1

PENCEGAHAN PENYAKIT,
KECACATAN DAN KEMATIAN PADA
GIZI KESEHATAN MASYARAKAT

Trias Mahmudiono

Department of Health Nutrition

UNIVERSITAS AIRLANGGA
 Introduction
An Introduction to Public Health Nutrition:
A framework for practice

What are some of the attributes that help define Public Health Nutrition?

How does Public Health Nutrition differ from other types of professional
nutrition practice?
 What is Public Health Nutrition?

The promotion and maintenance of nutrition related health and well-being of

populations through the organised efforts and informed choices of society
World Public Health Nutrition Association

Public Health Nutrition (PHN) is a relatively new and evolving area of practice
PHN practice is focused on solving nutrition problems and developing interventions
in population
PHN practice draws from the principles of health promotion
 Different Modes of Nutrition Practice

Comparing PHN with various types of professional nutrition practice can help
conceptualise PHN
Professional nutrition practice involves:
A continuum of practice
Overlap between various types of professional practice
Delineation by setting, reach, type of prevention, care paradigm, key
personnel, determinants of activity and outcome timeframe
 Clinical Community Community Public health
Dietetics Dietetics Nutrition nutrition

Feature Clinical Community Community Public health

dietetics dietetics nutrition nutrition
Setting Hospitals Community Community Community
Reach Individuals Individuals and Population sub- Populations
small groups groups
Prevention 20,30,40 10
Paradigm Illness Wellness
Key personnel Dietitians and health workers Many stakeholders, multi-
disciplinary and intersectoral
Determinant of Health worker referral Community development, needs
activity and policy directives
Outcome timeframe Short to medium Medium to long

Hughes and Somerset (1997)

 Different Modes of Nutrition Practice

Clinical dietetics utilises scientific principles and methods in the treatment of illness,
by optimising the nutritional status of individuals in an institutional environment.
Community dietetics utilises scientific principles and methods in the treatment of
illness, by optimising the nutritional status of individuals in a community setting.
Community and Public Health Nutrition utilises scientific principles and practice in
the promotion and prevention of nutrition related illness, by optimising the
nutritional status of communities, sub-populations and whole populations.

Note that the methodology of community nutrition and public

health nutrition is the same and that population reach is the key
difference.
 Emphasis on Prevention

PHN practice is often similar to and draws from the principles and practice of
health promotion

the process of enabling people to increase control over and to improve their
health
 Emphasis on Prevention

The defining features of a health promotion approach include actions that are:
Implemented across the whole population, not just those at risk of specific
diseases
Directed towards improving peoples ability to control the factors that
determine their health
Part of a process involving a mix of strategies from a number of stakeholders
which aim to improve health
Focus on the prevention of disease and enhancement of health for all through
tackling the social determinants of health.
 Emphasis on Prevention

The term prevention is reserved for interventions that occur before the diagnosis
of a condition/ disease is made

Levels of prevention conventional classification

Primary Avoid the onset of ill health and decrease in the number of
prevention new cases (incidence).

Secondary Prevent the progression if ill health and lower rate of

Prevention established cases in the community (prevalence).

Tertiary Stabilise or reduce the amount of disability and

Prevention complications arising from an irreversible
condition/disease.
Alternative prevention classification system

Category Description Examples for diabetes

prevention

Universal Interventions targeted at the general public or a whole Mass media programs to promote
population group that has not been identified on the fruit & vegetable consumption.
basis of individual risk for the specified health problem.

The intervention is desirable for everyone in that

group.

Selective Interventions targeted at individuals or a subgroup of Nutrition education for families

the population whose risk of developing the health with children identified as obese.
problem is significantly higher than average.
The risk may be imminent or it may be a lifetime risk.

Indicated Interventions targeted at high-risk individuals who are Industry product modification
identified as having minimal but detectable signs or (reduced sugar/fat/portion size)
symptoms foreshadowing the specified health condition, for high-risk individuals.
or biological markers indicating predisposition to it, but
who do not currently fulfil diagnostic criteria.
 Core Functions of PHN

Core functions describe the work required of PHN practitioners

Core functions can be used to benchmark against current work practices as a basis
for workforce development.

These core functions can be classified into 3 over-arching function categories for
PHN practice:
(i) Research and analysis,
(ii) Building capacity, and
(iii) Intervention management
 Core Competencies of PHN

Core competencies guide PHN practice by defining the knowledge, skills and
experience practitioners require

Core competencies describe the requirements of a whole workforce rather than

individuals however also provide guidance to individual practitioners

Core competencies can be grouped into the broad categories of:

Foundation and theoretical knowledge and skills
Analytical skills
Public Health Service
Socio-cultural and political
Management and leadership
Professionalism and communication
 A Socio-Ecological Approach

Focuses on the socio-economic, cultural and environmental determinants of health

Health determinants are factors that influence health

Health determinants are embedded in the social, cultural, economic, environmental

and other circumstances in which people live
collectively known as the ecology

Health opportunities are not distributed randomly within populations but are
determined by their ecology
 A Socio-Ecological Approach

Considered an upstream approach

Looks beyond the individual/ biological determinants of health

Analogy river of prevention

You come to a river that has people flowing downstream and drowning. To
intervene you can:
1. Jump in an pull people out and resuscitate then (downstream or curative approach)
2. Run upstream and stop people falling in the river (by building a fence or teaching them
to swim)

Upstream interventions focus on determinants (causes) of the problem rather than the
problem or outcome per se.
Ecological model of health behaviour
 A Socio-Ecological Approach to childhood
obesity and physical activity
Policy context: transport policy, traffic rules, school physical activity policy, crime
policy

Physical environment: physical activity facilities accessible at

home/school/community, foot/bike paths, safe environment, access to TV/computer,
community safety/ crime rates

Social/cultural environment: parental support, sibling physical activity levels,

parental education, physical education/school sports, peer support, TV/computer
rules, family income

Intrapersonal: self-efficacy, attitude, motivation/goals, physical skills and abilities,

values
 A Socio-Ecological Approach

Upstream action using determinants as basis for intervention, change and

evaluation

Measures/ evaluates both

Outcomes of intervention change to determinants (better education, social cohesiveness,
cooking skills)
Health outcomes reduced obesity/ diabetes rates

Targets inequality in health

Uses causative logic if we change what causes the problem, in

impacts of the problem will decrease or disappear
 The Importance of Capacity Building

Helping others to help themselves

A successful public health nutritionist provides initial leadership, develops the

systems, networks and organisational environment, and empowers the community or
population to successfully self-manage their nutrition problems.

Know thy community, show respect , engage with it and work with
(not on) the community to solve community problems
 Public Health Nutrition Practice

Developing solutions to nutrition-related health problems

Focused on indentifying and fixing the key-rate limiting steps in the causal pathway to
unhealthy conditions

Sensitive to context and circumstance because the interaction between and mix of
determinants is different in different populations and settings

Requires a logical, systematic and contextual approach to indentifying casual

pathways and creating effective interventions or solutions
Public Health Nutrition Practice
 Framework of the causes of maternal and child under nutrition and its
short-term consequences

Source: Lancet series on

Maternal and Child
Undernutrition 2008
adapted from Conceptual
framework for analysing the
causes of malnutrition, UNICEF,
1997