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8. Perspectives
8.1. Implications for clinical practice
Since results from the thesis and the included studies will be presented widely both nationally and
internationally, they can contribute to increase awareness of the challenges that HNC survivors are facing.
Results describing the magnitude and nature of unmet rehabilitation needs in Danish HNC survivors are useful for planning future clinical approaches/research and organisation of rehabilitation services. Since the population of HNC survivors is increasing with a consequent increased demand for proper
rehabilitation services, this is highly relevant.
The results underpin the need for a multidisciplinary approach in management of nutrition impact
symptoms and other late effects in HNC survivors, and it provides promising results for the effect of such multidisciplinary interventions. Even though residential rehabilitation programmes may not be readily implementable in all municipalities, elements of the NUTRI-HAB programme could be implemented.
With results showing how much participants benefited from meeting peers, diagnosis-specific group-based rehabilitation programmes could be considered as appropriate approaches in nutritional rehabilitation in the municipalities. With the national mapping of cancer rehabilitation services showing that only 17 of 98 municipalities offered diagnosis-specific rehabilitation services for HNC survivors in 2017, it becomes evident that the potential of peer support is not realised fully in the Danish municipalities.
The results confirm that assessment of rehabilitation needs in HNC survivors is crucial even years after treatment, and the assessment should be broader than simply assessing body weight, body mass index, or weight loss. Depending on the results of the future analyses of associations between PG-SGA SF or MDADI and intervention effect, the potential implementation of these in the systematic assessment of rehabilitation needs should be explored. As discussed, this include exploring the perspectives of the health care professionals who will be offering the needs assessment.
8.2. Future research perspectives
As concluded in the thesis, future studies should explore the effect of multidisciplinary nutritional rehabilitation in different subgroups of HNC survivors, and at what timepoint in the diseases trajectory it would be most appropriate to offer intervention. Since residential rehabilitation programmes may not be
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readily implementable everywhere, additional methods of delivering multidisciplinary nutritional rehabilitation services should be explored.
Furthermore, relevant inclusion criteria for referral to multidisciplinary nutritional rehabilitation, and hence methods to assess needs for nutritional rehabilitation should be assessed. This includes further assessment of the applicability of different nutrition screening and assessment tools both in clinical studies and in the ongoing systematic review143.
Given the social importance of meals and our participants’ experiences of how eating problems affected the relationship with the relatives, future studies on how the social interactions in the family are affected and on how nutritional rehabilitation services could include the relatives without jeopardising the candidness among participants are relevant.
As for my future research career, funding for a postdoctoral study will be applied for to follow-up on remaining analyses and dissemination of results from the NUTRI-HAB project and to pursue some of the new research perspectives that have emerged throughout the project.
Data collected in study 3 will be used to pursue objective 2 defined in paper III: to assess whether effect of the NUTRI-HAB programme was associated with nutritional score at baseline and, hence, whether any of the included screening and assessment tools could potentially be relevant to assess HNC survivors’ needs for nutritional rehabilitation.
Based on participants’ experienced benefit of eating together in a safe and supportive environment, I will aim at exploring how elements of the NUTRI-HAB programme can be implemented in a municipal context in Denmark.
Finally, a comprehensive data material was collected in the nationwide survey in study 2, and only few of these data were included in the thesis. Remaining data will be published in future papers and include analyses of QOL, unmet rehabilitation needs, psychological well-being, and health behaviour of Danish HNC survivors 1-5 years after curatively intended radiation therapy. Publishing these data will be given high priority to ensure that the voice of the many HCN who shared their valuable insights and experience will be heard.
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8.3. Usefulness of the public sector industrial PhD project
To be eligible as public sector industrial PhD projects, projects are evaluated by their usefulness to the host organisation, and by how the usefulness is realised and results are implemented. Usefulness for the
organisation can be, e.g. knowledge building that directly improves the organisation’s competences, systematic knowledge dissemination, and/or strengthening the quality of the product/service provided by the organisation153.
Being a university college, UCC Nutrition and Health’s primary service is education of the future nutrition professionals including clinical dietitians. With the strategy ‘Together for excellent teaching’, UCC’s vision is to educate professionals who succeeds in and together with clinical practice in realising some of the society’s ideals and solving some of its challenges. Aims included in the strategy are applied research that addresses challenges within the professions and the integration of more applied research and
development in teaching of the future professionals154. More specifically, UCC’s strategy for applied research include developing and testing tools, methods and interventions for professionals in practice and focusing on the potential to scale research projects to include several professionals155.
With the NUTRI-HAB project exploring the effect of multidisciplinary nutritional rehabilitation it
contributes to develop and test methods and interventions for nutrition professionals in a multidisciplinary collaboration. The project has furthermore tested different tools either to be used by the clinical dietitian in the nutritional assessment or to be used by other health professionals to screen for the need for referral to nutritional interventions.
With the initiation of the NUTRI-HAB project, a multidisciplinary group from different educational programmes at UCC and clinical practice took the initiative to establish a research network on late effects and QOL in head and neck cancer4 to facilitate multidisciplinary and cross-sectoral collaboration. Hence, the project has contributed to strengthen collaboration across UCC’s educational programmes with the prospect of future multidisciplinary research project.
During the 3-year project period, 10 students have been connected to the project either in practical placement or as a part of their BSc. thesis project. The students have been working with various tasks either directly as a part of the NUTRI-HAB project or as smaller related project e.g. developed recipe books and assisted with practical kitchen workshops at NUTRI-HAB programme or analysed data on nutritional interventions from REHPA’s mapping cancer rehabilitation in Denmark8 with a manuscript in
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preparation. Hence, the students have had the opportunity to work with research and rehabilitation in practice and to strengthen their competences.
Furthermore, results and experiences from the project will be implemented in my future teaching.
Returning to my position as senior lecturer, one of my first tasks is to develop a course on nutritional interventions including practical cooking and social eating in rehabilitation services for different patient groups as an elective course for our students. Eventually, continued education activities for trained health professionals will also be planned.
Through the NUTRI-HAB project a strong partnership between UCC and REHPA has been established.
So far it has led to another project collaboration on a report on current practice and perspectives within nutritional rehabilitation in life-threatening disease156 edited by REHPA and a colleague from UCC and with contributions from other colleagues from UCC myself included. This work has led to establishment of a professional network with representatives from REHPA, UCC, and other partners from clinical practice, educational institutions, and food service with the aim of developing practice within nutritional rehabilitation services in Denmark and to facilitate exchange of experiences and collaboration across the country.
Planned future collaboration between UCC and REHPA include planning and delivering the NUTRI-HAB programme again in September 2020 with the research-based purpose of qualifying ideas for future collaborative research projects.
Hence, the usefulness of the NUTRI-HAB project for UCC include all beforementioned aspects:
knowledge building that directly improves the organisation’s competences, systematic knowledge
dissemination, and strengthening the quality of the service provided by the organisation. While some of it has already been realised, other aspects of the usefulness will be realised in the future research and educational activities.
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