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Abstract
The concept of public nutrition
The present study
Results
Curriculum content: Responses of graduates of US programmes
Potential effectiveness of public nutrition education for improving nutrition
Professional definitions within public nutrition: Is it nutrition?
Institutional structure
Conclusion
References
Beatrice Rogers and Nina Schlossman
Beatrice Rogers is affiliated with the School of Nutrition Science and Policy at Tufts University in Medford, Massachusetts, USA. Nina Schlossman is affiliated with Global Food and Nutrition, Inc., in Silver Spring, Maryland, USA.
A study supported by the Pew Charitable Trusts investigated whether the nutrition situation in Central America and Mexico would be improved by professional training in applied, operationally oriented nutrition. The results reported here are based on interviews conducted with nutrition professionals in the United States and abroad and a survey of graduates of US graduate programmes. The respondents agreed that appropriate training of nutrition professionals could improve the nutrition situation of the region, recognizing that social and economic factors are critical determinants of nutrition. This field was seen as a social science discipline. The name “public nutrition” is proposed for the field. Critical elements of training include reaching a critical mass of persons at multiple levels; obtaining institutional commitment to allow newly trained professionals the resources and responsibility to apply what they have learned in their jobs; building in follow-up through networking, information exchange, and reunions of participants and faculty; and combining the skills and knowledge of public nutrition with a strong disciplinary base in a recognized field. The substance of the training programme would consist of applied research skills; communication and advocacy skills; programme management and administration; nutrition science; nutrition programmes and policies; social science concepts of economic and political economy; and fieldwork, internships, or practical. The usefulness of each of these fields is assessed by employed graduates of US programmes. Effective professionals also need personal qualities of leadership, dedication, motivation, and an entrepreneurial spirit. Immediate returns to short-term training of front-line programme managers should not result in ignoring the long-term benefit of higher-level professional education of senior administrators, policy makers, and researchers needed to advance the field of nutrition.
It is widely quoted among applied nutrition professionals that “nutrition is not a discipline to be studied; it is a problem to be solved.” If this is true, then by definition, solving nutrition problems requires multidisciplinary cooperation. The study of nutrition crosses boundaries from the most basic of laboratory sciences to an understanding of global economic and political interactions among nations. It takes nothing away from the importance of scientific research into the basic mechanisms of nutrient metabolism to assert that nutrition problems in developing countries (any more than in the developed world) cannot be solved in the laboratory or clinic alone. The constraints to populations achieving nutritional health fall in the economic, social, cultural, and behavioural realms: in the lack of access to food, its inappropriate distribution among and within households, and maladaptive food and health practices. The skills and knowledge needed to help address these constraints are quite different from those of the laboratory scientist or the medical practitioner. They require a different kind of training from that associated with the science of nutrition.
This paper addresses the appropriate education and training of applied nutrition professionals, specifically those planning to work in the realm of food and nutrition policy and programmes in developing countries. In a 1996 letter to The American Journal of Clinical Nutrition, Mason and others suggested the name “public nutrition” to define 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 [1]. The suggestion was based on the perception that the field already exists de facto, but that its recognition as a legitimate field of study would allow education and professional development to be more explicitly focused on its objectives. Like public health, public nutrition would focus on problem-solving in a real-world setting, making it, by definition, an applied field of study whose success is measured in terms of effectiveness in improving nutritional conditions.
The recognition that nutrition solutions often lie outside the domain of “nutrition” per se is not new. In the 1970s, the popular concept of multisectoral nutrition planning was based on that understanding. It was discredited [2, 3] not because the analysis was wrong, but because the proposed solution did not take account of political and structural barriers to the implementation of large multisectoral responses. More recent approaches have been based on the assumption that nutrition problems will be solved by incorporating nutrition concerns into a wide variety of disciplines as they are translated into action [4], for example, when consumption issues are integrated into agriculture policies. This approach is correct if it can be made to work, but it is dangerous because nutrition then risks being the responsibility of no one. Putting nutrition under the rubric of health tends to medicalize the field, while putting it under agriculture may marginalize it. Public nutrition has a distinct identity, incorporating the relevant aspects of the variety of disciplines that bear on the nutrition problem, as well as incorporating scientific advances in the understanding of nutritional problems.
The ideas presented in this paper were developed in part as a result of a study carried out at the Tufts School of Nutrition Science and Policy in 1994, with support from the Pew Charitable Trusts, to investigate the kinds of training needed for applied nutrition professionals, with a specific focus on the situation in Central America and Mexico [5]. The study involved two separate surveys. One was a series of in-depth, semi-structured, face-to-face interviews with 260 nutrition professionals from the United States, the region, and other parts of the world. Respondents included university professors, researchers, government officials at many levels from ministries to district programme officers, representatives of bilateral and multilateral donor agencies, and managers and practitioners from national and international non-governmental organizations. The sample was not random. Initial respondents were selected on the basis of their known involvement in the field of applied nutrition or their institutional affiliation, and these respondents referred us to others.
The second component of the study was a mailed survey to graduates of several graduate-level international nutrition programmes in the United States: the Cornell University Division of Nutritional Sciences, the Massachusetts Institute of Technology (MIT) International Nutrition Program, the Tufts University School of Nutrition Science and Policy programme in Social Sciences of Applied Nutrition and Food Policy, and the United Nations University nutrition programme at MIT. The questionnaire, a mix of closed-and open-ended questions, asked respondents about the relevance and usefulness of various aspects of their graduate education in their careers, and about their career paths over time. We sent out about 200 questionnaires and received about 100 responses, of which 91 were complete enough to be usable. Our resources did not permit follow-up of non-respondents. The results reported here must be interpreted cautiously in light of the low response rate.
The results of both these surveys, and the comments of a group convened to discuss the preliminary results, are incorporated into the discussion that follows.
Appropriate professional levels of education and training
There are several professional levels at which persons with nutrition-focused training can make a difference. Programme managers can improve implementation in areas such as outreach, operations, and other aspects of management. Existing programmes will be more effective if they meet the needs and constraints of the target population, address the immediate and underlying causes of the nutrition problem in the area, and achieve coverage of those who need the programme most. Appropriate training can give managers the tools to achieve these goals.
But policy makers, to be effective, also require applied, interdisciplinary, nutrition-focused education. The training of policy makers complements that of the more direct service provider. Each serves different immediate objectives. “One makes programmes better; the other makes better programmes,” as one respondent put it. Nutrition programmes are just one tool of nutrition policy. At the policy level, a few well-placed individuals can make a big difference if they understand the nutritional implications of the range of policy decisions and are in a position to alter them.
A third arena in which appropriate training and education is critical is that of knowledge-building through applied research. Virtually all our respondents, even those who were working in clinical and laboratory settings, agreed that “nutrition research,” if this term is understood to mean only laboratory and clinic-based investigation, does not alone meet the needs of those who are shaping policies and designing programmes. Equally rigorous research is needed on the feasibility, effectiveness, and cost-effectiveness of interventions. This is the bridge between scientific knowledge (the role of vitamin A status in determining morbidity and mortality, for example) and the use of this knowledge to promote the health of populations.
The study of nutrition problems in field settings and of programme design and evaluation is in no way simpler than laboratory science, a matter of common sense rather than of the application of specific research techniques. On the contrary, the need for scientific rigour may be greater, given the constraints on conducting research studies in natural settings. Similarly, research on the effects of alternative policies on nutrition is a complex and specialized endeavour.
These three general categories of public nutrition professional - programme manager, policy maker, and researcher - require distinct approaches to training and education. Which level offers the greatest promise of measurable effectiveness? In the short term (perhaps a five-year time horizon), the most direct impact will be achieved with the focused training of the management-level professionals. But it is short-sighted to ignore the preparation of the next generation’s policy makers. After all, the effect of a single policy change - eliminating food price subsidies, for example, or allowing unrestricted exports - can swamp the effects of specific targeted service-delivery programmes [e.g., ref. 6]. The payoff to advanced, graduate-level training is longer term, but a single individual in the right place can have a major impact on policies affecting nutrition. The cost of failing to invest in such people is high in terms of lost opportunities to protect or advance the nutrition agenda.
Nature of multidisciplinary education for public nutrition
Level and duration
The specific nature of educational programmes in the field of public nutrition depends on the target audience. They range from brief seminars (lasting a few days) focused on advocacy and sensitization of senior-level officials, to short courses (lasting a few weeks) concentrating on specific skills and information transfer, to formal degree programmes at the master’s and doctoral levels. Graduate programmes themselves may range from a one-year master’s degree programme designed for mid-career professionals with strong disciplinary expertise, to more traditional graduate degree programmes. There was general recognition that those planning to work at the policy level in governments or international agencies need graduate-level degrees both for the skills and information they provide and for the prestige and recognition they confer.
Outside the research and academic communities, respondents argued that preparation beyond the master’s level was not necessary; some even argued that it was counterproductive. Many felt that a doctorate tended to make students too narrowly specialized and academic, and that it unduly raised job and pay expectations. Another concern about doctoral-level training is that graduates may not return to the applied jobs they held before getting their degrees. We found in our survey that about 46% of Ph.D. graduates work in academic and research rather than operational settings. This number was higher among foreign graduates of US universities than among Americans: 54%, compared with 33% of US students. However, virtually all of the foreign graduates working in research institutions reported working outside the United States. This suggests that their training is contributing to the educational and research capacities of their own countries.
To create strong developing-country institutions for advanced training, there must be a cadre of trained faculty. Furthermore, if applied research is to be eligible to receive the same kind of funding and credence as laboratory science, it must be done by persons trained at the highest levels. Some in the laboratory sciences believe that field-based, programme- and policy-oriented research is inherently of poor quality and unreliable, because of the uncontrolled conditions of real-world studies. The continued education of serious, rigorous researchers willing to devote themselves to applied, operationally oriented or policy-relevant research is essential to ensure that this misperception is rectified.
Different educational models are appropriate for different purposes. On-site training conducted in the location where the trainees are currently working does not disrupt the personal and professional lives of the participants; more persons can attend; participants are more likely to remain connected to their jobs, during and after completion; and it can last longer if it is given in a series of short modules. But participants will be distracted by the day-to-day requirements of their jobs and lives, and they do not get the opportunity to interact with the range of students and professionals who would be present in a centralized, off-site educational institution. Off-site training programmes, especially ones offered outside the country, may be more appropriate for formal degrees. They are longer, more costly, and more personally (and sometimes professionally) disruptive, but they do offer intensive study and research opportunities, as well as extensive interaction with faculty and other professional colleagues. The ability to learn from others and the freedom to work intensively and focus exclusively on the training are important benefits of training and educational programmes conducted in a university or other setting away from the workplace.
Curriculum and educational content: Informant responses
Preparation for effective work in public nutrition requires substantive knowledge, specific skills, and practical experience. There was widespread agreement among respondents on the core of skills and knowledge essential to preparation in this field, and equal agreement that we were describing a programme in the social sciences. There was some disagreement about the depth of knowledge in nutritional biochemistry, clinical nutrition, and dietetics that would be needed by applied professionals, but nutrition science was in any case seen as a support discipline to the social sciences related to economic, social, and political behaviour relevant to nutrition inputs and outcomes.
Possibly because of the suspicion with which multi-disciplinary programmes are viewed, most respondents suggested that public nutrition training needs to be built on a professional disciplinary base such as economics, communications, health science (including medicine), or nutrition science. It is not possible to create professionals who are skilled in all the disciplines related to nutrition outcomes, so education in public nutrition must provide the skills and knowledge base to relate one of those disciplines to nutrition concerns.
The core elements of advanced training in public nutrition are the following:
Applied research skills (statistics; epidemiology: survey and field study design; data handling, analysis, and interpretation; application to community needs assessment, programme monitoring, and evaluation; qualitative and quantitative methods)
All respondents agreed that applied research skills are the core of a programme in public nutrition. Many respondents emphasized the central importance of learning how to frame a question in terms applicable to solving problems at hand. This is the immediate step before study design, when the purpose and objectives of a study are established. Lack of these skills was identified as a failing of much available research training. The other critical gap in existing training, on which academics and practitioners strongly agreed, is in the interpretation and use of information once it has been collected. It is far easier to gather data than to use it intelligently, and there were many anecdotes about studies (needs assessments, evaluations) carefully performed and put to no use.
These skills are not restricted to academic and research settings; on the contrary, they are closely integrated with policy analysis and programme design and modification. Because the range of possible causes of a nutrition problem is broad, people need tools to assess the situation, analyse the information, and develop appropriate solutions from a range of options. Multidisciplinary training means that public nutrition professionals are less likely to make mistakes often made by people with strong disciplinary specialities but without multidisciplinary nutrition training: that they understand the nutrition problem and its solutions in their own terms. Agriculturalists assume the solution lies in the food supply; medical professionals assume the solution lies in health care or supplementation; nutritionists may assume the solution lies in nutrition education or in food supplements. In any given case, any of these might be appropriate solutions, but the field requires a person who can use empirical information to assess the entire range of possible interventions and policy responses.
Professionals in the major non-governmental organizations and operational agencies and in consulting firms both in the United States and in the region frequently told us that these were the skills they look for. Practitioners were as strong as academics and researchers in their emphasis on the need for these skills.
Communication and advocacy skills (ability to write and speak persuasively; identify an audience and communicate ideas at the appropriate level; advocate for a point of view; train and work effectively with staff)
Respondents emphasized two key aspects of communication. Those who worked in community-level programmes underscored the importance of behaviour change in solving many nutrition problems and held that a critical area of expertise is the ability to do community education. Social marketing and community education represent specialities in their own right; this is indeed a critical area of knowledge and skill in the field, but it represents an area of substantive specialization within public nutrition, requiring specific in-depth training to apply these skills to the nutrition arena.
All respondents noted the need for advocacy at administrative and policy levels of governments and agencies, allowing the public nutrition specialist to act as a change agent in the community and within the organizational structures in which he or she works. This set of skills includes writing and speaking persuasively and concisely, organizing information in a logical way, and identifying the appropriate arguments and presentation style for a particular audience.
Specific to nutrition is the ability to integrate information from the wide variety of fields that affect nutritional situations and solutions - such as scientific information on diet and disease; economic data on incomes, prices, and consumption patterns; and data on public health indicators - and to be able to interpret and present it in an intelligible way. To work in the field of public nutrition, one must be at least an intelligent consumer of data (not necessarily a producer) in several disparate areas and be able to translate the data into terms a lay person can understand. For programme managers, the ability to train others is also critical.
Working in groups was mentioned by many as a separate, though related, skill essential to an effective applied nutrition professional. The ability to work with community groups is one aspect of this skill; another is the ability to work with other professionals in a team. Given the uniquely multisectoral nature of most nutrition issues and of their solutions, working in multidisciplinary teams is more relevant in nutrition than in many other applied fields.
Programme management and administration (as relevant to service delivery, non-governmental organization, government, and international agency settings: personnel management; and new management techniques)
Management skills are essential for those planning to work in programme implementation. Respondents working in the region and in programmes (as opposed to those in academic or research institutions) emphasized the importance of training in planning, logistics of implementation, and budgeting. The skills of monitoring and evaluation, widely cited as management skills, are really those of applied research. Some academic researchers did indicate that they used management skills more and more as they gained seniority and responsibility for running their own laboratories or divisions.
A related skill mentioned by both academics and those working in programmes is the ability to write proposals. This skill is really just one application of the ability to understand one’s audience, organize information, and write persuasively, combined with the ability to set priorities, develop clear plans, and estimate budget and resource needs - all of which are aspects of management.
Nutrition science (some study of the basic concepts of nutrition science: human nutrition, physiology, and diseases of nutrition and malnutrition; food and dietary composition; assessment of nutritional status in community settings)
Opinions varied widely on the question of what level of training in nutrition science is needed to work on policy or programmes. At one extreme was the opinion that the best programmes are run by strong managers who “picked up” some nutrition along the way. At the other, one respondent (a nutritional biochemist) believed that anyone working in nutrition requires “solid grounding in the nutrition sciences: biochemistry, pathology, physiology, and metabolism.” Both extremes, though, were very much minority opinions.
Most respondents agreed that persons working on nutrition policies and programmes need a basic but thorough understanding of human nutrition and of the nutritional aspects of food, but that intensive training in the laboratory side of nutrition science was not essential to this field. Practitioners put less emphasis on the importance of scientific backgrounds than did professors in academic nutrition departments and researchers in clinical and laboratory settings. However, several professors in academic nutrition programmes specifically suggested cutting basic science courses from the applied curriculum to make room for courses in research, communications, and management skills and in the social sciences. This suggestion was more widely endorsed by those currently working in applied programmes.
The controversy on this point relates to the fact that the new field of public nutrition has not achieved recognition as a speciality in its own right, resulting in a concern that the label of “nutrition” must carry with it expertise in the disciplines associated with the laboratory and clinical sciences. Several respondents working in international agencies and non-governmental organizations in the region emphasized that they rarely used the biochemistry they learned in school; at most, it represented a professional “entry card.” Some said that, although they did not use it much, their graduate-level scientific training gave them confidence and credibility in professional meetings and workshops. Given the large number of areas in which some degree of knowledge is needed, however, several courses in laboratory science would seem to be an expensive way to achieve this goal.
This de-emphasis of nutrition science in the training for public nutrition should in no way be construed as belittling the importance of scientific and clinical research for the advancement of nutrition as a field. But basic research is not sufficient to make a difference at the community or national level; the application of such research results is a separate area of expertise, and an important one. As the director of one master’s programme in the region put it, “The economists make decisions while the nutritionist is in the lab.”
Nutrition policies and programmes and related knowledge and skills (case study of successful and failed experience; techniques for conducting situation analyses; programme design processes, including planning, budgeting, implementation, operations, and how to select policy interventions from a range of possible options)
Persons being trained in public nutrition need a systematic introduction to the range of programmes and policies that have affected nutrition in various settings. This introduction should cover design and implementation issues, specific resource needs, and the conditions under which various programmes have been found to be more or less effective. Included in this must be not only nutrition programmes, such as Maternal and Child Health supplementary feeding, school meals, and nutrition education, but also areas outside nutrition, such as public health and environmental sanitation, household food and livelihood security, and food marketing. These programmes should be presented for their direct relevance and to illustrate forcefully the point that nutrition solutions range well beyond the areas typically defined as nutrition. A great deal of knowledge has been developed through problem analysis, programme evaluations, and cost-effectiveness studies; this is clearly an important knowledge base of the public nutrition profession.
Social science concepts (to understand the underlying economic and social conditions as related to nutrition and food security)
The two areas most commonly identified as important to public nutrition were economics and behavioural science. Many people emphasized the importance of understanding the economic determinants of nutrition. They noted that, for this applied field, training should not focus on econometric analysis or broad economic theory, but on some principles of economics as it applies to households (the household as a production and consumption unit; determinants of intra-household allocation; the value of time; the role of incomes, income sources, and local prices in determining household food security). Some exposure to the concepts of political economy - the political forces underlying the economic and social conditions that relate to the nutritional situation - was also generally held to be central to effectiveness in the field.
Food policy is heavily dependent on economics and somewhat less so on political economy; economics was identified commonly as a separate and important field of study. In terms of their ability to have an effect at the national level, at least one of our respondents, a World Bank staff member, suggested that there is a greater need for well-trained food policy analysts to work with governments and international donors than there is for persons trained to work on programme design and implementation. This is one area in which the focus needs to be different for those working at the applied programme level and those planning to work at the policy level in governmental and international organizations.
Respondents from regional UNICEF offices and non-governmental organizations, as well as those from government ministries and agencies such as the World Bank, specifically referred to the importance of understanding the nutritional implications of macroeconomic policies related to structural adjustment, trade and exchange rates, credit, and agricultural pricing policies. As we suggested with regard to social marketing and communication, economics and food policy constitute an area of specialization for persons planning to work on nutrition issues at the policy level.
Understanding the social context of nutrition problems implies knowing the behavioural and cultural factors that can, directly and indirectly, affect the nutritional situation of a community (and, more broadly, the country). This is not to say that formal study of psychology, anthropology, or sociology (the social sciences of culture and behaviour) must be part of public nutrition training. Exposure to the essential concepts may be incorporated easily at different levels of sophistication into training programmes of varying lengths. To become professionally competent in these disciplines requires intensive professional study; such study can, subsequently or concurrently, be related to nutrition and food consumption issues as a specialization, but would not form the essential core of public nutrition education.
Fieldwork, internships, practica (application of training to nutrition problems in field settings)
There was 100% agreement that classroom learning must be complemented by field application. Even if people have already worked in the field, education should include the opportunity to apply in a real-world setting what was learned in the classroom. Furthermore, fieldwork before graduation is as essential for employability as for the development of knowledge and skills. Field experience is a prerequisite for employment in many agencies; field-work conveys much greater employability for these agencies than more advanced (post-master’s degree-level) degree training.
Personal qualities (of leadership, dedication, motivation for working in public nutrition in cross-cultural settings, and an entrepreneurial spirit)
If we were to take literally some of the descriptions we heard of the personal characteristics of the ideal person to work in the field of public nutrition, we would conclude that to do this work requires a combination of Albert Schweitzer, Mother Teresa, and Lee Iacocca: brilliance, selflessness and commitment, charisma, and entrepreneurship. On a serious note, though, a number of our respondents did point out that, aside from skills and knowledge that can be transmitted directly by means of training and education, there are some personal characteristics that are important to success in the field.
These characteristics do indeed include a level of personal commitment. Equally important are skills typically used in fieldwork: the ability to listen and learn from the community and the flexibility to respond to local conditions and situations. Leadership, entrepreneurship, and the ability to engage in strategic thinking all contribute to a person’s effectiveness in the field. Although these are personality characteristics that some people have naturally, there are elements that can be taught.
Table 1 summarizes the responses of graduates currently working in a nutrition-related field to questions about which specific elements of their educational experience were most useful, and which were not useful. Table 2A and B reports the assessments of respondents of the usefulness of specific skills in their first job and in their current job. About two-thirds of respondents said they were currently working in nutrition-related jobs. Interestingly, the rating of the usefulness of each topic area was not very different in the group that included all the respondents.
Statistics, epidemiology, and research design were identified as “useful” by over 90% of those working in nutrition-related fields. No one identified any of these courses as “not useful.” There were no obvious differences in the responses according to whether the respondent received a master’s or a doctorate, or whether the respondent’s current employment was in the area of “research” or “operations,” suggesting that the usefulness of these skills is not only academic. Over 50% of respondents used these skills in their first job after graduation; this number was noticeably higher among respondents with a Ph.D. than those with a master’s degree. These skills apparently gain in usefulness (see table 2A and B): 70% or more reported using research design and data analysis skills in their current jobs. Those working in research were more likely to report using these skills, but over 60% of those in working in operations also used them.
Human or clinical nutrition was reported as useful by 91% of graduates, and as “not useful” by 2%, in contrast to nutritional biochemistry and dietetics, which were used by fewer, and held to be “not useful” by more of these graduates. On these questions, there were differences by terminal degree, with 60% of master’s graduates and 80% of doctoral graduates (many of whom work in research) saying that nutritional biochemistry was useful to them in their jobs.
Management and administration courses were taken by only 31% of the programme graduates we surveyed, but most of these (89%) identified the subject area as useful in their work. There was no apparent difference by degree level, job type, or location. (Note that these numbers were quite small.) That so few took these courses is an indication of the limitations in existing programmes.
Fewer than half of the US programme graduates who responded to our survey had taken a programme design course, a possible indication of curriculum limitations. Of those who had taken the course, 85% said it was useful in their work. Among those who had not taken any courses in programme design, over half (52%) said they wished they had taken one. This was the second highest percentage of graduates reporting they “wished they had taken” a particular course; notably, the highest was for research design (65%).
Among the social sciences, food policy and economics were most frequently identified as useful in their work by the students who had taken these courses: by 85% and 76% of respondents, respectively. Sociology, political science, and psychology/human behaviour were rated useful by a somewhat lower percentage of graduates in nutrition jobs: just over 58% for sociology and political science, and over 50% for psychology and human behaviour. These were also taken by fewer students, and higher percentages (17% and 14%, respectively) specifically said they were not useful. This reflects the fact that these areas of study represent specializations rather than generally applicable parts of a core programme. It may also reflect the fact that these courses are typically taught by departments lacking any focus on applications to nutrition or related areas. The methods of anthropology (qualitative research methods) were considered quite important and were rated useful in their work by 83% of graduates working in nutrition-related fields.
About 48% of the US programme graduates we surveyed did an international field internship or other field experience as part of their graduate study; 86% of these reported that it was useful in their subsequent nutrition-related work. Almost all of them (91%) cited the work experience gained; 86% cited the specific skills they acquired in the course of their work, and the same number cited greater understanding of nutrition-related issues as reasons for the usefulness of fieldwork. Future work contacts and greater confidence in their own abilities were cited by about 60% of these graduates, and almost 50% said that the fieldwork had strengthened their personal sense of commitment to their work.
TABLE 1. Respondents with nutrition-related jobs identifying selected courses as useful or not useful
|
Course
|
Overall (N = 58)
|
Terminal degree |
Nationality a |
Job type |
||||||||||||
|
M.S. |
Ph.D. |
US |
Non-US |
Research |
Operations |
|||||||||||
|
No. taking |
% taking |
Useful (%) |
Not useful (%) |
No. taking |
Useful (%) |
No. taking |
Useful (%) |
No. taking |
Useful (%) |
No. taking |
Useful (%) |
No. taking |
Useful (%) |
No. taking |
Useful (%) |
|
|
Nutritional biochemistry |
49 |
85 |
76 |
12 |
10 |
60 |
39 |
80 |
29 |
92 |
19 |
79 |
27 |
82 |
23 |
70 |
|
Human/clinical nutrition |
45 |
78 |
91 |
2 |
7 |
100 |
38 |
90 |
28 |
89 |
16 |
98 |
26 |
96 |
20 |
85 |
|
International nutrition |
49 |
85 |
90 |
4 |
11 |
82 |
38 |
92 |
27 |
85 |
21 |
95 |
26 |
96 |
24 |
83 |
|
Dietetics |
15 |
26 |
67 |
19 |
2 |
100 |
17 |
62 |
8 |
63 |
7 |
71 |
11 |
73 |
5 |
40 |
|
Statistics/biostatistics |
55 |
95 |
91 |
- |
13 |
92 |
42 |
91 |
32 |
91 |
22 |
91 |
28 |
89 |
28 |
93 |
|
Epidemiology |
43 |
74 |
91 |
- |
12 |
92 |
31 |
90 |
23 |
87 |
19 |
95 |
20 |
90 |
24 |
92 |
|
Research design |
44 |
76 |
88 |
- |
10 |
90 |
34 |
88 |
24 |
88 |
19 |
95 |
22 |
96 |
23 |
83 |
|
Qualitative methods |
24 |
41 |
83 |
- |
5 |
80 |
19 |
84 |
10 |
80 |
14 |
86 |
13 |
77 |
12 |
83 |
|
Anthropology |
21 |
36 |
62 |
10 |
5 |
80 |
16 |
56 |
13 |
54 |
8 |
75 |
11 |
55 |
11 |
73 |
|
Programme design |
27 |
47 |
85 |
4 |
6 |
67 |
21 |
91 |
15 |
80 |
11 |
91 |
12 |
75 |
15 |
93 |
|
Management/administration |
18 |
31 |
89 |
- |
9 |
89 |
9 |
89 |
11 |
82 |
7 |
100 |
10 |
90 |
9 |
78 |
|
Economics |
39 |
67 |
76 |
10 |
9 |
89 |
30 |
77 |
25 |
76 |
14 |
86 |
20 |
85 |
20 |
70 |
|
Food policy |
40 |
69 |
85 |
8 |
13 |
92 |
27 |
82 |
24 |
83 |
16 |
88 |
19 |
79 |
22 |
91 |
|
Sociology/political science |
29 |
50 |
59 |
17 |
5 |
60 |
24 |
58 |
20 |
50 |
9 |
78 |
15 |
60 |
15 |
60 |
|
Psychology/human behaviour |
21 |
36 |
52 |
14 |
4 |
50 |
17 |
53 |
14 |
43 |
6 |
67 |
14 |
57 |
8 |
38 |
|
Communications/social marketing |
13 |
22 |
85 |
8 |
6 |
67 |
7 |
100 |
5 |
60 |
8 |
100 |
7 |
86 |
6 |
53 |
|
Community organization/advocacy |
11 |
19 |
55 |
9 |
2 |
- |
9 |
67 |
6 |
50 |
4 |
50 |
6 |
67 |
5 |
40 |
|
Fieldwork/internship in US |
12 |
21 |
58 |
- |
2 |
50 |
10 |
60 |
10 |
70 |
2 |
- |
8 |
50 |
4 |
75 |
|
Fieldwork/internship outside US |
29 |
50 |
86 |
- |
4 |
100 |
25 |
84 |
16 |
81 |
13 |
92 |
17 |
88 |
13 |
85 |
a. One respondent did not provide information on nationality.
TABLE 2A. Respondents reporting use of specific skills in first job after graduatio a
|
Skill
|
Overall (N=75) |
Terminal degree |
Nationality b |
Country of first job |
First type of job |
|||||
|
M.S. (N=27) |
Ph.D. (N=48) |
US (N=46) |
Non-US (N=28) |
US (N=39) |
Non-US (N=36) |
Research (N=41) |
Operations (N=34) |
|||
|
No. using |
% using |
% using |
||||||||
|
Data collection |
34 |
45 |
22 |
58 |
39 |
57 |
41 |
50 |
66 |
21 |
|
Data analysis |
41 |
55 |
37 |
65 |
50 |
64 |
56 |
53 |
78 |
27 |
|
Research design |
39 |
52 |
26 |
67 |
46 |
64 |
46 |
58 |
81 |
18 |
|
Research management |
36 |
48 |
30 |
58 |
46 |
54 |
49 |
47 |
64 |
27 |
|
Programme design |
23 |
31 |
33 |
29 |
30 |
32 |
15 |
47 |
24 |
38 |
|
Programme management |
23 |
31 |
48 |
21 |
30 |
32 |
15 |
47 |
17 |
47 |
|
Programme evaluation |
17 |
22 |
19 |
25 |
20 |
29 |
18 |
28 |
17 |
29 |
|
Post-secondary-level teaching |
20 |
27 |
15 |
33 |
20 |
39 |
18 |
36 |
46 |
3 |
|
Policy analysis/making |
10 |
13 |
7 |
17 |
13 |
14 |
15 |
11 |
10 |
18 |
|
Advocacy |
7 |
9 |
4 |
13 |
7 |
14 |
8 |
11 |
10 |
9 |
|
Supervising staff |
38 |
51 |
48 |
52 |
50 |
54 |
33 |
69 |
56 |
44 |
|
Community organization |
7 |
9 |
7 |
10 |
9 |
11 |
- |
19 |
5 |
15 |
|
Nutrition education |
18 |
24 |
41 |
15 |
24 |
25 |
23 |
25 |
12 |
38 |
|
Clinical nutrition services |
12 |
16 |
30 |
8 |
17 |
14 |
26 |
6 |
7 |
27 |
|
Education management |
3 |
4 |
- |
6 |
2 |
7 |
3 |
6 |
7 |
- |
a. 75 respondents reported a first job; not all respondents had found jobs at the time of the survey.b. One respondent did not provide information on nationality.
TABLE 2B. Respondents reporting use of specific skills in current job a
|
Skill
|
Overall (N=82) |
Terminal degree |
Nationality b |
Country of current job c |
Type of current job d |
|||||
|
M.S. (N=30) |
Ph.D. (N=52) |
US (N=52) |
Non-US (N=29) |
US (N=55) |
Non-US (N=26) |
Research (N=32) |
Operations (N=49) |
|||
|
No. using |
% using |
% using |
||||||||
|
Data collection |
58 |
71 |
60 |
77 |
69 |
76 |
69 |
77 |
84 |
63 |
|
Data analysis |
61 |
74 |
60 |
83 |
75 |
76 |
73 |
81 |
88 |
67 |
|
Research design |
57 |
70 |
50 |
81 |
71 |
69 |
67 |
77 |
88 |
59 |
|
Research management |
46 |
56 |
30 |
71 |
56 |
59 |
53 |
65 |
78 |
43 |
|
Programme design |
50 |
61 |
40 |
73 |
60 |
66 |
55 |
77 |
66 |
59 |
|
Programme management |
44 |
54 |
47 |
58 |
54 |
55 |
53 |
58 |
50 |
57 |
|
Programme evaluation |
51 |
62 |
47 |
71 |
58 |
72 |
58 |
73 |
69 |
59 |
|
Post-secondary-level teaching |
29 |
35 |
17 |
46 |
25 |
55 |
24 |
62 |
72 |
12 |
|
Policy analysis/making |
36 |
44 |
37 |
48 |
50 |
35 |
49 |
35 |
34 |
51 |
|
Advocacy |
36 |
44 |
33 |
50 |
42 |
48 |
40 |
54 |
44 |
45 |
|
Supervising staff |
48 |
59 |
40 |
69 |
56 |
66 |
55 |
69 |
63 |
57 |
|
Community organization |
20 |
24 |
17 |
29 |
19 |
35 |
20 |
35 |
25 |
25 |
|
Nutrition education |
24 |
29 |
27 |
31 |
21 |
45 |
20 |
50 |
34 |
27 |
|
Clinical nutrition services |
9 |
11 |
17 |
8 |
6 |
21 |
11 |
12 |
16 |
8 |
|
Education management |
8 |
10 |
10 |
10 |
10 |
10 |
13 |
4 |
16 |
6 |
a. 82 respondents had found jobs at the time of the survey.
b. One respondent did not provide information on nationality.
c. One respondent did not provide information on country of current job.
d. One respondent did not provide information on type of current job.
A key question is whether any kind of education or training can make a difference in the nutritional situation of low-income countries. Many respondents identified social injustice and lack of empowerment of the poor as the most important issues to address. “Lack of commitment, not lack of training, is the problem,” said one respondent. Sustainable, long-term alleviation of nutrition problems depends on addressing what UNICEF publications refer to as the “basic” causes of malnutrition [7]: economic, political, and ideological structures, and patterns of control over available resources.
This observation notwithstanding, considerable effort and resources are devoted to improving nutrition, and the effectiveness of programmes is limited by the fact that appropriate, situation-specific analysis is not taking place before programmes are implemented. It is well documented [e.g., ref. 8] that programmes are rarely evaluated for impact, and of the evaluations that are performed, few feed back into programme redesign or modification (although there are exceptions). The inappropriate training of those designing and implementing them is one reason for programme failures. Those who know the research in the field of nutrition do not necessarily have the skills to translate that knowledge into programmes; different individuals are involved in scientific studies and in policy-making, and the structures do not exist to create those links.
Several key characteristics may contribute to the effectiveness of educational programmes in improving nutritional indicators:
» Reaching a critical mass of people at multiple levels within the system. The most effective training approach for managers may be to target persons already working in relevant jobs and to allow them to remain linked to their jobs while receiving training. More important, training needs to reach a significant proportion of them. At the policy level, one or two well-placed individuals can make a difference in nutrition policy, but it helps to have several such persons working together from different points in the system.» Obtaining institutional commitment to allow newly trained professionals the resources and responsibility to apply what they have learned after they return to their jobs. One way of achieving this is to involve higher-level supervisors in selecting candidates and in planning for their activities after training. When professionals are sent for training by their institutions, part of their commitment should be to assure returning graduates that they will have increased responsibilities to permit them to apply what they have learned.
» Building in follow-up through networking, information exchange and dissemination, and periodic reunions of participants and faculty. This can contribute to morale and commitment, and can provide a means to update participants on new developments in the field.
These are characteristics of training that can enhance its effectiveness. Still, education of professionals is a long-term investment whose contribution is difficult to measure directly, given the other factors also affecting nutrition. The effect of having a cadre of multidisciplinarily trained nutrition professionals may be in having people placed to prevent mistakes from being made, to ensure that nutritional consequences are considered in policy decisions and that programme designs are realistic and context specific. Where effective advocates for nutrition are present, the “counterfactual,” what would have occurred in their absence, may not be known.
Definitions matter. A concern raised by a surprising number of our respondents, in the United States and perhaps even more often in the region, was that the label “nutrition” is misleading and can be a distinct disadvantage for persons who wish to work on policies and programmes that can improve nutritional indicators. The label “nutritionist” does not convey skill in the policy and programme arena. Suggested alternatives were “planner,” “advocate,” “evaluation specialist,” and “food policy specialist.” The term “public nutrition specialist” may prove useful as a summary term for this concept.
The solutions to nutrition problems often lie outside the domain of nutrition. Nutritional status is important as a determinant and correlate of health status and as a marker of individual welfare, in addition to being an outcome in its own right. A consequence of emphasizing nutrition as the focus of a programme and policy specialization may be that solutions then are too often linked to food, failing to integrate health concerns such as immunization, environmental sanitation, disease prevention, and treatment, on the one hand, and poverty alleviation, entitlement, and empowerment, on the other. Even in the area of food, many of the region’s major food distribution programmes are not viewed primarily as nutrition programmes by those who run them, but as welfare or entitlement programmes.
This raises the question of whether the appropriate field of concentration is one of nutrition policies and programmes (public nutrition), or whether it would be better simply to add a nutrition focus to professional training in public health, economics, political science, or other relevant fields. Many of the most distinguished practitioners of what is here called public nutrition fit that model, having been trained in a profession, and having adapted their skills, out of interest and personal commitment, to the field of nutrition. Nonetheless, the field of public nutrition is unique in requiring at least some understanding of the entire range of determinants of nutritional outcomes.
The study of these basic determinants extends into areas of economics, agricultural policy, health science and policy, and the social sciences, as well as public policy and management. Training programmes in any one of these traditional disciplines alone would not address the needed complementary areas. This means that a multidisciplinary applied nutrition programme would provide the whole range of training, or would have to recruit professionals with relevant professional training and provide only those missing elements relevant to nutrition issues. Both models are likely to be effective.
Academic institutions typically reward their faculty for their research and publication record rather than for a history of effectiveness in the field application of their skills. In an applied field such as public nutrition, the most effective teachers are often those who have a great deal of experience working in the application of their knowledge. Hiring senior-level practitioners as teaching faculty in academic institutions can pose problems if the committees and administrators responsible for hiring decisions do not value or (equally important) know how to evaluate a history of applied work. Some institutions have responded to this problem by evolving parallel structures within the university. The Kennedy School of Government at Harvard University, for example, hires teaching faculty on a “professor of practice” track. These faculty are persons who have been senior-level public administrators but do not necessarily have the research experience rewarded by traditional academic departments. These are in no way “second-class” faculty, but rather faculty who bring a different set of experiences and skills to the educational enterprise.
As the field of public nutrition gains increasing recognition, there are more and more opportunities for professionals in the applied field to publish and disseminate their work in the academic community. There are journals devoted to food policy and programmes dating back to the 1970s, and nutrition journals now commonly contain sections devoted to the policy and programme applications of nutrition science.
Many academic institutions have associated centres of research, training, and technical assistance that function as a hybrid between an academic research institute and a consulting firm. These centres, usually focused on a specific area of specialization, often offer field opportunities for students; they provide a vehicle for hiring professionals who can enrich the teaching of the school without occupying full-time academic “slots.” These centres generally are more flexible administratively than the academic departments of universities, and may be appropriate venues for short courses and training programmes. The collaboration of such centres with the academic departments from which they draw faculty resources is an increasingly common phenomenon in the academic world, not only in nutrition but in other fields such as public health.
The multidisciplinary nature of public nutrition, aside from its focus on applied work, may pose a particular problem for the institutionalization of this discipline within universities. Universities are structured into departments, and there is a degree of competition among these for resources, faculty slots, and even students. For programmes in public nutrition to survive, they need to be integrated into the institutional structure in a permanent way.
New master’s-level training in public nutrition is being developed in Mexico and Central America at the Institute of Nutrition of Central America and Panama (INCAP) in Guatemala, the Instituto Nacional de Salud Pública (INSP) in Mexico, and the Universidad Nacional Autónoma de Nicaragua (UNAN), but all three programmes acknowledge the need to strengthen their social science, policy, programme management, and evaluation components because of the limited capabilities of their faculty in these areas. One approach to strengthening institutions and faculty in the region is through partnership with established graduate programmes. Indeed, partnering would be an effective means to ensure that quality professional training will be available in the region in the future at a reasonable cost (lower than in the United States, in any event) and that short courses as well as formal degree programmes will become institutionalized in several countries in the region. However, funding for many of these initiatives is severely constrained.
A comprehensive effort in public nutrition would need to address appropriate training to a critical mass of key individuals at each level of a country. Such a programme could achieve significant improvement in nutrition and create the human and institutional capabilities to sustain positive nutritional gains well into the twenty-first century.
Resource constraints would, however, prohibit an international effort of this breadth. An alternative is to select one country in which to implement the range of training, and monitor the results. The appropriate country would be of manageable size and with nutritional indicators that would make it a high priority for nutrition interventions. (Examples in the Central America-Mexico region are Nicaragua and Honduras.) Such a pilot comprehensive training programme would include the core set of skills listed above and would target professionals at all the appropriate levels, as follows:
» All programme managers: their programmes would keep them linked to their jobs in on-site training; training would proceed in a series of modules; the semipresence model or other distance-learning approach could be tried, but would have to be evaluated.» Selected programme managers and individuals working at higher levels who are influential or potentially influential in policy-making or training: a smaller number of fellowships (5 to 10) would provide access to one- to two-year master’s degrees in public nutrition.
» Promising applied and operations-oriented researchers and faculty: one or two fellowships would be provided for relevant Ph.D. or postdoctoral training in the United States.
» Higher-level administrators, supervisors, and district ministry representatives: brief sensitization workshops would be held to ensure that they buy into the training investment and are able to make the programme managers’ work settings more conducive to application of their training.
» Senior ministry representatives and policy makers: brief sensitization seminars and advocacy events would be tied to the training of programme managers from their departments.
» Faculty exchange: semester exchange programmes would be held for select faculty and human resource development professionals in areas related to nutrition.
The key would be to train a critical mass of people at the various levels, and to build in an evaluation component to measure impact on institutional and faculty development, programme effectiveness and appropriateness, policy change, and selected nutritional indicators after 5 and 10 years. The impact could be linked to international goals for the reduction of protein-energy and micronutrient malnutrition as accepted at the International Conference on Nutrition [9]. This would be a test of the concept.
The field of public nutrition has existed for a long time, although not by that name. A heterogeneous network of professionals with distinct training and career paths, working in applied nutrition programmes and policy, continues to shape the field, incrementally, through dedication and effort. Although the need for a continuing supply of such persons, albeit with more targeted and appropriate training, is acknowledged widely, funding for the preparation of such individuals is increasingly scarce. Explicit training in the field, however, is not widely available, and the field lacks recognition as a professional discipline in its own right, with its own professional body of knowledge and relevant skills. A few graduate-level programmes specifically designed to train public nutrition specialists do exist, although not by that name, and they will continue to train high-quality professionals. Non-degree training programmes in the field, in contrast, have not been institutionalized and are offered only on an ad hoc basis, which makes their continued availability less assured.
The appropriate training of applied nutrition professionals to work at the programme and policy levels needs to be supported and recognized. Organizations prepared to fund this set of training activities will play a significant role in enhancing institutional effectiveness, strengthen regional capacity for providing ongoing human resource development, and contribute to the establishment of sustainable training programmes.
1. Mason J, Habicht J-P, Greaves JP, Jonsson U, Kevany J, Martorell R, Rogers B. Public nutrition. Letter to the editor. Am J Clin Nutr 1996;63:399-400.
2. Pines J. National nutrition planning. Food Policy 1982;7:274-301.
3. Field JO. Multisectoral nutrition planning: a postmortem. Food Policy 1987;12:15-28.
4. Kazarinoff MN, Habicht JP. Future directions for the American Institute of Nutrition. J Nutr 1991;12:1498-9.
5. Rogers BL, Schlossman NP. Training and educational needs for operationally oriented nutrition professionals in the neighbors’ region of Mexico and Central America. A report submitted to the Pew Charitable Trusts. Medford, Mass, USA: Tufts University School of Nutrition Science and Policy, 1995.
6. Alderman H, Shively G. Prices and markets in Ghana. Working Paper No. 10. Washington, DC: Cornell Food and Nutrition Policy Program, 1991.
7. UNICEF. Estrategias regionales para la promoción de la salud y la nutrición de los niños y las mujeres 1993-1995. Bogota, Colombia: UNICEF Regional Office for Latin America and the Caribbean, 1994.
8. Musgrove P. Feeding Latin America’s children: an analytical survey of food programs. Washington, DC: World Bank Human Resources Division Technical Department, Latin America and the Caribbean Regional Office, Report No. 9526-LAC, 1991.
9. Food and Agriculture Organization/World Health Organization. World declaration and plan of action. In: International conference on nutrition. Geneva: WHO, 1992:13-26.
