Effects of using WeChat/WhatsApp on physical and psychosocial health outcomes among oncology patients: A systematic review

Abstract

The purpose of this systematic review is to summarize the potential effects of the WeChat and WhatsApp mobile applications in cancer management. This systematic review was written in accordance with PRISMA guidelines. CINAHL, PubMed, ProQuest Nursing and Allied Health Database, PsycINFO, PsycARTICLES, and ERIC were utilized for the literature search. Articles were included if they evaluated the outcomes of using WeChat/WhatsApp for cancer management, and excluded if they were qualitative studies, not published in peer-reviewed journals, protocols for a future study, or conference abstracts. 20 studies were included in this systematic review, with a total sample of 3110 participants. Interventions were utilized to share educational information with participants, follow-up after surgical operations, and in clinical communication. Outcomes, including pain, medication adherence, self-efficacy, quality of life, and depression, were statistically significantly improved in the WeChat/WhatsApp intervention groups in comparison to the control groups or to baseline measurements of the study participants. Outcomes of sleep and rehospitalization rate were improved without reaching statistical significance. Outcomes of anxiety, fatigue, and adverse drug reactions were found to be conflictive among included studies. This systematic review suggested that use of WeChat/WhatsApp on cancer management might improve various physical and psychosocial health outcomes among oncological patients. Limitations of the study include solely reviewing English language articles published in academic journals and most of the studies being from one country. Future research should be conducted in various countries among diverse communities, including rural areas, to ascertain the effects of WeChat/WhatsApp in different populations.

Keywords

effects WeChat WhatsApp oncology patients review

Introduction

Cancer is a disease of high prevalence in the world. In 2018, 18.1 million new cancer cases and 9.5 million cancer-related deaths were reported worldwide.¹ Based on data from 2015 to 2017, an estimated 39.5% of men and women will be diagnosed with cancer at one point during their lifetimes. By 2040, the annual number of new cancer cases is estimated to be 29.5 million, with 16.4 million cancer-related deaths.¹ Cancer management poses a serious financial burden on health systems, with an estimated national expenditure of 150.8 billion dollars in the United States in 2018.¹ Cancer also poses significant physical, social, and financial burdens on patients, their caregivers, families, and governments.

The introduction of technology into health care delivery has allowed for the management of noncritical care within the community, reduced hospitalizations and lowered costs to health systems.² The term of mHealth is defined as a health practice supported by mobile devices, including mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices.³ The integration of mHealth into health care allows for a more personalized, participatory, preventative, accessible, and cost-effective approach to health care delivery.² The use of WeChat/WhatsApp in cancer management is a form of mHealth. WhatsApp is the most popular messaging service application in more than 100 countries with over 2.5 billion active users. The greatest use of WhatsApp is in India (390 million users), followed by Brazil (108 million users) and the United States (75 million users).⁴ WeChat is among one of the top applications in the world based on user count, currently with over one billion active users and an average 19 million daily active users in the United States.^5,6 It is the most popular social network application in China and used by 78% of the 16–64 aged group in the country.⁵ The use of WeChat/WhatsApp as a mode of mHealth effectively capitalizes its familiarity since patients can readily navigate the platform and utilize its features.

Although some literature reviews have synthesized the results of using WeChat/WhatsApp for chronic disease management, there is a lack of specific knowledge synthesis on their use for cancer management. In a recent literature review, researchers investigated the value of WeChat in chronic disease management, including diabetes, hypertension, coronary heart disease, and cancer.⁷ WeChat was found to facilitate quick communication between providers and patients, acting as an effective tool for health promotion, and follow-up appointments.⁷ The absence of an updated review regarding the use of WeChat/WhatsApp in cancer management creates a knowledge gap in this emerging field. In response, research questions of this review were: (1) What are effects of WeChat/WhatsApp related cancer management interventions on patients’ physical health outcomes? (2) What are effects of WeChat/WhatsApp related cancer management interventions on patients’ psychosocial health outcomes?

Methods

The principles of the PRISMA statement⁸ was followed in the process of conducting this review. Papers were included if they investigated the use of WeChat or WhatsApp platforms as interventions for patients 18 years or older with oncological diseases. We included quantitative studies published in English peer-reviewed journals. Papers were excluded if they: (a) had a study population that did not relate to oncological diseases, (b) investigated interventions that were not associated with WeChat or WhatsApp, (c) were qualitative studies, (d) were not published in peer-reviewed journals, (e) were protocols for a future study, (f) were conference abstracts, reviews, cross-sectional or case studies, editorials, news articles, patent documents or commentaries. This systematic review did not use animals or recruit human participants. Thus, an ethics approval was not needed.

Databases, such as CINAHL, PubMed, ProQuest Nursing and Allied Health Database, PsycINFO, PsycARTICLES, and ERIC, were selected for the literature search (Figure 1). The databases were systematically searched in the field of Title and Abstract using a combination of the keywords, ((cancer) OR (oncolog*) OR (tumor)) AND ((WeChat) OR (WhatsApp)), in May 2021 by two reviewers (TH & PZ). Consistency in screening was ensured via independent evaluation by two researchers (TH & PZ), and discussions to reach consensus. The citations were exported into EndNote software to remove any duplicates. The rest of the citations were screened for relevance based on the established inclusion and exclusion criteria. Eligible articles were searched for full text documents. Then, the full text documents were carefully reviewed, with reasons for exclusion noted. Further, a manual search was conducted in the reference lists of eligible articles for additional papers not found in the electronic search. In December 2021, another systematic search was conducted to update most recent publications.

Figure 1.

Study selection flow diagram.

The Critical Appraisal Skills Program Checklists have been applied as quality assessment tools to assess the included papers (Appendix 1).⁹ Using these checklists and consulting current literature in the field, we classified the quality of papers as low, moderate, or high according to the final score.^10–13 Two researchers (TH & PZ) independently evaluated each article; any discrepancies in ratings were discussed to reach a consensus. All papers included in this review were with moderate to high quality.

Two reviewers (TH & PZ) independently extracted data according to pre-determined criteria. From each paper, various data including authors’ information, publication year, sampling strategies, sample characteristics, study design, features of the intervention, outcomes, measurements, significant findings, and limitations were extracted. The extracted data were entered into an Excel spreadsheet. The reviewers discussed disagreements in data extraction in order to reach a consensus.

Descriptive statistics (e.g. mean and percentage) were used to describe the characteristics of included studies. Then, thematic analysis was used to summarize the findings for each research question. Two reviewers (TH & PZ) independently conducted the thematic analysis. Categorization results were compared and any disagreements were resolved with a consensus decision. Due to the heterogeneity of the measurement tools used by the included studies, a meta-analysis was not performed since attempting to combine different measurements for the same variable would be inappropriate.

Results

Characteristics of included papers

Twenty published papers were included in this review. In all, 16 (80%, 16/20) studies were conducted in China, two in Italy, one in Mexico and one in Iran. Eighteen (90%, 18/20) studies were conducted in a developing country, as per the United Nations standards.¹⁴ Fifteen (75%, 15/20) studies were solely based in the community, 1 (5%, 1/20) was solely based in the hospital, and 4 (20%, 4/20) studies were set in the hospital and community. Three (15%, 3/20) studies were conducted with a rural population focus, and 3 (15%, 3/20) pilot and feasibility studies were conducted during the COVID-19 pandemic. The total sample size of the 20 included studies was 3110 (Table 1).

Table 1.

Characteristics of included studies.

Author (Year), Country	Sample, with mean age (SD)	Research purpose	Research design	Findings
Lyu (2016)³⁰ China	108 patients with cancer	To investigate	RCT, power: NR	• Time consumption in WeChat group for each patient was significantly shorter than that in telephone (p < 0.001)
	Mean age (SD): 61.5 (9.3) (control), 61.0 (13.0) (WeChat)	The feasibility and superiority of WeChat application in clinical follow-up	2 groups	• Total economic cost in WeChat group (RMB 90 yuan) was much lower than that in telephone group (RMB 196 yuan)
			Control: Telephone
			Intervention: WeChat follow up
Zou (2018) China	426 patients diagnosed with symptomatic uterine myoma	To explore the value of telephone and WeChat in health education on uterine myoma by high-intensity	RCT, power: NR	• Compared with the control group, the patients in telephone/WeChat preoperative health education group had less preoperative and postoperative anxiety, less postoperative pain, and higher treatment satisfaction (p < 0.05)
	Mean age (SD): 35.7 (9.2)	Focused ultrasound	2 groups
			Control: Routine preoperative education group
			Intervention: telephone/WeChat preoperative health education group
Chen (2019)²⁹ China	28 patients and 30 family members, patients had laryngectomy for laryngeal cancer	To determine the influence of collective esophageal speech training on self-efficacy of laryngectomees	Pre and post	• Self-efficacy scores of laryngectomees were higher than those before the training, with significant differences noted (p < 0.05)
	Mean age (SD): NR
Xia (2019)²⁴ China	155 with low rectal cancer, undergoing operation	To examine the effects of continuous care model of information-based hospital-family integration	RCT, power: NR	• In comparison with the control group, subjects in the experimental group had less anxiety and could better cope with anxiety, had a better self-efficacy and quality of life scores, and had fewer complications
	Mean age (SD): NR	On colostomy patients	2 groups	• The patients in the experimental group were shown to be more satisfied with the care model
			Control: Routine standard of care
			Intervention: Information-based (WeChat, blog, QQ, telephone, etc.) hospital-family integration continuous care model
Qiao (2019)²⁰ China	231 outpatients with cancer pain	To compare the effectiveness of nurse-led telephone calls plus WeChat versus telephone calls only for the pain management of outpatients with cancer	Quasi-experimental, non-randomized, power: NR	• Intervention group had a significantly lower rest pain (p < 0.01), and lower move pain but there was no statistical difference between the two groups
	Mean age (SD): 64.8 (5.0)		2 groups	• Among patients in the intervention group, constipation, nausea and vomiting, and dizziness were less (p < 0.01), while medication adherence (p < 0.05) and pain management satisfaction were higher (p < 0.01) than patients in the control group
			Control: Telephone
			Intervention: WeChat follow up
Zhang (2019)³² China	92 patients with cancer	To evaluate the feasibility and effects of the WeChat‐based life review program on anxiety, depression, self‐transcendence, meaning in life and hope among cancer patients	Quasi‐experimental, non-randomized, power 80%	• Statistically significant effects were identified in anxiety, depression, and self‐transcendence
	Mean age (SD): 59.2 (11.5)		2 groups	• An increase in the levels of meaning in life and hope was observed in the intervention group after the program
			Control: Usual care
			Intervention: WeChat life review program and usual care
Barca (2020)³¹ Italy	90 patients after oral and maxillo-facial surgery	To demonstrate the advantages of using telemedicine in the management of the outpatients with maxillofacial surgical pathologies during the COVID-19 pandemic	Pilot, Cohort study	• A high percentage of satisfaction emerged from the analysis of the satisfaction questionnaires of both patients and doctors
	Mean age (SD): 62.15 (NR)		2 groups
			Group A: Follow up patients: Patients
			In oncological follow-up after surgical treatment performed before the COVID-19 pandemic or suffering from chronic lesions such as precancerous lesions
			Group B: Urgent visits: Patients with suspected oncological pathology or patients with suspected urgent
			Disease such as medication-related osteonecrosis of the jaws, odontogenic abscesses
			Temporomandibular joint dislocation
Peng (2020)¹⁹ China	322 patients with cancer	To investigate effect of reinforced education using WeChat to the opioid titration treatment of cancer-related pain in the outpatient setting	RCT, power 80%	• No significant difference regarding pain intensity between the two groups at 72 h, the rate of numerical rating pain scale that reduced to less than three points in 24 h was significantly higher in the WeChat group than in the control group
	Mean age (SD): 55.6 (6.8) (intervention), 56.3 (7.0) (control)		2 groups	• Patients’ satisfaction was significantly higher in the WeChat group than in the control group
			Control: Usual care
			Intervention: Usual care and WeChat education
Shen (2020)²¹ China	112 urinary incontinent patients treated with radical prostatectomy	To study the effect of the WeChat application combined with pelvic floor muscle exercise on urinary incontinence for patients treated with radical prostatectomy	Retrospective, observational	• On 24 h pad test (weight of urine measured in grams), the WeChat group had significantly better results compared to the control group at 1, 3, 6, and 12 months
	Mean age (SD): 61.0 (4.1) (intervention), 59.0 (5.7) (control)		2 groups	• Regarding urinary continence, at 6 months, 50% were continent in the WeChat compared to 24% in the control group (p < 0:01)
			Control: Usual care
			Intervention: Usual care and additional WeChat training
Sui (2020)²² China	200 cancer patients after surgery	To explore whether WeChat app-based education and rehabilitation program affected anxiety, depression, quality of life, loss of follow-up and survival profiles in non-small cell lung cancer patients after undergoing surgical resection	RCT, power 80%	• The anxiety score and anxiety rate were lower in the WeChat group compared with control group
	Mean age (SD): 61.4 (11.2) (intervention), 62.4 (9.9) (control)		2 groups	• The depression score and depression rate were decreased in the WeChat group compared with the control group
			Control: Telephone	• The quality of life and functional score were higher, while the symptom score was similar in WeChat group compared with the control group
			Intervention: WeChat education and rehabilitation
Wu (2020)²³ China	60 patients with breast cancer	To examine the effects of nurse-led support on the social care app WeChat in breast cancer patients after surgery	Quasi-experimental non-randomized	• Physical well-being (p < 0.001), anxiety (p < 0.001), depression (p < 0.001), and support from outside of family (p = 0.037) were significantly better in the intervention group than in the control group
	Mean age (SD): 56.6 (7.9) (control), 55.1 (8.8) (intervention)		2 groups
			Intervention: WeChat education
			Control: Health-care
			Guidance manual, telephone
Zhou (2020)²⁷ China	111 breast cancer patients	To evaluate the benefits of a WeChat-based multimodal nursing program on early rehabilitation in postoperative women with breast cancer	RCT, power 80%	• Significant improvement in the health-related quality of life of participants
	Mean age (SD): 49.2 (9.3)		2 groups	• Program is an effective intervention for postoperative rehabilitation for breast cancer patients
			Control: Usual care
			Intervention: WeChat-based multimodal nursing program and usual care
Bandani-Susan (2021)¹⁵ Iran	38 women with breast cancer	To examine the effect of mobile health educational intervention on body image and fatigue in breast cancer survivors	RCT, power: 80%	• The mean score of cancer fatigue scale after the intervention in the intervention group was decreased significantly (p = 0.005), but no statistically significant difference was observed in the control group
	Mean age (SD): 46.34 (9.96)		2 groups	• There was a significant difference in the mean score of body image concern inventory in the intervention group (p = 0.002) after the intervention compared with the control group
			Control: wait list, then educational messages
			Intervention: Educational
Han (2021)¹⁷ China	132 patients with cervical cancer	To explore the effect of multidisciplinary collaborative continuous nursing on the psychological state and quality of life of cervical cancer patients	RCT, power: NR	• The anxiety and depression scores of patients in the observation group were significantly lower than those in the control group (both p < 0.001)
	Mean age (SD): 44.4 (8.2) (intervention), 45.5 (7.9) (control)		2 groups	• The scores on physical functioning, general health, social role functioning, emotional role functioning, and mental health, in the observation group were higher than those in the control group (all p < 0.01)
			Control: Regular continuous nursing
			Intervention: Three-month multidisciplinary collaborative continuous nursing
He (2021)¹⁸ China	96 patients with thyroid cancer	To explore the effect of perioperative nursing intervention based on WeChat app on the incidence of risk events and self-management efficacy after thyroid cancer surgery	Non-randomized control trial, power: NR	• The risk event rate in the WeChat app group was significantly lower than that of the conventional group (p < 0.05)
	Mean age (SD): 38.82 (3.11)		2 groups	• Stress reduction, positive attitudes, and decision-making scores were significantly higher in the WeChat app group than in the conventional group (p < 0.05)
			Control: Routine standard of care
			Intervention: WeChat-based perioperative nursing intervention plus conventional nursing
Zhang (2021)³² China	100 patients with cancer pain	To assess whether the joint physician-pharmacist team through MediHK	RCT, power: NR	• The worst pain scores, least pain scores, and average pain scores in the intervention group and the control group were statistically different at the end of the study
	Mean age (SD): 54.6 (14.0) (observation group), 58.7 (14.8) (control)	Would provide better self-management of ambulatory patients with cancer pain	2 groups
			Control: Conventional care
			Intervention: WeChat application supported program, reminders to fill out forms
Cheng (2021)¹⁶ China	589 patients with cancer	To evaluate WeChat approach to monitor patient recovery after lung cancer surgery	Pre and post	• Patients had a significant reduction in average pain (p < 0.001) and cough score (p < 0.001)
	Mean age (SD): NR
Xu (2021)²⁵ China	126 patients with breast cancer	To explore the effects of extended care based on the WeChat platform on self-efficacy and quality of life of postoperative breast cancer patients	RCT, power NR	• After the intervention, patients’ self-efficacy scores and quality of life scores were significantly higher in the observation group than in the control group
	Mean age (SD): 47.13 (7.58) (control), 48.74 (6.88) (intervention)		2 groups
			Control: Telephone
			Intervention: WeChat
Chavarri (2021)³³ Mexico	45 patients with cancer, 163 telemedicine interventions	To study use of telemedicine palliative intervention for patients with advanced cancer during the COVID-19 pandemic, find barriers and challenges	Pilot, feasibility study	• The most common interventions were psychological care, pain and symptom control, and nutritional counseling
	Median age: 68			• Half of the interventions were provided by video conferencing
				• During the interventions, the most frequent issues were interruptions, problems with Internet connectivity, and poor-quality video/audio
Nardo (2021)³⁴ Italy	49 postoperative cancer patients	To investigate the patient and family satisfaction of using WhatsApp for clinical communication	Pilot, cohort	• Patients are 86.7% extremely satisfied, 13.3% satisfied
	Mean age (SD): 70.1 (NR) (pre covid), 77.7 (NR) (covid)		2 groups	• Families are 80% extremely satisfied, and 20% satisfied
			Pre-COVID: Postoperative patients were provided with clinical information face-to-face
			Post-COVID: Postoperative patients communicated clinical data with surgical team using WhatsApp

RCT: Randomized-controlled trial; UC: usual care.

Characteristics of the interventions

The included studies explored WhatsApp and WeChat interventions in a diverse oncological patient population, including those with breast (4/20, 20%), prostate (1/20, 5%), uterus (2/20, 10%), colon (1/20, 5%), thyroid (1/20, 5%), head/neck (1/20, 5%), lung (2/20, 10%), maxillofacial (1/20, 5%), laryngeal (1/20, 5%), or multiple (6/20, 30%) cancers (Table 2). The majority (95%, 19/20) of the studies investigated the interventions in a postsurgical, post-chemotherapy, or post-radiation study population. Among the included studies, 16 (80%, 16/20) interventions were associated with WeChat, and four (20%, 4/20) were associated with WhatsApp. The studies displayed a range of features, with the most common being educational information regarding disease symptoms and treatment, evidenced in 14 (70%, 14/20) studies.^15–28 Two (10%, 2/20) studies incorporated push messages to remind patients to exercise or access the resources on the application.^21,25 Text messages were the most frequently used mode of information delivery, as identified in 17 (17/20, 85%) studies.^{15–25,27–32} To engage the participants, seven (35%, 7/20) studies utilized audio and/or video calls as part of the intervention.^{17,23,24,26,31,33,34} The duration of the intervention ranged from one-time use²⁸ to two and a half years,¹⁸ with the average duration being 4 months. The most frequent use of the intervention was daily in eight (40%, 8/20) studies,^{15,17,22,23,25,27,29,32} followed by non-consecutively in five (25%, 5/20) studies.^{16,18,19,24,30} All of the interventions involved a health care provider, most frequently a physician as indicated by 12 (60%, 12/20) studies.^{15,17–19,25,27–32,34} Additional health care providers included nurses,^{16–18,21–23,25–29} researchers,^15,27 pharmacists,^17,32 and other (psychologist, health education specialists, dietitians, sex counselors, liaison officers).^15,17,25

Table 2.

Characteristics of interventions.

Author (Year)	Name of intervention; purpose of intervention	Features and target population	Timing: Frequency of use, length of intervention	Healthcare professional involved and activity
Lyu (2016)³⁰ China	Name: NA	Features: Messages; delivering quality of life questionnaire to patients	Non-consecutively; 2 weeks, 1-, 2-, 3-, and 6-months following surgery	Physician sends the forms to the patients
	Purpose: To follow up with patients after tumor surgery, with WeChat	Target population: Patients with head and neck tumors, who underwent surgery	Length of intervention: 6 months
Zou (2018)²⁸ China	Name: NA	Features: Messages and face to face; psychological nursing, information about the disease, treatment, and the possible complications after treatment	24 h before surgery, face to face, and send information twice 12 h later, over WeChat	Head nurse, professional obstetrics, gynecology doctors trained the nurses to give information. Nurses the information sharing over face-to-face and WeChat, as well as communication with patients
	Purpose: To provide information on cancer treatment through WeChat video, messaging	Target population: Patients diagnosed with symptomatic uterine myoma	Length of intervention: NA - one time use
Chen (2019)²⁹ China	Name: NA	Features: In person training, practicing, and answering questions through WeChat group	Daily training, communication over WeChat	Head nurses planned project, professors evaluated patients’ phonatory function after speech training, doctor planned training time, nurse and skilled laryngectomees were teachers for speech training, another nurse was responsible for psychological counseling to patients
	Purpose: To educate laryngectomees on esophageal speech with use of WeChat	Target population: Diagnosis of laryngeal cancer, had undergone surgery	Length of intervention: 1 month
Xia (2019)²⁴ China	Name: NA	Features: Messages and calls; communications via WeChat, blog, telephone, QQ.	NA – as needed communication	Colostomy therapist communicates with patients
	Purpose: To share knowledge from hospital experts to family and patients	Target population: Post-operative colostomy patients
Qiao (2019)²⁰ China	Name: NA	Features: Messages; educational materials, ask questions to health care providers	Weekly sending educational materials, communication as needed	Health care provider (not specified) organized WeChat platform
	Purpose: To provide information on pain management to patients, through WeChat	Target population: Patients with cancer pain	Length of intervention: 2 months
Zhang (2019)³² China	Name: WeChat‐based life review program	Features: Calls and modules; four‐section e‐life review interviews and four life review modules	Weekly life review	Nurse (life review expert) conducted all the reviews
	Purpose: To aid with anxiety, depression, and increase hope among cancer patients	Target population: Patients with stage III or IV cancer	Length of intervention: 1.5 months
Barca (2020)³¹ Italy	Name: NA	Features: Video calls, imaging documentation, messages	NA – one time consultation	Physician consulted with patients
	Purpose: To provide patient care of outpatients with maxillofacial surgical pathology through WhatsApp	Target population: Patients with oral or facial lesions
Peng (2020)¹⁹ China	Name: NA	Features: Messages and published platform; answered questions, share information including the pain score, knowledge related to opioid analgesics, role of such drugs, common errors when taking tablets, possible adverse reactions, and prevention and treatment methods	Educational materials published once; communication occurred as needed; not planned	Doctors actively and timeously
	Purpose: To enable all participants to achieve satisfactory pain control and handle risk factors related to opioid use over WeChat	Target population: Cancer patients with pain	Length of intervention: 3 days	Answered patients’ concerns regarding the treatment
Shen (2020)²¹ China	Name: NA	Features: Messages; educational video for exercise, remind patients to do video, communication with patients	Weekly communication with patients, remind patients to exercise daily	Nurses communicated with patients
	Purpose: To promote physical exercise for pelvic floor, through WeChat	Target population: Patients post prostate cancer surgery and urinary incontinence	Length of intervention: 1 year
Sui (2020)²² China	Name: WeChat app-based education and rehabilitation program	Features: Messages; disease related education; short videos, question and answer, rehab exercise guidance: Videos, question and answer, daily activity supervision, psychological support	Disease related health education, weekly, for 12 weeks. After health education, rehabilitation exercise guidance delivered weekly, for 40 weeks. Throughout entire intervention, daily activity supervision promoted once a week and psychological support was completed once every 2 weeks	Nurses implemented WeChat program
	Purpose: To aid in rehabilitation of patients who underwent surgery, through WeChat	Target population: Postoperative lung cancer patients	Length of intervention: 1 year
Wu (2020)²³ China	Name: WeChat-based support program	Features: Text, voice message, video call, group chat; educational messages, management strategies on adverse events or distress, physical exercise and activities, and diet guidance	Daily communication with nurse	Nurses oversaw all interactions and information sharing
	Purpose: To support patients after surgery	Target population: Breast cancer patients postoperatively	Length of intervention: 6 months
Zhou (2020)²⁷ China	Name: WeChat-based multimodal nursing program	Features: Messages and published platform; educational information included disease, diet, rest, activity, pain relieving exercise, counselling, answering patient questions	Daily delivery of rehabilitation information	Researcher and nurse prepared information and delivered on WeChat. Nurse and physicians also responded to patient questions
	Purpose: To aid postoperative cancer patients in rehabilitation	Target population: Breast cancer patients post-surgery	Length of intervention: 6 months
Bandani-Susan (2021)¹⁵ Iran	Name: NA	Features: Messages; disease, treatment complications, cancer-related fatigue and body images, religious messages, cognitive behavioral therapy	Daily texts	Health education specialists, psychology, and oncologists developed the messages. Researchers sent the messages
	Purpose: To share educational messages with breast cancer survivors, via WhatsApp	Target population: Breast cancer survivors	Length of study: 7 weeks
Han (2021)¹⁷ China	Name: NA	Features: Calls and messages; guidance on diet, medication, pain control, psychological health, self-care, review time, recognition and processing of postoperative complications, daily activities, social behaviors and	Daily communication through WeChat, telephone follow up every 5 days, family in person visit every 2 weeks	Physicians answer questions about post-operative wounds, dietitian provides dietary prescriptions, pharmacist provides medication plans, psychological counsellor guides patients through psychological problems, sex counselor for education, head nurse coordinated and arranged the work of the team members to ensure the progress and its quality, and nurse in charge was responsible for guiding patients and their families in home self-care, health education, and making of follow-up files
	Purpose: To provide continuous multifaceted care for postoperative patients using WeChat	Target population: Postoperative cervical cancer patients	Length of intervention: 3 months
He (2021)¹⁸ China	Name: NA	Features: Messages; knowledge regarding disease epidemiology, diagnosis and treatment, surgical progress, postoperative treatment, and recovery of thyroid cancer	NA – as needed communication	Attending physicians and nurses communicate with patients
	Purpose: To transfer perioperative nursing intervention through WeChat	Target population: Patients after thyroid cancer surgery	Length of study: 2.5 years
Zhang (2021)³² China	Name: Medication housekeeper, WeChat-supported platform	Features: Messages; send 24-h pain diaries daily, adverse drug reaction forms every 3 days, and the brief pain inventory form every 15 days	Daily pain diaries, every 3 days for adverse drug reaction forms, every 15 days for pain inventory	Pharmacist sends forms, attending physician prescribes or adjusts medications
	Purpose: To enhance communication, optimize outcomes, and promote self-management of cancer pain in the home setting	Target population: Patients with cancer pain	Length of intervention: 1 month
Cheng (2021)¹⁶ China	Name: NA	Features: Messages; demonstration videos and repeated	Non-consecutively; 2-, 4-, 6-, 8-, and 12-weeks following surgery	Nurses coordinated the project and sent the messages
	Purpose: To monitor patient recovery and share health education after lung cancer surgery, through WeChat	Symptom surveys regarding pain and cough severity	Length of intervention: 3 months
		Target population: Patients after lung cancer surgery
Xu (2021)²⁵ China	Name: NA	Features: Messages and published platform; answer questions, share personal plans with nurse, push knowledge	Daily communication with nurses	Medical staff, as expert members, confirmed the case management nursing plan, answered all questions of patients, provided technical guidance, and reviewed
	Purpose: To extend care to patients postoperatively	Target population: Breast cancer patients after first chemotherapy treatment	Length of intervention: 3 months	Popular science knowledge and publicity materials. Nurses communicated patient questions to medical staff. Liaison officers responsible for maintaining WeChat platform, posting knowledge
Chavarri (2021)³³ Mexico	Name: Te acompañamos	Features: Video call; telemedicine	NA – one time consultation	Health care provider (not specified) called patients
	Purpose: To provide supportive and palliative care using WhatsApp	Target population: Patients with advanced cancer
Nardo (2021)³⁴ Italy	Name: NA	Features: Video call	NA – one time communication	Surgeons kept in contact with patients of surgical unit and families
	Purpose: To communicate clinical data virtually over WhatsApp	Target population: Oncological patients postoperatively

Physical health outcomes

Pain

Six (30%, 6/20) studies (four randomized controlled trials, one quasi-experimental non-randomized trial, and one pre-post study) reported improved pain control using instruments such as the Numeric Rating Score,^16,19,20,27 Visual Analogue Score,²⁸ and Brief Pain Inventory.³² Four of the experimental trial studies found statistically significant lower pain scores or a decrease in the number of patients with intense pain in the WeChat intervention group compared to routine care (p ≤ 0.05).^19,20,28,32 To complement these findings, a pre-post study found a statistically significant decrease in mean pain score from baseline after 3 months (p ≤ 0.001).¹⁶ In one randomized controlled trial, a non-statistically significant decreased pain median score was reported in the WeChat-based multimodal nursing program after 6 months.²⁷ The intervention features varied in the six studies, from one-time information communication,²⁸ 3 days of communication and educational materials,¹⁹ daily interactions for 1 month,³² weekly sharing of educational materials and communication for 2 months,²⁰ non-consecutive communication and education for 3 months,¹⁶ and daily delivery of rehabilitation information for 6 months (Table 3).²⁷

Table 3.

Outcomes of WeChat/WhatsApp interventions.

Study	Differences in physical/psychosocial health outcomes	Measurements/tools/instruments of outcomes
Lyu (2016)³⁰ China	Shorter time consumption after 6 months	Time consumption (in minutes) for follow-up delivery
	Int (26.36) vs Ctl (42.89)^a
	Higher satisfaction after 6 months	Satisfaction rate
	Int (94.34%) vs Ctl (80.43%)^a
	Lower cost after 6 months	Total economic cost (in yuan)
	Int (90) vs Ctl (196)
	Lower lost-to-follow-up rate after 6 months	Lost-to-follow-up rate
	Int (7.02%) vs Ctl (9.80%)
Zou (2018)²⁸ China	Lower anxiety score at 24 h	Hamilton anxiety scale
	Mean scores not reported^a
	Lower pain score at 24 h	Visual analogue score
	Mean scores not reported^a
	Increased satisfaction score at 24 h	Digital method with score from 0 (lowest)-10 (highest)
	Int (9.5) vs Ctl (9.1)^a
	Increased clinical effective rate at 3 months	According to change of tumor volume
	Int (93.6%) vs Ctl (93.1%)	Clinical effect defined as absolutely effective, effective, not effective
Chen (2019)²⁹ China	Increased self-efficacy mean score after 1 month	General self-efficacy scale
	Int (+1.54)
Xia (2019)²⁴ China	Reduced state anxiety mean score at 3 months follow up	State-trait anxiety inventory
	Int (−0.08) vs Ctl (+10.65)^a
	Increased trait anxiety mean score at 3 months follow up
	Int (+1.92) vs Ctl (+10.12)^a
	Increased self-efficacy mean score at 3 months follow up	Stoma care self-efficacy scale
	Int (+34.96) vs Ctl (+7.37)^a
	Increased quality of life mean score at 3 months follow up	Stoma quality of life scale
	Int (+19.08) vs Ctl (+5.62)^a
	Greater satisfaction at 3 months follow up	Degree of satisfaction table
	Int (4.15) vs Ctl (3.97)^a
Qiao (2019)²⁰ China	Decreased at rest pain mean score after 2 months	Numerical rating scale
	Int (−0.55) vs Ctl (+0.05)^a
	Less side effects after 2 months	Side effects incidence
	Int (44) vs Ctl (110)^a
	Higher medical adherence after 2 months	Medication possession ratio, score of
	Int (89.6%) vs Ctl (79.2%)^a	1 would indicate that a patient had medication in their possession 100% of the time for the calculated time period
	Higher satisfaction after 2 months	Satisfaction rate
	Int (93.4%) vs Ctl (57.6%)^a
Zhang (2019)³² China	Decreased anxiety mean score after 1.5 months	Zung’s self rating anxiety
	Int (−3.91) vs Ctl (+0.60)^a
	Decreased depression mean score after 1.5 months	Zung’s self rating depression
	Int (−3.7) vs Ctl (+2.19)^a
	Increased self-transcendence mean score after 1.5 months	Self-transcendence scale
	Int (+12.73) vs Ctl (+0.85)^a
	Increased meaning in life mean score after 1.5 months	Meaning in life questionnaire
	Int (+2.53) vs Ctl (−1.09)^a
	Increased hope mean score after 1.5 months	Herth hope scale
	Int (+0.5) vs Ctl (−1.17)
	High satisfaction score after 1.5 months	Satisfaction scale
	Int (90.9%)
Barca (2020)³¹ Italy	High satisfaction score after telemedicine consultation	Satisfaction questionnaire
Peng (2020)¹⁹ China	Decrease in number of patients with intense pain in 2 h	Numeric rating scale
	Int (96.1%) vs Ctl (81.3%)^a	Number of patients whose pain intensity reduced to less than three points in 24 h
	Lower adverse events over 3 days	Treatment-related adverse events
	Int (43) vs Ctl (52)
	Increased quality of life mean score after 3 days	Cancer-related quality of life
	Int (+11.1) vs Ctl (+7.1)
	Better sleep quality mean score after 3 days	Pittsburgh sleep quality index
	Int (−4.5) vs Ctl (−3.8)
	Decreased anxiety mean score after 3 days	General anxiety Disorder-7
	Int (−6.3) vs Ctl (−3.9)
	Decreased depression mean score after 3 days	Patient health Questionnaire-9
	Int (−7.1) vs Ctl (−3.8)
	Higher satisfaction after 3 days	Number of satisfied patients
	Int (85.5%) vs Ctl (74.7%)
Shen (2020)²¹ China	Better self-reported continence after 12 months	Urinary continence was defined as 0 g for a 24 h pad test (the pad was weighed before and after use)
	Int (−460) vs Ctl (−485)
Sui (2020)²² China	Decreased anxiety mean score after 12 months	Hospital anxiety and depression scale
	(−1.67) vs Ctl (−0.38)^a
	Decreased depression mean score after 12 months	Hospital anxiety and depression scale
	Int (−0.95) vs Ctl (−0.04)^a
	Increased quality of life mean score after 12 months	European organization for research and treatment of cancer quality of life questionnaire
	Int (+13.36) vs Ctl (+8.22)^a
	Reduced loss of follow-up after 4 years follow up	Follow up data
	Mean scores not reported
	Increased numerical survival after 4 years follow up	Survivorship values
	Mean scores not reported
Wu (2020)²³ China	Decreased anxiety mean score after 6 months	Hospital anxiety and depression scale
	Int (−3.56) vs Ctl (−1.96)^a
	Decreased depression mean score after 6 months	Hospital anxiety and depression scale
	Int (−2.16) vs Ctl (−0.76)^a
	Increased social support mean score after 6 months	Multidimensional scale of perceived social support
	Int (+3.5) vs Ctl (+1.26)^a
	Increased physical well-being mean score after 6 months	Physical well-being, medical outcome study of the quality of life inventory
	Int (+5.67) vs Ctl (+0.63)^a
Zhou (2020)²⁷ China	Increased quality of life median score after 6 months	Health-related quality of life, functional assessment of cancer therapy breast version
	Int (+3.04) vs Ctl (−5.92)^a
	Decreased pain median score after 6 months	Numerical rating scale
	Int (−0.36) vs Ctl (+1.02)
	Increase fatigue median score after 6 months	Numerical rating scale
	Int (+0.76) vs Ctl (+0.99)
	Decreased sleep median score after 6 months	Numerical rating scale
	Int (−0.71) vs Ctl (−0.4)
Bandani-Susan (2021)¹⁵ Iran	Decreased fatigue mean score after 7 weeks	Cancer fatigue scale
	Int (−4.84) vs Ctl (−1.28)
	Decreased body image concern mean score after 7 weeks	Body image concern inventory
	Int (−6.0) vs Ctl (−2.26)
Han (2021)¹⁷ China	Lower anxiety score after 3 months	Self-rating anxiety scale
	Mean scores not reported^a
	Lower depression score after 3 months	Self-rating depression scale
	Mean scores not reported^a
	Higher overall quality of life scores after 3 months	Medical outcomes study 36-item short-form
	Physical functioning mean score: Int (+78.17) vs. Ctl (+65.88)^a
	General health mean score: Int (+91.62) vs. Ctl (+85.05)^a
	Social role functioning mean score: Int (+72.31) vs. Ctl (+65.83)^a
	Emotional role functioning mean score: Int (+63.76) vs. Ctl (+55.52)^a
	Mental health mean score: Int (+68.23) vs. Ctl (+57.34)^a
	Lower overall fatigue scores after 3 months	Piper fatigue scale
	Behavioral/severity mean score: Int (+2.16) vs. Ctl (+5.10)^a
	Affective meaning mean score: Int (+1.95) vs. Ctl (+5.10)^a
	Sensory mean score: Int (+1.80) vs. Ctl (+4.83)^a
	Cognition/mood mean score: Int (+2.15) vs. Ctl (+5.50)^a
	Lower complications after 3 months	Incidence of patient complications between two groups
	Int (7.58%) vs Ctl (21.21%)^a
	Better sleep quality score after 3 months	Pittsburgh sleep quality index
	Mean scores not reported^a
He (2021)¹⁸ China	Increased overall self-management efficacy at 2.5 years	Chinese version of strategies used by people to promote health
	Self-determination mean score: Int (+6.115) vs. Ctl (+8.99)^a	Measures three scores: Self-determination, positive attitudes, and stress reduction
	Positive attitudes mean score: Int (+4.288) vs. Ctl (+2.083)^a
	Stress reduction mean score: Int (+4.341) vs. Ctl (+2.261)^a
	Reduced anxiety mean score at 2.5 years	Self-assessment scale for anxiety
	Int (−8.37) vs Ctl (−3.0)^a
	Reduced depression mean score at 2.5 years	Self-assessment scale for depression
	Int (−10.15) vs Ctl (−4.02)^a
	Reduced risk events: Int (2.13%) vs Ctl (14.29%)^a	Risk event rate
Zhang (2021)³² China	Reduced average pain score after 4 weeks	Brief pain inventory
	Median score: Int (−2.0) vs Ctl (0.0)^a
	Reduced present pain score after 4 weeks
	Median score: Int (−1.0) vs Ctl (−1.0)
	Reduced pain interference scores in daily life after 4 weeks	Brief pain inventory
	Median score: Int (0.0) vs Ctl (0.0)
	Increased number of forms submitted over 4 weeks	Patient-reporting outcome measures, number of form submissions
	Int (710) vs Ctl (95)^a
	Increased complete adherence score rate at the end of 4 weeks	Morisky medication adherence measure
	Int (20%) vs Ctl (18%)^a	Complete adherence (score = 4), incomplete adherence (score = 1–3), and nonadherence (score = 0)
	Increased adverse drug reactions in int group over 4 weeks^a	Adverse drug reactions incidence
	No significance difference in rehospitalization over 4 weeks	Rehospitalization rates
Cheng (2021)¹⁶ China	Decreased pain mean score after 3 months: Int (−2.1)	Numeric rating score
	Decreased cough mean score after 3 months: Int (−0.41)	Visual analog scale
Xu (2021)²⁵ China	Lower anxiety score after 3 months	Hospital anxiety and depression scale
	Mean scores not reported^a
	Lower depression score after 3 months	Hospital anxiety and depression scale
	Mean scores not reported^a
	Lower discomfort score after 3 months	Breast cancer treatment discomfort rating scale
	Mean scores not reported^a
	Increased self-efficacy mean score after 3 months	Self-efficacy scale
	Int (+33.37) vs Ctl (+0.73)^a
	Increased quality of life mean score after 3 months	Generic quality of life Inventory-74
	Int (+15.28) vs Ctl (+5.11)^a
	Greater satisfaction after 3 months	Satisfaction rate
	Int (12.93) vs Ctl (11.56)^a
Nardo (2021)³⁴ Italy	Extreme satisfaction after consultation	Satisfaction questionnaire
	Int (86.7%)

^aStatistically significant at p < 0.05.

Int: intervention; Ctl: control.

Fatigue

Three randomized controlled trials (15%, 3/20) reported conflicting findings related to the fatigue outcome using a Numerical Rating Scale,²⁷ Cancer Fatigue Scale,¹⁵ and the Piper Fatigue Scale.¹⁷ In a randomized controlled trial among a breast cancer population, participants of the WeChat intervention group received daily rehabilitation information through text messages.²⁷ The intervention group had an increase in the fatigue median score after 6 months.²⁷ However, the other randomized controlled trials on breast and cervical cancer patients reported significant lower fatigue mean scores after a 7-week WhatsApp intervention (p = 0.005) and statistically significant lower fatigue scores after a 3 month WeChat intervention (p = 0.000).^15,17 Daily communication through WeChat occurred as part of a multidisciplinary collaborative continuous nursing intervention, involving guidance on diet, medication, pain control, daily activities, and social behaviors.¹⁷ In the other randomized controlled trial, daily educational messages were sent through WhatsApp regarding breast cancer treatment, fatigue, body image, religion, and cognitive behavioral therapy.¹⁵

Sleep

Three (15%, 3/20) studies (three randomized controlled trials) reported improved sleep outcomes using the Pittsburgh Sleep Quality Index ^17,19 and a Numerical Rating Scale.²⁷ In a non-specified and breast cancer population, better sleep quality mean scores and improved sleep median scores were found in the WeChat intervention group after 3 days and 6 months, respectively.^19,27 Another randomized controlled trial reported significant improvements in sleep quality in a cervical cancer study population undergoing the WeChat intervention, after 3 months (p < 0.001).¹⁷

Medication adherence

Two (10%, 2/20) studies (one randomized controlled trial, one quasi-experimental non-randomized trial) reported improved medication adherence using the Medication Possession Ratio²⁰ and the Morisky Medication Adherence Measure.³² Both studies found statistically significant higher medical possession ratio scores after 2 months (p = 0.031) and increased complete adherence score rates after 4 weeks (p < 0.001) in a non-specified cancer population.^20,32 The randomized controlled trial utilized WeChat to send daily pain dairies, adverse drug reaction forms every 3 days, and pain inventory forms every 15 days.³² The quasi-experimental non-randomized trial provided information weekly on pain management through WeChat and telephone while the control group received telephone follow up.²⁰

Rehospitalization rate/incidence of side effects or adverse drug reactions

Five (25%, 5/20) studies (three randomized controlled trials, two non-randomized trials) reported conflicting findings related to the side effects outcome using the calculated Side Effects Incidence,²⁰ Treatment-Related Adverse Events,¹⁹ Incidence of Patient Complications,¹⁷ Risk Event Rate,¹⁸ Adverse Drug Reactions Incidence, and Rehospitalization Rates.³² In the studies with an intervention period ranging from 2 months to two and a half years, significantly lower complication, side effects, or risk event incidence were noted between the WeChat intervention groups and the usual care or telephone control groups (p ≤ 0.05).^17,18,20 These studies investigated patients with cervical, thyroid, and non-specified cancer. In a randomized controlled trial with a 3-day intervention among patients with non-specified cancer, lower adverse events were reported in the WeChat intervention, but the difference was not statistically significant.¹⁹ However, in a 1-month randomized controlled trial with non-specified cancer patients, a significant increase (p = 0.003) in adverse drug reactions was observed in the WeChat intervention group that received daily pain diaries, adverse drug reaction forms and the Brief Pain Inventory form biweekly.³²

Cough, urinary continence, treatment discomfort, survival

Some outcomes were only reported in a single study using a specific measurement tool, including cough using a Visual Analog Scale,¹⁶ urinary continence using a 24-h pad test,²¹ treatment discomfort using the Breast Cancer Treatment Discomfort Rating Scale,²⁵ clinical effectiveness according to the change of tumor volume,²⁸ and numerical survival using calculated Survivorship Values.²² Significant decreases in cough mean scores were reported after 3 months of a WeChat intervention among a lung cancer study population (p < 0.001).¹⁶ As well, after 1 year of WeChat intervention, there was significantly improved self-reported continence in post-surgical prostate cancer patients, compared to the participants’ immediate post-surgical continence (p < 0.001).²¹ Statistically significant lower treatment discomfort scores were reported among breast cancer patients after a WeChat and telephone intervention period of 3 months, compared to a telephone control group.²⁵ In a 4 year follow up period of a randomized controlled trial, there was increased non-statistically significant survivorship values reported when comparing the WeChat intervention group to the telephone control group.²²

Psychosocial health outcomes

Self-efficacy/confidence

Four studies (two randomized controlled trials, one pre-post study, one non-randomized trial) reported improved self-efficacy using the Self-Efficacy Scale ,²⁵ Stoma Care Self-Efficacy Scale²⁴ General Self-Efficacy Scale,²⁹ and the Chinese version of Strategies Used by People to Promote Health.¹⁸ In the randomized controlled trials, statistically significant increased self-efficacy mean scores were found in the WeChat intervention group after 3 months (p < 0.001).^24,25 The non-randomized trial reported statistically significant increased overall self-management efficacy findings in thyroid cancer patients after two and a half years of WeChat-based perioperative and conventional nursing, in comparison to solely conventional nursing (p < 0.001).¹⁸ To complement the aforementioned studies, the pre-post study reported a significant increased self-efficacy mean score among laryngeal cancer patients after 1 month of the intervention (p < 0.05).²⁹

Quality of life

Seven (35%, 7/20) studies (six randomized controlled trials, one non-randomized controlled trial) reported increased quality of life outcomes using the Cancer-Related Quality Of Life Tool,¹⁹ European Organization for Research and Treatment of Cancer Quality of Life Questionnaire,²² Medical Outcome Study of the Quality of Life Inventory,²³ Stoma Quality of Life Scale,²⁴ Health-Related Quality of Life Functional Assessment of Cancer Therapy Breast Version,²⁷ Medical Outcomes Study 36-Item Short-Form,¹⁷ and the Generic Quality of Life Inventory-74.²⁵ Increased quality of life scores were reported in all studies, with six studies reaching statistical significance (p ≤ 0.05).^{17,22–25,27} These six studies had intervention periods ranging from 3 months to 1 year.^{17,22–25,27} All six studies compared the effects of a WeChat intervention to a telephone, guidance manual, or routine standard of care control group.^{17,22–25,27} The research study participants had the following cancer types: rectal, cervical, lung, and breast.^{17,22–25,27} One randomized controlled trial comparing the WeChat intervention to usual care, for a period of 3 days, reported non-statistically significant improvements in quality of life scores among non-specified cancer patients.¹⁹

Anxiety

Nine (45%, 9/20) studies (seven randomized controlled trials, two non-randomized controlled trials) reported conflicting findings related to the anxiety outcome using the Hospital Anxiety and Depression Scale,^22,23,25 the Self-Assessment Scale for Anxiety,¹⁸ the Self-Rating Anxiety Scale,¹⁷ General Anxiety Disorder-7,¹⁹ Zung’s Self Rating Anxiety,²⁶ State-Trait Anxiety Inventory,²⁴ Hamilton Anxiety Scale.²⁸ Statistically significant decreased anxiety mean scores occurred in studies with longer WeChat interventions (one and a half months to two and a half years) compared to telephone or guidance manual control groups (p < 0.05),^22,23,25 with the sole exception of the one-time WeChat presurgical communication (p < 0.05).²⁸ In another shorter randomized controlled trial, with a 3-day usual care and WeChat intervention, decreased anxiety mean scores were reported for anxiety, but statistical significance was not reached.¹⁹ One randomized controlled trial reported conflictive findings on anxiety for the information-based hospital-family integration continuous care intervention group, with decreased state anxiety mean scores, and increased trait anxiety mean scores.²⁴ However, this can be explained by the intervention group having statistically lower state and trait anxiety mean scores compared to the control group (p ≤ 0.000).²⁴ Among post-surgical patients, the intervention group received messages and calls sharing an education program on colostomy care from the colostomy therapist.²⁴

Depression

Seven (35%, 7/20) studies (four randomized controlled trials, three non-randomized controlled trials) reported improved depression outcomes using instruments such as Zung’s Self Rating Depression,²⁶ Hospital Anxiety and Depression Scale,^22,23,25 Self-Rating Depression Scale,¹⁷ Self-Assessment Scale for Depression,¹⁸ and the Patient Health Questionnaire-9.¹⁹ Six studies, ranging from 3 months to two and a half years, reported statistically significant lower depression scores in the WeChat intervention groups compared to usual care, telephone, or guidance manual control group (p ≤ 0.05).^{17,18,22,23,25,26} One randomized controlled trial reported non-statistically significant decreased depression mean scores with a WeChat intervention of 3 days.¹⁹ The studies investigated the impact of the interventions on populations with lung, breast, cervical, thyroid, and advanced cancer.^{17–19,22,23,25,26}

Social support, spiritual outcomes, body image concern

Some outcomes were only reported in one single study using a specific measurement tool, including social support using the Multidimensional Scale of Perceived Social Support,²³ positive spiritual outcomes using the Self-Transcendence Scale, Meaning In Life Questionnaire, Herth Hope Scale,²⁶ and body image using the Body Image Concern Inventory.¹⁵ Non-statistically significant increased social support mean scores were reported among a breast cancer study population, after a 6-month WeChat education intervention (p = 0.209).²³ In the quasi-experimental non-randomized study, the intervention group underwent a WeChat life review program and usual care for one and a half months, while the control group received usual care.²⁶ Spiritual outcomes reached statistical significance demonstrated by an increased self-transcendence mean score (p = 0.001) and increased meaning in life mean score (p = 0.001), but the differences in hope mean score were not significant (p = 0.0980).²⁶ In addition, significant decreased body image concern scores were reported by breast cancer patients after 7 weeks of a WhatsApp educational intervention (p = 0.002).¹⁵

Discussion

Summary of findings

Findings of this review suggested that the use of WeChat and WhatsApp in cancer management has potential effects on physical and psychosocial health outcomes among oncological patients. Physical outcomes explored in the included studies were pain, fatigue, sleep, medication adherence, re-hospitalization rate or incidence of side effects, cough, urinary continence, treatment discomfort, and survival outcomes. Psychosocial outcomes explored were self-efficacy, quality of life, anxiety, depression, social support, spiritual, and body image concerns. This review found that certain outcomes, including pain, medication adherence, self-efficacy, quality of life, and depression, were significantly improved in the WeChat/WhatsApp intervention groups in comparison to control groups or baseline measurements. In outcomes of sleep and re-hospitalization rate, improvements were reported without reaching statistical significance. In addition, the potential effects of WeChat/WhatsApp on anxiety, fatigue, and adverse drug reactions were found to be conflictive among included studies.

Physical health outcomes

Our findings indicated that the use of WeChat/WhatsApp in cancer management has the potential to improve pain control. The significant impact of the pain outcome has been supported in another research study, which investigated the use of WeChat video calling in a post-total knee arthroplasty population, with a statistically significant pain score difference reported between the WeChat intervention and routine care group.³⁵ The similarities of the results may be due to the post-treatment nature of the study population, with pain being a key indicator of either surgery or cancer treatments. The correlation of decreased pain and the use of WeChat/WhatsApp has major implications for cancer management and may improve the lives of patients.

Our findings indicated that the use of WeChat/WhatsApp in cancer management has the potential to improve medication adherence. In this review, two studies investigated the impact of WeChat/WhatsApp on medication adherence, and both studies reported a significant difference between intervention and control groups. Medication adherence in cancer management is crucial in achieving optimal quality of life as cancer medication non-adherence has been shown to lead to lower survival rates and reoccurrence of disease.^36–38 Consistent with our findings, one randomized controlled trial examining the influence of an educational WhatsApp intervention among diabetes and hypertension patients reported a clinically significant 15% increase in medication adherence after the intervention.³⁹ Given the importance of medication adherence in cancer management, interventions using WeChat/WhatsApp could have notable impacts on disease treatment.

Psychosocial health outcomes

Our findings indicated that the use of WeChat has potential effects on self-efficacy among cancer patients. This finding is consistent with another randomized controlled trial evaluating the use of WeChat in a diabetic study population.⁴⁰ The trial reported significant improvements in self-efficacy among the WeChat intervention group compared to routine care.⁴⁰ Among cancer patients, previous literature has reported high self-efficacy to be associated with increased healthy behaviors such as regular exercise and communication with healthcare providers, greater determination in achieving desired health outcomes, and higher quality of life.⁴¹

Our findings indicated that the use of WeChat/WhatsApp has potential beneficial effects on quality of life. This finding is supported by a literature review of 98 publications, exploring the impacts of social media on breast cancer survivors.⁴² Among the included studies, psychosocial well-being was most commonly measured as an outcome of interest.⁴² The literature review concluded that online groups and communities may improve the well-being of breast cancer survivors by providing opportunities for social engagement.⁴² In addition, in a pre-posttest study among persons with dementia and their caregivers, supplementary video conferencing health care through Zoom, WhatsApp, or FaceTime was reported to reverse the decline in quality of life.⁴³

Our findings indicated that the use of WeChat/WhatsApp might have potential effects on depression outcomes among cancer patients. Depression is one of the most common symptoms affecting cancer patients, and is a risk factor for reduced survival.⁴⁴ Consistent with our findings, a cross-sectional research study investigated the prevalence of depression among cancer patients and reported a significant difference between depression in users of social networks and non-users.⁴⁴ In addition, a systematic review of 42 studies concluded that social media can provide social, emotional, or experiential support in patients with chronic diseases, such as cancer.⁴⁵ Treatments combining the use of WeChat/WhatsApp and medicine may improve depressive symptoms among cancer patients, ultimately improving health outcomes.

Our findings indicated that the use of WeChat has potential effects on social support; however, we only found one study reporting on the outcome. Consistent with our findings, a single-group pilot study among breast cancer survivors investigated a targeted physical activity intervention, via the MapMyFitness application, and utilized a social cognitive theory-based, Facebook-delivered health education intervention.⁴⁶ The ability to engage in social roles or activity were greatly improved after the use of the MapMyFitness application and Facebook intervention.⁴⁶ Our findings are also supported by a literature review, which highlighted that social media helps to improve well-being by allowing breast cancer survivors to engage with wider social networks and connect with peers having similar experiences.⁴² Social media has been emphasized to improve social relations of cancer patients; however, further research on WeChat/WhatsApp is necessary to clarify its effects on social support.

Conflictive outcomes

In this review, conflictive findings were reported for the anxiety, fatigue, and adverse drug reactions health outcomes. The majority of the included studies found potential effects of WeChat/WhatsApp on anxiety in cancer patients. However, one randomized controlled trial reported an increased trait anxiety mean score after 3 months of participation in an information-based WeChat-associated intervention.²⁴ This result can be explained by the timing of measuring scores, with the initial measurement taking place before the surgery, and the comparison taking place 3 months after discharge, when participants could be feeling anxiety post-surgery. In regard to the fatigue outcome, one randomized controlled trial studying breast cancer patients reported an increased fatigue score amongst the WeChat intervention group.²⁷ This trial was specifically studying post-operative women with breast cancer, and those in early rehabilitation from intensive surgery, which could have increased their levels of fatigue.²⁷ In comparison, the other studies investigated breast cancer survivors and inpatient cervical cancer participants who had not undergone intensive surgery prior to study participation.^15,17 Lastly, one randomized controlled trial reported a significant increase in adverse drug reactions incidence after a WeChat intervention.³² The authors noted in the discussion that the pain management team had added new drugs for pain management during the study period, which may have caused increased adverse drug reactions.³² Thus, the result may not be an effect of the WeChat intervention.

Use of WeChat/WhatsApp during the COVID-19 pandemic

Among 20 included studies, three (15%, 3/20) pilot studies investigated the use of WhatsApp in cancer management during the COVID-19 pandemic and reported high patient satisfaction to this innovative intervention.^31,33,34 Consistent with our findings, studies demonstrate the success of using WhatsApp or telephone services in maintaining health communication between patients, caregivers, and physicians.^47–49 Many oncological patients may be immunosuppressed from previous chemotherapy/radiation treatments, and subject to greater risk of infection.⁵⁰ By implementing technological solutions, immunosuppressed oncological patients can experience the full extent of cancer management while reducing their exposure to infectious agents.

Limitations of utilizing WeChat/WhatsApp in cancer care also exist. WeChat/WhatsApp communication is not a complete substitute for in-person visits and utilizing this technology may not be feasible for all patients or clinical situations. For example, one included pilot study indicates that technical difficulties may occur and interfere with the delivery of health care.³³ Determined from a clinical study, a significant limitation of WeChat/WhatsApp is the inability to conduct a face-to-face physical examination. This means that physicians cannot weigh their patients and accurately prescribe dosages for weight-based drugs.^51,52 As corroborated by research in the field, included articles indicate that Internet connections should be secure, transmitted data must be uncorrupted, and lastly, confidentiality must be maintained.^26,34,53 As well, patient privacy must be ensured in all situations, and further security measures must be taken when transmitting clinical information online. Patient privacy and data security are the major concerns during use of WeChat and WhatsApp in healthcare. These concerns have created barriers to the global adoption of WeChat and WhatsApp in healthcare practice. In the current 20 studies, there is no report on security measures taken. Current literature suggested developing guidelines in the management and use of WeChat and WhatsApp in order to prevent the unwanted consequences.^54,55 We also encourage future researchers to complete a full technology assessment to ensure patient privacy in use of online communications.⁵³

Implications

Findings of this review have implications for cancer patients, health care providers, health care organizations, communities, and society. For cancer patients, utilizing familiar online communication tools such as WeChat or WhatsApp will provide increased accessibility and facilitate contact with physicians via mobile devices. This is especially important when patients face financial, geographical, or physical limitations to accessing health care. WeChat/WhatsApp is used more frequently in developing countries, as they are more accessible compared to Text Messaging Services, which may require external payment. For health care providers, WeChat/WhatsApp provides a convenient and dynamic method for remote follow up with patients. The use of mHealth also allows for physicians to have continuous communication with patients, compared to conventional care. Health care organizations could also benefit from utilizing WeChat/WhatsApp by reducing costs and time on administrative tasks. Physicians will be able to virtually connect with patients instead of coordinating a time when both parties can physically be present at the office. This limits time spent on transportation and inherently reduces the need for large office spaces. The introduction of mHealth can facilitate more equality in accessing timely care in rural communities; however, efforts must be made to mobilize stable Internet access in such geographical locations before implementing mHealth programs.

Limitation and future research

There are some limitations in this review. Firstly, this review only included articles written in English. Studies focusing on WeChat or WhatsApp have been written in a variety of languages; however due to our research team knowledge, we were solely able to include English articles. Secondly, included articles were published in academic peer-reviewed journals, and articles from industrial or commercial publications were excluded. The majority of the included studies in this review were conducted in China; thus, our findings cannot be generalized to all cancer patient populations. Thirdly, there is a large variation in intervention design and implementation process. We noticed this limitation and included Table 2 to describe the features of each intervention. In the future, research studies should carefully review existing literature and design interventions through evidence-based approaches. We recommend that future studies can investigate the impact that duration, number of messages or calls, and types of messages or calls has on cancer patients. Lastly, the ages of the cancer patients were not specified in this review, which may impact findings since younger patients might be more comfortable navigating online platforms.

This review identified several directions for future research. Firstly, there is a need to disentangle conflicting findings of WeChat/WhatsApp and health outcomes within the current literature. For example, future research should examine the effects of WeChat/WhatsApp on anxiety, fatigue, and adverse drug reactions in a large-scale randomized controlled trial. Secondly, access to health services continues to be an issue in rural communities⁵⁶ and further research should be done to uncover the impacts of using WeChat/WhatsApp to connect with rural cancer patients. Finally, the majority of the studies were conducted in one country, China, limiting the generalizability of the findings. Future research should be encouraged in various countries and settings to further investigate the effects of WeChat/WhatsApp.

Conclusion

This review summarizes the potential effects of WeChat/WhatsApp use in cancer management on physical and psychosocial outcomes. Throughout the included studies, the applications were utilized to the full extent of the platforms, with knowledge being transmitted through public accounts, messages, push reminders, and video and audio calls. This review suggested that use of WeChat/WhatsApp on cancer management might improve various physical and psychosocial health outcomes among oncological patients. Future research should be conducted in various countries among diverse communities, including rural areas, to ascertain the effects of WeChat/WhatsApp in different populations.

Footnotes

Author contributions

Conceptualization, PZ and TH; methodology, PZ; formal analysis, PZ and TH; data curation, PZ and TH; writing of original draft preparation, TH and PZ; writing of review and editing, PZ, TH, YL, NT, MD, HZ, and CZ; supervision, PZ; funding acquisition, PZ. All authors have read and agreed to the published version of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Social Sciences and Humanities Research Council Institutional Grant (Ref # 102090).

ORCID iD

Ping Zou

Appendix

Table A1.

CASP checklist⁵⁷: Six cohort studies.

	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12	Total score (out of 12); level of evidence (high/medium/low)
Chen (2019)²⁹	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	11 – High
Barca (2020)³¹	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	11 – High
Shen (2020)²¹	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	11 – High
Cheng (2021)¹⁶	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	11 – High
Chavarri (2021)³³	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Yes	10 – Moderate
Nardo (2021)³⁴	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Yes	10 – Moderate
Total of YES	6	6	6	6	0	4	6	6	6	6	6	6

Notes: 12-point scale: high = greater than 10; moderate = 9–10; low = 8 or less.

Table A2.

CASP checklist⁵⁸: Fourteen randomised controlled trial studies.

	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Total score (out of 11); level of evidence (high/medium/low)
Lyu (2016)³⁰	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	11 – High
Zou (2018)²⁸	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	10 – High
Xia (2019)²⁴	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	10 – High
Qiao (2019)²⁰	Yes	No	No	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8 – Moderate
Zhang (2019)²⁶	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9 – Moderate
Peng (2020)¹⁹	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	10 – High
Sui (2020)²²	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	10 – High
Wu (2020)²³	Yes	No	No	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8 – Moderate
Zhou (2020)²⁷	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	11 – High
Bandani-Susan (2021)¹⁵	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	11 – High
Han (2021)¹⁷	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	10 – High
He (2021)¹⁸	Yes	No	No	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8 – Moderate
Zhang (2021)³²	Yes	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9 – Moderate
Xu (2021)²⁵	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	10 – High
Total of YES	14	10	9	4	14	14	14	14	14	14	14

Notes: 11-point scale: high = greater than 9; moderate = 8–9; low = 7 or less.

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