The co-design, feasibility, and acceptability of a remote multicomponent prehabilitation intervention (iPRehab) for patients awaiting liver transplantation

Abstract

Introduction
Liver disease presents significant physical, psychological, and dietary challenges that often lead to early mortality. Prehabilitation could help address these issues, but it remains largely inaccessible to UK patients awaiting liver transplantation (LT).

Aim
The aim was to co-design a remote multicomponent prehabilitation intervention for patients awaiting LT and assess its feasibility and acceptability.

Methods
Intervention development
A scoping review using the Levac framework identified potential components for the pre-liver transplantation support intervention. These components were refined through focus groups and an Experience-Based Co-Design workshop (EBCD) with patients, caregivers, and clinicians to inform the intervention’s structure, content, and delivery. The focus groups and EBCD workshop were delivered remotely online via Microsoft Teams. Both were facilitated by the lead researcher. Following confirmation of the intervention components and development of a draft intervention, collaboration was established with the iRehab trial team to leverage existing resources aligned with the draft design. This partnership supported the development of the liver transplant iPRehab intervention. A service evaluation of usual care in the RVH, Belfast, was conducted following the development of the intervention.

Feasibility study
A feasibility study using a mixed methods design, incorporating two components: a single-centre feasibility study and an acceptability assessment using the Theoretical Framework of Acceptability Questionnaire and a selection of interviews. The single-centre study took place in the Royal Victoria Hospital, Belfast. Patients were recruited from the active LT list in Northern Ireland. Clinical outcome measures included the Liver Frailty Index, 30 Second Sit to Stand, gait speed, Six Minute Walk Test. Patient-reported outcomes included the Euroqol-5 dimensions-5 levels, Duke Activity Status Index, ABC Activities Specific Balance Confidence Scale and Hospital Anxiety and Depression Scale.

Results
Intervention development
The scoping review identified 107 papers (including 20 abstracts) and informed the potential content of a prehabilitation intervention, covering domains such as exercise, psychology, nutrition, education, respiratory support, supplements, and relaxation. Focus groups with 52 participants (23 patients, 10 caregivers, and 19 clinicians) explored lived experiences and identified key themes ("sub-experiences") for intervention development. These were validated and finalised during a co-design workshop with 33 participants (17 patients, 5 caregivers, and 11 clinicians), which shaped the structure, content, and delivery format of a remote, multicomponent prehabilitation intervention. The final intervention prototype was co-developed with the iRehab trial, adapting and creating resources specific to LT patients. Core components included weekly 1-hour online 1:1 sessions for personalised exercise and symptom management, monthly peer support, and a psychology intervention using the ACT matrix. Optional components included group exercise and nutrition classes, on-demand exercise videos, and a website with educational materials. The service evaluation informed the relevance of iRehab components and guided the feasibility study’s delivery approach.

Feasibility
A total of 27 participants (77% of the eligible cohort) consented and enrolled in the feasibility study. The attrition rate was 26% (n=7), due to personal choice (n=2), death (n=2), and transplantation (n=3). The acceptability questionnaire was completed by 23 participants, supplemented by interviews with 10 participants and 2 clinicians to explore acceptability in depth. Participants reported improved mental health through peer connection and clinician support, increased awareness of exercise benefits, and enhanced self-esteem after overcoming initial doubts about exercising. The intervention also led to improvements in physical function, physical activity, and symptoms of anxiety and depression.

Conclusion
A remote multicomponent prehabilitation intervention for patients awaiting LT is acceptable for both patients and healthcare professionals, and a definitive trial is feasible with minor refinements.

Thesis is under embargo until 31 July 2028.

Date of Award	Jul 2026
Original language	English
Awarding Institution	Queen's University Belfast
Sponsors	Health and Social Care (Northern Ireland) Research and Development
Supervisor	Judy Bradley (Supervisor) & Bronwen Connolly (Supervisor)