Public Health Nutrition: 15(11), 1981–1988
The public health nutrition intervention management bi-cycle:
a model for training and practice improvement
Roger Hughes1,* and Barrie Margetts2
1School of Public Health, Griffith University, Gold Coast, Queensland 4212, Australia:2Public Health Nutrition,
Faculty of Medicine, University of Southampton, Southampton, UK
Submitted 12 April 2011: Accepted 25 June 2011: First published online 23 August 2011
Objective: The present paper describes a model for public health nutrition practice
designed to facilitate practice improvement and provide a step-wise approach to
assist with workforce development.
Design: The bi-cycle model for public health nutrition practice has been developed
based on existing cyclical models for intervention management but modified to
integrate discrete capacity-building practices.
Setting: Education and practice settings.
Subjects: This model will have applications for educators and practitioners.
Results: Modifications to existing models have been informed by the authors’
observations and experiences as practitioners and educators, and reflect a con-
ceptual framework with applications in workforce development and practice
improvement. From a workforce development and educational perspective, the
model is designed to reflect adult learning principles, exposing students to
experiential, problem-solving and practical learning experiences that reflect the
realities of work as a public health nutritionist. In doing so, it assists the develop-
ment of competency beyond knowing to knowing how, showing how and doing.
This progression of learning from knowledge to performance is critical to effective
competency development for effective practice.
Conclusions: Public health nutrition practice is dynamic and varied, and models
need to be adaptable and applicable to practice context to have utility. The paper
serves to stimulate debate in the public health nutrition community, to encourage
critical feedback about the validity, applicability and utility of this model in different
Public health nutrition
Promoting optimal nutrition is the central focus of public
health nutrition (PHN) as a discipline. While some pro-
gress has been made internationally in addressing
undernutrition, progress has been too slow to achieve the
Millennium Development Goals(1,2). Overnutrition, as
expressed by rates of overweight and obesity, is rising in
most countries(3), with many low- and middle-income
countries now suffering a double burden. Many countries
have responded by developing policies and action
plans that are aimed at addressing these major nutrition
problems(4), but they usually ignore issues relating to
capacity to implement and the determinants of capacity
such as workforce development(5). As a consequence,
many nutrition policies and plans are not being effec-
tively implemented(6). Building strategic and operational
capacity is recognised as a critical determinant of the
effectiveness of local, national and international nutrition
systems in delivering optimal nutrition outcomes for
populations(2,7). As both forms of capacity are dependent
on purposive and multi-strategy investments in workforce
development at all levels in the system, workforce
development remains an outstanding and often neglected
challenge in our discipline area. Workforce capacity
deficits in PHN are a universal problem, even in rich
economies with well-developed health systems(5,7–9). The
key determinants of workforce capacity that are consistent
internationally are summarised in Table 1.
Of the determinants outlined in Table 1 that impact on
workforce capacity, workforce preparation and practice
improvement are most amenable to change within, and
by, the PHN community.
Public health nutrition practice
PHN practice spans activities that range from academic
and analytical work through to working ‘in situ’ with
communities and stakeholders to address nutrition issues.
A focus on assessing, strategically changing and evaluating
the socio-economic, physical and cultural determinants of
*Corresponding author: Email email@example.com
r The Authors 2011
nutritional status affecting health characterises PHN prac-
tice(10). As a result, PHN practice involves a complexity that
creates significant challenges for the strategic development
of the practitioner workforce and its effectiveness. This is
exacerbated by changing practice paradigms in the field of
nutrition(11), which makes it difficult to apply a compre-
hensive description of the nature of PHN practice across all
practice settings. For the purposes of the present paper,
PHN practice is defined as the work required to effectively
develop, implement and evaluate interventions that
address identified, population-based nutrition problems.
In this context, intervention refers to actions that inten-
tionally focus on changing health outcomes by addressing
the determinants of nutritional exposures.
To date the PHN research literature has tended to apply
an epidemiological focus on exploring and understanding
the determinants and distribution of nutrition issues, and
evaluation of interventions. This assumption can be tested
by reviewing any issue of this journal. This work has been
critically important in understanding what determinants
cause nutrition problems, what strategies have merit in
terms of producing desired changes in health status and
how to measure these changes. Unfortunately, this litera-
ture does not provide adequate guidance about how to
practise PHN effectively within specific contexts, what
work is required and what competencies are required to
effectively promote and maintain the nutrition-related
health and well-being of populations.
Core functions and competencies
The lack of consideration of the practice of PHN constrains
PHN workforce development, practice effectiveness and
overall capacity(12). This has prompted efforts to identify,
assess consensus and codify the core functions of the PHN
workforce; core functions being those considered abso-
lutely necessary to ensure public health capacity(13). This
has been done to help focus workforce development
efforts in developed countries such as Australia and the
European Union(14–16). This consensus development work
has identified intervention management (the design, plan-
ning, implementation and evaluation of public health
interventions) as a dominant core workforce function (with
as much as 50% of core functions identified reflecting
intervention management practices), reinforcing earlier
findings in Australia about employer expectations(14)and
workforce practices(17). Capacity-building functions are
similarly rated as core functions, reinforcing the long-held
view of capacity building as an important strategic
approach in developing country PHN practice(18,19).
If an understanding of the core functions (the work) of
the PHN workforce is a prerequisite for strategic workforce
development, there is a powerful logic in aligning core
functions with the competencies required to perform these
functions(20); competencies here referring to the knowl-
edge, skills and ‘ways of thinking’ required to effectively
perform a work function(21). In practice, the competency
mix required to effectively manage interventions and build
capacity has been shown to be quite broad, drawing on a
mix of analytical, management, strategic planning, leader-
ship and organisational competencies(22,23). Unfortunately,
there is limited scholarship about the most effective and
efficient methods to develop these competencies in our
disciplinary literature. To help address this gap, the pre-
sent paper describes a new model for PHN intervention
management practice designed to facilitate practice
improvement and provide a step-wise approach to assist
with PHN workforce preparation.
Step-wise processes to guide practice
Step-wise processes for practice and learning have been
widely applied conceptual devices used to help bring
order to this complexity in health practice and education.
PHN practice borrows heavily from the related disciplines
of health promotion, public health and dietetics, and has
adopted many of the practice cycles that have evolved in
these disciplines(24), which are all loosely based on action
research processes that include cycles of planning, acting,
observing and reflecting(25). Cyclical and systematic pro-
cesses for intervention management and practice have
been used for many years to inform strategic decision
making and to enhance the quality and effectiveness
of intervention management(26,27). These have varied in
terms of the degree of segmentation in the step-wise
cycle. The Triple-A cycle(28)that includes three main
steps of Analysis, Action and Assessment was developed
to assist with interventions dealing with malnutrition.
Table 1 Determinants of public health nutrition (PHN) workforce capacity(5–9,17)
Practice improvement and
Inadequate and/or non-specific training, reliance on clinically trained practitioners
Workforce practices do not reflect required work, limited targeting of interventions to most needy
groups, strategy utilisation more aligned to clinical practice, limited environmental change
strategy use, limited workforce mentoring, barriers to continuing competency development
Small workforces relative to need, limited specialisation in PHN, high staff turnover, over-reliance
on overworked health generalists
Inadequate resource allocation to support action, leadership limited to rhetoric, absence of
systematic and strategic workforce development, workforce disorganisation
Suboptimal access to PHN intelligence, under-developed workforce research culture, limited
collaboration between practitioners and academics
Human resource infrastructure
Organisation and policy
Intelligence access and use
1982R Hughes and B Margetts
Intervention mapping was proposed in the late 1990s as a
sequential process of integrating theory, empirical find-
ings from the literature and information collected from
the population to inform strategic decision making about
how best to address health promotion challenges(29).
Borrowing from these earlier models, the PHN cycle(24)
has been proposed as a seven-step practice cycle to
describe the nature of PHN practice. This model repli-
cates the basic cycle of needs assessment, planning,
implementation and evaluation used in earlier health
promotion planning models. Both of these earlier PHN
practice cycles have more recently been adapted in an
attempt to more explicitly integrate capacity-building
principles and practice as part of the process of developing
As models for informing PHN practice and workforce
development, we believe these earlier models have limita-
tions in the context of workforce development and practice
improvement in that they do not adequately deconstruct
practice in a way that can inform responses to the ‘where
do I start?’, ‘how?’ and ‘with who?’ type questions that are
important in teaching students PHN practice compe-
tencies. They similarly do not reflect a notion of progress in
practice (moving forward rather than going around-and-
around), and they do not adequately integrate capacity-
building strategies with project planning in a step-by-step
A bi-cyclic framework for public health
We propose a bi-cyclic model for PHN practice (‘the bi-cycle’;
Fig. 1) over three distinct stages, to inform workforce
development and practice in the core practice area of
intervention management. This model recognises the
progressive and cumulative nature of PHN practice
(i.e. moving forward) and integrates capacity building
into the planning–implementation–evaluation sequence.
This practice framework emphasises the process, tools
and rationale for practice approaches in PHN. To
encourage discipline in PHN practice, it is intentionally
pedantic in the way that it has deconstructed earlier models
into what may seem to be overly numerous discrete steps,
which are summarised in Table 1.
Different phases in practice
The intelligence phase, represented by the first loop in
the bi-cycle, forces practitioners to engage with their
communities and key stakeholders and understand the
problem and contextual factors before acting; intelligence
in this context referring to information from various
sources and methods that help inform decision making
about intervention design. Understanding before acting
means careful and varied analysis of the community, the
community’s capacity for action, the problems faced and
what determinants have a causal relationship with the
problem – the logic being that until ‘upstream’ determi-
nants that need to be changed are identified, it is difficult
to develop strategies that will lead to a change in
‘downstream’ health outcomes. The action phase of PHN
practice, represented by the connection between the
intelligence and evaluation loops in the bi-cycle, focuses
on planning and managing intervention implementation.
The evaluation phase in the PHN practice bi-cycle focuses
on the different levels and types of evaluation, and
emphasises the importance of sharing practice leanings
via dissemination and scholarship.
Feedback between cycles
The backward arrow linking the action phase with eva-
luation and intelligence phases (the bi-cycle’s chain)
represents the dynamic nature of intervention manage-
ment that regularly requires practitioners to go back to the
intelligence, to fine-tune strategies and adapt to changing
contexts in practice. It also illustrates that evaluation builds
on the intelligence required to inform practice.
PHN practice, to be effective, needs to be dynamic,
responsive and contextual to the setting, situation and
available resources. Without an intentional and strategic
emphasis on the capacity-building approach to practice,
PHN practice and the resultant interventions are likely to
produce disappointing returns on investment in terms of
outcomes relative to resources used. The bi-cyclic model
for practice provides a systematic process for intervention
management that has applications irrespective of the issues
being addressed, the practice context, the strategy mix and
the level of intervention. It integrates capacity-building
steps (steps 1, 3, 5, 6, 7, 15, 17) into the sequential practice
cycle, making it an explicit approach to practice consistent
with previous arguments about the need to bring capacity-
building strategies to the forefront of PHN practice(30,31).
Our proposition then is that this model, if applied in
practice, will enhance practice effectiveness compared
with earlier less integrated approaches and serve a useful
practice improvement function.
We believe that the model has its greatest utility in the
development of PHN practice competencies during
workforce preparation, both in the pre-employment
and post-employment (continuing education) stages of
workforce development. We have previously used the
bi-cycle model as a framework for curriculum develop-
ment and instructional design in the courses and texts(32)
we use to teach in our respective universities, as a frame-
work for a PHN workforce mentoring intervention(33)and
a suite of online learning modules has been developed as
part of the JobNut Project funded by the European Union
Nutrition intervention bi-cycle1983
Each step provides an opportunity to engage students
in learning and skill development regarding the rationale
in practice, techniques and tools to assist with PHN
practice in a sequential manner. We have used the model
to guide students develop comprehensive PHN inter-
vention plans as a basis for assessment and later practice-
based implementation during professional internships.
In the process, we believe we are preparing students to
be employable, effective in practice and to be catalysts
Table 2 aligns each step in the practice cycle with a
summary of the competency elements derived from
recently published PHN academic standards(21)required at
each step and some of the learning and teaching strategies
that can be used to build these competencies.
Learning and teaching rationale
From an androgogical (adult learning and teaching) per-
spective, the bi-cycle model provides a conceptual frame-
work to structure experiential learning that reflects the key
Evaluating if the strategies have
been implemented as planned.
Community analysis and
Analysing the structure and
attributes of the community and
involving the community in
intervention management from
Clarifying and describing the
nature and impact of the
problem/issue, answering the
question ‘is action needed?’
Stakeholder analysis and
Identifying and understanding
various stakeholder agendas, in
order to engage appropriately
and build capacity.
Analysing the social, economic,
environmental and individual
determinants of PHN problems,
including the sequence of
Analysis of existing capacity/
capacity gaps for action in order
to focus capacity-building strategy.
Writing statements for action
(goals and objectives)
Statements that codify intervention
intent and targets for chage.
Impact and outcome evaluation
Evaluating if objectives and goals
Evaluating capacity gains
Evaluating capacity gains that
help explain intervention effects
and predict sustainability.
Economic analysis of costs
and/or benefits/outcomes of an
intervention to assist value
judgements about economic
Reflective practice and
Intellingence based on lived
experience of the intervention by
insights, etc. Sharing key
learnings/intelligence so that it is
integrated into and enhances
The logic sequence that links an
understanding of the problem,
determinants with strategies and
evaluation measures. A conceptual
device to enhance quality of
intervention management. Includes
testing feasibility among
stakeholder groups to ensure
strategies have support, meet
needs and test assumptions.
Implementation and evaluation
Detailing the logistics of work
required, budgeting and resource
management and scheduling.
The ‘doing phase’ of interventions
and related monitoring of
implementation to ensure
implementation sticks to the plan,
are completed and are ready for
Mandates for action
What government or institution
policy mandates exist that can
help support your call for action.
Intervention research and
Understanding and learning
from the experience of earlier
interventions. Ensuring a
thorough canvassing of all
strategy options and relevancy.
Risk analysis and strategy
Asking questions such as what
can go wrong if we successfully
achieve change in determinants.
Prioritising strategies based on
assessment of ‘best bets’.
Fig. 1 The bi-cycle framework for public health nutrition (PHN) practice(32)
1984R Hughes and B Margetts
Table 2 The bi-cycle framework for public health nutrition practice: aligning practice, competencies and learning and teaching strategies
Step Learning and teaching exercises: examplesEKNS AN PHSK FNSKNE MGT LDRPROF COM NAMS CB IM
Intelligence1 Community analysis
Sourcing, analysing and interpreting
mixed-source data in a local/real
community using research and
community engagement strategies
Problem description and profiling using
available epidemiological data, burden of
illness data, community needs data, etc.
Requires learners to make explicit the
focus of action
Using stakeholder analysis tools such as
stakeholder analysis grids(36)that
consider different categories of
stakeholders in the problem context,
considering constructs such as power
Determinant analysis diagrams that make
explicit the factors/determinants that
contribute to the problem identified
including the interactions and sequence of
each determinant’s effects
Analysis and description of local capacity to
address the problem identified, using
techniques such as force field analysis(36)
or checklists that explicitly outline
elements of capacity to act
Identifying and drafting statements that
position required action in the context of
existing government and institutional
mandates for action
Critical and systematic assessment of
previous interventions to identify
intervention context, strategy application,
evidence of effectiveness and key learning
for practice. Learners can be tasked to
draft justifications for a portfolio of
strategies to address the defined problem
based on available intervention research,
with particular attention to the contextual
issues presented by the localised problem
Learners can be tasked to consider
unintended effects of strategy
implementation as a basis for managing
associated risks and to prioritise
strategies with a justification for this
prioritisation, considering key prioritisation
issues such as size and seriousness of
the problem, effectiveness of strategies
and propriety, economics, acceptability,
resource and legal issues(37)
2 Problem analysis
3 Stakeholder analysis
4 Determinant analysis
5 Capacity analysis
6 Mandates for action
7 Intervention research
and strategy portfolios
8 Risk analysis and
Nutrition intervention bi-cycle
Table 2 Continued
Step Learning and teaching exercises: examplesEK NSAN PHSK FNSK NEMGTLDR PROF COM NAMSCBIM
Action9 Writing statements
Learners can be tasked to write goals and
objectives that clearly relate to the
determinants and problem defined in
earlier steps, the emphasis being on
identifying modifiable determinants, the
anticipated change in the problem
associated with change in determinants,
so that action statements drafted are
specific, measurable, achievable, realistic
and time-specific (SMART)
Logic modelling involves diagrammatically
representing the logic and assumptions
underpinning an intervention’s strategy
mix, including the anticipated cause–effect
of strategy implementation through to
evaluation of changes in determinants and
related outcomes. Tasking learners to
make explicit this logic forces learners to
critically reflect on assumed cause–effect
Learners can be tasked to consider the
logistics of strategy implementation by
deconstructing strategies into work
packages/tasks, considering the
sequence of work required and the
associated human and other resources
required (budgeting). These exercises
provide assessable products based on
experiential learning (learning by doing)
Evaluability assessment involves assessing
whether or not an intervention is ready for
evaluation(38). Learners can conduct an
evaluability assessment on an intervention
scenario using a step-wise assessment
worksheet. This exercise focuses
learners’ attention to questions of strategy
exposure, extent of implementation and
available evaluation data
The key learning task associated with issues
of all forms of evaluation is in the design of
evaluation methods to effectively measure
achievement against goals and objectives,
to assess intervention implementation,
capacity gains and to make judgement
about costs v. outcomes. Learners can be
tasked to develop and justify evaluation
plans, reflecting expectations in practice
10 Logic modelling
11 Implementation and
Evaluation13 Process evaluation
R Hughes and B Margetts
motivations for adult learning. These motivations include
needing to know the reason for learning something,
experience as a basis for learning, involvement in the
planning and evaluation of their instruction, learning of
immediate relevance to their work lives and learning that is
problem centred(34). This approach goes beyond didactic
teaching for knowing to teaching so that learners can
‘know how’, ‘show how’ and ‘do’(35). This model has an
intentional focus on developing the meta-cognitive aspects
of practitioner competency, including ways of thinking
about problems and possible solutions, making decisions
and reflecting on practice in order to continue learning and
improving practice. It therefore can be an important part of
the process of professionalisation required in the prepara-
tion and continuing education of PHN professionals. As
Table 2 illustrates, the breadth of competency development
opportunities that working through the bi-cycle step-wise
process presents suggests it has potential as the basis for a
comprehensive approach to PHN competency develop-
ment as a curriculum component.
The bi-cycle model for PHN practice is proposed as a
new framework for workforce development and practice
improvement that builds on earlier models. As a conceptual
model designed to assist a disciplined and sequential process
for practice and learning, that integrates capacity building
with intervention management, we have found it useful as a
scaffold for learning interventions, competency development
and critical reflection on PHN practice. The assumption that
this model, if applied in practice, will more effectively
enhance public health outcomes than other less systematic
and intentional approaches to practice is yet to be sub-
stantially and objectively evaluated. This is currently a focus
of ongoing work. We acknowledge that PHN practice is
dynamic and varied, and that models need to be adaptable
and applicable to practice context, to have utility. The pre-
sent paper serves to stimulate debate in the PHN community,
to encourage critical feedback about the validity, applicability
and utility of this model in different practice contexts.
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
There are no conflicts of interest. R.H. took the principal role
in conceptualising the model and drafting and finalising the
paper. B.M. contributed to model conceptualisation, paper
drafting and editing. The development of the bi-cycle model
has been assisted by feedback from many of our students
over the past decade and input from our colleagues Christina
Black, Jenny Davies and Nick Kennedy. The constructive
suggestions from the reviewers have contributed to the
fine-tuning of this paper, and are acknowledged.
Table 2 Continued
Learning and teaching exercises: examples
PROF COM NAMS
Impact and outcome
Evaluating capacity gains
Reflective practice and
Learners can be tasked to present a
comprehensive intervention plan, based
on the outcomes of earlier steps and
learning tasks, as a basis for assessment
and feedback. Stepping students through a structured experience of problem solving
resulting in a strategic plan reflects
*The World Public Health Nutrition Association competency standards framework categorises competency elements and performance indicators under thirteen competency module categories including: EK, enabling
knowledge; NS, nutrition science; AN, analytical; PHSK, public health system knowledge; FNSK, food and nutrition system knowledge; NE, nutrition education; MGT, management; LDR, leadership; PROF, professional;
COM, communication; NAMS, nutrition assessment monitoring and surveillance; CB, capacity building; IM, intervention management.
Nutrition intervention bi-cycle 1987
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