Barriers and facilitators to prehabilitation participation among older adults undergoing major elective surgery: a qualitative study using the capability, opportunity, motivation - behavior model

BACKGROUND: Prehabilitation may improve patients’ functional capacity before surgery and enhance postoperative recovery. This study aimed to identify facilitators and barriers to participation in a multi-component prehabilitation program among older adults undergoing major elective surgery. METHODS: This qualitative study, nested within a single-arm feasibility trial, included patients aged ≥ 65 years who participated in a prehabilitation program consisting of exercise, nutrition counseling, and meditation. Semi-structured interviews were conducted, and a hybrid deductive–inductive thematic analysis approach was applied. Finalized thematic summaries were subsequently organized using the Capability, Opportunity, Motivation-Behavior framework. RESULTS: Twenty-four participants completed interviews (mean age 76.5 years; 42% female; 8% black; 17% frail; 75% undergoing cardiovascular surgery). Fewer barriers and more facilitators were identified for the exercise and nutrition components, whereas more barriers than facilitators were found for meditation. Limited physical opportunity (e.g., limitations of physical environment, resources, and time) was the most prominent barrier to engagement, while social opportunity and reflective motivation emerged as major facilitators. Barriers to engagement, across program components, included physical symptoms, limited knowledge, environmental and logistical constraints, negative social influence, habit formation challenges, personal skepticism, lack of discipline, and negative emotional responses. Facilitators encompassed enhanced self-efficacy, guided instruction, prior experience, accessible resources, individualized planning, support from instructors and family, positive beliefs, emotional reinforcement, goal setting, and integration of routines. CONCLUSION: This study highlights the importance of a person-centered approach to maximize participation in multi-component prehabilitation among older adults before major elective surgery. Targeting barriers related to physical opportunity, while simultaneously fostering a supportive social environment and strengthening internal motivation through personalized goals and positive reinforcement, may enhance adherence and contribute to the success of prehabilitation programs. CLINICAL TRIAL REGISTRATION: NCT05752474.