Identifying quality and inequality in prehabilitation services before cancer surgery: a Delphi study informed by lived and professional experience

Identifying quality and inequality in prehabilitation services before cancer surgery: a Delphi study informed by lived and professional experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Identifying quality and inequality in prehabilitation services before cancer surgery: a Delphi study informed by lived and professional experience Laura Wareing, Yasemin Hirst, Cliff Shelton, Christopher Gaffney, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3950661/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Preoperative cancer prehabilitation interventions have been described as the practice of enhancing a patient’s functional capacity before surgery, aiming to improve postoperative outcomes. Internationally, it is increasingly recommended for implementation in clinical practice to improve patients’ functional and psychological wellbeing before cancer surgery. There is a gap in evidence on how and where it is delivered, what patients want from interventions and how inequalities in access and resources are addressed. In this study, both people with lived experience of cancer and healthcare professionals created criteria for quality and equitable preoperative cancer prehabilitation. Methods A modified Delphi technique was implemented over three rounds of online questionnaires with prehabilitation professionals (experts by profession) and people with lived experience of cancer (experts by experience). The criteria statements included in the first round of the questionnaire were suggested and developed in a series of co-design workshops. In each Delphi round, participants were asked to rank the statements on a 5-point Likert scale and make suggestions for refinement or additional statements. The consensus rate was defined as at least 75% of participants voting to indicate agreement on each statement. Results A total of 22 participants voted in Delphi questionnaire with a 76% response rate. 63.6% of the participants were ‘experts by experience’ and 36.4% were ‘experts by profession’. The questionnaire started with 54 statements and 60 statements reached consensus. The criteria cover seven themes including developing and delivering prehabilitation , (covering prehabilitation definitions, safety and evaluation processes and interactions with patients), emotional health, nutritional, physical and multi-modal interventions, integrating community-based care and addressing inequalities . Conclusions To the authors’ knowledge, this is the first study that has developed criteria to guide the evaluation and design of prehabilitation interventions before cancer surgery with an emphasis on addressing inequalities, which have been developed by both experts by experience and profession. The criteria enhance the evidence base on patient and healthcare professional preferences for quality and equitable access to prehabilitation interventions. The results will be of interest to researchers, healthcare professionals and service providers interested in designing, evaluating and delivering prehabilitation before cancer surgery. Prehabilitation cancer surgery Delphi questionnaire co-design quality criteria evaluation health inequalities Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Every year, over 9 million individuals worldwide undergo surgery for cancer, and this number is expected to increase ( 1 ). In the United Kingdom, there are around 375,000 new cancer cases annually, and 1 in 2 cancer patients will have surgery as their primary cancer treatment ( 2 ). While survival is strongly linked with the stage at diagnosis, it is also dependent on the success of the treatment and subsequent recovery ( 3 ). Prehabilitation (sometimes referred to as ‘prehab’) has been defined as ‘the practice of enhancing a patient’s functional capacity before surgery, with the aim of improving postoperative outcomes’ ( 4 ). Prehabilitation has been described as ‘a process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment’( 5 ). Prehabilitation before cancer surgery typically includes physical, nutritional and psychological interventions, which are delivered alone or in combination (referred to as ‘multi-modal’) to improve patients’ functional and psychological capacity before surgery to improve outcomes ( 6 ). Interventions are universal (suitable for all cancer patients), targeted (for cancer patients with acute chronic or latent adverse effects from the disease or treatment) or specialist (for patients with complex needs, including disabilities)( 6 ). The value of prehabilitation for cancer patients is increasingly recognised internationally, including in the Netherlands, Canada, the UK ( 7 ), the United States of America and Italy ( 8 ). Prehabilitation has the potential to reduce the length of hospital stay ( 9 ), healthcare costs, and postoperative complications, and improve quality of life and long-term health after treatments ( 10 , 11 ), and prehabilitation programmes are increasingly recommended as part of the cancer pathway ( 6 , 12 ). Principles and guidance for prehabilitation for cancer were launched in the UK in 2019. The principles were developed by Macmillan Cancer Support, the National Institute for Health and Care Research (NIHR) and The Royal College of Anesthetists’ (RCoA)( 6 ) and have been welcomed by many National Health Service (NHS) sites ( 12 ). The guidance called for action in several areas including the integration of prehabilitation into clinical pathways for people with cancer, examples of implementation and the development of quality assurance and improvement frameworks ( 6 ). Currently, in the UK, cancer prehabilitation interventions vary in how and where they are offered to patients ( 12 – 15 ). Many UK healthcare providers offer prehabilitation programmes as part of cancer care, many of which prepare patients for surgery. Implementation of prehabilitation is often supported by local cases for change aiming to integrate personalised care in cancer diagnosis and treatment pathways ( 16 – 19 ). For instance, Prehab4Cancer in Manchester, UK is one of the first cancer prehabilitation programmes to describe their implementation strategy, programme evaluation and intervention details ( 20 ). The complexity of prehabilitation interventions in cancer care, limited evidence of (cost)-effectiveness, limited resources and unawareness of the importance of prehabilitation by both patients and healthcare professionals have been recognised as a gap and barrier to implementation ( 21 , 22 ). The facilitators of prehabilitation have been found to include personalised programmes, considerations for accessibility ( 21 ) and peer support ( 21 , 22 ). A recent editorial in the British Medical Journal by Giles and Cummins ( 22 ) highlighted the potential widening inequalities resulting from prehabilitation due to disparities in how interventions are delivered to patients and how they gain access. Furthermore, patient preferences for prehabilitation have been found to vary ( 23 ) and very little is known about what patients want from prehabilitation interventions ( 24 ). There are significant gaps in the prehabilitation evidence base. There is a need to understand how prehabilitation is implemented, who is involved and evaluate the effectiveness of interventions, as well as engage with patients and healthcare professionals to understand what is important to patients. It is also important to understand what can support fair and equitable prehabilitation as part of cancer treatment. This paper begins to fill these gaps. Here we present the results of a modified Delphi study completed by people with diverse characteristics and lived experience of cancer, as well as healthcare professionals with a role in prehabilitation. This research is part of a national multi-phase study called PARITY: Prehabilitation for Cancer Surgery: Quality and Inequality ( 25 ). The PARITY study is mapping what prehabilitation services are available before cancer surgery, discovering best practices in prehabilitation to cancer surgery and identifying how the delivery of prehabilitation before cancer surgery can be improved to reduce inequalities in access and provision. Methods In a modified Delphi questionnaire based on best practice guidelines ( 26 , 27 ), 22 participants with lived experience of cancer (n = 14) and professional experience (n = 8) voted on a set of statements in a series of rounds to reach consensus on criteria to evaluate quality and equity in prehabilitation interventions before cancer surgery. The statements that were included in the first round of the Delphi questionnaire were created by 29 people in a series of co-design workshops. In the co-design workshops, the participants collectively decided that those with lived experience (through direct experience and being a friend, relative or carer to someone with cancer) would prefer to be known as ‘ experts by experience’ and the healthcare professionals would be known as the ' experts by profession’ . In the following section, the co-design approach is briefly explained, followed by details of the Delphi process. Co-design Approach A series of interactive co-design workshops were delivered with people with lived experience of cancer, professionals with a role in prehabilitation services, PARITY researchers (LA, LW, YH) and the project’s public and patient involvement (PPI) lead (AP). Participation in the workshops enabled the participants to individually and collectively understand and shape their views on the aims, objectives and values of prehabilitation before cancer surgery. Co-design for healthcare is a values-based approach seeking to capture and embed the values that patients, healthcare professionals and other stakeholders consider important for healthcare interventions ( 28 ), which is increasingly posited as an approach to actively include diverse stakeholders in creating interventions to address health inequalities ( 29 – 31 ). A co-design approach was considered suitable for bringing together the different groups to create a set of statements outlining quality and equitable prehabilitation. The participants, purposively recruited based on diversity characteristics (including age, sex, ethnicity and income), attended three co-design workshops, which took place in November and December 2022, and January 2023. Initially, this included 17 experts by experience and 12 experts by profession , although there was some attrition due to the participants’ other priorities (experts by experience in workshop 2 (n = 16) and workshop 3 (n = 14), and experts by profession in workshop 2 (n = 5), in workshop 3 (n = 2), and the online workshop (n = 8)). In the first two workshops, the participants took part in a series of varied, interactive and flexible activities, to prompt thinking on the aims, objectives and values of quality and equitable prehabilitation. The activities were designed by the team to enable individuals with varying confidence to actively contribute to the formulation of the set of statements to be transferred to a Delphi questionnaire. An example from workshop one asked the participants to imagine a person’s life before cancer, their cancer treatment journey and barriers to accessing care (Fig. 1 ). Ideas were discussed collectively and shaped into a list of priorities and features of quality and equitable prehabilitation services (information on the co-design approach is included in a forthcoming publication by Wareing et al .) For the final workshop, the participants worked in groups to discuss, refine, edit and remove or edit statements. There was also an opportunity to remove or add statements. Following the workshops, the final 54 statements were categorised into six themes; emotional health, physical health, nutrition, community, service delivery and addressing inequalities . The methods and the results of the co-design workshops are reported in a separate forthcoming paper to demonstrate the novel methods used and substantial information obtained about past experiences in cancer care, health inequalities and impact on care, and understanding people’s expectations of ideal support and care to be delivered before cancer surgery. Modified Delphi Technique The set of co-designed statements to evaluate prehabilitation interventions was used by the researchers to form an online modified Delphi questionnaire to be shared with the same group of experts by experience and profession in three rounds of voting. The Delphi technique has been described as a structured process using a series of questionnaires to gather a consensus of ‘opinion, judgement or choice’ ( 32 ). There is no single and correct way to conduct a Delphi questionnaire, but there are distinguishing features that make it different from other group interaction methods; it should allow participants to respond anonymously, allow multiple rounds of questions and responses and provide feedback between rounds ( 27 , 33 ). In healthcare settings, the Delphi technique is often used to determine guidelines for practice, tools for assessment, treatment strategies, protocols and for selecting healthcare quality indicators ( 26 , 34 ). The Delphi technique uses an open-ended questionnaire, but a modified Delphi technique, as used in this study, may use a set of preselected questionnaire statements ( 33 ). The method is recommended for improving understanding of problems, opportunities and solutions ( 35 ), and for when there is limited evidence on a particular research question ( 27 ). This approach was appropriate to develop the key standards expected from prehabilitation services before cancer surgery. The online method enabled participants from the co-design workshops to individually respond to the set of statements remotely from varied geographical locations and at times that suited them. This paper reports on the findings of the Delphi questionnaire based on guidelines for planning, using and reporting on Delphi methods by Boulkedid and colleagues ( 26 ) and recommendations by Savic and Smith ( 27 ). Participant Recruitment The participants who took part in the co-design workshops were invited to take part in the Delphi questionnaire. The co-design participants consisted of individuals with lived experience of cancer across the UK and any healthcare professionals who are involved in prehabilitation in cancer care (See Table 1 for participant characteristics). Participants were invited opportunistically through word of mouth, social media, and NIHR Research for the Future and Be a part of Research, and purposefully using community-based networks (e.g. Cancer Care, Kind Communities) to reach individuals who are commonly under-represented in health research. The invitation to participate was also interpreted in British Sign Language for reaching d/Deaf individuals and shared widely on social media channels. Reimbursement for attending each workshop and participating in the Delphi questionnaire was offered as well as travel and expenses in line with NIHR’s guidance ( 36 ) to recognise the value of their experience. Healthcare professionals with a role in prehabilitation were invited to participate through emails, social media channels and the Centre for Perioperative Care (CPOC). Reimbursement for healthcare professionals’ time was available via NHS research costs. A quota sampling approach was used with a pre-registry demographic questionnaire that allowed the research team to ensure they invited individuals with diverse characteristics and from communities traditionally underrepresented in research. Patient and Public Involvement In addition to the co-design workshops, seven members of the public living across the United Kingdom with personal experience of cancer as a patient, carer or friend of a cancer patient were recruited to the PARITY Patient and Public Involvement (PPI) panel in October 2022. The PPI panel remained detached from the Delphi process and they were not involved in statement development co-design workshops or the Delphi questionnaire. Only the PARITY PPI lead and project co-investigator AP, was consulted throughout the study period to ensure the statements for the criteria were easy to read and understand. Following the completion of the Delphi questionnaire in May 2023, a PPI panel meeting was held to present the criteria for prehabilitation that had met consensus and ask if the group felt it met the project aims. Further reflections from panel members included potential biases that might arise from the study limitations, and how to disseminate the results and apply them to prehabilitation in the UK. Elaboration of these reflections, linking with wider literatures on prehabilitation in cancer care and implementation of complex interventions in the NHS is presented in the discussion. Survey Structure and Delivery The participants were invited to participate in each round of the Delphi questionnaire by email, which directed them to an online questionnaire based on Microsoft Forms. Figure 2 shows the process used for preparing and sharing the questionnaire. The questionnaire for each round is included in the supplementary materials. Participants were asked to rate the importance of each criteria item for evaluating prehabilitation services from a 5-point Likert scale of one to five, one being ‘not important’ and five being ‘very important’. Participants received a maximum of two email reminders to maximise participation with tailored emails highlighting the response rate at each round. The second and third-round invitations included a summary of the response rate to the previous round, the number of statements that reached consensus, and a breakdown of the number of statements included in the next round based on consensus rates, newly generated statements or revisions that were made. All rounds included a free-text section for providing comments and suggestions. A £50 monetary compensation was provided for participant contributions if they completed all three rounds. Therefore, participants were asked to provide their names at each round. Data Analysis The descriptive characteristics of the participants at each Delphi round are described in Table 1 . The consensus agreement was calculated using the proportion of participants rating each item as important (Likert scale rating 4 or 5) or unimportant (Likert scale 1 or 2). The rate of consensus was defined as at least 75% of participants rating an item as important or very important, or unimportant or not at all important. If consensus was achieved, the strength of consensus was ranked as moderate (75–79%), strong (80–84%), very strong (85–89%), or overwhelming (90–100%). All the free-text comments associated with the statements were assessed at each round and revisions were applied irrespective of the consensus result in rounds 1 and 2. All statements with moderate consensus were included in the next round. New statements were generated based on the comments and included in the next round (except at the end of round 3). This process was repeated for each survey round. The stability of the consensus at each round was assessed for revised statements and discussed among the research team. Between-group tests were applied to investigate if there was variation between the experts by experience and experts by profession . No significant difference was found and therefore excluded in the reporting of the results. An ad-hoc sensitivity analysis was carried out by identifying the interquartile range of each item. If the range was less than 1 and the statements did not have any revisions, it was assumed that the consensus was achieved. The revised criteria were recorded into the key themes that were included for evaluating the quality of prehabilitation services. All data analyses were performed using IBM SPSS Statistics Version 28. Results Participant Characteristics Table 1 includes participant characteristics at each round of the Delphi questionnaire including the response rates. In total, 22 people took part at least once out of the initial 29 people who took part in the PARITY study co-design workshops equating 76% overall response rate. Table 1 Participant Characteristics Round 1 Round 2 Round 3 Total n 22 17 22 Role Expert by experience 14 (63.6%) 13 (76.5%) 14 (63.6%) Response rate 82% 76% 82% Expert by profession 8 (36.4%) 4 (23.5%) 8 (36.4%) Response Rate 67% 33% 67% Age (years) 25–34 5 (22.7%) 4 (23.5%) 5 (22.7%) 35–44 8 (36.4%) 6 (35.3%) 6 (27.3%) 45–54 4 (18.2%) 2 (11.8%) 4 (18.2%) 55–64 0 0 1 (4.5%) 65–74 3 (13.6%) 3 (17.6%) 3 (13.6%) 75 and above 2 (9.0%) 2 (11.8%) 2 (9.0%) Missing 0 0 1 (4.5%) Sex Man 9 (40.9%) 7 (41.2%) 10 (45.5%) Woman 13 (59.1%) 10 (58.8%) 11 (50%) Missing 0 0 1 (4.5%) Ethnicity White 13 (59.1%) 10 (58.8%) 12 (54.5%) Asian/Asian British 6 (27.3%) 3 (17.6%) 5 (22.7%) Mixed 1 (4.5%) 2 (11.8%) 2 (9%) Other 2 (9%) 2 (11.8%) 2 (9%) Missing 0 0 1 (4.5%) At the beginning of the Delphi questionnaire, the experts by profession stated that their roles in prehabilitation were as follows: Service Lead/Advanced Clinical Practitioner, Specialist in Patient Advocacy and Engagement, Clinical Psychologist, Clinical Nurse Specialist for Gynae Oncology, Prehabilitation Dietitian, Prehab Physiotherapist and Project Manager, Speech and Language Therapist in a pre-treatment clinic, Working ‘directly involved in patient care/delivering informal prehabilitation interventions’. Delphi Process Results The statements and the proportion of consensus reached each round can be found in the supplementary materials. Round One Of the 54 statements included in the first round, an overwhelming majority reached consensus, over 75%, leaving only four statements that did not reach consensus (7.4%). Among those with consensus, there were 14 statements considered as reaching moderate consensus (77.3%). 17 statements had an overwhelming consensus of over 90% (one item had 100% consensus) and 18 statements had a very strong consensus of 80–89%. Free-text comments resulted in revisions to 24 statements and the generation of ten new statements. Six statements that had no proposed changes and a consensus below 80% were re-introduced. As a result, only 20 statements out of 54 (37%) reached consensus and were removed from the next rounds as they were to be included in the final criteria. Round Two There were 42 statements in round two. In total, four statements (9.5%) did not reach consensus and six statements (14.3%) reached moderate consensus and had an interquartile range greater than one. 30 statements (73.8%) reached consensus with an assigned importance over 80%, however, ten statements had proposed revisions. As a result, only 22 statements out of 42 (50%) reached consensus and were removed from the next round. Round Three There were 18 statements included in round three. In total five statements (27.8%) did not reach consensus and only one item remained at moderate consensus. The remaining 12 statements (66.7%) reached a consensus. The comments from the participants were further considered for revisions only if they clarified the statements further. No major revisions were carried out in round three. In total, 60 statements were selected to create the evaluation criteria. The combined Delphi consensus criteria are available in the supplementary materials. Synthesis of the results In this section, a summary of the consensus results is presented under seven thematic headings; criteria for developing and delivering prehabilitation, emotional health interventions, nutritional interventions, physical health interventions, multi-modal interventions, integrating community-based care and addressing inequalities. The category headings were informed by discussions in the workshops and agreed upon by the co-design participants. At the beginning of round 1, the participants were asked to vote on or suggest the terms the statements would use throughout to refer to patients and the team working in prehabilitation services. The majority of the participants voted to use the term s ‘patients’ (12 votes) and ‘care team’ (8 votes). 1. Criteria for developing prehabilitation services (n = 18) This category was originally labelled “service delivery” and changed to reflect the additional statements that were added throughout the Delphi consensus process. By the end of Round three, only two statements did not reach consensus. Statements were further categorised to understand what was important for defining aims, objectives and values of prehabilitation. Within the statements, there are recommendations for how to define the services for its users and the providers, the information to be collected for evaluation, and considerations for patient safety in service design. There are also key elements of the interactions with the patient’s life and values, empowerment, support and enhanced information about prehab and links with cancer surgery, providing continuity of care before, during and after prehabilitation. 2. Criteria for delivering emotional health-based interventions (n = 7) Most statements in this category were revised after round one to provide more clarity around who, why, where and for whom the intervention is being delivered. The main revisions to statements in this group were to define the appropriate timing of psychological assessments and the aims of interventions. The statements were also categorised into universal (for every patient), targeted and specialist, based on what they include. Behaviour change interventions were also included under this group as a universal emotional health-based intervention. The statements cover considerations for the aims of emotional health interventions, timings, understanding worries and enabling patients to continue living their lives and coping with diagnosis and treatment. The inclusion of tailored support occurs three times in this category. 3. Criteria for delivering nutrition interventions (n = 9) Many statements for this category were revised after round one to provide more clarity around who is delivering the interventions, why it is being delivered and where and for whom. There were comments specifically highlighting the use of appropriate language in the context of nutrition-based interventions. Comments from participants often argued that a healthy diet does not always result in optimum nutrition for cancer patients, therefore this should be carefully communicated in patient-facing documents. Two statements in round two were combined and reintroduced in round three as new statements and not reported in the final criteria. The statements cover considerations for programmes, resources, plans and specialist support, as well as the importance of timing when preparing for surgery. 4. Criteria for delivering physical health-based interventions (n = 6) Many statements in this category reached consensus in round one and the remaining item reached consensus after revisions in round three. The themes are focused on recommendations to tailor and personalise physical health interventions for all patients irrespective of their functional capacity at diagnosis. The statements included in this category highlight the importance of patient-led activities, achievable goals, shared-decision making and accessibility. 5. Criteria for delivering multi-modal interventions (n = 4) The criteria in this category focus mainly on prehabilitation for frail and vulnerable populations. These criteria statements emerged for people who will require tailored care in prehabilitation with a multimodal approach (a combination of physical, nutritional and emotional support) to prehabilitation. 6. Criteria for integrating community-based care (n = 8) These statements include identification of local providers and access, offer for community-based outdoor activities, community-based social support and access to community-based care beyond prehabilitation once discharged. The statements include considerations for assessments and provision based on social support, tailored peer support, accessibility of support the inclusion of family members. 7. Criteria for addressing inequalities (n = 8) All statements in this category reached a consensus at round two. The key focus for addressing inequalities in prehabilitation services is to design and provide a service that is personalised and patient-centred, thus including training to develop cultural competencies and reduce biases, understanding health inequalities and wider determinants of health to provide equitable care. An important aspect of personalisation is achieved by improving accessibility and reducing exclusion by design. Services are encouraged to have patient advocates for improving engagement with vulnerable populations. Figures 3 and 4 show all of the criteria for quality and equitable prehabilitation which met consensus during the modified Delphi process. There is more detail on the criteria included in the supplementary information. Discussion 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. Conclusion This paper presents the implementation of a modified Delphi study in which both experts by experience and experts by profession were able to refine and reach consensus on 60 criteria for the evaluation of what is important in prehabilitation interventions for patients undergoing cancer surgery in the UK. The research responds to a need for research that engages with both people with lived experience and healthcare professionals to understand what is important to prehabilitation and how it can support fair and equitable access to prehabilitation. Statements within the set of criteria highlight the need for further clarity on how prehabilitation is defined and what is involved, consistency of care, as well as what might constitute quality interactions with patients during prehabilitation. To ensure that all patients receive equitable care, it is recommended that the design of prehabilitation considers personalisation and tailoring where possible, improved shared decision-making processes and accessibility for people with a wide variety of needs. The criteria indicate the value of interventions beyond what is traditionally recognised as components, including the use of community-based care, peer support and the inclusion of family and friends. There is scope for further research into the variety of services available to patients during prehabilitation locally and nationally, as well as how patients and healthcare professionals are involved in defining the boundaries of what is included in prehabilitation. Furthermore, the paper outlines potential further research for improving how Delphi questionnaires are used to inclusively involve people with lived experience with diverse characteristics, alongside professionals. The set of criteria will be used to inform further research to understand how prehabilitation is implemented, where and by whom within the United Kingdom, leading to the creation of best practice principles. This research will be useful for evaluating the structure and delivery of prehabilitation interventions across the UK and will be useful to healthcare professionals and researchers with an interest in the design, delivery and evaluation of prehabilitation services. Declarations Ethics Lancaster University Faculty of Health and Medicine Research Ethics Committee Approval was obtained (REAMS 1083) for this study and all participants provided informed consent to participate in this study. Consent for publication All participants provided informed consent to participate in this study. Availability of data and materials Data from the Delphi questionnaire used in this study and the resulting criteria are included in this published article and its supplementary information files. Competing interests The authors declare that they have no competing interests Funding This study is funded as part of the project: ‘Mapping and Identifying Quality and Inequality in Prehabilitation for Cancer Surgery: Evidence for Improvement’ by the National Institute for Health and Care Research (Award ID: NIHR134282). Authors’ contributions CS, LA, CG, AS, AP and JRM conceived the study idea. LA, LW, YH led the ethics approval applications. LW, YH, LA and AP carried out recruitment, data collection and data analysis. YH wrote the first draft of the manuscript. LW wrote subsequent versions and finalised the manuscript. All authors reviewed and commented on the drafts. Acknowledgements The authors would like to thank the experts by experience and experts by profession for their contributions to the PARITY study, as well as members of the PARITY PPI Panel. References Perera SK, Jacob S, Wilson BE, Ferlay J, Bray F, Sullivan R, et al. 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National Institute for Health and Care Research. Payment guidance for researchers and professionals. NIHR. 2023. Raichurkar P, Denehy L, Solomon M, Koh C, Pillinger N, Hogan S, et al. Research Priorities in Prehabilitation for Patients Undergoing Cancer Surgery: An International Delphi Study. Ann Surg Oncol [Internet]. 2023 Nov 1 [cited 2023 Dec 13];30(12):7226–35. Available from: https://link.springer.com/article/10.1245/s10434-023-14192-x Boereboom CL, Williams JP, Leighton P, Lund JN. Forming a consensus opinion on exercise prehabilitation in elderly colorectal cancer patients: a Delphi study. Tech Coloproctol [Internet]. 2015 Jun 26 [cited 2023 Dec 13];19(6):347–54. Available from: https://link.springer.com/article/10.1007/s10151-015-1317-2 Beck A, Vind Thaysen H, Hasselholt Soegaard C, Blaakaer J, Seibaek L. Prehabilitation in cancer care: patients’ ability to prepare for major abdominal surgery. Scand J Caring Sci [Internet]. 2021 Mar 1 [cited 2023 Nov 30];35(1):143–55. Available from: https://pubmed.ncbi.nlm.nih.gov/32043644/ Beck A, Vind Thaysen H, Hasselholt Soegaard C, Blaakaer J, Seibaek L. What matters to you? An investigation of patients’ perspectives on and acceptability of prehabilitation in major cancer surgery. Eur J Cancer Care (Engl) [Internet]. 2021 Nov 1 [cited 2023 Nov 30];30(6). Available from: https://pubmed.ncbi.nlm.nih.gov/34106493/ Fong M, Kaner E, Rowland M, Graham HE, McEvoy L, Hallsworth K, et al. The effect of preoperative behaviour change interventions on pre- and post-surgery health behaviours, health outcomes, and health inequalities in adults: A systematic review and meta-analyses. PLoS One [Internet]. 2023;18(7):e0286757. Available from: http://www.ncbi.nlm.nih.gov/pubmed/37406002 Macmillan Cancer Support. Cancer Information And Support [Internet]. 2023 [cited 2023 Dec 12]. Available from: https://www.macmillan.org.uk/cancer-information-and-support Macmillan Cancer Support, Personalised Care Institute. Social prescribing for cancer patients [Internet]. London; 2021 [cited 2023 Nov 30]. Available from: https://www.macmillan.org.uk/healthcare-professionals/news-and-resources/guides/social-prescribing-for-cancer-patients-a-guide-for-primary-care-networks Drinkwater C, Wildman J, Moffatt S. Social prescribing. BMJ [Internet]. 2019 Mar 28 [cited 2023 Nov 30];364. Available from: https://www.bmj.com/content/364/bmj.l1285 McHale S, Pearsons A, Neubeck L, Hanson CL. Green Health Partnerships in Scotland; Pathways for Social Prescribing and Physical Activity Referral. Int J Environ Res Public Heal 2020, Vol 17, Page 6832 [Internet]. 2020 Sep 18 [cited 2023 Nov 30];17(18):6832. Available from: https://www.mdpi.com/1660-4601/17/18/6832/htm Hasson F, Keeney S, Patrick Mckenna H, Hasson FB, Keeney MRes SB, McKenna RCN RMN DipN Adv Dip Ed RNT FRCSI H. Research guidelines for the Delphi survey technique. Artic J Adv Nurs [Internet]. 2000 [cited 2023 Dec 14]; Available from: https://www.researchgate.net/publication/12233148 Sumsion T. The Delphi Technique: An Adaptive Research Tool. http://dx.doi.org/101177/030802269806100403 [Internet]. 1998 Apr 1 [cited 2023 Dec 14];61(4):153–6. Available from: https://journals.sagepub.com/doi/10.1177/030802269806100403 Hussler C, Muller P, Rond P. Is diversity in Delphi panelist groups useful? Evidence from a French forecasting exercise on the future of nuclear energy. Technol Forecast Soc Change. 2011 Nov 1;78(9):1642–53. Thangaratinam S, Redman CW. The Delphi technique. Obstet Gynaecol [Internet]. 2005 Apr 1 [cited 2023 Dec 14];7(2):120–5. Available from: https://onlinelibrary.wiley.com/doi/full/10.1576/toag.7.2.120.27071 Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additionalfile2.pdf Additionalfile3.pdf Additionalfile4.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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year, over 9\u0026nbsp;million individuals worldwide undergo surgery for cancer, and this number is expected to increase (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In the United Kingdom, there are around 375,000 new cancer cases annually, and 1 in 2 cancer patients will have surgery as their primary cancer treatment (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). While survival is strongly linked with the stage at diagnosis, it is also dependent on the success of the treatment and subsequent recovery (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Prehabilitation (sometimes referred to as \u0026lsquo;prehab\u0026rsquo;) has been defined as \u0026lsquo;the practice of enhancing a patient\u0026rsquo;s functional capacity before surgery, with the aim of improving postoperative outcomes\u0026rsquo; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Prehabilitation has been described as \u0026lsquo;a process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment\u0026rsquo;(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Prehabilitation before cancer surgery typically includes physical, nutritional and psychological interventions, which are delivered alone or in combination (referred to as \u0026lsquo;multi-modal\u0026rsquo;) to improve patients\u0026rsquo; functional and psychological capacity before surgery to improve outcomes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Interventions are \u003cem\u003euniversal\u003c/em\u003e (suitable for all cancer patients), \u003cem\u003etargeted\u003c/em\u003e (for cancer patients with acute chronic or latent adverse effects from the disease or treatment) or \u003cem\u003especialist\u003c/em\u003e (for patients with complex needs, including disabilities)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe value of prehabilitation for cancer patients is increasingly recognised internationally, including in the Netherlands, Canada, the UK (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), the United States of America and Italy (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Prehabilitation has the potential to reduce the length of hospital stay (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), healthcare costs, and postoperative complications, and improve quality of life and long-term health after treatments (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and prehabilitation programmes are increasingly recommended as part of the cancer pathway (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Principles and guidance for prehabilitation for cancer were launched in the UK in 2019. The principles were developed by Macmillan Cancer Support, the National Institute for Health and Care Research (NIHR) and The Royal College of Anesthetists\u0026rsquo; (RCoA)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and have been welcomed by many National Health Service (NHS) sites (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The guidance called for action in several areas including the integration of prehabilitation into clinical pathways for people with cancer, examples of implementation and the development of quality assurance and improvement frameworks (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrently, in the UK, cancer prehabilitation interventions vary in how and where they are offered to patients (\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Many UK healthcare providers offer prehabilitation programmes as part of cancer care, many of which prepare patients for surgery. Implementation of prehabilitation is often supported by local cases for change aiming to integrate personalised care in cancer diagnosis and treatment pathways (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). For instance, Prehab4Cancer in Manchester, UK is one of the first cancer prehabilitation programmes to describe their implementation strategy, programme evaluation and intervention details (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The complexity of prehabilitation interventions in cancer care, limited evidence of (cost)-effectiveness, limited resources and unawareness of the importance of prehabilitation by both patients and healthcare professionals have been recognised as a gap and barrier to implementation (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The facilitators of prehabilitation have been found to include personalised programmes, considerations for accessibility (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and peer support (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). A recent editorial in the British Medical Journal by Giles and Cummins (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) highlighted the potential widening inequalities resulting from prehabilitation due to disparities in how interventions are delivered to patients and how they gain access. Furthermore, patient preferences for prehabilitation have been found to vary (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and very little is known about what patients want from prehabilitation interventions (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are significant gaps in the prehabilitation evidence base. There is a need to understand how prehabilitation is implemented, who is involved and evaluate the effectiveness of interventions, as well as engage with patients and healthcare professionals to understand what is important to patients. It is also important to understand what can support fair and equitable prehabilitation as part of cancer treatment. This paper begins to fill these gaps. Here we present the results of a modified Delphi study completed by people with diverse characteristics and lived experience of cancer, as well as healthcare professionals with a role in prehabilitation. This research is part of a national multi-phase study called PARITY: \u003cem\u003ePrehabilitation for Cancer Surgery: Quality and Inequality\u003c/em\u003e (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The PARITY study is mapping what prehabilitation services are available before cancer surgery, discovering best practices in prehabilitation to cancer surgery and identifying how the delivery of prehabilitation before cancer surgery can be improved to reduce inequalities in access and provision.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIn a modified Delphi questionnaire based on best practice guidelines (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), 22 participants with lived experience of cancer (n\u0026thinsp;=\u0026thinsp;14) and professional experience (n\u0026thinsp;=\u0026thinsp;8) voted on a set of statements in a series of rounds to reach consensus on criteria to evaluate quality and equity in prehabilitation interventions before cancer surgery. The statements that were included in the first round of the Delphi questionnaire were created by 29 people in a series of co-design workshops. In the co-design workshops, the participants collectively decided that those with lived experience (through direct experience and being a friend, relative or carer to someone with cancer) would prefer to be known as \u0026lsquo;\u003cem\u003eexperts by experience\u0026rsquo;\u003c/em\u003e and the healthcare professionals would be known as the '\u003cem\u003eexperts by profession\u0026rsquo;\u003c/em\u003e. In the following section, the co-design approach is briefly explained, followed by details of the Delphi process.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCo-design Approach\u003c/h2\u003e \u003cp\u003eA series of interactive co-design workshops were delivered with people with lived experience of cancer, professionals with a role in prehabilitation services, PARITY researchers (LA, LW, YH) and the project\u0026rsquo;s public and patient involvement (PPI) lead (AP). Participation in the workshops enabled the participants to individually and collectively understand and shape their views on the aims, objectives and values of prehabilitation before cancer surgery. Co-design for healthcare is a values-based approach seeking to capture and embed the values that patients, healthcare professionals and other stakeholders consider important for healthcare interventions (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), which is increasingly posited as an approach to actively include diverse stakeholders in creating interventions to address health inequalities (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). A co-design approach was considered suitable for bringing together the different groups to create a set of statements outlining quality and equitable prehabilitation.\u003c/p\u003e \u003cp\u003eThe participants, purposively recruited based on diversity characteristics (including age, sex, ethnicity and income), attended three co-design workshops, which took place in November and December 2022, and January 2023. Initially, this included 17 \u003cem\u003eexperts by experience\u003c/em\u003e and 12 \u003cem\u003eexperts by profession\u003c/em\u003e, although there was some attrition due to the participants\u0026rsquo; other priorities (experts by experience in workshop 2 (n\u0026thinsp;=\u0026thinsp;16) and workshop 3 (n\u0026thinsp;=\u0026thinsp;14), and experts by profession in workshop 2 (n\u0026thinsp;=\u0026thinsp;5), in workshop 3 (n\u0026thinsp;=\u0026thinsp;2), and the online workshop (n\u0026thinsp;=\u0026thinsp;8)). In the first two workshops, the participants took part in a series of varied, interactive and flexible activities, to prompt thinking on the aims, objectives and values of quality and equitable prehabilitation. The activities were designed by the team to enable individuals with varying confidence to actively contribute to the formulation of the set of statements to be transferred to a Delphi questionnaire. An example from workshop one asked the participants to imagine a person\u0026rsquo;s life before cancer, their cancer treatment journey and barriers to accessing care (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Ideas were discussed collectively and shaped into a list of priorities and features of quality and equitable prehabilitation services (information on the co-design approach is included in a forthcoming publication by Wareing \u003cem\u003eet al\u003c/em\u003e.)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFor the final workshop, the participants worked in groups to discuss, refine, edit and remove or edit statements. There was also an opportunity to remove or add statements. Following the workshops, the final 54 statements were categorised into six themes; \u003cem\u003eemotional health, physical health, nutrition, community, service delivery\u003c/em\u003e and \u003cem\u003eaddressing inequalities\u003c/em\u003e. The methods and the results of the co-design workshops are reported in a separate forthcoming paper to demonstrate the novel methods used and substantial information obtained about past experiences in cancer care, health inequalities and impact on care, and understanding people\u0026rsquo;s expectations of ideal support and care to be delivered before cancer surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eModified Delphi Technique\u003c/h2\u003e \u003cp\u003eThe set of co-designed statements to evaluate prehabilitation interventions was used by the researchers to form an online modified Delphi questionnaire to be shared with the same group of experts by experience and profession in three rounds of voting. The Delphi technique has been described as a structured process using a series of questionnaires to gather a consensus of \u0026lsquo;opinion, judgement or choice\u0026rsquo; (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). There is no single and correct way to conduct a Delphi questionnaire, but there are distinguishing features that make it different from other group interaction methods; it should allow participants to respond anonymously, allow multiple rounds of questions and responses and provide feedback between rounds (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn healthcare settings, the Delphi technique is often used to determine guidelines for practice, tools for assessment, treatment strategies, protocols and for selecting healthcare quality indicators (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The Delphi technique uses an open-ended questionnaire, but a modified Delphi technique, as used in this study, may use a set of preselected questionnaire statements (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The method is recommended for improving understanding of problems, opportunities and solutions (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), and for when there is limited evidence on a particular research question (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This approach was appropriate to develop the key standards expected from prehabilitation services before cancer surgery. The online method enabled participants from the co-design workshops to individually respond to the set of statements remotely from varied geographical locations and at times that suited them. This paper reports on the findings of the Delphi questionnaire based on guidelines for planning, using and reporting on Delphi methods by Boulkedid and colleagues (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) and recommendations by Savic and Smith (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Recruitment\u003c/h2\u003e \u003cp\u003eThe participants who took part in the co-design workshops were invited to take part in the Delphi questionnaire. The co-design participants consisted of individuals with lived experience of cancer across the UK and any healthcare professionals who are involved in prehabilitation in cancer care (See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for participant characteristics). Participants were invited opportunistically through word of mouth, social media, and NIHR Research for the Future and Be a part of Research, and purposefully using community-based networks (e.g. Cancer Care, Kind Communities) to reach individuals who are commonly under-represented in health research. The invitation to participate was also interpreted in British Sign Language for reaching d/Deaf individuals and shared widely on social media channels. Reimbursement for attending each workshop and participating in the Delphi questionnaire was offered as well as travel and expenses in line with NIHR\u0026rsquo;s guidance (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) to recognise the value of their experience. Healthcare professionals with a role in prehabilitation were invited to participate through emails, social media channels and the Centre for Perioperative Care (CPOC). Reimbursement for healthcare professionals\u0026rsquo; time was available via NHS research costs. A quota sampling approach was used with a pre-registry demographic questionnaire that allowed the research team to ensure they invited individuals with diverse characteristics and from communities traditionally underrepresented in research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePatient and Public Involvement\u003c/h2\u003e \u003cp\u003eIn addition to the co-design workshops, seven members of the public living across the United Kingdom with personal experience of cancer as a patient, carer or friend of a cancer patient were recruited to the PARITY Patient and Public Involvement (PPI) panel in October 2022. The PPI panel remained detached from the Delphi process and they were not involved in statement development co-design workshops or the Delphi questionnaire. Only the PARITY PPI lead and project co-investigator AP, was consulted throughout the study period to ensure the statements for the criteria were easy to read and understand.\u003c/p\u003e \u003cp\u003eFollowing the completion of the Delphi questionnaire in May 2023, a PPI panel meeting was held to present the criteria for prehabilitation that had met consensus and ask if the group felt it met the project aims. Further reflections from panel members included potential biases that might arise from the study limitations, and how to disseminate the results and apply them to prehabilitation in the UK. Elaboration of these reflections, linking with wider literatures on prehabilitation in cancer care and implementation of complex interventions in the NHS is presented in the discussion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSurvey Structure and Delivery\u003c/h2\u003e \u003cp\u003eThe participants were invited to participate in each round of the Delphi questionnaire by email, which directed them to an online questionnaire based on Microsoft Forms. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the process used for preparing and sharing the questionnaire. The questionnaire for each round is included in the supplementary materials. Participants were asked to rate the importance of each criteria item for evaluating prehabilitation services from a 5-point Likert scale of one to five, one being \u0026lsquo;not important\u0026rsquo; and five being \u0026lsquo;very important\u0026rsquo;. Participants received a maximum of two email reminders to maximise participation with tailored emails highlighting the response rate at each round. The second and third-round invitations included a summary of the response rate to the previous round, the number of statements that reached consensus, and a breakdown of the number of statements included in the next round based on consensus rates, newly generated statements or revisions that were made. All rounds included a free-text section for providing comments and suggestions. A \u0026pound;50 monetary compensation was provided for participant contributions if they completed all three rounds. Therefore, participants were asked to provide their names at each round.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe descriptive characteristics of the participants at each Delphi round are described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The consensus agreement was calculated using the proportion of participants rating each item as important (Likert scale rating 4 or 5) or unimportant (Likert scale 1 or 2). The rate of consensus was defined as at least 75% of participants rating an item as important or very important, or unimportant or not at all important. If consensus was achieved, the strength of consensus was ranked as moderate (75\u0026ndash;79%), strong (80\u0026ndash;84%), very strong (85\u0026ndash;89%), or overwhelming (90\u0026ndash;100%). All the free-text comments associated with the statements were assessed at each round and revisions were applied irrespective of the consensus result in rounds 1 and 2. All statements with moderate consensus were included in the next round. New statements were generated based on the comments and included in the next round (except at the end of round 3). This process was repeated for each survey round. The stability of the consensus at each round was assessed for revised statements and discussed among the research team. Between-group tests were applied to investigate if there was variation between the \u003cem\u003eexperts by experience\u003c/em\u003e and \u003cem\u003eexperts by profession\u003c/em\u003e. No significant difference was found and therefore excluded in the reporting of the results. An ad-hoc sensitivity analysis was carried out by identifying the interquartile range of each item. If the range was less than 1 and the statements did not have any revisions, it was assumed that the consensus was achieved. The revised criteria were recorded into the key themes that were included for evaluating the quality of prehabilitation services. All data analyses were performed using IBM SPSS Statistics Version 28.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e includes participant characteristics at each round of the Delphi questionnaire including the response rates. In total, 22 people took part at least once out of the initial 29 people who took part in the PARITY study co-design workshops equating 76% overall response rate.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eParticipant Characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRound 1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRound 2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRound 3\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal n\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRole\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExpert by experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (76.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExpert by profession\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u0026ndash;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u0026ndash;54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u0026ndash;64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65\u0026ndash;74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (41.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWoman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (59.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (58.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (59.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (58.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsian/Asian British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eAt the beginning of the Delphi questionnaire, the experts by profession stated that their roles in prehabilitation were as follows:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eService Lead/Advanced Clinical Practitioner,\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eSpecialist in Patient Advocacy and Engagement,\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eClinical Psychologist,\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eClinical Nurse Specialist for Gynae Oncology,\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePrehabilitation Dietitian,\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePrehab Physiotherapist and Project Manager,\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eSpeech and Language Therapist in a pre-treatment clinic,\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eWorking \u0026lsquo;directly involved in patient care/delivering informal prehabilitation interventions\u0026rsquo;.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eDelphi Process Results\u003c/h2\u003e\n \u003cp\u003eThe statements and the proportion of consensus reached each round can be found in the supplementary materials.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eRound One\u003c/h2\u003e\n \u003cp\u003eOf the 54 statements included in the first round, an overwhelming majority reached consensus, over 75%, leaving only four statements that did not reach consensus (7.4%). Among those with consensus, there were 14 statements considered as reaching moderate consensus (77.3%). 17 statements had an overwhelming consensus of over 90% (one item had 100% consensus) and 18 statements had a very strong consensus of 80\u0026ndash;89%. Free-text comments resulted in revisions to 24 statements and the generation of ten new statements. Six statements that had no proposed changes and a consensus below 80% were re-introduced. As a result, only 20 statements out of 54 (37%) reached consensus and were removed from the next rounds as they were to be included in the final criteria.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eRound Two\u003c/h2\u003e\n \u003cp\u003eThere were 42 statements in round two. In total, four statements (9.5%) did not reach consensus and six statements (14.3%) reached moderate consensus and had an interquartile range greater than one. 30 statements (73.8%) reached consensus with an assigned importance over 80%, however, ten statements had proposed revisions. As a result, only 22 statements out of 42 (50%) reached consensus and were removed from the next round.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eRound Three\u003c/h2\u003e\n \u003cp\u003eThere were 18 statements included in round three. In total five statements (27.8%) did not reach consensus and only one item remained at moderate consensus. The remaining 12 statements (66.7%) reached a consensus. The comments from the participants were further considered for revisions only if they clarified the statements further. No major revisions were carried out in round three.\u003c/p\u003e\n \u003cp\u003eIn total, 60 statements were selected to create the evaluation criteria. The combined Delphi consensus criteria are available in the supplementary materials.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eSynthesis of the results\u003c/h2\u003e\n \u003cp\u003eIn this section, a summary of the consensus results is presented under seven thematic headings; criteria for \u003cem\u003edeveloping and delivering prehabilitation, emotional health interventions, nutritional interventions, physical health interventions, multi-modal interventions, integrating community-based care and addressing inequalities.\u003c/em\u003e The category headings were informed by discussions in the workshops and agreed upon by the co-design participants.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;At the beginning of round 1, the participants were asked to vote on or suggest the terms the statements would use throughout to refer to patients and the team working in prehabilitation services. The majority of the participants voted to use the term\u003c/em\u003es \u003cem\u003e\u0026lsquo;patients\u0026rsquo; (12 votes) and \u0026lsquo;care team\u0026rsquo; (8 votes).\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003e1. Criteria for developing prehabilitation services (n\u0026thinsp;=\u0026thinsp;18)\u003c/h2\u003e\n \u003cp\u003eThis category was originally labelled \u0026ldquo;service delivery\u0026rdquo; and changed to reflect the additional statements that were added throughout the Delphi consensus process. By the end of Round three, only two statements did not reach consensus. Statements were further categorised to understand what was important for defining aims, objectives and values of prehabilitation. Within the statements, there are recommendations for how to define the services for its users and the providers, the information to be collected for evaluation, and considerations for patient safety in service design. There are also key elements of the interactions with the patient\u0026rsquo;s life and values, empowerment, support and enhanced information about prehab and links with cancer surgery, providing continuity of care before, during and after prehabilitation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003e2. Criteria for delivering emotional health-based interventions (n\u0026thinsp;=\u0026thinsp;7)\u003c/h2\u003e\n \u003cp\u003eMost statements in this category were revised after round one to provide more clarity around who, why, where and for whom the intervention is being delivered. The main revisions to statements in this group were to define the appropriate timing of psychological assessments and the aims of interventions. The statements were also categorised into universal (for every patient), targeted and specialist, based on what they include. Behaviour change interventions were also included under this group as a universal emotional health-based intervention. The statements cover considerations for the aims of emotional health interventions, timings, understanding worries and enabling patients to continue living their lives and coping with diagnosis and treatment. The inclusion of \u003cem\u003etailored\u003c/em\u003e support occurs three times in this category.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003e3. Criteria for delivering nutrition interventions (n\u0026thinsp;=\u0026thinsp;9)\u003c/h2\u003e\n \u003cp\u003eMany statements for this category were revised after round one to provide more clarity around who is delivering the interventions, why it is being delivered and where and for whom. There were comments specifically highlighting the use of appropriate language in the context of nutrition-based interventions. Comments from participants often argued that a healthy diet does not always result in optimum nutrition for cancer patients, therefore this should be carefully communicated in patient-facing documents. Two statements in round two were combined and reintroduced in round three as new statements and not reported in the final criteria. The statements cover considerations for programmes, resources, plans and specialist support, as well as the importance of timing when preparing for surgery.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003e4. Criteria for delivering physical health-based interventions (n\u0026thinsp;=\u0026thinsp;6)\u003c/h2\u003e\n \u003cp\u003eMany statements in this category reached consensus in round one and the remaining item reached consensus after revisions in round three. The themes are focused on recommendations to tailor and personalise physical health interventions for all patients irrespective of their functional capacity at diagnosis. The statements included in this category highlight the importance of patient-led activities, achievable goals, shared-decision making and accessibility.\u003c/p\u003e\n \u003ch2\u003e\u003cspan\u003e5. Criteria for delivering multi-modal interventions (n\u0026thinsp;=\u0026thinsp;4)\u003cbr\u003e\u003c/span\u003e\u003c/h2\u003e\n \u003cp\u003eThe criteria in this category focus mainly on prehabilitation for frail and vulnerable populations. These criteria statements emerged for people who will require tailored care in prehabilitation with a multimodal approach (a combination of physical, nutritional and emotional support) to prehabilitation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003e6. Criteria for integrating community-based care (n\u0026thinsp;=\u0026thinsp;8)\u003c/h2\u003e\n \u003cp\u003eThese statements include identification of local providers and access, offer for community-based outdoor activities, community-based social support and access to community-based care beyond prehabilitation once discharged. The statements include considerations for assessments and provision based on social support, tailored peer support, accessibility of support the inclusion of family members.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003e7. Criteria for addressing inequalities (n\u0026thinsp;=\u0026thinsp;8)\u003c/h2\u003e\n \u003cp\u003eAll statements in this category reached a consensus at round two. The key focus for addressing inequalities in prehabilitation services is to design and provide a service that is personalised and patient-centred, thus including training to develop cultural competencies and reduce biases, understanding health inequalities and wider determinants of health to provide equitable care. An important aspect of personalisation is achieved by improving accessibility and reducing exclusion by design. Services are encouraged to have patient advocates for improving engagement with vulnerable populations.\u003c/p\u003e\n \u003cp\u003eFigures \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e show all of the criteria for quality and equitable prehabilitation which met consensus during the modified Delphi process. There is more detail on the criteria included in the supplementary information.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the authors\u0026rsquo; 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 (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), although the inclusion of patients in future studies has been strongly recommended (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). This study has produced criteria that include 60 statements organised within seven categories (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) covering the \u003cem\u003edeveloping and delivering prehabilitation services, addressing inequalities, community-based care, emotional health, nutrition, physical health and multi-modal interventions.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003cp\u003eThe study\u0026rsquo;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\u0026rsquo;s condition and individual life circumstances was also highlighted in Netherlands-based research by Beck and colleagues (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), contributing to patients\u0026rsquo; adherence to prehabilitation plans and research by Heil and colleagues (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) 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.\u003c/p\u003e \u003cp\u003eThe results of this research expand on the \u0026lsquo;principles and guidance for prehabilitation within the management and support of people with cancer\u0026rsquo; published in the UK by Macmillan, NIHR and RCoA (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), 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\u0026rsquo; lives that affect their access and adherence to prehabilitation. Previous research has highlighted variations in how and where prehabilitation services are delivered (\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), as well as the need for a greater understanding of how prehabilitation can equitably improve experiences, access and outcomes for all (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). 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.\u003c/p\u003e \u003cp\u003eThe 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 (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). 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 (\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). 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.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003e \u003cem\u003eThe 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\u003c/em\u003e (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). 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 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). A mix of both experts by experience and experts by professional has been argued to lead to more reliable results (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e), 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\u0026rsquo; prehabilitation focused Delphi study (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). 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.\u003c/p\u003e \u003cp\u003eWhilst 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.\u003c/p\u003e \u003cp\u003eUsing 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 (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). 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 (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e 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.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, rather just presenting lengthy Delphi reports (as included in the supplementary material). It was suggested that, at this stage of defining the service, \u0026ldquo;less is more\u0026rdquo; 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eFuture implications\u003c/h2\u003e \u003cp\u003eOur 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 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). 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.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis paper presents the implementation of a modified Delphi study in which both experts by experience and experts by profession were able to refine and reach consensus on 60 criteria for the evaluation of what is important in prehabilitation interventions for patients undergoing cancer surgery in the UK. The research responds to a need for research that engages with both people with lived experience and healthcare professionals to understand what is important to prehabilitation and how it can support fair and equitable access to prehabilitation. Statements within the set of criteria highlight the need for further clarity on how prehabilitation is defined and what is involved, consistency of care, as well as what might constitute quality interactions with patients during prehabilitation. To ensure that all patients receive equitable care, it is recommended that the design of prehabilitation considers personalisation and tailoring where possible, improved shared decision-making processes and accessibility for people with a wide variety of needs. The criteria indicate the value of interventions beyond what is traditionally recognised as components, including the use of community-based care, peer support and the inclusion of family and friends.\u003c/p\u003e \u003cp\u003eThere is scope for further research into the variety of services available to patients during prehabilitation locally and nationally, as well as how patients and healthcare professionals are involved in defining the boundaries of what is included in prehabilitation. Furthermore, the paper outlines potential further research for improving how Delphi questionnaires are used to inclusively involve people with lived experience with diverse characteristics, alongside professionals.\u003c/p\u003e \u003cp\u003eThe set of criteria will be used to inform further research to understand how prehabilitation is implemented, where and by whom within the United Kingdom, leading to the creation of best practice principles. This research will be useful for evaluating the structure and delivery of prehabilitation interventions across the UK and will be useful to healthcare professionals and researchers with an interest in the design, delivery and evaluation of prehabilitation services.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLancaster University Faculty of Health and Medicine Research Ethics Committee Approval was obtained (REAMS 1083) for this study and all participants provided informed consent to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided informed consent to participate in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from the Delphi questionnaire used in this study and the resulting criteria are included in this published article and its supplementary information files. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded as part of the project: \u0026lsquo;Mapping and Identifying Quality and Inequality in Prehabilitation for Cancer Surgery: Evidence for Improvement\u0026rsquo; by the National Institute for Health and Care Research (Award ID: NIHR134282). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCS, LA, CG, AS, AP and JRM conceived the study idea. LA, LW, YH led the ethics approval applications. LW, YH, LA and AP carried out recruitment, data collection and data analysis. YH wrote the first draft of the manuscript. LW wrote subsequent versions and finalised the manuscript. All authors reviewed and commented on the drafts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe authors would like to thank the experts by experience and experts by profession for their contributions to the PARITY study, as well as members of the PARITY PPI Panel.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePerera SK, Jacob S, Wilson BE, Ferlay J, Bray F, Sullivan R, et al. Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040: a population-based modelling study. Lancet Oncol. 2021 Feb 1;22(2):182\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eCancer Research UK. Cancer Research UK. 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Obstet Gynaecol [Internet]. 2005 Apr 1 [cited 2023 Dec 14];7(2):120\u0026ndash;5. Available from: https://onlinelibrary.wiley.com/doi/full/10.1576/toag.7.2.120.27071\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prehabilitation, cancer surgery, Delphi questionnaire, co-design, quality criteria, evaluation, health inequalities","lastPublishedDoi":"10.21203/rs.3.rs-3950661/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3950661/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative cancer prehabilitation interventions have been described as the practice of enhancing a patient’s functional capacity before surgery, aiming to improve postoperative outcomes. Internationally, it is increasingly recommended for implementation in clinical practice to improve patients’ functional and psychological wellbeing before cancer surgery. There is a gap in evidence on how and where it is delivered, what patients want from interventions and how inequalities in access and resources are addressed. In this study, both people with lived experience of cancer and healthcare professionals created criteria for quality and equitable preoperative cancer prehabilitation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA modified Delphi technique was implemented over three rounds of online questionnaires with prehabilitation professionals (experts by profession) and people with lived experience of cancer (experts by experience). The criteria statements included in the first round of the questionnaire were suggested and developed in a series of co-design workshops. In each Delphi round, participants were asked to rank the statements on a 5-point Likert scale and make suggestions for refinement or additional statements. The consensus rate was defined as at least 75% of participants voting to indicate agreement on each statement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 22 participants voted in Delphi questionnaire with a 76% response rate. 63.6% of the participants were ‘experts by experience’ and 36.4% were ‘experts by profession’. The questionnaire started with 54 statements and 60 statements reached consensus. The criteria cover seven themes including \u003cem\u003edeveloping and delivering prehabilitation\u003c/em\u003e, (covering prehabilitation definitions, safety and evaluation processes and interactions with patients), \u003cem\u003eemotional health, nutritional, physical and multi-modal interventions, integrating community-based care and addressing inequalities\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo the authors’ knowledge, this is the first study that has developed criteria to guide the evaluation and design of prehabilitation interventions before cancer surgery with an emphasis on addressing inequalities, which have been developed by both experts by experience and profession.\u003c/p\u003e\n\u003cp\u003eThe criteria enhance the evidence base on patient and healthcare professional preferences for quality and equitable access to prehabilitation interventions. The results will be of interest to researchers, healthcare professionals and service providers interested in designing, evaluating and delivering prehabilitation before cancer surgery.\u003c/p\u003e","manuscriptTitle":"Identifying quality and inequality in prehabilitation services before cancer surgery: a Delphi study informed by lived and professional experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-15 15:48:53","doi":"10.21203/rs.3.rs-3950661/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4dbdc73-caec-4c3a-ab98-63e3c9827c84","owner":[],"postedDate":"February 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-13T12:49:51+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-15 15:48:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3950661","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3950661","identity":"rs-3950661","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}