The study, conducted by researchers at Public Health Wales alongside collaborators, focused on a service developed by Cardiff and Vale University Health Board, one of seven health boards within NHS Wales. Prehab2Rehab is a personalised, multimodal intervention designed to support eligible cancer patients before their treatment begins. Rather than addressing a single dimension of health, the programme simultaneously targets three pillars: exercise, nutrition and mental wellbeing. Staff working within the service tailor the intervention to each individual, aiming to improve patients’ lifestyle behaviours and, in turn, their physical and psychological resilience ahead of surgery, chemotherapy or radiotherapy. The underlying logic is straightforward but powerful: a fitter, better-nourished and psychologically steadier patient is better equipped to tolerate aggressive treatment and to recover from it.

To understand how the programme performs in practice, the research team adopted a mixed methods design, with the published paper presenting the qualitative strand of the evaluation in depth. Between April and November 2024, the researchers carried out semi-structured interviews with fourteen members of staff, including those working directly on Prehab2Rehab and others involved in the wider cancer pathway, and fifteen patients who had first-hand experience of the programme. The interviews were analysed using inductive thematic analysis, an approach that allows themes to emerge from the data itself rather than being imposed by a pre-existing framework. The researchers then triangulated these interview findings with secondary data collected by the Prehab2Rehab team, which provided an overview of programme attendance, strengthening the credibility of the conclusions.

The headline finding is encouraging. Most patients who took part in the evaluation found the programme feasible and acceptable, and reported positive experiences overall. The majority of interviewed patients felt that the exercise and diet support and guidance had helped them make genuine improvements to their lifestyle. Before starting treatment, participants reported improved knowledge and confidence to be physically active or to improve their nutrition. In a health system where the interval between diagnosis and treatment can feel like an anxious limbo, the idea that patients can use that time to actively prepare their bodies represents a meaningful shift in the philosophy of cancer care, from passive waiting to active preparation.

One of the most striking findings concerns the role of peer support. Patients reported benefiting from meeting other people going through similar experiences, connections they made through Prehab2Rehab. The psychological value of this should not be underestimated. A cancer diagnosis can be an isolating experience, and the opportunity to share fears, practical tips and encouragement with others on the same pathway appears to have added a dimension to the programme that goes beyond its formal exercise and nutrition components. This suggests that the social architecture of prehabilitation programmes may be as important as their clinical content, a lesson that could inform the design of similar services elsewhere.

However, the evaluation also exposes an uncomfortable truth about equity in prehabilitation. Patients with more available time, stronger social support networks and better baseline physical capacity were able to engage more fully with the programme. In other words, those who arrived with greater resources, whether temporal, social or physical, extracted more benefit from the service. This pattern raises important questions for policymakers and clinicians. If prehabilitation disproportionately helps those who are already better positioned to help themselves, there is a risk that the intervention could widen rather than narrow inequalities in cancer outcomes. The findings suggest that programmes like Prehab2Rehab may need to build in additional scaffolding, such as flexible scheduling, transport support or adapted activities, to reach patients who face barriers to engagement.

The technical logic behind prehabilitation rests on well-established physiological principles. Cancer treatments, particularly major surgery and systemic therapies, impose significant physiological stress on the body. A patient’s cardiopulmonary fitness, muscle mass and nutritional status at the point of treatment are strong predictors of complications, treatment tolerance and recovery speed. Exercise interventions in the pre-treatment period can improve aerobic capacity and muscular strength, while dietary optimisation can address the malnutrition and weight loss that many cancer patients experience. Psychological support, meanwhile, can reduce anxiety and depression, which are themselves associated with poorer adherence to treatment and worse recovery. Prehab2Rehab’s multimodal design reflects this evidence base, attempting to intervene on all three fronts simultaneously rather than in isolation.

The process evaluation methodology itself deserves attention. Unlike a randomised controlled trial, which asks whether an intervention works under ideal conditions, a process evaluation asks how an intervention is actually delivered, received and experienced in the messy reality of routine care. This distinction matters enormously for health services trying to scale up innovations. A programme can have strong trial evidence yet fail in practice if referral pathways are unclear, staff capacity is insufficient or patients find it impractical. By systematically capturing the perspectives of both staff and patients, and by triangulating these accounts with attendance data, the Welsh team has produced the kind of implementation intelligence that health boards across the United Kingdom and beyond can learn from.

Despite its successes, the evaluation identified a significant gap that the programme and the wider health system must address: post-treatment support. Patients and the evaluation highlighted a need for improved rehabilitation after treatment to ensure that the healthy behaviours established during prehabilitation are sustained. This finding points to a structural weakness in many cancer pathways, where support intensifies before treatment and then tapers off precisely when patients are grappling with the physical aftermath of surgery or the fatigue of chemotherapy. Without a bridge from prehabilitation to rehabilitation, the gains made in the pre-treatment window risk erosion. The programme’s very name, Prehab2Rehab, signals an ambition to create that continuum, but the evaluation suggests that the rehabilitation side of the equation requires further development to match the pre-treatment phase.

The implications of this research extend well beyond Wales. Health systems internationally are grappling with how to embed prehabilitation into standard cancer care, driven by evidence that it can improve surgical outcomes and recovery. The Welsh experience demonstrates that such programmes can deliver positive patient experiences and genuine lifestyle change when delivered through a national health service, but it also provides a candid account of the challenges: unequal engagement across patient groups, the need for sustained support beyond the pre-treatment period, and the practical realities of delivering personalised, multimodal care at scale. As cancer survival rates improve and more people live with and beyond the disease, the question of how to prepare patients for treatment, and how to support them afterwards, will only grow in importance. This evaluation offers both a template and a warning: prehabilitation works best when it meets patients where they are, and its benefits endure only if the system is built to carry them forward.

Subject of Research: Process evaluation of the delivery and patient experience of a multimodal cancer prehabilitation programme in Wales

Article Title: How is cancer prehabilitation delivered in practice? A process evaluation of a Welsh cancer prehabilitation programme

Article References: Walklett, J., Christensen, A., Grey, C. N. B., Greene, G., Davies, A. R., & Mugweni, E. (2026). How is cancer prehabilitation delivered in practice? A process evaluation of a Welsh cancer prehabilitation programme. BMC Cancer. https://doi.org/10.1186/s12885-026-17048-1

Image Credits: AI Generated

DOI: 10.1186/s12885-026-17048-1

Keywords: cancer prehabilitation, Prehab2Rehab, process evaluation, NHS Wales, patient experience, exercise intervention, nutrition, peer support, multimodal care, health inequalities, cancer recovery, qualitative research

RESSA was developed by the Global Commission on Evidence to Address Societal Challenges, an international initiative convened to strengthen the use of evidence in decision-making at every level of government. The tool is not designed to evaluate a single policy decision. Instead, it assesses the entire evidence support system of a country or jurisdiction: the institutions, networks, processes and products that together determine whether policymakers have timely access to high-quality research when they need it. As evidence-informed policy-making has gained prominence worldwide, the commission and its partners have argued that such systems deserve the same scrutiny as the policies they inform. Until now, however, systematic process evaluations of system-level assessment methodologies have been scarce, particularly in the complex, politically charged environments where they are most needed.

The Irish assessment provided an ideal test case. It involved an unusually broad coalition of national institutions: the Department of Health, the Health Research Board, Evidence Synthesis Ireland, Cochrane Ireland and the Global Commission on Evidence itself. Researchers led from the University of Galway, including Marie Tierney and Declan Devane, conducted the process evaluation alongside the RESSA itself, asking three linked questions. Was the assessment delivered as intended? Did the stakeholders involved find it acceptable? And what did their experiences reveal about how such assessments should be run in future?

Methodologically, the study was a qualitative process evaluation with quantitative elements, framed by the Medical Research Council’s guidance on evaluating complex interventions. Three participant groups were recruited: key informants from the Department of Health and affiliated organisations, members of the project’s Oversight Group, and the RESSA lead who carried out the assessment. Delivery fidelity was measured in two ways. The research team qualitatively explored the RESSA lead’s preparedness for the task, and quantitatively compared the delivered assessment against the published RESSA protocol, checking whether each specified component had been implemented as written. Qualitative interviews were analysed using a hybrid inductive-deductive thematic approach anchored in pre-specified process evaluation domains, while acceptability findings were interpreted through the Theoretical Framework of Acceptability, a validated model covering constructs such as affective attitude, burden, perceived effectiveness and ethicality. Reporting followed the Consolidated Criteria for Reporting Qualitative Research, and the study received ethics approval from the University of Galway Research Ethics Committee in March 2024, with written informed consent obtained from all participants.

The headline result is striking in its simplicity. The RESSA was delivered with complete fidelity: all eight protocol components were implemented exactly as specified, a score of eight out of eight, or one hundred percent. In the world of complex interventions, where implementation drift is the norm rather than the exception, such perfect adherence to a published protocol is noteworthy. It suggests that the RESSA methodology, despite operating in the messy reality of a national policy environment, is specified clearly enough to be reproduced faithfully by a trained assessor. Equally important, the assessment proved acceptable to stakeholders across all three participant groups, indicating that the process did not feel extractive, opaque or burdensome to those whose system was being examined.

Beneath those headline findings, however, the qualitative analysis surfaced three cross-cutting themes that the researchers argue are essential to understanding how such assessments actually succeed. The first concerns internal advocacy and governance structures. Stakeholders’ engagement with the assessment, its implementation and its potential impact were shaped by whether champions inside the organisations involved could advocate for the process and whether governance arrangements gave it legitimacy and traction. An assessment of an evidence system, in other words, is not a neutral technical exercise dropped into a vacuum; it lands in an institutional landscape where sponsorship, authority and accountability determine whether its findings are absorbed or ignored.

The second theme centred on communication. Clear, sustained communication supported stakeholder understanding of what the RESSA was and why it was being conducted, fostered engagement throughout the process, and influenced the assessment’s potential to drive change. This may sound obvious, but in practice system-level assessments involve many actors with different expectations, vocabularies and levels of familiarity with evidence terminology. Misalignment at any point can erode trust and blunt the assessment’s usefulness. The third theme concerned relational dynamics: the patterns of trust, collaboration and interpersonal connection among stakeholders were described as central to successful implementation. Where relationships were strong, the assessment could surface candid information about how the evidence system worked; where they were fragile, the process risked becoming superficial.

Taken together, these findings carry a message that extends well beyond Ireland. The researchers conclude that the RESSA can be implemented with high delivery fidelity and in a manner acceptable to stakeholders within complex policy environments, which is precisely the context in which such tools must function. But they also conclude that successful implementation depends not only on methodological fidelity. Organisational context, governance structures, communication practices and stakeholder relationships all shape whether an assessment of an evidence support system delivers meaningful insight. For countries considering a RESSA, the practical implication is that preparation should extend beyond training the assessor and assembling documents: it should include mapping internal advocates, establishing clear governance, and investing deliberately in communication and relationship-building from the outset.

The study also fills a methodological gap. Process evaluation is well established for clinical and public health interventions, but it has rarely been applied to system-level assessment methodologies in the policy sphere. By demonstrating that fidelity can be measured against a published protocol, that acceptability can be systematically assessed using an established theoretical framework, and that qualitative themes can be rigorously derived and reported, the Irish team has provided a template that others can adapt. The authors offer practical recommendations to support the adaptation of RESSA-style assessments across diverse policy settings, from ministries of health in high-income countries to evidence units in low- and middle-income contexts where the Global Commission on Evidence has focused much of its attention.

There are, of course, limits to what a single process evaluation can establish. The study examined one assessment in one jurisdiction, with a small number of participant groups, and the findings about relationships and governance are context-dependent by nature. The research team was also transparent about competing interests: several authors are employed by the Health Research Board, which funded the work, and by the Department of Health, although the design, analysis and decision to publish were led independently by the research team. Even so, the study’s core contribution stands. It shows that the invisible infrastructure connecting research to health policy can be examined systematically, and that when it is, the most important variables may be human ones. As governments worldwide commit to evidence-informed decision-making, the Irish experience suggests that the tools to audit that commitment now exist, and that using them well requires as much attention to trust and communication as to protocol and method.

Subject of Research: Process evaluation of the RESSA methodology for assessing evidence support systems in Irish health policy-making

Article Title: Process evaluation of the Rapid Evidence Support System Assessment (RESSA) methodology for health policy-making in Ireland

Article References: Tierney, M., Byrne, P., Whelan, B., Burke, N. N., Creely, C., Gill, C., Horgan, M., Lavis, J. N., Maguire, T., O’Neill, J., Toomey, E., Waddell, K., & Devane, D. (2026). Process evaluation of the Rapid Evidence Support System Assessment (RESSA) methodology for health policy-making in Ireland. Health Research Policy and Systems. https://doi.org/10.1186/s12961-026-01533-x

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01533-x

Keywords: RESSA, evidence-informed policy-making, health policy, Ireland, process evaluation, delivery fidelity, acceptability, knowledge translation, evidence support systems, Global Commission on Evidence, Health Research Board, governance

The study, led by Vita Hagelskjær and colleagues from the Parker Institute at Copenhagen University Hospital Bispebjerg-Frederiksberg, the University of Southern Denmark, and VIA University College, evaluated the content and delivery of ABLE 2.0, an eight-week, individualized occupational therapy intervention designed for adults with chronic somatic conditions. The evaluation was conducted alongside a randomized controlled trial in a Danish municipality, with data collected between August 2020 and July 2021. Of 38 clients allocated to the ABLE arm of the trial, 29 completed the program, and the results paint a picture of an intervention that works largely as intended, with goal attainment achieved in 55 of 64 cases—an impressive 86 percent success rate.

ABLE 2.0 is the product of nearly a decade of systematic development within the A Better Everyday research programme, established in 2015 and guided by the United Kingdom Medical Research Council’s framework for developing and evaluating complex interventions. The first version, ABLE 1.0, was developed and feasibility-tested between 2015 and 2018. Feedback from that phase prompted targeted refinements: the mandatory number of sessions was reduced, standardized evaluation of activities of daily living (ADL) ability and collaborative goal setting were emphasized, and recent occupational therapy theory was incorporated to strengthen occupation-centered reasoning. The result was ABLE 2.0, a program structured by the Occupational Therapy Intervention Process Model (OTIPM), which provides a systematic framework for client-centered, occupation-based practice.

The technical architecture of the intervention is worth examining closely because it illustrates how modern rehabilitation science translates theory into practice. In the first session, clients undergo standardized evaluation of both self-reported and observed ADL ability using the ADL Interview (ADL-I) and the Assessment of Motor and Process Skills (AMPS), a validated observational instrument that measures the motor and process skills a person enacts while performing chosen everyday tasks. This session also involves determining any discrepancy between what clients report about their ability and what structured observation reveals. The second session centers on collaborative goal setting using Goal Attainment Scaling (GAS), a measurement approach in which goals are scaled across levels of expected attainment, alongside an analysis of the underlying reasons for task performance problems using the Person-Environment-Occupation model or the Transactional Model of Occupation.

Sessions three through seven then offer an individualized combination of nine intervention components, ranging from changing habits related to task performance and changing attitude, to modifying the physical or social environment, using tools and assistive technology, dividing tasks into smaller steps, and simplifying task processes. The program builds on a compensatory intervention model, applying adaptational strategies—changes to the environment, assistive devices, adjusted routines—rather than attempting to restore impaired performance skills directly. The final session includes re-evaluation of goal attainment. Sessions one, two, and the final session are mandatory, establishing a minimum dose of three contacts, and the program can be delivered face-to-face or by telephone, with homework assigned between sessions in more than 71 percent of cases. Examples of such homework included practicing to vacuum using new body positions, taking out the waste with a walker, and sitting down while dressing.

The process evaluation, structured according to the framework proposed by O’Cathain and colleagues, examined five dimensions: intervention development and components, mechanisms of action, perceived value and unintended consequences, feasibility and acceptability in practice, and fidelity, reach, and dose. Data came from registration forms completed independently by clients and occupational therapists after every session, with clients submitting their forms in sealed envelopes to avoid influence from the treating therapist. All nine intervention components were applied during the study period, with changing habits the most frequently implemented (34 instances), followed by changing attitude (32) and the use of tools, technology, and assistive devices (23). Session duration varied considerably, from a median of 42.5 minutes in session four to 120 minutes in the evaluation-heavy first session, underscoring the individualized nature of the delivery.

Perhaps the most striking findings concern the mechanisms of action. Both clients and therapists reported that the standardized ADL evaluations in the first session provided new insights into the client’s ability, clarified the focus of the intervention, and established a solid foundation for the collaborative relationship. This is notable because data from the parallel effectiveness trial showed that clients receiving usual occupational therapy in the municipality were typically not offered standardized evaluations at all, and their goals were usually set by the referral service rather than negotiated with the client. The 86 percent goal attainment rate in the present study also represents a substantial improvement over the 52 percent achieved in the earlier ABLE 1.0 feasibility study, suggesting that the refinements to the manual and the enhanced training—particularly the emphasis on collaborative goal setting—paid off. Occupational therapists themselves reported feeling skilled to a high or very high degree and found delivering the sessions satisfying, and no side effects were reported at all.

The findings do, however, reveal persistent friction points. A small number of deviations from the manual occurred: the AMPS evaluation was omitted for two clients, and one client expressed no goals, making GAS-based goal setting impossible. Therapists noted challenges with goal setting, and one remarked on doubt about whether a client fully understood the discrepancy dialogue. The authors argue these difficulties reflect limited routine in conducting standardized evaluations and collaborative goal setting within Danish municipal practice—a concern echoed by recent Swedish and Danish studies documenting sparse use of standardized assessment tools in primary healthcare and assistive technology services. Because collaborative goal setting was identified in the companion realist evaluation as a core mechanism of change in ABLE, the researchers recommend further refinement of the manual and training course on this specific aspect before wider implementation.

Retention also emerged as a key consideration for future rollout. Five clients dropped out before the first session, mainly due to hospitalization, and four more left before the second session, citing lack of motivation, bereavement, or no perceived need for intervention. Those who dropped out were slightly younger and had somewhat higher baseline ADL motor ability than completers, hinting that the program may be most beneficial for older adults with lower ADL ability—a conclusion supported by the effectiveness trial, which found clinically relevant and statistically significant improvements in observed ADL motor ability at both ten and twenty-six weeks among ABLE recipients, though no significant changes in self-reported ADL ability. The gap between observed and self-reported outcomes remains an intriguing puzzle for the field, but the observed gains translate into clients performing daily tasks with greater efficiency, less physical effort, and improved safety.

Taken together, the process evaluation confirms that ABLE 2.0 is feasible, acceptable, and deliverable with high fidelity within real-world municipal rehabilitation services. Its essential ingredients—standardized evaluation of ADL ability, collaborative goal setting, identification of the reasons behind task performance problems, and client engagement in trying out adaptational strategies at home—form a coherent, evidence-based template for helping people with chronic conditions reclaim their everyday lives. The authors emphasize that future implementation efforts should prioritize embedding standardized evaluation into clinical routines, optimizing training in collaborative goal setting, and treating recruitment as a central uncertainty. With a cost-effectiveness evaluation still in progress and an implementation strategy on the research agenda, the ABLE programme is steadily building the comprehensive evidence base needed to move from promising trial results to routine clinical practice across Danish municipalities and beyond.

Subject of Research: Feasibility and delivery of a home-based, occupation-centred problem-solving occupational therapy intervention for adults with chronic somatic conditions

Article Title: Content and delivery of occupation-centred problem-solving occupational therapy for people with chronic somatic conditions: A process evaluation of ABLE 2.0

Article References: Hagelskjær, V., Nielsen, K. T., Frilev, T. R., von Bülow, C., & Wæhrens, E. E. (2025). Content and delivery of occupation-centred problem-solving occupational therapy for people with chronic somatic conditions: A process evaluation of ABLE 2.0. Scandinavian Journal of Occupational Therapy, 32(1), 1-16. https://doi.org/10.1080/11038128.2026.2619344

Image Credits: AI Generated

DOI: 10.1080/11038128.2026.2619344

Keywords: occupational therapy, ABLE 2.0, activities of daily living, chronic conditions, process evaluation, goal attainment scaling, AMPS, rehabilitation, home-based intervention, adaptational strategies, municipal health services, Denmark