FNN202 - Midterm #2

How to move from identification of a population level nutrition problem into plannign and implementing an appropriate response

• using the bi-cycle model we can consider what is the most appropriate response to a problem

Knowing by addressing: practice foundations

• identification of nutrition problems, knowing their determinants and developing a response

• selecting appropriate interventions within complex organizatinoal and policy contexts

• more than nutrition knowledge

  • analytical, pratical implementation and evaluation

Systemic action

• societal, technological and public health tranformations should lead to changes in how we approach science and public health

  • adoption of new innovations and how they create opportunities for societies

  • consideration of anti-racism and decolonization in science

  • need for robust science and risk communication, open science approaches and advice mechanisms

Systemic action and systems approach

• structured, evidence informed and coordinated process used to define problems, interventions, implement solutions and evaluate outcomes rather than relying on reactive measures (ad-hoc)

• looking at health problems as part of the larger interconnected network rather than individual failures

what is the nature of public health nutrition problems

• wicked problems whcih are complex persistent challenges (obesity, food insecurity, malnutrition) resistant to simple or permanent fixes because they lack clear definition, involve stakeholder values and are entangled in social, economic and political systems

Wicked problems are

• complex and influenced by many determinants

• unequally distributed across populations

• shaped by environmental, economic and social conditions

• difficult to address through single intervention

• dependent on partnerships, resources and implementation capacity

Horticultural metaphor for PHI

• focus on identifying effective interventions while also determining which are the most appropriate for a given context and what else needs to be done to ensure that the interventions are as effective as possible

• think about all parts of the garden

Bi-cycle model

• intelligence:

  • understand the community, problem, determinants, evidence and capacity

  • 1-8

• Action

  • plan and manage implementation

  • 8-12

• Evaluation

  • assess, learn, disseminate findings

  • 13-17

Capacity building in bi-cycle

• integrated throughout rather than as a separate tast

Intelligence

• information from different sources and methods supporting public health nutrition decision making (soil, seed, harvest)

Intelligence based practice involves

• population health and nutrition date

• scientific research

• community and stakeholder perspectives

• knowledge of local determinants and local context

• existing interventions and available resources

• organizational and workforce capacity

Bi-cycle use

• systematic, stepwise process for managing PHN interventions (seed selection)

• structured way to connect evidence and practice

• explicit role for capacity building in the PHN workforce

• opportunities to revisit decisions as new information emerges

• framework for developing professional competencies

Guidance of Bi-cycle

• knowing → knowing how → showing how → doing

• emphasis on experiential learning and practical competencies

Intelligence questions to investigate

• community and stakeholders: who is affected, what matters to them?

• Problem: what is happening, to whom and how extensively

• determinants: what factors contribute to the problem

• evidence: what interventions might address those determianants

• capacity and context: resources, partnerships, capabilities exist

  • informs what determinants to target not to confirm a preferred intervention

What counts as intelligence

• Epidemiological data: Diet related diseases

• Nutrition and food environment data: food availability, prices and dietary intake

• peer-reviewed literature: evidence of intervention effectiveness

• Community knowledge: experiences, priorities and percieved barriers

• policy/organizational information: existing programs, policies and constraints

• capacity assessment: staff, funding, partnerships and infrastructure

Action phase: intelligence into intervention

• translating what has been learned into a feasible intervention and managing implementation

• prioritizing determinants and intervention objectives

• selecting appropriate combination of strategies

• identifying partners and responsibilities

• mobilizing resources and building capacity

• establishing implementation processes

• anticipating barriers and opportunities for adaptation

• should follow from intelligence gathered

Possible action strategies

• advocacy or policy change

• settings-based approach

• capacity building

• co-design and community engagement

• social marketing and education

• combined or systems oritented action

Hughes 2003 5 interconnected components of workforce development

• problems and priorities - what PHN problems require action

• solutions and best buys - what responses would be effective?

• work needed - what tasks must be performed to deliver those responses?

• capacity to do the work - what workforce capacity currently exists

• workforce development needs - what competencies and capabilities must be strengthened?

Iterative bi-cycle

• intelligence informs the action and subsequent implementation and evaluation provide opportunities for learning and adaptation

Evaluation

• effective evaluation involves engaging stakeholders, assessing resources, developing evaluation questions, gathering and analyzing data and utilizing the results

• starts in the implementation stage

Evaluation in PHN

• demonstrates accountability for resources and public investment

• determines whether interventions are reachign intended populations

• assess if intended changes are occurring

• identifying unintended consequences

• understanding what worked and what doesn’t and why

• improve future interventions contributing to practice-based evidence

Practice based evidence

• documentation, measurement and analysis of real-world routine clinical or organizational practice

Main evaluation steps

• process evaluation (was it implemented as intented)

• impact and outcome evaluation (did we achieve our objectives and goals)

• evaluation of capacity gains (was capacity strengthened for sustained action)

• Economic evaluation (cost related to results achieved)

• reflective practice and dissemination of learning (what did we learn and how to share and use it)

Process evaluation

• was the plan implemented correctly and successfully

• How were participants reached as intended? were planned activities delivered? how much of intervention was delivered and received?

• Reach: who participated

• Dose: how much intervention was delivered or received?

• Fidelity: how close the implementation was to the intended approach

Impact evaluation

• examines changes in the determinants or intermediate conditions that the intervention intended to influence

Outcome evaluation

• Examines changes in broader or longer term nutrition or health goals

Impact and outcome evaluations

• examine whether meaningful changes occured not whether activities were delivered

Impact indicators

• improved availability of healthier foods

• changes in organizational food policies

• improved access to nutritious foods

• changes in food purchasing patterns

Outcome indicators

• sustained improvements in dietary patterns

• reduced diet-related health risks

• improved nutrition related health outcomes

• longer-term improvements in population health

Simple evaluation plan addresses

• process: how we know if the intervention was implemented as planned

• impact: how we know whether the intended determinant or intermediate condition changed

• outcome: what longer-term nutrition or health change would we hope to observe

• capacity: how could we assess whether the intervention strengthened community or organizational capacity

Step 15: Evaluating capacity gains

• PHN interventions aim to strengthen communities and organizations ability to respond to nutrition problems

• gains include

  • stronger partnerships and collaborative networks

  • improved workforce knowledge and competentices

  • increased organizational resources and infrastructure

  • greater community participation and leadership

  • improved ability to plan, implement and sustain interventions

Step 16: economic evaluation

• assesses the relationship between costs and consequences of an intervention

  • resources required

  • costs associated with implementing the intervention

  • benefits or outcomes

  • costs and consequences compared with alternative approaches

  • is the intervention feasible to sustain and expand?

Economic evaluation example

• team compares resources for a school food policy vs those needed for a nutrition education program

• compared along with their respective outcomes

Step 17: reflective practice and dissemination

• should inform future practice

• interpret findings critically, identify strengths, limitations and unintended effects

• reflect on implementing and decision making

• share findings with community partners and stakeholders

• translate lessons into recommendations for future action

• EVALUATION GENERATES NEW INTELLIGENCE

Strong evaluation questions

• connected to the intervention objectives

• specific about what is being assessed

• relevant to the population and context

• reasible to answer with available resources

• useful for decisionmaking

• evaluation question specifies what we want to know, indicators identify what will be measured

Logic models

• representation of how the intervention is expected to work

• Inputs → activities → outputs → impacts → outcomes

Equity and community engagement evaluation

• continue an effective intervention

• adapt implementation to improve reach or effectiveness

• strengthen capacity or partnerships

• reconsider assumptions about determinants

• discontinue an intervention that is ineffective or inappropriate

• generate new question requiring additional intelligence

Social Marketing

• understanding people and designing strategies that support beneficial behavioural change

• applying marketing principles and techniques to influence behaviours which benefit individuals and society

Systems thinking

• understanding how interconnected components of food systems (and health, political educatoin etc systems) influencing dietary health and identifying opportunities for broader change

Social marketing in PHN

• understanding may involves understanding a target audiences needs, motivations and behaviours

• identifying specific behaviours to influence

• developing an attractive and feasible behavioural proposition

• reducing barriers and increasing perceived benefits

• designing interventions using audience insights and evidence

Principles of social marketing

• Principle 1: Behavioural objective

  • specify the behaviour to influence

• Principle 2: Audience insight

  • understand motivation and behaviour

• Principle 3: Segmentation

  • tailor approaches to different groups

• Principle 4: exchange

  • make benefits of chaning worthwile relative to its costs

• Principe 5: Competition

  • identify competing behaviours and influences

• Principle 6: Marketing Mix

  • coordinate intervention strategies

Marketing Mix: 4 Ps

• Product

  • Desired behaviour and its associated benefits including any supporting goods or services

• price

  • financial and non financial costs

  • time effort, inconvenience

• place

  • Where and how the behaviour can occur

• promotion

  • How the intervention communicates and engages with the intended audience

Overview: Social marketing for a healthy diet: Systematic literature review (Chatterjee et al., 2025)

• 45 publications addressing social marketing

• review of research landscape

• review included:

  • methodological, theoretical, intervention, geographic distribution, gaps and opportunities

Key findings of Social marketing systematic literature review

• Social marketing research is diverse with gaps in the use of theory, research methods and geographic representation

• Research was concentrated in europe and North America

• Social media and digital communication were the main approaches

• only 4 of the 45 reviewed studies used mixed methods

• many studies lacked explicit theoretical foundations

• authors called for more theory driven approaches and greater geographic diversity

Strengths and limitations of social marketing

• strengths

  • audience directed so it is targeted

  • wide reach → large impact potential

  • cheaper than other legislation

• Limitations

  • behaviour change can be hard because the structural barriers remain

  • campaigns can unintentionally emphasize individual responsibility

  • digital appraoches may not reach everyone equitably

  • awareness and engagement do not necessarily ttranslate into sustained dietary change

Systems appraoch

• considers the nutrition problems as outcomes of interacting factors, actors, institutions and processes

• considers

  • relationships within food system

  • feedback loops and interdependencies

  • how patterns emerge over time

  • unintended consequences of interventions

  • opportunities to influence underlying structures

Usefullness of systems thinking

• looks at seeing wholes while looking at the interrelationships rather than things and for seeing patterns of change rather than static snapshots

  • changing one part (or advocating for change in one part) of the food system can produce consequences elsewhere

• can be useful for complex problems that cannot be adequately addressed by simple cause and effect explanations

Why do food systems matter for dietary health

• health is influenced by diet (modifiable risk factor)

• diet is influenced by interconnected factors including food production, processing, packaging, distribution, retail, policy, social conditions, and food environments

• changes in one part of the system can influence other parts

understanding and applying food systems approaches to improve dietart health (Bryant et al., 2026)

• Introduces 3 important questions for PHN professionals

  • why is dietary health a food systems issue rather than individual behaviour?

  • what does a systems perspective reveal that a conventional intervention approach might overlook?

  • How can PHN professionals identify opportunities for coordinated action?

Interconnections of systems thinking

• parts of the system influencing one another

• food prices affecting purchasing and retailer demand

Feedback loops in systems thinking

• changes that can reinforce or counteract other changes

• increased demand for a product can influence what items retailers stock

Leverage points in systems thinking

• places where intervention could influence system behaviour

• procurement rules, pricing structures or institutional policies

Identifying leverage points

• place within a system where an intervention may influence how the system functions

  • changing institutional procurement standards

  • adjusting pricing or subsidy arrangements

  • modifying retail food placement

  • strengthening coordination between food system actors

  • changing organizational incentives

  • influencing food policy and regulation

• Important to note that this is where there can be wider system change from action not simply the intervention point where action is taken

Feedback loops example

• low demand for vegetables further reducing availability further reducing purchasing and therefor reduced convenience

Policy generation and analysis

• influence population dietary health through policies that shape

  • food availability, affordability, accessibility

  • food environments and dietary behaviours

  • institutional practices and organizational standards

  • food production, distribution and marketing

  • health equity and the broader determinants of nutrition

• policy is relevant when improving dietary health requires changes beyond an individuals behaviour (upstream intervention)

Policy importance in PHN

• policy can influence the conditions where food decisions occur

  • changing rules and standards

  • changing financial incentives

  • redistributing resources

  • influencing food production and marketing

  • supporting equitable access to nutritious food

  • establishing accountability for population health

What is policy

• solution to a problem

• decision-making process as to how best achieve a specific objective

• at the end of the day, the formation of public health policy involves a process of making good decisions for public health

What is policy in public health nutrition

• refers to government or institutional decisions, rules, strategies and actions intended to influence nutrition-related conditions and population health

• eg.

  • school food and nutrition standards

  • food labelling requirements

  • restrictions on food marketing to children

  • food procurement policies

  • taxes or subsidies affecting food prices

  • food security and income support policies

Double-Duty actions (Hawkes et al., 2020)

• Challenge for policy generation: Malnutrition in all its forms

  • Multiple co-existing problems

  • under and over nutrition, overweight and obesity, diet related non-communicable diseases

• Traditionally interventions have been developed throguh separate policies, programs, and funding systems