Dilemmas of nudging in public health: an ethical analysis of a Danish pamphlet.

Nudging has been discussed in the context of public health, and ethical issues raised by nudging in public health contexts have been highlighted. In this article, we first identify types of nudging approaches and techniques that have been used in screening programmes, and ethical issues that have been associated with nudging: paternalism, limited autonomy and manipulation. We then identify nudging techniques used in a pamphlet developed for the Danish National Screening Program for Colorectal Cancer. These include framing, default nudge, use of hassle bias, authority nudge and priming. The pamphlet and the very offering of a screening programme can in themselves be considered nudges. Whether nudging strategies are ethically problematic depend on whether they are categorized as educative- or non-educative nudges. Educative nudges seek to affect people's choice making by engaging their reflective capabilities. Non-educative nudges work by circumventing people's reflective capabilities. Information materials are, on the face of it, meant to engage citizens' reflective capacities. Recipients are likely to receive information materials with this expectation, and thus not expect to be affected in other ways. Non-educative nudges may therefore be particularly problematic in the context of information on screening, also as participating in screening does not always benefit the individual.

Storytelling as part of cancer rehabilitation to support cancer patients and their relatives.

Previous research on psychosocial support for cancer-related concerns has primarily focused on either patients or their relatives, although limited research is available on how patients and their relatives can be supported together. The aim of this article is to explore the use of storytelling as a part of a residential cancer rehabilitation intervention for patients together with their relatives, with a specific focus on their management of cancer-related concerns. Ten pairs participated in the intervention and data were generated through ethnographic fieldwork, including participant observations, informal conversations and follow-up interviews conducted one month after completing the intervention. Analysis was performed drawing on narrative theory combined with social practice theory. The results demonstrate that the use of storytelling and metaphors intertwined with other course activities, such as dancing and arts & crafts, provided the patients and their relatives with strategies to manage cancer-related concerns, which they were later able to apply in their everyday lives. The study results may be useful to other professionals in clinical practice for rehabilitation purposes for addressing issues of fear and worry.

Involvement of patients with lung and gynecological cancer and their relatives in psychosocial cancer rehabilitation: a narrative review.

INTRODUCTION: Getting cancer is stressful for most patients and their relatives, and research has shown that psychosocial support is needed. Still, cancer care fails to appropriately address psychosocial problems associated with cancer. Research on this topic is often seen from the perspective of either the patient or the relative, even though it is suggested that psychosocial support is beneficial for the patient and the relative as a pair. Furthermore, research on the need for psychosocial support rarely involves patients with gynecological and lung cancer and their relatives, even though they often suffer from isolation and stigmatization. The aim of this review was therefore to summarize knowledge about psychosocial support with regard to individual needs, involvement of significant others, and providers of psychosocial support focusing on this specific population. METHOD: A narrative review procedure was chosen. This method is a specific kind of review, which summarizes, explains, and interprets evidence on a selected topic. The review process was structured according to typical scholarly articles with attention to the search and review process. RESULTS: A total of 16 studies were included in the review. The studies were divided into two main categories: (1) studies focusing on needs for psychosocial support; and (2) studies focusing on interventions. The needs studies were analyzed, and three themes emerged: the needs of the patient and the significant other across the cancer trajectory; the needs of the significant other as a carer; and needs and ongoing and tailored support. The intervention studies were directed toward the patient and the relative, the patient, or the relative. Five interventions comprising various forms of support that were purely supportive and were carried out by healthcare professionals were identified. CONCLUSION: There were overlaps between the needs of the patient and the relative, but there were also distinctive characteristics of the needs in the two groups. The needs varied during the cancer trajectory, and we therefore recommend that support be offered continuously. It was also evident that the relatives should be involved in the patients' care and that the involvement was beneficial for both the patient and the relative.

"An arena for sharing": exploring the joint involvement of patients and their relatives in a cancer rehabilitation intervention study.

BACKGROUND: Despite an increasing focus on cancer rehabilitation programs, there is limited knowledge about the experiences of residential rehabilitation focusing on both the patients and their relatives. OBJECTIVE: The aim of this study was to explore the experienced benefits of the joint involvement of patients and their relatives in a 5-day residential cancer rehabilitation course, provided as part of a larger intervention study in Denmark. METHODS: Ethnographic fieldwork, consisting of participant observations and informal conversations, was conducted with 20 individuals (10 patients and 10 relatives). In-depth interviews were conducted in the participants' homes 1 month after the rehabilitation course. Data were analyzed by a constant comparative method. RESULTS: Residential rehabilitation course was identified to serve as an "arena for sharing," underpinned by 3 dimensions of sharing: sharing cancer experiences, sharing strategies, and sharing mutual care. CONCLUSION: Sharing in residential rehabilitation is experienced as useful for cancer patients and their relatives, to validate cancer-related strategies and strengthen mutual understanding within relationships. IMPLICATIONS FOR PRACTICE: The results can guide the development of cancer rehabilitation to involve patients and their relatives and provide opportunity for sharing and empowerment on individual as well as couple and group levels.

Outcome of supportive talks in a hospital setting: insights from cancer patients and their relatives.

BACKGROUND: In psychosocial cancer rehabilitation, relatives are often central to patients' experiences and management of their cancer disease, and they need to be actively involved in rehabilitation. To address this need we developed a psychosocial rehabilitation intervention. As part of the intervention, lung or gynecological cancer patients and a relative as a pair were offered three supportive talks initiated on the date of admission and completed within 2 months. OBJECTIVE: The objective of this study was to qualitatively assess the outcome of supportive talks from the pairs' perspectives and to provide a nuanced understanding of psychosocial support offered to pairs in a hospital setting in Denmark. METHODS: Using a qualitative approach, we conducted semi-structured interviews with pairs receiving supportive talks and pairs receiving usual care. The interviews focused on the pairs' experiences of psychosocial supportive talks in a hospital setting. A constant comparative analysis was applied to identify themes related to the ways the pairs experienced the talks. RESULTS: The analysis revealed two main themes: 'appreciation of the supportive talks' and 'the influence of the hospital setting'. The majority of pairs valued the focus on relationship and interpersonal communication, although they appreciated various aspects of the talks. The hospital setting provided valuable resources (trained nurses and medical expertise), but existing clinical routines challenged the implementation of the supportive talks. CONCLUSIONS: The supportive talks were appreciated as psychosocial support in line with the objective, or as information on cancer treatment and routine care. The implementation of a new rehabilitation practice was challenged by the influence of the hospital setting.

Feasibility of a psychosocial rehabilitation intervention to enhance the involvement of relatives in cancer rehabilitation: pilot study for a randomized controlled trial.

BACKGROUND: Cancer often affects the quality of life and well-being of patients as well as their relatives. Previous studies have suggested that relatives should be involved in psychosocial rehabilitation to address the needs for an interpersonal relationship with others in the disease trajectory. We developed an innovative rehabilitation program to be offered to the patient and a relative as a pair. OBJECTIVE: The aim of the present pilot study was to examine the feasibility of the intervention in a randomized controlled trial (RCT) and to evaluate the impact on quality of life. METHODS: The study was designed as an RCT comparing the new multimodal psychosocial rehabilitation with the usual services. The intervention comprised three 'supportive talks' and a residential rehabilitation course. From March 2010 to March 2011, participation was offered at the time of diagnosis to patients with lung or gynecological cancer from two departments at Odense University Hospital in Denmark. Questionnaires were used to estimate changes in quality of life (EORTC-QLQ-C30 on global health status) and well-being (WHO-Five Well-Being Index) at baseline and after 2 and 12 months. Information on the participants' views about the rehabilitation intervention was obtained from assessment charts and qualitative interviews. RESULTS: A total of 209 patients were assessed for eligibility, but only 42 pairs were randomized to the study. The 2-month follow-up was completed by 34 patients and 32 relatives, and 19 patients and 21 relatives completed the 12-month follow-up. A higher dropout rate at the 12-month follow-up was reported in the intervention group compared with controls. Quality of life and well-being increased for patients and relatives in both the intervention and the control group, and no clinically significant difference was observed between the intervention and the control group. Pairs reported that the time of inclusion was inconvenient and that rehabilitation ought to meet their changing needs. CONCLUSIONS: The pilot study showed that it may be difficult to conduct an RCT of a psychosocial rehabilitation intervention for pairs, and difficulties with inclusion and drop out have to be addressed. Interventions need to be carefully developed and tested before evaluating an effect in a large-scale study.