To the authors’ knowledge, this is the first study that has developed criteria for the evaluation and design of prehabilitation interventions before cancer surgery in the UK with an emphasis on addressing inequalities. This study was successful in enabling both experts by experience (people with lived experience of cancer) and experts by profession (professionals with a role in prehabilitation services) to create and reach consensus on the criteria based on values, objectives and aims for prehabilitation delivery and care. Previous Delphi studies on prehabilitation have focused mainly on the input of healthcare professionals with a role in prehabilitation (37, 38), although the inclusion of patients in future studies has been strongly recommended (37). This study has produced criteria that include 60 statements organised within seven categories (Figs. 3 and 4) covering the developing and delivering prehabilitation services, addressing inequalities, community-based care, emotional health, nutrition, physical health and multi-modal interventions.
The participants reached a consensus on the need for a clear understanding of what prehabilitation before cancer surgery is and this should be clearly communicated to patients using the service. Criteria statements 1 and 2 for developing and delivering prehabilitation (detailed in supplementary material) received over 90% consensus. This reflects the breadth and complexity of the types of interventions that could be included in prehabilitation and how they are delivered, as well as discussions during the co-design workshops on the difficulty of defining prehabilitation for both experts by experience and experts by profession.
The study’s PPI panel also highlighted that patients should be able to opt-in to interventions based on their preferences. To ensure that all patients receive equitable care, the design of prehabilitation should consider personalisation and tailoring, improved shared decision-making processes, adopting innovation in prehabilitation as well as continuity of care beyond prehabilitation through the integration of community-based care. Tailoring elements of prehabilitation was a strong theme throughout the criteria statements reaching consensus. The importance of tailoring prehabilitation to both the patient’s condition and individual life circumstances was also highlighted in Netherlands-based research by Beck and colleagues (39, 40), contributing to patients’ adherence to prehabilitation plans and research by Heil and colleagues (21) highlighting the personalised programmes as facilitators. The criteria statements also highlight the importance of quality interactions between the prehabilitation care team and patients with considerations for patient empowerment, avoiding overwhelm, consistency and the inclusion of information provided for family, carers and loved ones. The importance of the timing of the delivery of the intervention between diagnosis and treatment is frequently indicated in the statements, as are the times and locations where interventions can be accessed.
The results of this research expand on the ‘principles and guidance for prehabilitation within the management and support of people with cancer’ published in the UK by Macmillan, NIHR and RCoA (6), which advocates for prehabilitation to be incorporated into routine cancer care. The principles and guidance were also developed using a modified Delphi technique, which drew on a synthesis of the evidence base and input from three multidisciplinary expert groups comprised of mainly healthcare professionals with input from patient representatives. This research contributes evaluation criteria that detail the preferences based on the experience of those with lived and professional experience that highlights many of the same themes (e.g. promotion of healthy behaviours including exercise, nutrition and psychological interventions, service development and patient empowerment). The criteria presented contribute consensus of preferences on addressing inequalities, including awareness of pressures and responsibilities in individuals’ lives that affect their access and adherence to prehabilitation. Previous research has highlighted variations in how and where prehabilitation services are delivered (12–15), as well as the need for a greater understanding of how prehabilitation can equitably improve experiences, access and outcomes for all (7, 41). With regard to addressing health inequalities, the criteria statements included show the importance of overcoming potential geographical and communication barriers to access, as well as considerations for different cultures and religions, the impact of life circumstances on access (e.g. caring responsibilities and employment) and tailoring support for different patient characteristics. This study contributes to an area where few previous studies focusing on prehabilitation for adults undergoing surgery have focused on examining health inequalities.
The criteria highlight the value of interventions beyond those traditionally found in prehabilitation, for example, the use of community assets, peer support and the inclusion of family and friends. Macmillan offers a range of support to cancer patients after diagnosis although they are not defined as prehabilitation services (42). Socially prescribed activities, such as those that encourage patients to do outdoor activities were also valued, which previous studies have highlighted as beneficial to cancer patients, but not linked to prehabilitation (43–45). There is scope for further research to understand the variety of services available to patients during prehabilitation locally and nationally in the UK, including social prescribing. The research could also explore the potential problems associated with defining other interventions as part of prehabilitation and the risks to reduction in funding for those interventions.
Strengths and Limitations
The overall response rate for the Delphi questionnaire presented in this study was 76%. A response rate of over 70% has been suggested to maintain rigour in Delphi studies (46, 47). The study PPI panel commended the participant diversity, inclusive of gender, disabilities, ethnicities and ages in the UK, representing many groups who are typically underrepresented in health research. Addressing inequalities in representation in this way helped to inform statements considering equitable prehabilitation interventions, which as previously discussed, is an under-researched area for prehabilitation. The online questionnaire allowed participants to vote from geographically diverse locations in the UK at a time that suited their lifestyles. The study successfully managed to incorporate the views of both experts by experience and experts by profession. Other research has shown that this is a strength for Delphi studies, as experts by experience are less likely to have judgements affected by their self-interests and are more likely to see issues from multiple perspectives (35, 48). A mix of both experts by experience and experts by professional has been argued to lead to more reliable results (48), as well as contribute to understanding how interventions can be patient-centred. Among the eight experts by profession who participated, individuals from diverse disciplines took part including a clinical psychologist, dietitian, physiotherapist, clinical specialist nurse and others involved in direct delivery of prehabilitation. However, no general practitioners, surgeons or anaesthetists participated. As prehabilitation is a complex intervention that requires the input of multidisciplinary teams, a wider mix of professions may have enhanced the results as discussed by Raichurkar and colleagues’ prehabilitation focused Delphi study (37). The Delphi consensus was achieved because the criteria at each round had strong consistency, it was not driven by either the experts by profession or experts by experience and no major revisions were needed in round three. The number of participants dropped slightly for the second round of the questionnaire, which may have been due to the circulation time corresponding with an Easter holiday period.
Whilst it did not affect the consensus results, a common reoccurring comment throughout the Delphi study was that statements are a representation of good care and practice rather than the direct responsibility of prehabilitation design and delivery. From discussions during the initial development of the statements during the co-design phase, it was noted by the research team that frustrations with services and experiences influenced by current challenges facing the NHS in the UK, such as limited resources and strain on staff, impacted the priorities of participants. A lower number of healthcare professionals participated than originally anticipated by the research team, which was likely impacted by the workloads and different priorities of the professionals.
Using a co-design approach to collaboratively develop the criteria statements for the consensus study (details of which will be published in an additional paper by Wareing et al.) was a key strength and unique feature of this prehabilitation focused study. However, the use of a co-design approach to enable both groups to collectively explore the values and aims of prehabilitation may have led to already confirming the importance of the statements to the participants involved. The same participants were invited to participate in the Delphi questionnaire, leading to no statements excluded being as part of the consensus process. It is possible that by inviting a wider population of patients currently undergoing cancer treatments and healthcare professionals who provide prehabilitation, different importance could have been assigned to each criteria statement. Additionally, the Delphi technique literature states a defining feature of Delphi studies is the anonymity of the participants and that anonymity provides all participants with the confidence to participate (33, 46, 49). A challenge for this study was the offer to compensate participants for their time in recognition of the value of their contribution, which required asking participants to fill in their names for each round. This may also have discouraged participants from voting out criteria but may have improved the response rate (37).
A challenge for the study was the clarity of the language used in the statements, which may have made it difficult for some participants to take part. In the last co-design workshop, some participants commented that the statements were too complex and used words used in professional contexts. The team worked to improve the statements based on feedback in further iterations, however, feedback from the PPI panel stated the criteria presented in their full format was difficult to understand and needed to be tailored for target populations, which led to the creation of the easy-read criteria in Figs. 3 and 4, rather just presenting lengthy Delphi reports (as included in the supplementary material). It was suggested that, at this stage of defining the service, “less is more” and the description should be clearer and more concise depending on the audience. Whilst our criteria are a co-design outcome, it is possible that, due to the complexity of prehabilitation services, further discussions are required for the dissemination of the results and the development of user-friendly guidance for implementing prehabilitation in cancer care. There is scope for further research to examine how Delphi techniques and criteria creation can be made more inclusive, exploring possibilities of less lengthy written forms.
Future implications
Our findings through this Delphi questionnaire study provide evaluation criteria for prehabilitation before cancer surgery which will be used to evaluate what is important for quality and equitable prehabilitation provision throughout the PARITY study (25). The overall PARITY study aims to evaluate these findings by collecting data through a UK-wide survey which aims to identify what is being delivered as prehabilitation in the UK and carry out eight in-depth case studies of prehabilitation services provided in the UK. The criteria will be brought together with the findings from the subsequent stages of the study to inform the development of the best practice guidelines for standardising the prehabilitation services in cancer care and these will be evaluated in future studies. Previous to this research, there was limited understanding of what is important for prehabilitation according to patients and views on how to address challenges of unequal access to services. This research has begun to explore this area with the potential to build on it in the future and advocates for patients to be involved in establishing the definitions and boundaries of what is included in the different types of prehabilitation.