Addressing inequities in the design and delivery of prehabilitation in the UK: case studies of challenges, complexities and good practice*

Abstract

Introduction

Prehabilitation has become increasingly prominent in the context of cancer surgery. While prehabilitation offers significant benefits, it can also inadvertently broaden inequalities because it is often more accessible to some than others. To explore the connection between health inequalities and prehabilitation before cancer surgery, we designed a qualitative study based on case study methodology.

Methods

Diverse prehabilitation services were purposively sampled. We conducted orientation interviews with service leads; semi-structured interviews with professionals, patients and carers; and observations of prehabilitation practice. These were conducted following topic guides informed by implementation science theory. We employed an inductive thematic approach to allow themes to emerge, highlighting connections between prehabilitation and health inequalities.

Results

Six prehabilitation services across England and Wales were included, comprising a combination of established and new services, urban and semi-rural settings and varied healthcare delivery models. We conducted 47 interviews with professionals, 47 interviews with patients (including eight with carers) and 28 observations of practice. We developed six themes, which illuminated how: patients' circumstances influence their ability to engage; the value of prehabilitation to patients depends on how it is introduced and understood; services can address, but also exacerbate, health inequalities; services may offer more and/or less than the prototypical prehabilitation model; services use and develop an incomplete evidence base; and services work with limited resources to provide the most benefit.

Discussion

Our findings highlight that while prehabilitation is often presented as a simple concept in the literature, in practice it is a complex intervention that must integrate with other ongoing treatments (e.g. surgery, chemotherapy, radiotherapy) during an already challenging period in patients' lives. Our qualitative findings from real-world settings illustrate how and why disparities arise in practice and offer insights for more equitable prehabilitation.