The research team, led by Hualong Qiang and corresponding author Huiping Wang, surveyed two hundred adult patients scheduled for elective surgery across multiple surgical specialties between February 2024 and March 2025. Engagement was defined operationally as participation in at least one preoperative experience service, whether an education class, a counseling session or a prehabilitation program. Using structured questionnaires, the researchers collected data on demographics, clinical factors and patients’ own perceptions of the barriers and facilitators shaping their decisions. To add texture to the numbers, the team also analyzed open-ended responses with descriptive qualitative content analysis, allowing patients to explain in their own words why they did or did not show up. The study received ethical approval from the Ethics Committee of The Second Xiangya Hospital of Central South University and was conducted under the principles of the Declaration of Helsinki, with written informed consent from all participants.

The headline number is sobering: only 59.5 percent of patients — 119 of the 200 surveyed — engaged with any preoperative service. That means roughly two in five patients walked into the operating room without the preparation these programs are designed to provide. More striking still was the variation across surgical specialties. Cardiac surgery patients engaged at a rate of 82.4 percent, while neurosurgery patients engaged at only 40.0 percent. This nearly twofold difference hints that the perceived stakes of an operation, the culture of each surgical department, and perhaps the intensity of preoperative counseling routines all shape whether patients seek out preparation services. A patient facing open-heart surgery may feel an obvious urgency to prepare; a patient scheduled for a neurosurgical procedure may, paradoxically, receive less structured encouragement or may respond to fear with avoidance.

When the researchers examined why patients stayed away, two barriers towered above the rest: time and distance. Among patients who did not engage, 69.1 percent reported time constraints, compared with 27.7 percent of those who did engage — a difference that was highly statistically significant. Difficulty traveling to the hospital told a similar story, cited by 54.3 percent of non-engaged patients versus 19.3 percent of engaged patients. In other words, the patients most likely to skip preoperative services were those juggling work obligations or living far from the hospital, precisely the populations that may also face challenges attending follow-up appointments after surgery. These are not exotic findings, but their quantification matters: they suggest that the decision to engage is often a simple cost-benefit calculation about time and transportation, not a considered rejection of medical advice.

Beyond logistics, the survey identified informational and motivational barriers that were significantly more common among non-engaged patients. Lack of awareness that the services existed, low perceived need for preparation, and anxiety or active avoidance of pre-surgical information all distinguished the non-engaged group at statistically significant levels. The qualitative responses put human faces on these statistics. Non-participants repeatedly offered explanations such as having no time due to work or, most damningly for hospital communication systems, that no one told them about the class. That a patient can reach the day of major surgery without ever learning that preparation programs exist points to a failure of outreach rather than a failure of patient motivation — a distinction with clear implications for how hospitals design their information flows.

On the facilitator side, the data were equally decisive. A strong recommendation from a healthcare provider was reported by 66.4 percent of engaged patients but only 23.5 percent of non-engaged patients, and family support showed a parallel pattern, cited by 49.6 percent of the engaged versus 13.6 percent of the non-engaged. Both differences were highly significant. In the open-ended responses, engaged patients emphasized wanting to be prepared and encouragement from doctors and family. Taken together, these findings suggest that patient engagement is not primarily a matter of individual personality or health literacy alone; it is a social process, catalyzed by clinicians who explicitly urge participation and by family members who provide both practical help and emotional reinforcement. A single sentence from a surgeon or nurse — a direct, personalized recommendation — appears to be among the most powerful levers available.

The consequences of engagement showed up in the patients’ psychological states. Those who participated in preoperative services had significantly lower preoperative anxiety scores and higher preparedness scores than those who did not. Anxiety was measured using the six-item short form of the State-Trait Anxiety Inventory, a validated instrument widely used in perioperative research. Lower anxiety before surgery is not merely a matter of comfort; elevated preoperative anxiety has been associated in the broader literature with poorer recovery experiences and higher postoperative pain perception. While a cross-sectional survey cannot prove that engagement causes reduced anxiety — it is equally plausible that less anxious patients are more inclined to engage — the association aligns with the mechanistic rationale for preoperative education and counseling, and it strengthens the case for prospective intervention trials.

To disentangle the independent effects of each factor, the team performed multivariate analysis, and the results sharpened the demographic profile of the engaged patient. Higher education doubled the odds of engagement, with an odds ratio of 2.16 and a 95 percent confidence interval of 1.17 to 3.99. Younger age modestly predicted engagement, with an odds ratio of 0.98 per year of age, and cardiac surgery patients had 3.67 times the odds of engaging compared with general surgery patients, with a confidence interval of 1.27 to 10.63. These predictors paint a familiar picture in health services research: engagement skews toward younger, better-educated patients, raising equity concerns. If preoperative programs genuinely improve outcomes, then the patients least likely to access them — older, less educated, and logistically burdened — may be those who stand to benefit the most, compounding existing disparities in surgical care.

The authors argue that their findings point toward concrete, testable interventions. Flexible scheduling could directly attack the time-constraint barrier, allowing working patients to attend sessions outside standard clinic hours or through remote formats. Enhanced patient education outreach — proactive communication at the moment surgery is scheduled, rather than passive availability of brochures — would address the awareness gap captured by the phrase no one told me about the class. And deliberately involving family supporters, perhaps by inviting a designated relative to education sessions, would harness the social facilitation effect the data reveal so clearly. None of these measures requires new drugs or expensive technology; they are organizational redesigns, which makes them unusually cost-effective candidates for implementation science.

The study’s limitations are worth keeping in view. It was conducted at a single large tertiary hospital in Changsha, so the specific engagement rates may not generalize to community hospitals or to health systems with different referral patterns and insurance structures. The cross-sectional design captures associations at one point in time and cannot establish causal direction between engagement and anxiety. Self-reported barriers are also subject to recall and social desirability biases. Nevertheless, the convergence of quantitative statistics and qualitative testimony gives the findings credibility, and the study was supported by the Medical Science Research Project of Hebei. For hospital administrators and perioperative teams, the message is actionable: the biggest obstacles between patients and better surgical preparation are missed conversations, rigid schedules and long journeys — problems that thoughtful service design can solve. As preoperative optimization programs such as enhanced recovery after surgery pathways continue to spread, ensuring that all patients, not just the young and well-connected, actually walk through the door may become one of the most important quality metrics in surgery.

Subject of Research: Barriers and facilitators to surgical patients' engagement in preoperative experience services

Article Title: Barriers and facilitators to surgical patients’ engagement in preoperative experience services: a cross-sectional survey

Article References: Qiang, H., Song, T., Ren, H., Yang, T., & Wang, H. (2026). Barriers and facilitators to surgical patients’ engagement in preoperative experience services: a cross-sectional survey. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15777-4

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15777-4

Keywords: patient engagement, preoperative care, surgery, health services research, prehabilitation, patient education, preoperative anxiety, cross-sectional survey, health communication, barriers and facilitators, elective surgery, hospital services