Patient characteristics and preferences for a surgical prehabilitation program design: results from a pilot survey

Abstract

Purpose

Surgical prehabilitation aims to reduce a decline in the functional capacity thereby optimising health and fitness before surgery. One of the major barriers in successfully implementing a prehabilitation program in hospitals has been poor patient adherence. In our pilot survey on surgical patients, we sought to explore patient preferences regarding the program design, the barriers and enablers to patient participation in a multimodal prehabilitation program.

Methods

The survey was administered to patients undergoing major abdominal surgery in the preoperative period. The first two parts of the instrument mainly included questions on demographics, social history, activity levels, interest towards prehabilitation program and their involvement in co-design, preferences towards the components of the program, the barriers and enablers. The last part of survey included symptom and physical assessments.

Results

The survey was completed by 24 patients undergoing major abdominal surgery. The median age of our cohort was 71 (range 35–91) years and 75% were retired. 75% of our participants were extremely interested in improving health and fitness and 63% were very keen to co-design their program when explained. Home-based programs were preferred by most participants and among exercises, walking was preferred by 71% of the participants. One third of the participants were interested in professional dietary counselling. There were only two participants who preferred group psychological therapy while 25% preferred individual psychological counselling sessions.

Conclusion

Our survey highlighted a need to design a personalised program with tailored interventions due to the wide variation in the interest and preferences among surgical patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-022-04420-4.

Introduction

Prehabilitation is the process of increasing the functional capacity of an individual to enable them to withstand the stress of surgery. Multimodal prehabilitation traditionally encompasses exercise, nutritional optimisation, and reduction of psychological stress with an intention to increase physiological reserves in the preoperative period (Carli et al. 2017). Although prehabilitation has been shown to improve functional exercise capacity and muscle strength (Awasthi et al. 2019), patient engagement and adherence have repeatedly been identified as major barriers to implementing a prehabilitation program (Martin et al. 2021). Adherence with any treatment is the key contributing factor to its success and can be increased if the programs are patient-centred (Hayden et al. 2005; Wright 2017). According to the Health Belief Model framework, patients tend to engage in health-related programs if they perceive a personal threat from a condition, believe that the program is effective in reducing this threat and that the perceived barriers to engagement are acceptable (Rosenstock 1974). Therefore, patient preferences should be considered in the treatment plan and planning for new services in order to improve clinical outcomes by ensuring their satisfaction and therefore adherence (Belinchon et al. 2016). The aim of our survey was to gain insight into the perception amongst patients undergoing major abdominal surgery about prehabilitation and to explore the preferences and barriers which will inform the design of a patient-centred prehabilitation program.

Methods

This was a pilot cross-sectional survey performed in line with the principles of the Declaration of Helsinki. Approval was granted by the ethics committee of the hospital (HREC/18/QPCH/114; dated 19/4/2018). It was conducted between September 2019 to November 2020 on a convenience sample of patients undergoing elective major abdominal surgery during their pre-anaesthetic clinic visit at a tertiary hospital in Australia (ACTRN12618001075279). Informed consent was obtained from all individual participants included in the analysis of the survey.

Survey instrument

The first section of the survey included questions on participants’ demographics, smoking status, alcohol use using the CAGE Alcohol Questionnaire (Ewing 1984) and their activity levels using the European Prospective Investigation into Cancer and Nutrition (EPIC) physical activity questionnaire (Cust et al. 2008). The second section of the survey included questions on participants’ preferences for a multimodal prehabilitation program and its elements (exercise, nutrition, psychological support), barriers to participation, participants’ interest in co-designing their program and motivational readiness to change in relation to physical activity and smoking habits. The third part of the survey involved baseline assessment of their nutritional status using the malnutrition screening tool (MST) (Ferguson et al. 1999), physical status using the Short Physical Performance Battery (SPPB) (Guralnik et al. 1994) and their current symptoms using the Edmonton Symptom Assessment System: (revised version) (ESAS-R) (Watanabe et al. 2012). SPPB is an assessment tool for disability and mobility limitations, that combines the results of gait speed, chair stand and balance tests (Guralnik et al. 1994). ESAS, used in oncology patients, comprises of nine general domains of symptom assessment including pain, tiredness, depression, anxiety, drowsiness, nausea, appetite, overall wellbeing, shortness of breath, and any other issues, ranked between 0 and 10 (Watanabe et al. 2012). The list of survey questions is provided as supplementary table. The survey was administered through Survey Monkey^® (http://www.surveymonkey.com). Descriptive statistics were calculated for the demographics and participants’ responses. The results are reported as frequencies and percentages.

Results

The survey included 24 participants (14 male and 10 female) with a median age of 71 (range 35–91) years (Table 1). 75% (n = 18) were living with their family; the majority (17/24; 71%) had completed secondary schooling and most 18 (75%) were retired. None of the patients had alcohol use issues and 13 (54%) were previous smokers. In terms of their current physical activity, 9 (37.5%) reported their daily physical activity as sedentary and 14 participants (58%) reported they had not undertaken physical activity sufficiently vigorous to cause a sweat in the previous week. 18/24 (75%) participants were scheduled to undergo cancer surgery.

Table 1.

Demographics and baseline characteristics of survey participants

Demographics and baseline activity responses	N = 24 Mean (SD); n (%)
Age (years)	69 (14)
Height (cm)	168 (11)
Weight (kg)	84 (24)
Gender
Female	10 (42%)
Male	14 (58%)
Surgical pathology
Abdominal cancer	18 (75%)
Non-malignant abdominal pathology	6 (25%)
Highest level of education completed
University	5 (21%)
Secondary school	17 (71%)
Primary school	2 (8%)
Current employment status
Full-time	3 (12.5%)
Part-time	0 (0.0%)
Retired	18 (75.0%)
Unemployed	2 (8.3%)
Other	1 (4.2%)
With whom do you live?
Spouse/Partner	14 (58.3%)
Spouse/partner and children	3 (12.5%)
Children only	1 (4.2%)
Alone	6 (25.0%)
Medical conditions
None	11 (45.8%)
Osteoarthritis	10 (41.7%)
Ischaemic heart disease	2 (8.3%)
Chronic obstructive pulmonary disease	0 (0.0%)
Vision Impaired	1 (4.2%)
Smoking status
Never	7 (29.2%)
Ex-smoker	13 (54.2%)
Currently-smoking	4 (16.6%)
If current smoker: Number pack years	15 (14)
Alcohol consumption (CAGE questionnaire)
Have you ever felt you should Cut down alcohol consumption? (Yes)	1 (4.2%)
Have you ever Annoyed others with your drinking? (Yes)	3 (12.5%)
Have you ever felt Guilty because of drinking? (Yes)	1 (4.2%)
Have you ever used alcohol first thing in the morning (Eye-opener)? (Yes)	1 (4.2%)
Current activity level
Sedentary	9 (37.5%)
Manual Work	4 (16.7%)
Standing occupation	9 (37.5%)
Heavy manual work	2 (8.3%)
In a typical week in the last year did you perform any activity vigorously enough to cause sweating? (Yes)	10 (42%)
If yes, for how many hours per week did you perform vigorous activity?	3 (11)
In a typical week how many flights of stairs did you climb?	6 (12)

Most participants (n = 18; 75%) expressed a medium to high interest in improving their preoperative health and fitness. Amongst the components of prehabilitation, 46% (n = 11), 50% (n = 12) and 33% (n = 8) considered preoperative exercise, nutrition, and psychological counselling to be very or extremely important respectively. Of the 24 participants, 11 (46%) were very/extremely interested to participate in prehabilitation if offered, whilst 15 (63%) expressed a great interest in designing their program.

Most participants (n = 16; 67.7%) expressed a preference for moderate to vigorous exercise activities with a structured prehabilitation program, with walking (71%) the most preferred type of exercise. Two-thirds (16/24) expressed a preference for a home-based program, however, 14 participants (58%) reported that they would be able to attend one or more hospital sessions per week if needed. The participants chose transport issues, lack of time and parking costs as the main barriers to hospital-based programs. In terms of home-based programs, motivation issues, musculoskeletal conditions and other commitments were the most likely barriers.

In terms of the nutritional aspect of prehabilitation, only 7 (29%) were interested in receiving professional dietary counselling. Of the 14 participants who expressed their preferences with psychological interventions, six (25%) preferred individual counselling session, 5 (21%) preferred to learn self-management skills such as stress management techniques, while only two (8%) preferred support through group sessions (Table 2).

Table 2.

Participants’ preferences for their prehabilitation program

Survey question stem and responses	N = 24 n (%)
Given a choice, would you prefer home based, hospital based, or a combination program?
Home	16 (66.7%)
Hospital	2 (8.3%)
Combination	4 (16.7%)
No preference	2 (8.3%)
How many sessions in a week would you be able to attend at the hospital?
None	10 (41.7%)
Once per week	9 (37.5%)
More per week	5 (20.8%)
What level of intensity do you prefer your exercise sessions to be?
No-preference	1 (4.2%)
Light	7 (29.2%)
Moderate	13 (54.1%)
Vigorous	3 (12.5%)
Most preferred exercise activity
Walking	17 (70.7%)
Any gym	1 (4.2%)
Ball games	1 (4.2%)
Cycling	0 (0%)
Dancing	1 (4.2%)
Running/jogging	0 (0%)
Yoga/Pilates	3 (12.5%)
Swimming	1 (4.2%)
Would you be interested in advice on appropriate nutrition and/or the use of dietary supplements by a registered dietitian?
Not-at-all	6 (25.0%)
Not	3 (12.5%)
Neutral	8 (33.3%)
Very	6 (25.0%)
Extremely	1 (4.2%)
Most preferred method of psychological support
No-preference	11 (45.8%)
Skills-training	5 (20.8%)
Support-group	2 (8.4%)
Counselling	6 (25.0%)
Other	0 (0.0%)
Most preferred method of receiving dietary advice
No preference	5 (20.8%)
Face to face	11(45.8%)
Brochure	3 (12.5%)
Web based	2 (8.4%)
Telephone	2 (8.4%)
Combination of methods	1 (4.2%)

When we examined the motivational readiness in relation to physical activity, 13 participants reported that they were currently doing regular exercises. Of the 11 participants who were not currently active, 10 had intentions to start exercise in the following six months (contemplation phase) and one was not thinking of increasing their physical activity soon (pre-contemplation phase). In relation to smoking, of the 10 current smokers, seven participants did not intend to quit any time soon (precontemplation), while two participants were planning to quit soon (contemplation phase), and one did not respond.

In relation to current symptoms, six participants with bowel cancer (n = 23; 26%) reported moderate to severe symptoms on the ESAS-R scale (Watanabe et al. 2012). Nineteen participants had complete SPPB scores available. Of them, 12 (63%) scored less than 10, indicating either frailty or mobility limitation. Ten participants (83%) in the SPPB < 10 category expressed medium to high interest to both participate in the prehabilitation program and to improve their health and fitness, compared to five (71%) and 4 (57%) participants in the SPPB ≥ 10, respectively. In terms of association with motivational readiness to physical activity, 5/12 participants (42%) of those who scored SPPB < 10 were in the contemplation phase compared to 2/7 (29%) of those who scored SPPB ≥ 10. One-fourth of the participants (6/24) reported to have lost weight and felt anorexic.

Discussion

In our survey, we observed that 75% of our participants showed high levels of interest in improving preoperative health and fitness. Around 46% were highly inclined to participate in the program and 63% were very keen to co-design their own program when we explained about the program. This high interest is consistent with that reported by another recent Australian survey (Waterland et al. 2021) on patients undergoing abdominal cancer surgery. This was not surprising as most of the participants had an active lifestyle before their diagnosis. This mirrors the findings of a recent study performed in Canada, where the participants were found to be active prior to enrolling in the prehabilitation program and therefore appreciated the importance of exercise (Ferreira et al. 2018). Baseline physical activity can have a significant impact on the adherence to exercise programs (Jack et al. 2010).

In terms of the motivational readiness to engage in physical activity, 54% of our participants were currently active and 42% were intending to exercise very soon. In patients who scored SPPB less than 10, there was also a greater interest and awareness of the need to improve health and fitness, and a greater number of patients intending to increase their activity levels (contemplation phase), compared with those who scored SPPB ≥ 10. However, intent does not commonly translate into action or change (Conroy et al. 2011). One of the major factors contributing to participation and compliance in exercise programs is prior involvement in physical activity. In a study on advanced cancer patients, motivation towards physical activity was found to be the strongest predictor for physical activity (Frikkel et al. 2020). In addition, they found that motivation was predicted by cancer related symptoms, pre-diagnosis physical activity, interest in exercises, and existing knowledge on physical activity and its benefits (Frikkel et al. 2020). On the other hand, pre-existing sedentary lifestyle generally leads to less involvement in physical activity, however, this has been shown to respond to increasing participants knowledge regarding how exercise can improve their quality of life, reinforcing the importance of comprehensive and personalised education (Eng et al. 2018). While our results indicated increased commitment to exercise in half our participants, others ambivalent about the benefits of exercise may benefit from education.

Among the activities listed, walking was selected as the most preferred option by 71% of the participants, and moderate to vigorous exercise activities were preferred by 67%. This high level of interest in walking has been reported by several previous studies (Abrantes et al. 2011; Waterland et al. 2021) and reinforces that an exercise that is well tolerated and accepted by patients does not necessarily need any special equipment or to be performed in a health care centre or hospital.

Our findings suggest that most patients are receptive to discussions about health and fitness options in the preoperative period. However, in terms of changes in health behaviour, it was concerning that nearly 70% of the current smokers in our survey had no plans to quit. Improving patient knowledge about the perioperative risks of smoking has been recommended a useful strategy to encourage quitting (Webb et al. 2013).

Consistent with other surveys from Australia and Canada, home-based programs were preferred by most participants in our study and the most cited barriers to attending the hospital program were transportation, parking issues, lack of time and costs (Ferreira et al. 2018; Waterland et al. 2021). Despite the logistical and financial barriers reported, nearly 60% of our participants were agreeable to attending at least one session per week in the hospital. In our survey, nearly one-quarter of the participants had moderate-severe symptoms, had lost weight and appetite and were frail. However, a tailored multimodal prehabilitation program can still benefit this cohort of patients. Interest and participation in prehabilitation programs may be improved by removing perceived barriers to make participation as easy as possible. Providing free or discounted parking tickets is a useful measure to ensure participant adherence to exercise sessions (Gurunathan et al. 2022).

In terms of the nutritional aspect of prehabilitation, less than one-third were interested in receiving professional dietary counselling. A previous Australian study has highlighted the need to improve the dietitian-patient relationship to promote patient-centred care in dietetics (Sladdin et al. 2018). Adapting nutritional counselling to individual psychological needs of the patients rather than just a brochure or a generic counselling session is essential to ensure compliance in patients with chronic issues such as obesity (Endevelt and Gesser-Edelsburg 2014). Similarly, consistent with our study, previous studies have demonstrated individualised face-to face professional counselling as the most preferred mode of psychological intervention amongst cancer patients when compared to cancer support group or peer counselling (Arch et al. 2018; Schuit et al. 2021).

To our knowledge, our survey is the first on patient-centred surgical prehabilitation which included perspectives on physical, nutritional, and psychological interventions, motivational readiness to change and assessment of baseline status. Previous surveys have only focused on physical activity and its related concepts (Ferreira et al. 2018; Waterland et al. 2021). Prior to establishing a multimodal prehabilitation service, we felt it was important for us to understand the overall perspectives of the participants rather than making assumptions on what we think they need and want. Applying the constructs of Health Belief Model, we observed sufficient motivation, perception of disease-related symptoms and understanding of benefits of physical activity amongst the participants to convince the study team that it would be worthwhile implementing a patient-centric prehabilitation program at our facility (Rosenstock 1974). Assessment of pre-existing exercise behaviour and beliefs, achieving symptom control and the need to provide preoperative education regarding exercise benefits are pivotal to improve engagement and participation.

In addition, our survey was administered to surgical patients when they visited the preadmission clinic for assessment, while the previous survey by Ferreira et al. evaluated cancer patients after their prehabilitation program (Ferreira et al. 2018). We felt that by interviewing preoperative patients we would obtain unbiased views on the perceptions regarding prehabilitation program mirroring those of future potential patients who would benefit from our program. However, our greatest limitation was the small sample of consented participants that were surveyed, and this prohibited any detailed statistical analysis. Another limitation is that our survey may not adequately represent the opinions of those from culturally and linguistic diverse backgrounds as the survey was only offered in English.

In summary, these findings build on the limited available literature, and suggest there is a wide variation in interest and motivation to participate in a prehabilitation program. Our cohort were mainly an older, retired group of patients waiting for their cancer surgery. Most of them had an active baseline lifestyle and were motivated to design, engage and participate in prehabilitation program despite many health-related, logistical and financial barriers reported. Both education and personalising a multimodal program to everyone’s preferences and individual circumstances is essential to optimise patient participation in prehabilitation. Future research is recommended on measures to assess and improve compliance such as predictive factors for high or low patient compliance, compliance based algorithmic approach to designing a prehabilitation program and the use of digital tools for improved patient engagement.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by UG and CS. The first draft of the manuscript was written by UG and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Data availability statement

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of interest

The authors have no relevant financial or non-financial interest to disclose.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of The Prince Charles Hospital (HREC/18/QPCH/114; dated 19/4/2018).

Consent to participate

Informed consent was obtained from all individual participants included in the above submission.