Public health nutrition in Europe : workforce development and policy change

Sammanfattning: Public health nutrition workforce development is an important prerequisite for developing a nation’s capacity to achieve public health nutrition objectives. Presently, there is a lack of knowledge about public health nutrition workforce development in Europe, in particular, about how governments have developed strategies for promoting a skilled and adaptable public health nutrition workforce and about the current workforce in terms of roles, competencies and functions. The aim of this thesis is to explore workforce development in order to identify current needs and to develop a better understanding of the policy processes that lead to public health nutrition policy changes. Initially, a qualitative study comprising semi-structured face-to-face interviews was conducted to identify enabling and constraining factors of workforce development in seven European countries (Study I). In the following case-study, the agenda setting of a food and nutrition policy in Slovenia was scrutinised by applying Kingdon’s streams model (Study II). In Study IV, the Swedish public health policy process from 1960- 2006 was examined to distinguish policy learning patterns. Finally, we conducted a Delphi-study in order to develop a set of core functions to guide strategic workforce development (Study III). This thesis shows that public health nutritionists as a workforce is largely missing in practice. In countries where public health nutritionists were recognised in policies and organisational aims and programmes, it was more likely that employers supported the roles and saw the value of employing public health nutritionists (Study 1). Investigation of specific cases showed how a food and nutrition policy could be established in Slovenia despite weak initial interest from dominant coalitions in the government (Study II). It specifically points to the importance of particular individuals and their cognitive characteristics (i.e. analytical, strategic and entrepreneurial skills) in order to influence the policy process. Study IV points to the importance of the Swedish committee system as a decision-making arena where public health ideas can be debated and consensus agreed upon in order to enable public health policy learning across groups and influence policy change. Consensus on the core functions of the public health nutrition workforce emphasized the importance of analytical, advisory and interventionist functions in the context of preventing diet-related diseases in populations (Study III). In order to secure public health nutrition processes and change, we need to learn about the context of policy subsystems (actors who have decision-making power in public health nutrition issues, expert networks, governmental agencies, intergovernmental organisations) and the relationships between actors and institutions, including their power and authority. Potential implications based on the findings presented in this thesis are that it is necessary to stimulate relationships between governmental agencies, public health organisations at regional level, practitioners and private sector in order to improve public health nutrition agendas and workforce development strategies. Considering the current gap of knowledge about public health nutrition workforce development in Europe, there is a need to learn from countries that have been successful in increasing the national and sub-national institutional capacity to lead, coordinate and implement public health nutrition objectives.