Table 4 Refined Programme theories for barriers to the implementation of prehabilitation for frail patients into routine health care

1 Overwhelming and/or inadequate information provision

If information is provided

• at an inappropriate time when patients are “minimally able to process further information”([42], p. 3)

• in a non-engaging, imprecise manner, and

• does not address patients’ incorrect conceptions of health behaviour

then this enacts

• overwhelming of the patients,

• no engagement and understanding for the benefit of the programme by the patient, and

• continuance of detrimental behaviour

Resulting in

• no motivation/will to participate,

• no awareness of own role in improving pre-surgery, and

• difficulties in adherence

[31, 33, 38, 42, 44, 50, 52, 56]

2 Lack of multi-modality and/or adaptability

If the prehabilitation programme

• is a “one-size-fits-all intervention”([38], p. 13),

• is not adaptable to the individual capabilities, needs and mobility of the patient, e.g., if there is “inflexibility of ‘prescribed’ prehabilitation”([44], p. 11), and

• is not adapted to the local setting

then this enacts

• excessive demand on the patients (feeling overwhelmed),

• extra stresses,

• dissatisfaction with the intervention

resulting in

• low compliance or drop out,

• inability to participate in or even access the intervention (e.g., due to long distances),

• exclusion of patient groups

[31, 38, 40,41,42,43,44,45, 48, 49, 52, 54, 56, 59, 61]

3 Fragmentation and misalignment of providers

If providers

• do not endorse the prehabilitation intervention equally,

• “are unaware of (the importance) of prehabilitation programs”([44], p. 4), and

• if parts of the patient pathway take precedence over others

then this

• enacts “miscommunication and misaligned goals among the healthcare team and lack of commitment among the patients”([51], p. 21),

• enacts a lack of common purpose, and

• disturbs the referral of patients

resulting in

• difficulties in implementation,

• difficulties in maximising the benefits of the intervention, and

• lack of care integration

• tension between different professions along the care pathway

[33, 34, 44, 47, 48, 50, 51]

4 Resource constraints

If the “clinical demand could outstrip existing resources, both human and financial”([47], p. 1) and there is a lack of reimbursement

then this enacts

• lack of acceptance for the implementation, and

• variability in content of prehabilitation provided

resulting in

• exhaustion,

• lack of sustainability, and

• suboptimal and limited prehabilitation provision

[33, 34, 37, 40, 44, 47, 48, 50, 51, 56, 61, 62]

5 Lack of (social) support

If there is a “lack of physician support, attributed to a lack of conviction regarding the benefit of prehabilitation”([51], p. 21) and if patients feel like a burden to their family and friends, especially due to transportation needs

then this enacts

• lack of focus on the intervention,

• emotional/psychological stress, and

• uncertainty about the importance of the intervention

resulting in

• difficulties in compliance/adherence,

• limited success, and

• non-participation/drop-out of patients

[42, 51]