Effect of WeChat‐based continuous care intervention on the somatic function, depression, anxiety, social function and cognitive function for cancer patients: Meta‐analysis of 18 RCTs

Abstract Aim This meta‐analysis systematically reviewed and identified the effects of WeChat‐based continuous care (WCC) interventions on various outcomes in cancer patients. Design Systematic review and meta‐analysis. Methods In this study, outcome measures included somatic function, anxiety, depression, social function, and cognitive function. The standardized mean differences and 95% CIs of pooled effect sizes were calculated using fixed‐ and random‐effects models. NFail‐safe and Begg's tests were performed to evaluate publication bias, and sensitivity analysis was performed to evaluate the robustness of the meta‐analysis results. Results The meta‐analysis included 18 RCTs of moderate quality. WCC interventions significantly improved somatic function, depression, anxiety, social function, and cognitive function in cancer patients. There was no significant publication bias, and the sensitivity analysis indicated robust results. Patient or Public Contribution WCC interventions improved depression, anxiety, social function, and cognitive function in cancer patients.

To alleviate the economic burden caused by the high incidence and mortality of cancer, the concept of tertiary prevention has been proposed in China. Third-level prevention refers to measures such as preventing recurrence, reducing complications, preventing disability, improving survival and recovery rates, relieving pain caused by cancer, improving quality of life, and promoting rehabilitation for patients with existing cancer (Maomao & Wanqing, 2021). Continuous care is a new model of care that has emerged in response to social developments and changes in healthcare services. This involves inpatient care that extends to the treatment and rehabilitation of patients after discharge, helping to improve patient self-management and ensuring uninterrupted information, treatment and care services (Hirschman et al., 2015;Liu et al., 2015). For patients with cancer, reasonable out-of-hospital health guidance can, to a certain extent, change poor health behaviours, reduce the likelihood of hospital readmission (Chen et al., 2019), and reduce the mortality rate of cancer patients (Justiniano et al., 2019), which is one of the important measures of tertiary cancer prevention. Compared to routine discharge follow-up care, continuous care can prevent postoperative cancer fatigue (Huanzhi et al., 2017) and reduce anxiety and depression in cancer patients (Yingying et al., 2019).
There are an increasing number of forms of continuous care for cancer patients, such as the establishment of nursing clinics and continuity of care centres, telephone follow-up visits, and the creation of online platforms (Chen et al., 2019;Ye et al., 2016). However, there are still a series of problems with regard to its development, such as insufficient human resources, imperfect coordination mechanisms between hospitals and communities (Li & Yimin, 2018), insufficient awareness of patients about continuity of care, and low cooperation (Easley et al., 2016). With rapid economic development, mobile applications have started to be widely used in the health field (Higgins, 2016), such as storing patients' medical records and providing online health information, appointment reminders, and telemedicine (Lewis et al., 2016). WeChat, an application launched by Tencent in 2011, has become one of the most popular social software programs in China, and many researchers are exploring its application in the field of continuous care (Jingjing et al., 2016). The application provides voice, text and image sharing among a large number of active users, with 1.225 billion active users as of 30 December 2020, and 5.2% growth year-over-year (Tencent website, 2021). Compared to traditional interventions, when using WeChat for interventions, patients are not only able to receive relevant health guidance in a timely manner (Ma et al., 2018) but also have voice communication and video consultation with medical staff (Lyu et al., 2016); this is an intervention method that addresses the spatial and temporal limitations of medical services and enables medical staff to provide specific medical aspects of health guidance to patients during follow-up visits (Ma et al., 2018).
In recent years, the application of WeChat-based continuous care (WCC) interventions in cancer patients has gradually developed, and a large number of experimental studies have been conducted by relevant researchers evaluating somatic, mental, cognitive, and social functioning (Zhao et al., 2020;Zhang Dongfang et al., 2019;Jiaoyan et al., 2020), but these studies have been small in scope and have reported inconsistent or even contradictory findings. A typical example was the study of improving depression in cancer patients. One study (Yu, 2017) reported a significant improvement (p < 0.001), but the improvement effect in another study was not particularly significant, p = 0.05 (Jiaoyan et al., 2020). A similar situation could be found in studies on somatic function. One study reported that WCC intervention was ineffective for somatic health (Xianghua et al., 2017), but another study (Lihui et al., 2018) showed a significant improvement in somatic health. The results of the current literature search indicated that there are no uniform standards and no standardized processes for the timing, periodicity, methods, content, and processes of WCC interventions, the implementation has varied greatly across locations, and there is a lack of a comprehensive evaluation of the effects reported in the literature. Therefore, the application of meta-analysis to explore the effects of WCC interventions applied to cancer patients was studied, and the effectiveness of the interventions was quantitatively analysed, which has positive implications for the development of relevant clinical practice in the future.

| Selectionprocedure
A study was included in the present analysis if (a) the participants were cancer patients; (b) the intervention involved WCC; (c) the outcomes included somatic function, anxiety, depression, social function, or cognitive function; and (d) the study was an RCT. If the study included multiple assessment time points, data from the post-intervention time point were chosen for the analysis. A study was excluded from the present study if (a) the articles received a poor quality evaluation (Physiotherapy Evidence Database scale [PEDro] score <4) or (b) the data for the study were incomplete or unavailable.
Two researchers independently searched and screened the literature in strict accordance with the inclusion and exclusion criteria and then extracted and cross-checked the data, which included author, date of publication, country, sample size, age, gender, interventions, and outcome indicators of the included subjects. A third researcher was consulted to resolve any disagreement in the screening results.

| Qualityassessment
The PEDro scale (Moseley et al., 2019) was used to evaluate the effect of WCC interventions on cancer patients in 18 randomized clinical trials. PEDro was introduced by the Centre for Evidence-Based Physiotherapy at The George Institute for Global Health. Eighteen studies with PEDro scores of less than 4, 4 to 5, 6 to 8, or 9 to 11 were considered to have poor, fair, good, or excellent methodological quality, respectively.

| Computingeffectsizes
For the meta-analyses, the mean change from the baseline to postintervention assessment for the intervention and control groups was calculated as the effect size (ES). The group mean deviation and the pooled SD were calculated (Cochrane Handbook 16.1.3.2, The Cochrane Collaboration). When 2 or more intervention groups were included, the ES for only the most active group was calculated.
Given that these variables are continuous outcome measures with different units of measurement, standardized mean differences (SMDs) were estimated using fixed-or random-effects models with 95% confidence intervals (CIs).

| Heterogeneity
Heterogeneity was explored using heterogeneity measures χ 2 and I 2 . I 2 is the proportion of total variation observed between studies that are attributable to differences between studies rather than sampling error (chance). When I 2 > 50%, the studies in the metaanalysis were considered to be heterogeneous, and a randomeffects model was used (Moazzami et al., 2020). Otherwise, a fixed-effects model was used.
Sensitivity analyses were conducted to identify potential sources of heterogeneity and to determine how sensitive the final study conclusions were to a particular method or study design feature that was used (Thabane et al., 2013). If the effect and CIs in the sensitivity analyses led to the same conclusion as the primary metaanalysis value, the results were considered robust.

| Publicationbias
The Begg test and fail-safe number (NFS) were used to determine whether there was publication bias (Begg & Mazumdar, 1994;Gjerdevik & Heuch, 2014). The Begg test provides a statistical parameter for the evaluation of publication bias. If Z > 1. 96, p < 0.05 indicates that publication bias may exist. Values of Z < 1.96 and p > 0.05 were considered to indicate no publication bias. NFS is a method of sensitivity analysis that calculates how many reports of negative results are needed to reverse the results when the analysis results are statistically significant (Hongyan, 2007). The larger the safety factor is, the more stable the meta-analysis results. A reasonable level was achieved if the NFS exceeded 5K + 10 (where K is the number of studies in the meta-analyses).

| Ethicsapproval
This study was approved by the Ethics Committee of the Bengbu Medical College (2017054).

| Studyselection
A total of 418 articles were retrieved from the 4 electronic databases (PubMed, WOS, CNKI and CBM). Of these, 277 duplicate articles were excluded, 79 articles were excluded because they were not relevant to our study, and 44 articles were excluded because they did not meet the inclusion criteria. Thus, 18 RCTs were included in this study, and there were no significant differences between the general information of patients in the experimental and control groups in each study. A total of 1622 cancer patients were included in the 18 studies, including 815 in the experimental group and 807 in the control group. The article selection process is described in the flow diagram ( Figure 1).
All interventions were delivered to cancer patients and were conducted by trained health care providers through WeChat groups or WeChat public accounts. The intervention durations ranged from 3 weeks to 12 months. The patients in the control groups were offered the usual discharge follow-up intervention (Table 1).

| Somatic function
Nine studies measured the somatic function of cancer patients scale. Meta-analysis showed that the heterogeneity test resulted in I 2 = 95.1%, and the SMD of the combined ES was 1.348 (95% CI, 0.653 to 2.043; p < 0.001) using a random-effects model, suggesting that WCC improves somatic functioning in cancer patients.

| Social function
Eleven studies measured the social function of cancer patients (Guolian, 2017;Hong, 2015 can improve the social competence of cancer patients. Figure 5 shows a forest plot of the ES of the WCC on the social functioning of cancer patients.

| Publicationbias
In the 5 meta-analyses, a large publication bias was found with the Begg test for the somatic function outcome, with the exception of the outcome indicator of physical function, which was found to be robust when recalculated without the safety factor. No significant publication bias was found with the Begg test (p > 0.05) or NFS values (NFail-safe > criterion) for other outcome indicators. The results of the heterogeneity tests and publication bias assessments are shown in Table 2.

| Subgroupanalysis
Subgroup meta-analyses were performed to better understand the effects of different interventions within the WCC interventions for cancer patients (Table 3). In a five-item meta-analysis, it was found that different WCC interventions improved somatic functioning, anxiety, depression, social functioning, and cognitive functioning in cancer patients (p < 0.05). Regarding physical function, SMD 1 > SMD 3 > SMD 2 among the three interventions, which
Cancer is a malignant disease involving abnormal cell growth (Maman & Witz, 2018), which leads to millions of new cases and deaths every year. Therefore, the implementation of a continuous follow-up strategy and reasonable out-of-hospital guidance is of great significance to improve the quality of life and survival rate of cancer patients. In previous studies, the continuity of care interventions for cancer patients have focused on psychological interventions (Muzi, 2016), relaxation training (Jing et al., 2019), exercise therapy (Hua, 2017), and systematic nursing interventions (Chuanlin et al., 2014;Maimaiti et al., 2013). In this study, we focused on the effects of applying WCC interventions in cancer patients. Due to different intervention methods and measurement methods of the outcome indicators adopted by the different researchers, this paper selected five outcomes, including somatic function, depression, anxiety, social function and cognitive function, from 18 RCTs for meta-analysis.
Meta-analysis results showed that the WCC intervention was effective in improving somatic function in cancer patients, which was inconsistent with the results of previous studies (Wang et al., 2017).
A possible reason for this was the high heterogeneity of the results in the meta-analysis for somatic function in this study (I 2 = 95.1%).

F I G U R E 4 A forest plot of the ES of WCC on Anxiety in cancer patients.
Although caregivers were able to remind patients to take their medications through the WeChat platform, clarify the side effects of relevant medications, and reinforce their compliance behaviours (Xiaowei & Hong, 2020), cancer is an organic disease, and more rigorous and large sample size intervention studies are needed in the future to explore the effectiveness of WeChat intervention programmes for improving somatic function in cancer patients.
In terms of mental health, compared to conventional nursing in-  Ah & Crouch, 2021), and some even experience a decline in memory, processing speed, attention and executive ability (Ono et al., 2015), which requires healthcare professionals to provide cancer patients with specific programs to improve memory and enhance Recording the detailed usage of WeChat is very valuable for better drawing on existing experiences in future interventions.
However, in the analysis of 18 RCTs included in this study, we found that none of the studies gave an introduction on how to record the usage of WeChat. This is detrimental to the implementation of WCC interventions in the future. We also call for more open reporting of detailed intervention processes in future studies.
Partial heterogeneity was found in this study, and in the metaanalysis, the large heterogeneity may be due to dissimilarities between studies, which mainly included differences in study popula- studies. The results of this study showed that WCC interventions were effective in improving depression, anxiety, social functioning, and cognition in cancer patients with a positive effect compared with conventional out-of-hospital follow-up. Given the small number of studies and their methodological limitations, these results should be regarded as preliminary and interpreted with caution.

ACK N O WLE D G E M ENTS
This study was supported by funding from the Innovation Team of

Health Information Management and Application Research, Bengbu
Medical College (grant no. BYKC201913) and Bengbu Medical College's 512 Talent Project (grant no. BY51201209). We thank Prof.
Sun Xinying (School of Public Health, Peking University) for her suggestion on the revision of this paper. We thank American Journal Experts (AJE) for language editing.

CO N FLI C TO FI NTE R E S TS TATE M E NT
There are no conflicts of interest.

DATAAVA I L A B I L I T YS TAT E M E N T
All datas is from the quoted articles listed in the reference list.

E TH I C SS TATEM ENT
This study was approved by the Ethics Committee of the Bengbu Medical College (2017054).

R EG I S TR ATI O NA N DPROTO CO L
This review was not registered.