|Food and Nutrition Bulletin Volume 18, Number 2, 1997 (UNU Food and Nutrition Bulletin, 1997, 118 pages)|
|"Public nutrition": The need for cross-disciplinary breadth in the education of applied nutrition professionals|
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.