purposes, but also served as an effective mechanism for engaging stakeholders and building consensus.

A call for more research that enhances public health nutrition practice

A call for more research that enhances public health nutrition practice

Aspiring dietitians study: A pre‐enrolment study of students motivations, awareness and expectations relating to careers in nutrition and dietetics

AbstractObjective: To qualitatively explore the attitudes, expectations and career plans of aspiring dietetic students.Design: Qualitative study involving open‐ended semi‐structured face‐to‐face interviews.Subjects: Sixty‐three student applicants to the Griffith University Master of Nutrition and Dietetics Program over the 2002–2003 period.Main outcome measures: Attitudinal data about the motivations, competency expectations and career plans of Nutrition and Dietetic program applicants.Analysis: Qualitative content analysis.Results: Student applicants had a mix of health science and exercise science undergraduate training backgrounds, were in their early to mid‐20s and were recent graduates. The most common motivations for becoming a dietitian was a long‐term primary interest in nutrition, health and helping people inspired by previous experience with other dietitians, family or personal illnesses and significant others such as mothers and teachers. Approximately 30% of applicants reported being motivated by personal experiences (self or friends) with obesity or eating disorders. High‐level communication and organisational skills and nutrition knowledge were the common competency expectations of dietitians among potential students. Most reported working clinically, running a private practice (particularly in sports nutrition) or in mixed practice settings with autonomy and practice diversity as long‐term career aspirations. There was a generally low level of specific awareness of public health nutrition or food service management practice opportunities in the profession.Conclusions: There appears to be a need to further market the diversity of practice in the profession to senior school‐age and undergraduate students so that applicants are more informed of the realities of career opportunities.

Competencies for effective public health nutrition practice: a developing consensus.

To assess the level of consensus amongst an international panel of public health nutrition leaders regarding the essential competencies required for effective public health nutrition practice. A modified Delphi study involving three rounds of questionnaires. A panel of 20 public health nutrition experts from seven countries in the European Union, the USA and Australia. Expert panellists completed three rounds of the study relating to competencies. A literature review conducted as a prelude to the expert panel survey identified common competency units from the fields of public health, health promotion, nutrition and dietetics, and health education. These were categorised into seven competency areas including analytical, socio-cultural and political, public health service, communication, management and leadership, nutrition science and professional competency categories. There was strong initial agreement (> or = 90% of panellists at Round 1) that developing internationally recognised competencies for public health nutrition specialists was a priority. Twenty-six of an initial listing of 52 competency units were rated as essential competencies by > or = 80% of the panellists after Round 1. Iteration rounds resulted in the addition of five extra competency units suggested by panellists after Round 1 and an increase by 13 in the number of competencies rated as essential to consensus levels. From a total of 57 competency units rated after the final survey round, 41 competency units were rated as essential competencies by > or = 80% of the panellists (consensus), with 21 of these unanimously rated as essential competencies. There is strong international agreement amongst public health nutrition leaders in Europe, the USA and Australia about a range of competencies required for effective public health nutrition practice. Essential competency units identified can be used to develop and review competency standards for public health nutrition.

Competency development needs of the Australian public health nutrition workforce.

To assess factors affecting competency development of the Australian public health nutrition workforce and investigate competency development intentions, barriers and self-reported training needs. Cross-sectional study using self-administered mail- or email-delivered questionnaire. Two hundred and forty practitioners working in designated community and public health nutrition positions in the Australian health system. An 87% questionnaire response rate was achieved. The profile of the sample included female practitioners (95%) within the age range of 26-45 years (67%), from dietetic backgrounds (75%) and employed in state health departments as community dietitians/nutritionists (52%) or public health nutritionists (32%). Only 14% had completed higher degree qualifications but most (80%) reported an intention to do so in the future. Entry-level dietetic education was considered by most respondents (57%) to be inadequate preparation for public health nutrition practice but considered it had utility as a precursor for public health nutrition competency development because of its strong grounding in nutrition knowledge, basic research skills and problem-solving. On-the-job learning was the most prominent competency development influence reported by this workforce. Flexibility in teaching and learning approaches is needed to facilitate workforce participation in further competency development. The main competency development needs focused on analytical and policy process competencies; however, there was a general need expressed for competency development across many competency areas. These data provide intelligence to inform public health nutrition workforce development, particularly that relating to continued professional development amongst the existing workforce.

Public health nutrition practice in the United States

Public health nutrition practice in the United States