Work practices of the community and public health nutrition workforce in Australia

Original research Work practices of the community and public health nutrition workforce in Australia Roger Hughes Abstract (Nutr Diet 2004;61:38 45) Objective: To assess the roles, practice and work-related attributes of the community and public health nutrition workforce in Australia. Design: Cross-sectional survey using self-administered mail or email delivered questionnaire. Setting and subjects: 240 practitioners working in community and public health nutrition positions in the Australian health system. Main outcome measures: Self-reported core functions, frequency of work-related practice activity and extent of multidisciplinary and inter-sectoral collaboration. Results: An 87% questionnaire response rate was achieved. The demographic and educational profile of the sample showed female practitioners (95%) from 26 to 45 years (67%), from dietetics training backgrounds (75%) employed in state health department community health services as community dietitian/nutritionists (54%) and public health nutritionists in government health or non-government organisations (18%). Public health nutrition type of positions tended to report most frequently core functions in project management, nutrition education resource development, health professional education, evaluation and policy development. Dietitian type of positions in this sample reported core functions that tended to reflect functions such as clinical and group education, professional advisory services and implementing community-wide nutrition education and food supply programs. Public health nutrition positions reported more multidisciplinary and inter-sectoral collaboration than the dietitian type of positions. Health promoters, community health nurses and general practitioners were the most common professional groups and community organisations and other state government departments the most common inter-sectoral organisations involved in workforce collaborations. Conclusions: This section of the workforce performs a mix of functions, many of which are in the clinical domain of individual care and education. The small number of practitioners predominantly practising in a way consistent with public health core functions and the clinical service orientation of the existing community dietetics workforce, limits the capacity of the public health nutrition workforce. It also indicates a need for strategic workforce growth, practice reorientation and workforce development research to increase the workforce s capacity for effective public health nutrition action. Key words: public health nutrition, workforce, core functions, practices Introduction The launch of the ten-year national agenda for action for public health nutrition in Australia (Eat Well Australia) in 2001 has provided a mandate for accelerated public health nutrition workforce development under its capacity building priority area (1). The need for information from various sources that can guide effective and systematic workforce development strategy planning and problem resolution (hereafter referred to as intelligence) has recently been stated (2). Despite considerable professional debate about definitions, role delineation and exploration of workforce attitudes about workforce development in public health nutrition (3 9), there is still a lack of intelligence about the public health nutrition (PHN) workforce in Australia. This limits systematic workforce development (10). The limited literature relating to nutrition and dietetics workforce development published in Australia over the last few years has focussed on entry-level dietetics competencies (11,12) and the training needs associated with the developing work roles of dietitians (13). Information about the determinants of workforce capacity such as composition, size, practices, educational attributes and the training needs required for efficient and strategic workforce development, is limited. Practice studies in the international literature have been limited to workforce studies in the United Kingdom (14) and the USA (15). In Australia, three studies (two unpublished) have been undertaken that provide limited intelligence about work- Nutrition Unit, School of Health Science, Griffith University, Queensland R. Hughes, BSc, GradDipNutrDiet, PGradDipHlthPromo, MPH, APD, RPHN, Director Correspondence: R. Hughes Nutrition Unit, School of Health Science, Griffith University, PMB 50, Gold Coast, Queensland 4217. Email: r.hughes@griffith.edu.au 38 Nutrition & Dietetics (2004) 61:1

force practices (7,16,17). Estimates of the amount of time spent practising community and public health nutrition (16,17) suggest the community-based nutrition and dietetics workforce in Australia spent on average less than one day in a working week in community and public health nutrition practice. This limited investment of human resources suggests a small capacity to effectively act on public health nutrition issues. Workforce practices are a factor affecting human resource contributions to the structural capacity of the public health system (18) and potentially are very significant. A large workforce that practices in a way that is inconsistent with population-based disease prevention (e.g. individual dietary counselling for obesity as an obesity prevention strategy) may have low overall effectiveness in disease prevention, because of limited reach and or efficacy. While there is no consensus yet about the type of practice that represents best practice in public health nutrition, there is agreement on the core functions for public health practice that provide a basis for reviewing and re-orientating nutrition workforce practices (19,20). This study aimed to assess the practices of the community- and populationbased nutrition workforce (hereafter referred to as the public health nutrition workforce), in terms of nominated core functions, frequency of work activity and extent of collaboration in practice. Method A cross-sectional survey using an e-mail or mail-delivered questionnaire was used to obtain workforce data for the three-month period between November 2001 and February 2002. Ethics approval for the study was provided by the Griffith University Human Research Ethics Committee and informed consent was provided by all respondents. Sampling Existing public health nutrition network contact databases in state health departments were used in all states and the Northern Territory (except for Victoria) to develop a sample frame. Questionnaires with an invitation to copy and send on to other known public health nutritionists (snowball sampling using existing networks and word of mouth to access otherwise unknown cases (21)) were distributed to this whole sample. Victoria had no existing public health nutrition contact database so a mail-delivered questionnaire to all members of the Victorian branch of the Dietitians Association of Australia was used for this workforce sub-population as a basis for further self-selection and snowball sampling. Database contacts consisted of a mix of designated public health nutritionists, community nutritionists, dietitians, health promotion practitioners and other nutrition-related workers in health departments, non-government organisations and other organisations. This snowballing technique identified a total sample frame of 276 practitioners nationwide (from an initial contact list of 190). All questionnaires included a cover letter inviting respondents to complete the questionnaire and return either by email or via reply-paid post within a twoweek timeframe. Follow-up emails were distributed to non-respondents after this time to encourage participation. No attempt was made to collect information from non- respondents. Only one respondent from the total sample frame of 276 replied that he/she was unwilling to complete the questionnaire. Instrument Data reported in this paper was obtained from a larger questionnaire (238 items) developed for a broader investigation of the Australian public health nutrition workforce that included assessment of workforce profile, selfreported roles and practices, training needs and attitudes about competency requirements for effective public health nutrition practice. Only workforce practice data is reported here from 11 questions. Questions relating to workforce practice were modelled on an earlier questionnaire designed for this workforce (16) and are summarised in Table 1. Questions included a mix of closed and openended questions. Pilot testing of the whole questionnaire was conducted among 39 public health nutritionists based in Western Australia. Post-questionnaire completion group debriefing was used to assess questionnaire ambiguity. No changes were required based on this consultation process and the data obtained from this process was subsequently included in the overall analysis. Table 1. Summary of questions and response format used in survey instrument Question Response format Age Closed-ended multiple choice (5 age-range categories) Gender Closed-ended multiple choice (Male or female categories) Title Open-ended script Nature of position Closed-ended multiple choice (13 response categories, including other) Employer Closed-ended multiple choice (6 employer categories) Number of years experience Open ended working in community nutrition/public health nutrition What qualifications have you completed? What are the 3 or 4 major roles/activities of your current position? To what extent does your role involve collaboration/networking with other health professionals, other agencies and other sectors? On average, how often would you be involved in the following activities? Open ended Open ended, responses categorised into 36 different roles Closed-ended (4-point frequency scale 1=never, 2=rarely, 3=occasionally, 4=often) 7 listed sectors, 9 different professional groups, room for other Closed-ended (6-point frequency scale 1=never, 2=less than monthly, 3=monthly, 4=weekly, 5=2 3 times per week, 6=daily), 23 listed activities and room for other Nutrition & Dietetics (2004) 61:1 39

Data analysis All questionnaire data was entered onto SPSS software (SPSS Inc, Chicago, SPSS for Windows, version 10 2001) for storage and analysis. Descriptive statistics were used to present sample characteristics data. In order to assess differences in practices between practitioners in this sample based on reported position type, respondents were categorised as having public health nutrition type (PHNtype) positions if they reported the nature of their position to be designated public health nutritionists, nutrition project officers in health promotion teams or nutrition project officers on project grants. All other positions in the respondent sample were categorised as dietitian type of positions based on the self-reported nature of these positions (see Table 2). The assumption was that designated and project-specific public health nutrition practitioners would be more likely to be practising in a way consistent with population-based and preventive practice. Quantification of frequency of activity (see Table 4) was calculated by multiplying the proportion of respondents in each frequency category with the following weightings and summing (never=0, occasionally=0.5, monthly=1, weekly=4, 2 3 times/wk=10, daily=30). This calculation being based on the approximate number of times a work function would be performed each month (i.e. daily=30 times/month, weekly=4 times/month). Comparisons between respondent workgroup categories and activity frequency scores were made using independent Student t- tests (P <0.05). A comparison between respondent workgroup categories and extent of collaboration was made using Chi-square analysis (P <0.05). Results A total of 240 useable questionnaires were returned from a total sample frame estimate generated by the snowballing technique of 276. This represents a response rate of 87%. Sample characteristics The gender distribution of this workforce sample was predominantly female (95%) with only 12 male respondents nationwide. Just over half (51%) of respondents were 35 years or younger (67% between 26 to 45 years of age) and half (52%) had five years or less work experience in community or public health nutrition practice. The mean length of work experience in this field was 7.3 years. Table 2 presents data on responses to self-reported descriptions of positions and details of qualifications. Education profile The large majority (75%) of respondents in this study had entry-level dietetics qualifications. Eighty-six percent of dietetics qualified practitioners had entry-level dietetics qualifications as their highest qualification. There was a small national pool (n = 10) of doctorate-level qualified practitioners in this sample and only 17 graduates from Master of Public Health programs nationally. Of the 32 dietetics qualified practitioners who had completed higher degree research or public health qualifications, most had completed public health coursework (14 Master of Public Health, ten Graduate Diploma in Health Promotion). Table 2. Sample characteristics summary, nature of position and qualifications Percent (a) Number Nature of position ( n = 239) PHN-type position category PHN in regional/zonal public health unit 6 15 PHN in non-government organisation 4 10 PHN in state health department 8 18 Project officer in health promotion team 8 20 Nutritionist in nutrition project grant 5 11 Dietitian-type position category Community dietitian/nutritionist in 34 81 community health service/centre Community dietitian/nutritionist in 6 14 hospital Regional dietitian/nutritionist 8 20 Hospital-based dietitian with community 7 16 role Nutritionist in academic institution 5 13 Nutritionists working with food industry 1 2 Other (b) 8 19 Proportion of workforce with entrylevel dietetics qualification (n = 239) (c) 75 180 Highest qualification (n = 235) None 3 7 Certificate 3 6 Diploma/Graduate Diploma 44 104 Bachelors 10 23 Masters (Nutr & Diet) 29 67 Masters (other) (d) 10 23 Doctorate 4 10 (a) All percents rounded to nearest integer unless noted. (b) Includes practitioners based at Food Standards Australia New Zealand (FSANZ). (c) Entry-level qualification in dietetics includes BND, MND and Graduate Diploma Nutrition & Dietetics. (d) Includes 17 MPH qualifications. Nominated roles and functions Table 3 depicts the most commonly nominated roles/functions by position type category. Direct comparison of the percent of respondents reporting roles between PHN-type and dietitian-type positions for the complete list of roles indicates that PHN-type positions were more than twice as likely to nominate roles such as evaluation and monitoring (24% vs 7%), nutrition education resource development (30% vs 7%), program management (47% vs 22%), policy development (24% vs 3%), advocacy (19% vs 3%) and providing technical advice (16% vs 2%). Those in dietitian-type positions were more than twice as likely to nominate group nutrition education (49% vs 12%), patient education (51% vs 4%) and other clinical dietetics services (22% vs 5%) than others in PHN-type positions. 40 Nutrition & Dietetics (2004) 61:1

Table 3. Most commonly nominated roles/functions by position type category (a) Total sample (n = 237) PHN-type positions (n = 74) (b) Dietitian-type positions (n = 163) (c) Percent of cases Count Percent of cases Count Count Group nutrition education 89 38 Project management 35 47 Patient education 83 51 22 30 Group nutrition education 80 49 Patient education 85 36 Nutrition education resource development Project management 70 30 Health professional education 19 26 Clinical dietetics services (other than 36 22 patient education) Health professional education 49 21 Evaluation and monitoring 18 24 Project management 35 22 Clinical dietetics services (other than 37 16 Policy development 18 24 Health professional education 30 18 patient education) Nutrition education resource 33 14 Advocacy 14 19 Health promotion 28 17 development Workforce education other sectors 33 14 Technical advice 12 16 Workforce education other sectors 22 14 Evaluation and monitoring 30 13 Workforce education other sectors 11 15 Research 17 10 Policy development 29 13 Research 11 15 Tertiary education 14 9 Health promotion 29 12 Statewide program management 10 14 Networking 13 8 Research 28 12 Networking 10 14 Increasing community awareness 12 7 Advocacy 26 11 Managing staff 9 12 Advocacy 12 7 Networking 23 10 Group nutrition education 9 12 Evaluation and monitoring 12 7 Technical advice 23 10 Mentoring other nutritionists 7 10 Nutrition education resource 11 7 development Managing staff 20 8 Increasing community awareness 7 10 Managing staff 11 7 Total all roles nominated 795 261 534 (a) Up to 4 major roles able to be nominated. (b) PHN-type position category includes designated public health nutrition position categories, nutrition project officers in health promotion teams and nutrition project officers on project grants. (c) Dietitian-type positions category represents all others. Percent of cases Nutrition & Dietetics (2004) 61:1 41

Among the total sample, the most commonly repeated main roles/functions (in less than 15% of all cases) were group nutrition education, one-on-one patient education, project management, health professional education and provision of clinical dietetics services (other than nutrition education). Frequency of work-related activity Self-reported frequency data for involvement in various practice activities is reported in Table 4. Results suggest that the work activity of this workforce sample is dominated by regular involvement in providing information and advice, counselling and education, complemented with relatively infrequent but a very varied range of activities. Responding to individual requests for information and advice was the prominent activity for both PHN and dietitian-type workforce categories, featuring as a daily activity for greater than 70% of this workforce sample. There were statistically significant differences in frequency scores for involvement in activity by workgroup category. Those in dietitian-type positions reported being more frequently involved in a clinical one-on-one role, small group activities with clients with health problems or the general community and consulting to nursing homes, than others in PHN-type positions (t-test on frequency scores, P <0.05). Those in PHN-type positions were statistically more likely to report more frequent involvement in implementing community-wide education programs and food supply programs, project evaluation, research and research communication, policy development, developing strategic plans, actively liaising with the media, presenting research, seeking funding for projects and training other health professionals in developing community programs. Table 4. Frequency response distribution (percent) and scores for self-reported involvement in practice activities n Frequency score (a) Never Monthly or less (b) Weekly or more (c) Daily Responding to individual requests for information and advice (d) 230 2154 5 29 71 18 Clinical one-on-one role (d) 235 2103 39 51 49 22 Implementing/coordinating community-wide nutrition 231 1094 28 75 25 12 education programs (e) Implementing/coordinating community programs re: food supply/access issues (e) 230 699 50 83 17 7 Research 229 552 38 88 12 5 Small group activity with clients with health problem (d) 230 428 35 67 33 0 Project evaluation (e) 231 403 12 84 16 5 Policy development (e.g. local government or food 229 363 37 91 9 3 service) (e) Supporting statewide or national media campaigns 229 338 28 92 8 1 Developing and updating organisation s strategic and/or 230 323 20 92 8 2 business plans (e) Small group activity with general community (d) 231 281 24 85 15 0 Participation in development/review of national or state food- and nutrition-related legislation or policy 230 262 42 93 7 2 Nutrition monitoring and surveillance 229 237 48 88 12 5 Food supply monitoring and surveillance (e) 231 237 63 95 5 2 Student training and/or supervision 230 230 23 95 5 1 Consulting to nursing homes or other food service 229 202 42 92 8 0 Proactive media liaison/advocacy (e) 231 180 23 94 6 0 Training other health professionals addressing clients nutrition needs 229 170 17 96 4 0 Seeking funding for projects (e) 231 155 23 97 3 0 Present research to professional forums (e.g. conferences, 229 137 38 97 3 0 seminars) (e) Nutrition training for non-health staff (e.g. day centre staff) 230 131 28 97 3 0 Training other health professionals in developing community programs 230 129 43 98 2 0 Submission writing to ANZFA on food regulation issues (e) 225 28 75 99 1 0 (a) Frequency score calculated by multiplying the proportion of respondents in each frequency category with the following ratings and summing (never=0, occasionally=0.5, monthly=1, weekly=4, 2 3 times/wk=10, daily=30). (b) Monthly or less created by collapsing monthly with less than monthly and never. (c) Weekly or more created by collapsing weekly with 2 3 days per week. (d) Statistically different frequency score for activity by workforce category (t-test, P <0.05), dietitian-type positions statistically more frequently involved in activity. (e) Statistically different frequency score for activity by workforce category (t-test, P <0.05), PHN-type positions statistically more frequently involved in activity. 42 Nutrition & Dietetics (2004) 61:1

Collaboration with others Self-reported extent of collaboration data is present in Table 5. Community organisations, other state government departments and non-government organisations were most often nominated as sectors in which respondents collaborate with and health promotion, public health, community nurses and general practitioners the most often nominated collaborating professional groups. Those in PHN-type positions were more likely to report more frequent collaboration with most groups than dietitian-type positions, except for general practitioners which were more regularly reported in collaboration with dietitian-type positions. There was no significant difference in response distribution for frequency of collaboration between PHN-type and dietitian-type positions for private industry and professional associations (Chi-square, P <0.05). Discussion The sample frame construction of this study was due to many of the methodological issues outlined in broader public health workforce research, such as the lack of workforce definitions, the multidisciplinary nature of the public health workforce and the limited information systems enabling workforce enumeration and profiling (22,23). The lack of information systems required at a national level to accurately enumerate the specialist tier of the public nutrition workforce, and the 45% improvement on the sample frame from existing networks following snowball sampling, justified the use of this sampling technique. The differences in state health department structures and the variable networks developed in each state had an impact on the sample frame construction, particularly in Victoria where the study relied on a profession-specific network (DAA) as a basis for snowball sampling. The sample was self-selecting (i.e. respondents considered themselves to be part of the public health nutrition workforce or were recognised by others as such) in that individuals had volunteered to be part of a public health nutrition network or in the case of Victoria had responded to a questionnaire specifically requesting responses from practitioners working in community and public health nutrition. Using the mostly email-delivered questionnaire, the response rate of 87% that was achieved provides an adequate representation of the known public health nutrition workforce, with a low risk of response bias. This response rate compares favourably to results from other questionnaire-based studies of similar workforce groups (14,16,24 28). The characteristics of this workforce sample identify the Australian public health nutrition workforce to be predominantly dietetics qualified and with considerable experience in community and public health nutrition practice. This is a similar profile of the public health nutrition Table 5. Other sectors Extent of collaboration with other sectors and health professionals (percent of responses) (a) Never Rarely Occasionally Often Community organisations (b) (e.g. Nursing Mothers Association) 4 12 40 42 Other state government departments (e.g. education) (b) 8 21 35 33 Non-government health organisations (e.g. Heart Foundation) (b) 3 22 42 30 Universities (b) 14 30 36 18 Local government (b) 14 27 39 16 Private industry (e.g. food industry) 18 35 28 13 Professional associations (e.g. DAA, PHAA) 10 32 42 12 Other professionals Health promotion staff (b) 6 9 28 55 Community health nurses (b) 8 17 28 44 General practitioners (c) 12 21 26 37 Public health staff (b) 10 22 27 35 Indigenous health workers (b) 26 26 23 22 Researchers/academics (b) 23 26 31 16 Teachers (b) 17 30 34 15 Environmental health officers (b) 28 30 27 11 Epidemiologists (b) 40 31 14 10 (a) Percents rounded to nearest integer. (b) Statistically different frequency of collaboration rating by workforce category (Chi-square, P <0.05), PHN-type positions statistically more frequently involved in activity. (c) Statistically different frequency of collaboration rating by workforce category (Chi-square, P <0.05), dietitian-type positions statistically more frequently involved in activity. Nutrition & Dietetics (2004) 61:1 43

workforce obtained by similar Australian (16,17) and international studies (14,24,29). The lack of data from earlier studies in Australia limit comparison of results relating to workforce practices, although Steele s 1995 study of the community nutrition workforce (excluded non-government organisation-based practitioners and senior PHN-type positions) did highlight a similar practice emphasis by community-based dietitians towards clinical and direct-care type practices, and a variable mixing of roles and functions depending on the individual practitioner (16). Although relatively homogenous in terms of entrylevel qualifications in dietetics, the workforce sample in this study demonstrates significant differences between PHN-type and dietitian-type positions in terms of selfreported core functions, frequency of practice activity and extent of collaboration. This suggests a two-tiered workforce within the public health nutrition field, at least in terms of current practice. The PHN-type workforce tier s practice was characterised by an emphasis on community intervention planning, evaluation, research, capacity building via community education, upskilling and broad collaboration outside of the health sector. The practice of the community dietetics-type tier was characterised by community-based direct care, counselling, education and program development with most collaboration within the health sector. This delineation reflects the different organisational environments of the different workforce groups, with PHN-type positions more likely to be employed in non-government organisations and public health units and dietitian-type positions working in community health services. If public health nutrition practice is delineated by its emphasis on population-based problem resolution through intervention development, community building and other functions consistent with public health practice (20), then it appears that in reality, there is a small national workforce practising predominantly in this way. The most obvious approach to increasing the capacity of the public health nutrition workforce in Australia is by investing in workforce growth, because the small size of the dedicated public health nutrition workforce in Australia is a limiting factor (30). Workforce growth however, without attention to the existing and new workforce practices, is likely to be less effective than a mix of growth and practice re-orientation. Data from this study suggests the majority of practitioners in this sample are practising a hybrid of direct care and public health, with much of the effort applied in direct care and limited reach activities. There is a powerful but simplistic argument that practice re-orientation among sections of this workforce in favour of practice consistent with core public health functions, will increase workforce capacity (31). This argument is simplistic because it assumes current dietitian-type practices (and associated services) are less efficient or less needed than public health practices. There is currently inadequate intelligence available to make these types of assessments and there is a need for further practice research of this type. Despite this difficulty, it seems that practice development in public health nutrition is required at a workforce level, not only for the existing workforce but particularly for the developing and future practitioner. This points to the need for an increased emphasis on developing public health nutrition competencies and enhancing exposure to public health nutrition practice in dietetics education and post-qualification professional development. This is particularly relevant given the majority of existing public health nutrition workforce has progressed via dietetics training and professional acculturation is primarily clinical (33). This study has not provided data that can be used to help explain why practitioners practice in the way they report. It is likely that practices are influenced by a range of intrinsic and extrinsic factors. Intrinsic factors may include individual confidence in competencies, actual competency levels, personal preferences for the type of work conducted or personality traits. For example, it is unlikely that an individual practitioner who has low-level confidence and competence in media advocacy will voluntarily seek out that type of work or strategy as a solution to a local problem. Questions about the adequacy of competency development of the public health nutrition workforce in pre-employment training have previously been asked by United States researchers (15), but there is yet to be any formal debate about how well dietetics education prepares graduates for public health nutrition practice in Australia. Extrinsic factors may include the organisational environment in which practitioners work, the related mandates they have for preventive practice or the ease of access they have to mentors or professional development opportunities. The deleterious impact of not having organisational mandates or structures to work in a preventive manner on the work practices of community-based nutritionists has recently been observed in Victoria (32). Further research that focusses on these practice influencers is required in order to direct effective practice and service re-orientation towards public health nutrition practice. The public health nutrition workforce is in a state of flux in Australia, with workforce development initiatives evident in most states. There is a high degree of agreement among public health nutrition leaders in Australia and internationally about the need for a specialist public health nutrition workforce (33,34). This need is starting to be addressed in states such as Queensland where considerable investment to developing this workforce infrastructure has begun (35). There is a need for further workforce development scholarship to ensure that current emphasis on workforce development is effective, sustainable and informed by accurate intelligence. Data obtained in this study provides baseline workforce intelligence data for future workforce monitoring and to assist the assessment of workforce development needs. Acknowledgments The assistance of public health nutritionists in state health departments in identifying and providing access to existing network contacts for sample frame construction is appreciated. Christina Pollard supported the piloting and associated consultation with the public health nutrition network group in Western Australia and their collective assistance is acknowledged. Julie Woods assisted with organising the mail-out to members of the Victorian Branch of the Dietitians Association of Australia. The constructive feedback by the anonymous reviewers has contributed to the quality of this paper and is acknowledged. 44 Nutrition & Dietetics (2004) 61:1

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