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Revised May 2009
NATSINSAP Senior Project Officer
Building the 'Aboriginal and Torres Strait Islander Nutrition Workforce' is a key action area in the National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-2010 (NATSINSAP). This action area has been prioritised in the implementation of NATSINSAP since 2004. To progress this work, this paper has been developed under the direction from the NATSINSAP Steering Committee and Reference Group to conceptualise the composition, roles, settings, training requirements and workforce supports required to develop and support a specialised nutrition workforce with a focus on Aboriginal and Torres Strait Islander communities. This paper provides a broad outline which could be used and adapted to inform the specific workforce strategies at the national or state/territory government level, or within the Aboriginal Community Control Health sector or other relevant non-government organisations.
To provide a case for increasing the numbers and developing the capacity of the nutrition workforce to support food and nutrition initiatives for Aboriginal and Torres Strait Islander communities.
Aboriginal and Torres Strait Islander people continue to suffer a much greater burden of ill-health than other Australians, with life expectancy around 17 years less than for the total Australian population. Poor nutrition contributes to over 16% of the burden of disease in these populations (Queensland Health 2008). Diet-related diseases, including cardiovascular disease, cancer and type 2 diabetes are major causes of illness and death among Aboriginal and Torres Strait Islander adults.
The impact of poor diet can be traced from conception through to adulthood, with increasing evidence linking low birth weight and poor growth in infancy, as well as childhood overweight to adult onset chronic diseases such as diabetes (Barker 1999). Low birth weight and poor growth in infancy are major concerns in remote Aboriginal communities. Such inter-generational effects of poor health and nutritional status may in part explain why diseases such as diabetes are over-represented in the Aboriginal and Torres Strait Islander population, with age standardised prevalence up to three times higher than for other Australians (ABS 2006). The clustering of poor nutrition (both under nutrition and over-nutrition) with smoking, physical inactivity and socioeconomic factors in Aboriginal and Torres Strait Islander communities, require multifaceted strategies to address food and nutrition issues across the life-cycle.
In the response to the above issues, the National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP) was developed for the Strategic Inter-Governmental Alliance (SIGNAL) and endorsed at the Australians Health Ministers Conference in August 2001. The NATSINSAP is aligned to the whole of population nutrition strategy, Eat Well Australia 2000-2010.
While the NATSINSAP is nearing the end of its term, one of the key action areas to 'Increase the numbers and develop the capacity of the nutrition workforce to support food and nutrition initiatives for Aboriginal and Torres Strait Islander communities' remains as pertinent today as it did from the strategy inception. This includes both:
Building the Aboriginal and Torres Strait Islander nutrition workforce was again endorsed as a key recommendation of the 2008 National Nutrition Networks Conference, attended by more than 200 predominately Aboriginal and Torres Strait Islander people working in nutrition and related fields. Refer to Attachment A.
Increasing Aboriginal and Torres Strait Islander participation in the specialised nutrition workforce is long over-due, though timely with new investments in Indigenous specific maternal and child health, obesity and chronic disease prevention programs. Building the nutrition workforce is vital to increase the dose and extend the reach of community based nutrition programs.
Numerous national policy documents recognise the importance of building an Aboriginal and Torres Strait Islander health workforce. The National Strategic Framework for Aboriginal and Torres Strait Islander Health (2003-2013) considers a skilled and appropriate workforce to be one of the crucial mechanisms for improving Aboriginal and Torres Strait Islander health. To achieve workforce reform, collaboration between the Commonwealth, State and Territory Governments and the Aboriginal and Torres Strait Islander Community Controlled sector is essential. It sets out a range of strategies to achieve a competent health workforce to improve the delivery of comprehensive primary health care services for Aboriginal and Torres Strait Islander people.
Increased participation by Aboriginal and Torres Strait Islander people in the health workforce has a range of benefits beyond the direct impact on service delivery. The 2005 report 'Healthy futures: Defining best practice in the recruitment and retention of Indigenous medical students' explained that the positive effects of Indigenous doctors for the physical, emotional and cultural wellbeing of Indigenous Australians has long been recognised and include:
These positive effects could also be attributed to other Indigenous health workers including those working in nutrition.
More recently, 'A blueprint for action- pathways into the health workforce for Aboriginal and Torres Strait Islander people' (NATSIHC, 2008) outlines recommendations to strengthen the education and training pathways to maximise Aboriginal and Torres Strait Islander participation across a breadth of health disciplines. These initiatives are a key component of the health workforce and education reform agendas being managed through the Council of Australian Governments (COAG). They form part of the overarching commitment by COAG to improve health and 'Close the Gap' in life expectancy between Aboriginal and Torres Strait Islander and non- Indigenous Australians.
Throughout Australia there is an insufficient specialist workforce focussed on Aboriginal and Torres Strait Islander nutrition, particularly given the scale to which poor nutrition contributes to the poor health of Indigenous Australians. The NATSINSAP specifically identifies the need to increase the numbers of skilled and supported Aboriginal and Torres Strait Islander people in the nutrition workforce. Table 1 identifies the current community nutrition workforce with a dedicated focus on the Aboriginal and Torres Strait Islander population (including Indigenous and non- Indigenous positions). It is estimated 33% of these positions are filled by Aboriginal or Torres Strait Islander people, the majority of which are employed as Advanced Health Workers (Nutrition Promotion) in Queensland.
|Total community nutrition positions dedicated to Indigenous population (1.0 EFT)||Total community nutrition positions/100,000 Indigenous population (Based on ABS 2004)|
|New South Wales||4.5||3.1|
(Last updated February 2007)
The NATSINSAP also identifies the need to improve the capacity of the general health workforce to support and deliver nutrition initiatives with Aboriginal and Torres Strait Islander people. Across Australia there are Aboriginal and Torres Strait Islander health positions that may include a focus on nutrition, however the number of positions and the extent of nutrition training and support provided is variable. In Queensland and the Northern Territory, Strong Women Workers and Child Health Workers receive training in maternal and child nutrition as part of their role. In other states, Aboriginal Health Promotion or Chronic disease positions may also include nutrition within broader roles.
Opportunities currently exist across the continuum of health care to build the Aboriginal and Torres Strait Islander focussed nutrition workforce, from primary health care settings to population based approaches with a focus on food supply and access, chronic disease prevention, and maternal and child health.
|Scope||Primary Health Care Nutrition Workforce||Public Health Nutrition Workforce|
|Source: Adapted from Hughes & Somerset, 1997|
|Position||Advanced Health Workers (Nutrition promotion)||Community Dietitians/Community Nutritionists||Community & Public Health Nutritionists, Advanced Health Workers (Nutrition Promotion)|
|Setting||Aboriginal Community Controlled Health Services (ACCHS) or mainstream Primary Health Care services||Regional settings in partnership with ACCHS|
|Reach||Indigenous individuals, small groups & local organisations||Indigenous populations at state and regional level|
|Paradigm||Management of diet related disease (Dietitians only) and primary prevention programs||Promoting health and preventing disease through regional programs|
|Determinant of activity||Community development & health referral||Community development and health referral||Community development, needs and policy directives|
|Outcome timeframe||Short to medium||Medium to Long|
Primary health care organisations which include Aboriginal Community Controlled Health Services (ACCHS) as well as mainstream Community Health Services are ideal settings to build the Aboriginal and Torres Strait Islander focussed nutrition workforce. Advanced Health Workers (Nutrition promotion) as well as Community Dietitians/Nutritionists can work effectively in partnership to develop programs to promote healthy eating and improve access to nutritious and affordable food, based on the local needs of the Aboriginal and Torres Strait Islander community. Positions located in primary health care organisations also play an important role to extend the reach and local engagement of state and national health/nutrition programs within a population health framework.
In primary health care settings Dietitians are qualified to work with individuals or groups of people to help treat or manage diet related disease. An Advanced Health Worker (Nutrition Promotion) or a Community Nutritionist does generally not work with individuals for the treatment or management of disease.
It is recommended that the Advanced Health Worker (Nutrition Promotion) be co-located or have a formal working partnership with a locally based community Nutritionist/Dietitian. In this partnership arrangement the Advanced Health Worker can contribute Aboriginal and Torres Strait Islander expertise, providing guidance and support around cultural issues. The Community Nutritionist/Dietitian can provide nutrition and project management expertise. Partnership arrangements are particularly recommended given the majority of States and Territories do not offer accredited training in nutrition for Aboriginal and Torres Strait Islander Health Workers. Professional partnerships bring together evidence based approaches and cultural understandings to enhance the delivery of quality outcomes.
An Advanced Health Worker (Nutrition promotion) has completed Certificate IV or Diploma level studies in Aboriginal and/or Torres Strait Islander Primary Health Care, specialising in nutrition (currently available only in Queensland - see section on Development of Nutrition Learning and Assessment Resources). They have knowledge in nutrition across the lifespan, nutrition for common diseases and a good understanding of local issues and best approaches to improve nutrition in the community. Evidence for the effectiveness of these roles in working alongside Community Nutritionists/Dietitians has been demonstrated in several successful Indigenous community nutrition programs (NHMRC 2000). Examples of the sorts of initiatives which Advanced Health Workers (Nutrition promotion) undertake include:
The designation of positions as 'Community Dietitian' or 'Nutritionist' , defines a work role in most cases rather than a specific qualification, although both roles require tertiary qualifications in nutrition. Community Nutritionist roles will have a focus on project and primary prevention activities related to food and nutrition. Community Dietitians may also have a focus on primary prevention activities, in addition to clinical responsibilities assisting individuals in the treatment and management of diet related conditions.
In primary health care settings across Australia, Community Dietitians or Nutritionists take up a variety of roles and responsibilities including:
Building the public health nutrition workforce is important to provide strategic and operational program support at state-wide and regional level around food and nutrition issues for Aboriginal and Torres Strait Islander communities. An effective regional level workforce can build the momentum and reach for state coordinated programs; ensuring consistency; coordination and avoiding duplication of effort.
This second tier public health nutrition workforce are directed towards strategic priorities and major work areas as identified consistently under Eat Well Australia and the NATSINSAP. These include promoting healthy weight; increasing consumption of vegetables and fruit; improving maternal and child nutrition and programs which focus on improving food supply and food security. The regional public health nutrition workforce support the strategic direction provided by the state-wide nutrition positions/teams within each state.
Given the unacceptable burden of diet related disease among Aboriginal and Torres Strait Islander Australians across all states and territories, it should be considered that:
In partnership with Advanced Health Workers (Nutrition Promotion), communities, government and non government service providers, Public Health Nutritionists:
This workforce strategy should be considered within the broader context of maternal and child health, obesity and chronic disease prevention. Building the Aboriginal and Torres Strait Islander focussed nutrition workforce has great potential to value add and extent the 'reach' of funded policies and programs at the state, territory and national level. Some examples include:
From July 1st 2006, the Australian Government and the State and Territory Governments commenced implementation of a five year, $500 million national package called the Australian Better Health Initiative (ABHI). The aim was to reduce the impacts of chronic disease across the population, with a priority focus on Indigenous Australians. Building the Indigenous nutrition workforce has relevance to the following strategies within ABHI:
The Australian government provided $102.4 million over four years to enhance the capacity of over 80 Aboriginal and Torres Strait Islander primary health care services with core objectives to improve:
Expansion of the Enhanced Primary Care (EPC) program provides new opportunities for clients with chronic conditions to access allied health services, including nutrition. Medicare rebates are now available for Dietitians, Diabetes Educators and Sports Physiologists to provide individual counselling and or group education (diabetes only at this stage) to clients with a chronic condition who are managed by their GP. This is a significant development that could potentially enable Aboriginal Community Controlled Health Organisations to build their allied health workforce in the delivery of multidisciplinary primary health care. This could provide increased opportunity for Aboriginal and Torres Strait Islander people to access specialist nutrition services.
The NATSINSAP prioritises Aboriginal and Torres Strait Islander nutrition training with the expressed objective to 'establish accredited, accessible, and culturally relevant training in each State and Territory'.
Steps towards defining the training requirements for a nutrition specialisation has been significantly advanced over recent years through the following two achievements:
1. The inclusion of specific core and elective nutrition units in the Certificate 1V level of the Aboriginal and Torres Strait Islander Primary Health Care qualification.
The units listed in bold are the units with a specific nutrition focus. The unit listed in italics is a health promotion unit which provides program planning skills considered essential to underpin community nutrition work.
2. Development of Nutrition Learning and Assessment Resources
In March 2009, Nutrition Learning and Assessment resources were released to support Registered Training Authorities(RTOs)in the delivery of the above listed units. This project was undertaken by the CSHISC with guidance provided by an Industry Reference Group and a nutrition expert committee organised by the NATSINSAP Senior Project Officer. The Learning and Assessment resources for Nutrition include:
To register to obtain a free copy of the above resources visit the Industry Skills Council website
In 2009, Queensland Health was the first state to use the new nutrition units to deliver a nutrition course for Aboriginal Health and Torres Strait Islander Health Workers specialising in nutrition. This course is currently being delivered by the Aboriginal and Torres Strait Islanders Corporation for Health Education and Training (ATSICHET) through funding from the Queensland Government. At the present time equivalent courses are not been offered in other states and territories.
In the Northern Territory, the Batchelor Institute of Indigenous Tertiary Education (BIITE) now offers a Diploma of Community Nutrition and a Bachelor of Applied Science (Community Nutrition) as part of their Higher Education program. Duration of the Diploma is one year full time (two years part time) and six of the existing units are transferable to the Bachelor of Applied Science. For further information visit www.batchelor.edu.au or Freecall: 1800 621 890
While the identification of the above nutrition units and associated learning and assessment resources are important steps towards developing nationally accredited nutrition training, the formal endorsement of a 'Nutrition Skills Set' is still required. In May 2009 a submission was lodged with the CSHISC to seek endorsement for a nationally recognised 'Nutrition Skill Set' within the Certificate 1V level of the Aboriginal and Torres Strait Islander Primary Health qualification. To gain endorsement, the CSHISC will undertake a consultation process across state and territory jurisdictions, Registered Training Organisations and the Aboriginal Community Controlled Health sector to gauge the level of industry support.
National recognition of a 'Nutrition Skills Set' is valuable in formalising the role and maximising the workforce opportunities for dedicated nutrition positions. Consistent with recommendations from 'A blueprint for action- pathways into the health workforce for Aboriginal and Torres Strait Islander people 2008', recognising a Nutrition Skills Set will strengthen training pathways into the nutrition workforce from secondary school to the Vocational Education and Training (VET), pre-entry university enabling courses, and transition between VET, university and the workplace. An agreed 'Nutrition Skills Set' will also provide consistency in training between states and provide national recognition.
In the submission lodged with the CSHISC, the four nutrition and one health promotion unit described above were recommended to form the basis of a proposed 'Nutrition Skill Set'. In addition, the following units of competence which incorporate basic cooking and nutrition focussed menu planning skills were highlighted for consideration. Additional early childhood units from the Child and Youth Stream may also be applicable as follows:
In addition to the development of a specialised nutrition workforce, there is a need to increase nutrition knowledge and skills among the broader Aboriginal and Torres Strait Islander health and community workforce. An achievement of the implementation of NATSINSAP since 2005 has been the inclusion of nutrition as a 'core unit' in the Aboriginal and Torres Strait Islander Primary Health Care qualification (practice stream). This means that every Health Worker undertaking the 'practice' stream at Certificate 1V level will now study nutrition as part of their course. This is a significant development that will enhance the consistency and quality of nutrition content across Australia.
There is also scope to deliver specific accredited nutrition units as short courses, or incorporate them into training courses for other sectors of the Aboriginal and Torres Strait Islander workforce, including child care workers, community development workers and drug and alcohol workers.
An existing accredited training opportunity is the Certificate II in Health Support Services offered by Batchelor Institute of Indigenous Tertiary Education. This course has a strong nutrition focus and is designed for Aboriginal and Torres Strait Islander people working in community based food services such as Aged Care and Women's Centres. The focus of the course includes basic cooking; food safety; OH&S; and catering for the nutritional needs of clients in a culturally appropriate manner. The course is nationally accredited as part of the Health Training Package. Additionally, a Certificate III level course has been put on scope by Batchelor Institute and is designed to extend the skills gained by graduates of the Certificate II course to become supervisors and further build capacity of Indigenous people to manage community food services. For further information visit www.batchelor.edu.au
Strategies to support 'workforce' are commonly identified as an important element of the broader concept of 'capacity building'. A commonly accepted definition and model of capacity building by Australian health promotion practitioners is:Capacity building to improve health is an approach to the development of sustainable skills, organisational structures, resources and commitment to health improvement in health and other sectors, to prolong and multiply health gains many times over (Hawe, King and Noort, 1998).
It is useful to recognise that increasing the number of Aboriginal and Torres Strait Islander nutrition positions will only be part of the solution towards the development of effective nutrition programs at the community, regional and state level. Application of the 'New South Wales Health Department Capacity Building Framework' provides a useful tool to identify the mix of strategies required at a number of levels of health and within broader community systems to build workforce capacity (Figure 1). This framework identifies five key areas: partnerships, leadership, workforce development, organisational development and resource allocation as essential drivers. An example of how the NSW Capacity Building Framework can be applied to build the Aboriginal and Torres Strait Islander workforce, the experience of the Northern Territory between 1995 and 2006 serves as a useful model (See attachment B).
Figure 1. New South Wales Health Department Capacity Building Framework
(NSW Health Department 2001)
The essential role of nutrition in improving maternal and child health and preventing obesity and chronic disease within the Aboriginal and Torres Strait Islander population has led to a critical need for an experienced public health and community nutrition workforce to meet the demand. The escalating treatment costs for diet related disease is unsustainable and an investment in workforce needs to be orientated towards prevention. This should include a focus on both primary health care settings and the establishment of public health nutrition workforce to provide expertise and coordination of strategic 'good practice' initiatives at a regional, state and national level. Local and regional positions extend the geographic coverage and access (increase the 'dose') of well informed policies and programs. In their absence, the best intentioned policies fail to gain traction at the local level or are short term and poorly implemented.
While some States and Territories have made significant and ongoing investments in this area, across Australia there continues to be a critical lack of a specialist nutrition workforce focussed upon the Aboriginal and Torres Strait Islander communities. While the priority is to increase the number of trained Aboriginal nutrition staff at all levels of the food and nutrition system, this paper also describes the need to re-orientate and support more of the existing mainstream nutrition workforce to prioritise working with Aboriginal and Torres Strait populations, as well as incorporating quality nutrition training for the broader Indigenous workforce including health workers, child care workers and aged care workers.
Building the Aboriginal and Torres Strait Islander nutrition workforce is a national priority identified within the NATSINSAP. Key elements to achieve this have been described including the establishment of accredited and culturally relevant training within both the VET and tertiary sectors; creating employment and career pathways, leadership, partnerships, resource allocation and organisational supports.
ABS, National Aboriginal and Torres Strait Islander Health Survey 2004-05. Vol. cat. no. 4715.0. 2006, Canberra: ABS
Productivity Commission 2005, Australia's Health Workforce, Research Report, Canberra
Barker DJ (1999a) Foetal origins of Cardiovascular disease. Annals of Medicine 31 (Suppl 1): 3-6
Hawe,P, King,L, Noort, M Gifford and Lloyd, B (1998) Working Invisibly: Health Workers Talk About Capacity Building In Health Promotion, Health Promotion International 13,4,pp 285-295
Hobson, Vivienne- Director- Nutrition and Physical Activity Program, Northern Territory Department of Health and Community Services- personal communication, 2006
Hughes, R. and Somerset, Definitions and conceptual frameworks for public health and community nutrition: a discussion paper. Aust. J Nutr. Diet, 1997. 54(1): p 40-45
National Aboriginal and Torres Strait Islander Health Council (NATSIHC), A blueprint for action- pathways into the health workforce for Aboriginal and Torres Strait Islander people, Commonwealth of Australia 2008.
National Strategic Framework for Aboriginal and Torres Strait Islander Health- Framework for Action by Governments 2003-2013. Commonwealth of Australia 2004
National Health and Medical Research Council (NHMRC) 2000. Nutrition in Aboriginal and Torres Strait Islander peoples: An information paper
National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan. National Public Health Partnership 2001. http://www.nphp.gov.au/signal
NSW Health Department. A Framework for Building Capacity to Improve Health, www.health.nsw.gov.au, March 2001
Priestly, J. R, Growing Stronger Together: Cross- cultural Nutrition Partnership in the Northern Territory 1974-2000. University of Western Sydney. Master of Arts (honors), 2003
Standing Committee on Aboriginal and Torres Strait Islander Health, Aboriginal and Torres Strait Islander Health Workforce National Strategic Framework, AHMAC, Canberra, 2002
Strengthen the nutrition workforce working with Aboriginal and Torres Strait Islander populations.
From the mid 1970s the Northern Territory food and nutrition workforce increased substantially from three Nutritionists working for one organisation to an extensive network of 28 Community Dietitians/Nutritionists, 11 Community based Aboriginal Nutrition Workers, 15 Aboriginal Child Health workers involved predominately in the Growth Assessment and Action programs (GAA), and 27 Aboriginal women employed in the Strong Women's Strong Babies Strong Culture (SWSBSC) program (Hobson 2006). In research undertaken by Priestly 2003, the following table provides a snap-shot of the elements which led to the building of a successful nutrition workforce pitched at many levels within and across systems on a wide variety of food and health related issues. For the three nutritionists who commenced during this time and lead the profession for over 20 years, strong philosophical commitments to adult education, community development and self determination were key drivers. The development and funding of the NT Food and Nutrition policy was a significant factor in gaining strategic and high level support for building workforce capacity over this time.
|Capacity Building strategy||Activities and enablers|