No thanks and not for me: A qualitative study of barriers to prehabilitation participation

Prehabilitation programs have been shown to improve functional status prior to surgery, postoperative recovery, and even long-term outcomes. However, these programs often lack participation, often by patients who seem to need it the most. This study aimed to identify the primary reasons for patients' declining enrollment or low adherence to a prehabilitation program.

We recruited adult patients who had undergone or planned to undergo major abdominal surgery for semistructured one-on-one audio-recorded interviews. Interviews were transcribed verbatim and iteratively coded deductively and inductively. Thematic analysis was performed.

We interviewed 11 patients, at which point we reached thematic saturation. The patients were on average 53 years old (range 38-75) and 27% were women and 73% were men. The pooled kappa score was 0.81, indicating concordance among the coding researchers. Seven potential barriers to prehabilitation participation and adherence were identified: poorly timed recruitment efforts, misconceptions about prehabilitation diet recommendations, competing priorities that made prehabilitation less feasible, lack of family alignment, belief that prehabilitation would not be helpful, concerns over specific prehabilitation program components, and belief that prehabilitation is helpful for others but not for themselves.

Low participation and adherence limit the success and reach of many prehabilitation programs. Improved timing and content of communication by the prehabilitation team is critical for improving recruitment of patients. Flexibility and customization may reframe prehabilitation as feasible rather than a difficult chore, increasing participation and adherence. Understanding patients' concerns and readiness to adopt new health behaviors is a necessary component of any behavioral intervention.