The public health nutrition workforce is a key part of improving population health( Reference Yngve, Tseng and Haapala 1 – Reference Shrimpton, du Plessis and Delisle 3 ). For the public health nutrition workforce, preparation usually involves university-based education coupled with practical work placement experiences. Recent work internationally has focused on ensuring that dietitians are prepared for practice in public health with changes to competency standards( 4 , Reference Wentzel-Viljoen 5 ) and nomenclature to include the term ‘nutritionist’( Reference Wentzel-Viljoen 5 , 6 ). Despite this effort, this workforce has been found to be underprepared for work to address food and nutrition problems with multiple interrelated socio-ecological determinants whose solutions involve a range of sectors( Reference Shrimpton, du Plessis and Delisle 3 , Reference Hughes 7 , Reference Haughton and George 8 ). This is not unique to nutrition, with criticism that most health professions’ education curricula do not prepare graduates to work in prevention to address the social determinants of health, focusing on ‘facts to be known rather than as conditions to be challenged and changed’( Reference Sharma, Pinto and Kumagai 9 , Reference Sklar 10 ). There is a need to support public health nutritionists to operate in such complex environments by addressing barriers identified by this workforce as impeding its effectiveness.
Workforce development requires different methods that include workforce preparation towards the competency standards identified for practice( Reference Jonsdottir, Thorsdottir and Kugelberg 11 ). While there is some evidence to suggest that mentoring and other peer learning networks support the workforce in practice( Reference Holden, Ferguson and Brimblecombe 12 , Reference Palermo, Hughes and McCall 13 ), there is limited literature on the effectiveness of workforce development interventions that focus on competence development prior to entry to the workforce. ‘Real-life’ or practice-based learning is popular with learners due to its ability to contextualise learning and support the development of critical thinking. While there is no denying the role of work-based learning in the development of professional competence, there is a need for evidence on other approaches which support the development of skills in addressing the social determinants of health( Reference Sharma, Pinto and Kumagai 9 ). The present study aimed to test the likely effectiveness of an innovative teaching approach to develop the capabilities of pre-entry public health nutritionists in being able to address access to nutritious food.
Methods
Access to nutritious food is a key social determinant of health( Reference Wilkinson and Marmot 14 ). Two international contexts for interventions aimed at improving access to nutritious food include indigenous community stores in remote locations and emergency food relief services. In remote community stores, changing the store environment to support healthy food choices can play a significant role in improving the population’s nutritional intake( Reference Butler, Tapsell and Lyons‐Wall 15 , Reference Mead, Gittelsohn and Roache 16 ). Reorienting emergency food relief agencies to help tackle underlying inequities can reduce barriers to accessing nutritious food( Reference Gallegos, Booth and Kleve 17 , Reference Loopstra 18 ). Public health nutritionists are at the forefront of addressing access to nutritious food. This workforce plays a critical role in translating evidence to key decision makers in both settings and requires the capability to work across cultural and sectoral boundaries. Public health nutritionists play a key role in leading changes to remote indigenous community store retail foods and drinks and in advocating for changes to inequities’ impact on access to healthy food.
Case studies and problem- or case-based learning centre on learning interactions and critical thinking to support learners understand the complexity of issues and multiple possible solutions. Unfolding case studies are a version of these approaches whereby learners are provided with information about the case ‘using a staged approach that allows them to analyse and respond to information before moving forward to access additional information related to the case’( Reference West, Usher and Delaney 19 ). They are also useful for bridging the gap between theory and practice. With a view to prepare learners for ‘real-life’ situations and develop skills in working to improve access to nutritious food, we sought to test the role of unfolding case studies in situations where access to nutritious food was a determinant of health.
Unfolding cases were designed by three authors (M.F., S.K. and C.P.) based on real-life experiences working in remote community stores and in reorienting food relief services. These authors have extensive experience in working to improve access to nutritious food and in the education of the public health nutrition workforce. Scenarios describing a typical situation of the work of a health professional in addressing access to nutritious food were developed: one case in a remote indigenous community store (five parts) and the other in a metropolitan community health setting (three parts). As the cases progressed so did the increasing complexity (case content available from the authors on request). The time required to prepare the unfolding cases equated to the same time or less taken to prepare a traditional interactive lecture.
The session was developed for final-year dietetics students (in 2017) from a university located in Melbourne, Australia, who were at the mid-point of completing a 320 h supervised work-based practical placement in public health nutrition. The sessions aimed to extend learning rather than replace existing teaching of interventions that aim to improve access to nutritious food. All thirty-eight students in the cohort were invited to attend; the session was not compulsory yet all thirty-eight attended. Learners were not required to prepare prior to attending a face-to-face workshop to discuss the cases but were informed that the cases would build on foundational teaching and assessment related to the social determinants of health being applied to public health nutrition practice that had occurred in previous years (available from authors on request). Over the two by two-hour workshops, the authors (M.F. and C.P. or S.K.) provided each part of each case in a written format (approximately 100 words), concluding with a question that invited learner responses about the possible approaches and why the approach was chosen. This unfolding case discussion format allowed multiple approaches to be heard by the whole group after having some prior discussion in smaller groups to develop ideas. The session was audio-recorded for later data analysis.
Two authors (S.K. and C.P.) reviewed the recorded transcripts and transcribed student responses. This involved the authors analysing the students’ responses against the authors’ previous experience about what was likely to work in practice as well as for depth and complexity based on their perspectives. The authors undertook this process together through discussion, with the aim of reaching consensus on key concepts related to the learners’ capability to work in complex environments to address access to nutritious food. Key findings were verified with a third author (M.F.).
Results
The analysis revealed that the unfolding case studies provided a method to challenge and deepen knowledge and to think about the application of theory. For example, students were able to apply theory on community development and translate this to what it may look like in practice:
‘It is important for the public health nutritionist to spend some time at the community store, to stay behind after the cooking classes and generally get to know her community better and build relationships.’
In addition, they demonstrated the ability to apply evidence and past practice to inform their own practice:
‘Have others implemented any interventions in the past? If they did, how did it go? Could we possibly gauge some ideas from them?’
The cases also provided the opportunity for students to demonstrate cross-cultural capabilities:
‘Be respectful of … culture, respectful of their system, do not change anything but try to understand how that community works first.’
Students also demonstrated their ability to develop strategies to address the social determinants of health and their role in this work:
‘Improving the price of healthy foods and the food supply will have a bigger effect on the community compared to individual consults.’
‘This case study has stressed the importance of the [nutritionist’s] facilitation role rather than being the doer … Know the community’s agenda and priorities and make this a focus.’
While students generally recognised the importance of relationship building and adopting a community development approach to improve access to nutritious food, many were challenged when asked to explain what steps they might take to go about this in practice. The unfolding case study format allowed facilitators to share their practice experience with students and articulate their suggested approach as the cases increased in complexity:
‘Spending time talking to people who are experienced, such as working with leaders in communities and understanding the processes of work, is important.’
As the cases developed and became more challenging, students were supported to consider appropriate approaches and recognised the constant evolution of and dynamic nature of practice:
‘The challenges never stop coming, the navigation path you need to follow to achieve health outcomes continues to challenge you throughout your work.’
However, as the complexity of the cases developed, their ideas for ways forward lessened.
Discussion
Findings from our study suggest that this classroom-based learning environment supported students to propose a range of ideas or approaches to solve the cases, even when they became complex and were challenged by each other to think more deeply about the situation and possible underlying factors. Our work aimed to build on theory of the social determinants of health taught in early parts of the student-learning journey. The case studies focused on showing students how they may go about addressing these determinants in future work, rather than just acknowledging these as ‘facts to be known’; that is, the realisation of the concept of the right to adequate food and that access to nutritious food is a factor influencing what people eat. Focusing on the latter may result in students feeling powerless to respond to this complex issue. Students demonstrated their ability to ‘not give up’ when the cases became more complex and continued to focus on their learnt theory and its importance in shaping practice. The case studies complemented work-based practice in supporting the development of public health nutrition competence.
This small innovation, requiring similar investment of time to other teaching approaches, demonstrated that it was possible to create classroom experiences that empower students with ‘know-how’ to change the conditions and structures to address a social determinant of health. The skill required by educators to design relevant case studies is a key requirement to its success. The limitation of this work is that the impacts were based only on qualitative analysis of student responses. More objective measures of change in learner capabilities to address social determinants may provide further insight. In addition, it is not known what role the students’ later supervised practice had on their ability to navigate these cases.
Further work is warranted to investigate how this experience shapes perceived preparedness for those students who find themselves in similar work situations upon graduation. While these case studies were tested within nutrition and dietetics training, this innovative approach may be utilised to teach the social determinants of health within other health disciplines. This learning approach may also be useful at a graduate level and for continuous education of nutritionists and/or dietitians to empower those in the workforce to address the social determinants of health, rather than just acknowledging them as a set of barriers that prevent people and communities from achieving optimal health.
Acknowledgements
Acknowledgements: The authors would like to acknowledge Dianne Reidlinger for encouragement to write this story for publication. Financial support: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest: None. Authorship: C.P. conceptualised the learning activity and evaluation with input from S.K., M.F. and J.M. C.P., S.K. and M.F. collected data and analysed data. J.M. and J.B. assisted in data interpretation. C.P. drafted the manuscript with all authors making significant contributions. Ethics of human subject participation: This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by Monash University Human Research Ethics Committee (approval number 12252). Informed consent was provided by all participants for use of data and audio recording of sessions.
