MISS XIAOLING ZHANG (Orcid ID : 0000-0002-3819-2007)

Accepted Article Article type : Original Research: Clinical Trial

Evaluation of a WeChat-based life review program for cancer patients ：A

quasi-experimental study

Running head

WeChat-based life review program for cancer patients

Author details and qualifications

Xiaoling Zhang MM RN

School of Nursing, Fujian Medical University, Fuzhou, China

Huimin Xiao PhD RN

Professor and Vice Dean of School of Nursing,

Fujian Medical University, Fuzhou, China

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jan.14018

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 Ying Chen MM RN
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School of Nursing, Fujian Medical University, Fuzhou, China

Correspondence

Huimin Xiao, School of Nursing, Fujian Medical University, Fuzhou, China.

Email: huiminx@126.com

Tel: (86) 591 2286 2015. Fax: (86)591 2286 2526.

Conflict of interest

No conflict of interest has been declared by the authors.

Funding Information

Chinese National Nature Science Foundation, Grant Number: 8140 1863

Fujian Provincial Nature Science, Grant Number:2017J01814

Fujian Provincial Health Commission, Grant Number:2017-CX-35

MOE (Ministry of Education in China) Project of Humanities and Social

Sciences, Grant Number: 18YJA190017

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 Author Contributions
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[(This will be published with your article. Please provide authors’

initials as appropriate)]

Criteria Author Initials

Made substantial contributions to conception ZXL; CY; XHM

and design, or acquisition of data, or analysis

and interpretation of data;

Involved in drafting the manuscript or revising it ZXL; XHM

critically for important intellectual content;

Given final approval of the version to be ZXL; CY; XHM

published. Each author should have participated

sufficiently in the work to take public

responsibility for appropriate portions of the

content;

Agreed to be accountable for all aspects of the XHM；ZXL

work in ensuring that questions related to the

accuracy or integrity of any part of the work are

appropriately investigated and resolved.

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 Abstract
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Aim: 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.

Background: Life review is effective in improving the psychospiritual well-being of palliative

patients. However, traditional life review programs are limitedly applied in clinical practice.

Design: A non-concurrent controlled quasi-experimental design.

Methods: 92 cancer patients were recruited from April 2017 to February 2018, with 44

patients in the control group receiving routine care and 48 in the experimental group

receiving a six-week WeChat-based life review program plus routine care. Compliance with

the program, difficulty in participation and satisfaction with the program were used to

explore its feasibility. Anxiety, depression, self-transcendence, meaning in life and hope

were measured at baseline and immediately after the program.

Results: All experimental participants who completed the program used the WeChat

platform; 39 participants had no difficulties in operating the platform and 40 were satisfied

with the program. Statistically significant effects were identified on anxiety, depression and

self-transcendence. An increase in the levels of meaning in life and hope was observed in

the experimental group after the program.

Conclusion and Impact: The innovative WeChat-based life review program is an effective

non-pharmacological intervention in improving psychospiritual well-being of

community-dwelling cancer patients. It could be integrated into transitional care for cancer

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 patients. Future research with rigorous design is necessary to test the effects on-line life
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reviews among cancer patients.

：
Trial registration This study was registered on the Chinese Clinical Trial Registry

(Registration No: ChiCTR-IOR-17011998)

KEYWORDS

nursing, internet, life review, cancer patients, anxiety, depression, self-transcendence, hope,

meaning in life, psychospiritual well-being

1 INTRODUCTION

Global cancer figure has climbed to 18.1 million in 2018, with estimated to rise about 70%

over the next 20 years (World Health Organization, 2018). Appropriately 32.5% to 75.7% of

cancer patients suffer from significant psychospiritual distress (Li & Feng 2008; Zhang et al.,

2007; Chida et al., 2008). Anxiety and depression are the most common negative emotions

in the cancer trajectory (Jørgensen et al., 2016). With the progress of the illness, the

deteriorated physical function and psychological burden, patients often encounter

difficulties in transcending the current predicament, seeking meaning in life and feeling a

sense of hopelessness (Henoch & Danielson, 2010; Ming, 2015). Unfortunately, most

patients do not access treatments because of geographic distance, lack of time, long waiting

time, or unwillingness to disclose psychological problems (Collins et al., 2004).

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 The Internet, an interconnected network which allows greater flexibility in working hours
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and location, has increasingly applied in psychological interventions (Wagner, 2014). It

enables participants to access treatment in their familiar environment that are often

perceived as anonymous, private and nonstigmatizing (Cuijpers et al., 2010). WeChat is one

of the world’s largest standalone mobile applications with over 1 billion monthly active

users by 2018 (TechNode, 2018). Due to its simplicity, convenience, efficiency and mobility,

WeChat has been gradually penetrated in various nursing fields, including nursing

management (Liu, 2015), health education (Xu, 2015) and nursing teaching (Zhang, 2015;

Zhu et al., 2015). However, very few studies have explored WeChat-based psychological

interventions.

1.1 Background

Life review has been recognized as an effective psychological intervention. It is a

process of recalling, evaluating and integrating life experiences to facilitate the achievement

of ego integrity at the final life stage (Butler, 1963). It is grounded in Erikson’s psychosocial

development theory. According to Erikson (1950), a healthily developing human should pass

through eight developmental stages from infancy to late adulthood. The development crisis

of the last life stage is “ego integrity” vs. “despair”. Butler (1963) further pointed that

reviewing a life can facilitate participants to achieve ego-integrity and reduce despair.

Haight and colleagues (1984; 1993) have found that a successful life review should focus on

an individual’s whole life events regardless of positive or negative and provide his or her

new significance and meaning to life. Previous systematic review or meta-analysis have

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 demonstrated that life review can reduce anxiety and depression, foster hope and improve
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quality of life (Zhang et al.,2017; Wang, 2017; Bohlmeijer et al.,2003). Some studies have

also found the effectiveness of life review on patients’ enhancement of meaning in life and

self-transcendence (Wang, 2017; Ando, 2010; Chen, 2011). However, most studies delivered

a life review in a traditional face-to-face setting. Such programs cannot always be accessed

by cancer patients due to geographic distance and traffic issues. Thus, several innovative life

review programs for older adults (Preschl et al., 2012; Lamers et al., 2014) and cancer

patients (Wise et al., 2010) have been explored. For example, Preschl et al. (2012)

investigated life review therapy for older adults with depression in a face-to-face setting,

together with computer use. In the computer section, the participants were asked to write

down their positive life events and do some exercises to induce positive emotions. These

exercises could be a mindfulness-based intervention, a relaxation exercise, or a guided

exercise focusing on recalling positively valuated episodes in their lives (Preschl et al., 2012).

This study indicated that the life review therapy in this combined setting was effective at

alleviating depression and elevating levels of self-esteem in depressed older adults. Another

study by Lamers et al. (2014) explored an online guided self-help life review program for

older adults. The participants reviewed their lives using a self-help book, rather than having

a facilitator guide them. They sought support from the researchers via e-mail. The study

findings revealed that the program was effective at reducing anxiety and depression.

Additionally, Wise et al. (2009) designed an integrated life review program for cancer

patients. This program contained a telephone-based life review interview, a text-formed life

story and a self-directed website for patients to share their personal story. The study

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 findings indicated that most patients thought the program was helpful. The themes
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emerging from their life stories involved simplicity, forgiveness and meaning. However, the

telephone-based life review interviews did not provide the opportunity to observe

non-verbal cues. Recently, our research team developed a WeChat-based life review

program (WBLRP) for cancer patients, based on Erikson’s psychosocial development theory

and Reed’s self-transcendence theory (Zhang & Xiao, 2018). Our program, which has been

validated by a panel of experts and patient advisers, contained four-section e-life review

interviews, Memory Prompts, Review Extraction, Mind Space and E-legacy products. This

current study aimed to examine its feasibility and effects on cancer patients’ psychospiritual

well-being.

2 THE STUDY

2.1 Aim

This study aimed to evaluate the feasibility and effects of the WBLRP on anxiety, depression,

self-transcendence, meaning in life and hope among cancer patients undergoing

chemotherapy.

2.2 Hypothesis

The hypothesis was that the WBLRP was feasible and suitable for cancer patients. When

compared with those in the control group, patients in the experimental group would have a

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 statistically significant improvement in self-transcendence, meaning in life and hope and a
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reduction in anxiety and depression after the WBLRP.

2.3 Design

The study was a non-concurrent controlled quasi-experimental design.

2.4 Participants

The control group was recruited from April to July 2017 and the experimental group, from

August 2017 to February 2018. The control group data came from the Mind-map based life

review project. The study settings were two oncology departments at a medical

university-affiliated general hospital in Fujian, southeast China. The inclusion criteria for

participants were: (1) diagnosed with Stage III or IV cancer and undergoing chemotherapy;

(2) aged 18 years or above; (3) aware of their diagnosis and treatment; (4) able to access the

Internet via multiple devices, for example, a mobile phone. The exclusion criteria were: (1)

currently taking anxiolytics or antidepressants; (2) receiving other psychotherapeutic

treatments; (3) experiencing verbal communication impairment, cognitive impairment or a

psychiatric disorder; (4) severely disabled or the disease progressing rapidly (Karnofsky

Performance Status, KPS<40%).

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 2.5 Sample size calculation
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Power analysis of independent t-test for the measure outcomes was used to calculate the

sample size (Hayat, 2013). Assuming a two-tailed alpha of 0.05, a probability of 0.02 for beta

error (80% power), an effect size of 0.42 and a standard deviation of 0.32 on anxiety (Chan

et al., 2017), a minimum of 64 participants was required. For depression (effect size 0.52

and standard deviation 1.21) and self-transcendence (effect size 0.39 and standard

deviation 0.42) (Chan. 2014, Chen, 2011), the sample sizes should have been 30 and 56

respectively. Considering an expected 20% attrition rate in this study, a total of 70 cancer

patients was needed. This study recruited 92 cancer patients.

2.6 Intervention

2.6.1 Control group

The control group received only routine care, which included personal care, medical care,

health education and emotional support, all provided by the study hospital. The control

group participants could use the Internet freely to search for information. However, they

had no access to the WBLRP.

2.6.2 Intervention group

The intervention group received the WBLRP plus routine care. The WBLRP consisted of

four-section e-life review interviews and four life review modules, which has been published

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 (Zhang & Xiao, 2018). The interviews covered each participant’s entire life, including the
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present (cancer experience), adulthood, childhood and adolescence and a summary of their

life. The life review modules included Memory Prompts, Review Extraction, Mind Space and

E-legacy products. Memory prompts helped to evoke patients’ memories and facilitate life

review process by means of images, music, videos and audio-picture books. Review

Extraction referred to a summary of the meaningful events where patients can view and

leave their comments; Mind Space provided an opportunity to express emotions, hand

down wishes, or reveal their true feelings to anyone who is important at that stage. E-legacy

product was a video booklet that can be preserved as a spiritual memorial.

Patients in the experimental group followed the procedure below. Prior to the

intervention, they were guided to install WeChat, register an account, launch a video call

and go through each module on the WeChat platform. The process of instruction, practice

and demonstration enabled patients to master the operation of the WBLRP platform.

Additionally, they were able to consult an operation brochure. Before each session, patients

accessed the Memory Prompts Module to obtain an overview of the current session.

Subsequently, an e-life review interview was arranged, along with the creation of a family

tree or a timeline of their life. The e-life review interview was a virtual face-to-face session

with additional instant messaging methods available, including text message and voice

message, as well as emotion icons. After the life review interview, patients accessed the

24-hour open asynchronous communication modules to relive and integrate the reviewed

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 content, express feelings and deliver e-legacy products, or supplement any content. Each
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session followed the same process.

The WBLRP was conducted weekly over six weeks by the first author, who acted as the

facilitator. She has received approximately 50 hours of life review training. Each life review

interview ranged from 40 to 60 minutes, depending on the patient’s physical condition and

willingness to talk. During the life review process, researchers monitored participants’

physical condition, emotional status, responses to the life review’s guiding questions and

compliance with the intervention. If participants experienced negative emotions, a

follow-up by a clinical psychologist could be arranged.

2.7 Instruments and Measures

2.7 .1 Participant characteristics

Participant characteristics were collected using a personal information form and their

medical records. Demographic characteristics included age, gender, marital status,

education, income, religion and monthly income. Clinical characteristics included diagnosis

of disease, metastasis (yes, no), surgery (yes, no), first-time chemotherapy (yes, no) and

KPS.

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 2.7 .2 Feasible outcomes
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2.7 .2.1 Compliance with the WBLRP

We recorded whether the experimental group finished the relevant activities coordinated

by the facilitator. Compliance involved: (1) completing the four-session life review

interviews; (2) creating a family-tree and lifeline; (3) reviewing content, making

supplements, or leaving comments on the Review Extraction Module; (4) expressing

emotions, setting down wishes, or revealing true feelings on the Mind Space Module.

Additionally, the names of patients who accessed the WBLRP platform were automatically

recorded on the WBLRP platform’s back end, which was reflected in their compliance with

the program.

2.7 .2.2 Difficulty in participation

Difficulty in participation refers to patients’ difficulties in using the WBLRP platform

according to a Likert-type point scale ranging from 1 (very difficult) - 5 (very easy).

2.7 .2.3 Satisfaction with the WBLRP

Satisfaction with the WBLRP was used to evaluate participants’ satisfaction with what they

had experienced in the WBLRP process, from 1 (maximum dissatisfaction) - 5 (maximum

satisfaction).

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 2.7 .3 Outcome Measures
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2.7 .3.1 Anxiety

Anxiety was measured using Zung’s self-rating anxiety scale (Zung, 1971), a 20-item

four-point Likert-type scale from 1 (seldom) - 4 (most of the time). The total score ranges

from 20-80, with a score of more than 50 indicating mild to moderate anxiety. Widely used

to quantify anxiety levels, it has been proven to be reliable among cancer patients in China

(α= 0.799) (Hu et al. 2015).

2.7 .3.2 Depression

Zung’s self-rating depression scale (Zung, 1965) is useful in detecting depression levels. This

four-point scale also consists of 20 items, with a total maximum score of 80. A score of more

than 53 can indicate mild depression. Good reliability has been shown with Cronbach’s

alpha 0.87 (Wei, 2012).

2.7 .3.3 Self-transcendence

Self-transcendence was measured by the self-transcendence scale (Reed, 1991). This is a

15-item scale, with each item rated from ‘1= not at all’ - ‘4 = almost always’. The total score

ranges from 15 to 60, calculated by adding all of the individual items. The Chinese version of

the scale has been validated with high reliability (α= 0.83-0.87) (Zhang et al., 2014).

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 2.7 .3.4 Meaning in life
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Meaning in life was measured by the Meaning in Life Questionnaire (Steger et al., 2006). It

consists of 10 items measuring the presence of meaning and the search for meaning. Each

item is rated on a 7-point Likert scale from ‘1 = strongly disagree’ - ‘7 = totally agree’. It has

been shown to have good reliability, with internal consistency values between 0.79-0.93

(Wang, 2008).

2.7 .3.5Hope

Hope was measured by the Herth Hope Scale (Herth, 1991), a 12-item scale comprising

three dimensions: temporality and future, positive readiness and expectancy and

interconnectedness. Good validity and reliability have been reported among patients with

lung cancer, with Cronbach’s alpha value 0.87 and construct validity 0.85 (Li, 2005).

2.8 Data collection

Data were collected by two research assistants at baseline and at the six-week point

immediately after the program’s conclusion. The assistants, who were blinded to the group

assignments, collected patients’ demographic data and measured outcomes. During the

study, the assistants ensured the study’s confidential and voluntary nature and explained

the requirements of each measure to participants. If patients encountered difficulties while

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 completing the questionnaires, the assistants would help them by reading each item aloud,
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repeating the item if necessary and recording the participants’ responses.

2.9 Data analysis

Data were analyzed using IBM SPSS 22.0. Descriptive statistics were used to summarize the

demographic data, the outcome variables, compliance with the WBLRP, difficulty in

participation and satisfaction with the WBLRP. Chi-square tests or Fisher’s Exact Tests were

used to compare the differences in the demographic and clinical variables between the

intervention and control groups. Independent sample t-test was used to examine the

differences in the scores of the five variables in the intervention and control groups.

2.10 Ethical considerations

Ethical approval was obtained from the Biological and Medical Research Ethics Committee

of the corresponding author’s university (IRB Ref No: 2016/00020) in July 2017. All

participants were assured that study participation was voluntary and that they could

withdraw from the study at any time without negative consequences. Written informed

consent was obtained from each participant. The data collected were kept confidential and

anonymous and were used exclusively for this research only.

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 2.11 Validity and reliability
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The study was designed to ensure maximum validity and reliability. First, the study protocol

was developed to standardize the study. Second, the same researcher delivered the

intervention to all participants in the experimental group, to maintain consistency. Third,

the instruments used for the study were valid and reliable. Fourth, all data were carefully

checked, immediately after collection. They were crosschecked and scrutinized for errors

after being entered in SPSS. Additionally, the research team met regularly to monitor the

study’s progress and ensured the study was strictly following the protocol.

3 RESULTS

3.1 Participant Recruitment

Initially, 350 cancer patients were contacted. After being assessed for eligibility, 92

participants were recruited. Among them, two participants in the control group withdrew

from the study, while four in the experimental group did not complete the intervention

phase. A total of 86 participants remained at study completion, with 42 in the control group

and 44 in the experimental group (Figure 1).

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 3.2 Participant Characteristics
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The control and experimental groups were similar in terms of demographic characteristics

(Table 1). The mean age was 59.2 years (SD 11.5), with participant ages ranging from 23-80

years. In each group, over 50% of participants were male with a spouse, but without

religious affiliation. Most patients had received a secondary school education (53.40%) and

lived with a monthly income of more than 3.000 yuan.

In terms of clinical characteristics (Table 2), more than 50% of participants were

diagnosed with gastrointestinal cancer with a metastasis in both groups. Most had had

surgery, undergone chemotherapy and their KPS was more than 70%. There were no

significant differences between the control and experimental groups in terms of

demographic characteristics (Table 1) or clinical characteristics (Table 2), which suggested

that the two groups were well balanced and comparable.

3.3 Feasible outcomes

3.3.1 WBLRP Compliance

Completion with e-life review interviews

A total of 44 patients in the experimental group completed the six-week life review

interviews. During the life review interviews, 75% of the patients created a family tree on

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 their own, while the remaining 25% created their family tree with the help of a family
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member. All patients drew a lifeline in the summary of life session.

3.3.2 Participation in the WBLRP platform

Table 3 shows participants landing on the WBLRP platform. Nearly every patient landed on

the platform and viewed the Memory Prompts module. In the Review Extraction Module,

three experimental patients (6.82%) made revisions to key life events summarized by the

facilitator; 27 patients (61.36%) supplemented with images and other relevant content; 10

patients (22.73%) left comments; and five shared the reviewed content online. A total of 24

patients (54.55%) expressed their thoughts or set down their wishes in the Mind Space

Module.

3.3.3 Difficulty in participation and satisfaction with the WBLRP

A total of 39 out of 44 patients (88.64%) had no difficulties in operating the WBLRP

platform; four patients rated it as moderate in difficulty; and one patient rated it as difficult.

As for satisfaction with the WBLRP, most participants (90.9%) were satisfied with the

program and none reported they were dissatisfied.

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 3.4 Effects of the WBLRP
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3.4.1 Anxiety

Immediately after the intervention, the anxiety scores increased from 31.50 (SD 6.515) to

32.10 (SD 5.525) in the control group and decreased from 29.84 (SD 4.524) to 25.93 (SD

3.738) in the experimental group. There was a significant difference in anxiety between the

two groups (t=6.031, P<0.01) and compared with the experimental group at

pretest-posttest (t=5.330, P<0.01). However, there was no significant difference compared

with the control group at pretest-posttest (t=-0.726, P > 0.05) (Tables 4 and 5).

3.4.2 Depression

Study results found an increase in depression scores, from 36.83 (SD 8.097) to 39.02 (SD

7.475) in the control group; and a decrease in scores, from 34.18 (SD 4.637) to 30.48 (SD

4.369) in the experimental group. When comparing the effects of the program on

depression, the independent sample t-test indicated that significant differences existed

between the two groups (t=6.434, P<0.01) and compared with the experimental group at

pretest-posttest (t=4.423, P < 0.01) (Tables 4 and 5).

3.4.3 Self-transcendence

Immediately after the intervention, the self-transcendence scores increased from 43.05 (SD

6.105) to 43.90 (SD 6.585) in the control group and from 40.75 (SD 6.521) to 53.48 (SD

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 4.583) in the experimental group. Significant changes in self-transcendence were observed
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between the two groups (t=-7.791, P<0.01) and compared with the experimental group at

pretest-posttest (t=-2.244, P<0.05), but no significant differences compared with the control

group at pretest-posttest (t =-0.723, P > 0.05) (Tables 4 & 5).

3.4.4 Meaning in life

There were no significant differences in meaning in life compared with the control group or

the experimental group at pretest-posttest (P>0.05) (Table 5). However, the scores of

meaning in life decreased from 50.52 (SD7.747) to 49.43 (SD 8.642) in the control group,

while increasing from 54.11 (SD 8.162) to 56.64 (SD 10.109) in the experimental group

immediately after the intervention.

3.4.5 Hope

Immediately after the intervention, the hope scores decreased from 36.31 (SD 2.934) to

35.14(SD 3.482) in the control group and increased from 35.86 (SD 3.092) to 36.36 (SD

3.293) in the experimental group. There was no significant difference in hope between the

two groups (t=-1.671, P>0.05) and compared with the experimental group at

pretest-posttest (t=-0.972, P > 0.05) (Tables 4 and 5).

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 4 DISCUSSION
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4.1 Primary findings

This was the first study to evaluate the effects of the WBLRP on Chinese cancer

patients undergoing chemotherapy. It demonstrated that the WBLRP is feasible and suitable

for cancer patients and may be effective at alleviating cancer patients’ anxiety and

depression, as well as improving self-transcendence. It also revealed that the WBLRP is a

promising psychological intervention in fostering cancer patients’ meaning in life and hope.

4.2 Feasibility of the WBLRP

Six participants withdrew from the study (a dropout rate of 6.52%), which was lower than

previous studies on life review conducted in a face-to-face setting (Ando et al., 2007; Xiao,

2011). In the experimental group, 44 out of 48 patients completed the e-life review

interviews, which indicated that the online life review interview was well implemented.

Possible reasons may be that the WBLRP took advantage of the WeChat platform. The

WeChat benefits of simplicity, cheapness, convenience, efficiency and mobility determined

its ease of use for all age groups (Wu & Ding, 2017). It provides a range of ways to

communicate, including text and pictures, voice message and video call. This makes

simultaneous video and audio for communication between individuals possible in real-time.

The WBLRP based on the WeChat platform is enabled to conduct face-to-face e-life review

interviews, which allows the researcher to observe non-verbal cues. Additionally, the four

life review modules were designed to provide images, videos, music and audio-picture

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 books. This information empowers patients to recall memories, summarize key life events,
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express their emotions and set down their wishes. The WBLRP enriches the life review

interview process and more importantly, increases patients’ enthusiasm for participating in

the study.

As for difficulty in participation, most cancer patients experienced little difficulty in

operating the WBLRP platform. It may be because the facilitator provided the participants

with full instruction on the operation of the WBLRP platform until they grasped it

completely. If patients experienced any difficulties afterwards, they were able to consult an

operation brochure. In addition, several considerations were made for older adults, such as

simplifying the procedure for accessing the WeChat platform, adjusting the size of text and

images and so on.

Regarding cancer patients’ attitudes towards the WBLRP, most were satisfied with the

program. A possible reason for this may be because WBLRP is a convenient way for patients

to review their life, beyond the limitations of time and space. Patients can arrange for the

interview to be conducted at a convenient time and at any location. Another reason, may be

due to the fact that WBLRP provides a range of memory prompts, assisting in awakening

patients’ memories and facilitating their recall of their life. In addition, the e-legacy product

is a vivid and a convenient way for patients to review and record their memories for

younger generations. The e-legacy product can help patients appreciate their entire life all

over again and leave a personal legacy for their loved ones.

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 4.3 Effects of the WBLRP
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In this study, there was a statistically significant effect of WBLRP on anxiety and depression

levels among cancer patients, which is in accordance with previous studies (Chen, 2011; Lin

et al., 2016). Possible reasons may be due to the fact that the WBLRP provides an

opportunity for patients to express suppressed frustrations and feelings about misfortunes,

which can release negative emotions accumulated in the heart. Although there may be

painful memories in the life review process, the facilitator would guide them to re-consider

these memories from other perspectives, help them let go, accept or even gain new insights

into their lives and ultimately achieve self-integrity (Woods et al., 2005). Another reason for

the reduction in negative emotions may be because patients retrieve more positive

memories during the WBLRP. Korte et al. (2012) have stated that the accumulation of

positive thoughts play an important part in reducing anxiety and depression. Reviewing their

entire life enables patients to awaken positive feelings from past experiences, learn from

the past and reflect on their contributions to their families and society, which may induce

positive emotions. In addition to the life review interview, the life review modules played a

vital part in alleviating patients’ negative emotions. For example, the Mind Space Module

helped patients reveal their true feelings and thoughts through words; and the Memory

Prompts Module presented a range of familiar materials that awakened positive emotions

of patients.

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 Significant improvements in self-transcendence were detected in this study, which is in line
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with the study by Chen (2011). Self-transcendence is a four-domain quality inherent in

human beings that can be strengthened (Teixeira, 2008). Reviewing a life involves every

domain of self-transcendence. First, life review is a process of recalling and evaluating life

experiences, which can strengthen the inward domain of self-transcendence. During the

WBLRP, patients were encouraged to express their feelings and views on their life

experiences. Importantly, they were facilitated to accept, let go or give new meaning to

negative experiences. Second, the WBLRP helps patients to experience their connectedness

to the moment, self and others, which strengthens the outward domain. They can

reconsider and reflect on their relationships with others and establish a sense of connection

with their surroundings beyond their personal boundaries. One study has found that

creative activities help establish a sense of connection between individuals and their

surroundings (Chen, 2011). When patients created a family tree, it triggered their

recollections of family life. They experienced a sense of warmth as a result of thinking about

their family members, which facilitated a strong link with others. Third, the WBLRP allows

patients to further think about themselves, their illness and life, enhancing the spiritual

domain of self-transcendence. It helps patients gain a better understanding of their current

situation and inspires them to explore the meaning of their life, beyond the physical domain

and the limitations of their disease. When patients created their family tree or lifeline, their

reflections on their family and life were strengthened. Fourth, the WBLRP integrates

patients’ past life and future to enhance their present, which is helpful in enhancing the

temporal domain of self-transcendence. When reviewing their life, patients can collate their

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 life experiences, learn from their past, bring clarity to their current situation and accept or
Accepted Article
even restore order in their life. In addition to the life review interview, the life review

modules also help to enhance self-transcendence. For example, the Mind Space Module can

help strengthen the inward domain of self-transcendence. It is an internal process, where

patients look inside themselves and clarify their personal values, priorities and life meaning.

The Review Extraction Module is a summary of the meaningful events of each life stage and

the e-legacy product helps patients summarize and value their life once again, which can

enhance the temporal domain of self-transcendence.

In this study, there may not be a clear conclusion that the WBLRP exerted a significant

effect on meaning in life and hope between the two groups. However, an increase in the

scores of meaning in life and hope were revealed in the experimental group and a decrease

in the control group, immediately after the intervention. The WBLRP seemed to bolster a

sense of meaning in life and hope in these cancer patients. During the WBLRP, patients not

only expressed their feelings and thoughts and affirmed life values; more importantly, they

were facilitated to find the meaning in negative experiences and finally reconcile them.

However, future studies need to further identify the WBLRP’s effect on meaning in life and

hope.

4.4 Limitations

Several limitations may exist in this study. First, the WBLRP may not be suitable for people

with poor literacy skills, because they may encounter difficulties in completing the four life

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 review modules. Second, due to the non-concurrent controlled group design, there was a
Accepted Article
statistical difference between groups on income, thus the validity of the study findings was

hindered. Third, the generalizability of the findings is limited, as there was only one study

setting. Multi-center and transregional research with a rigorous design is necessary in future

research.

5 CONCLUSIONS

The innovative WeChat-based life review program is a promising non-pharmacological

intervention for cancer patients. It is not only feasible, but also effective in improving

patients’ psychospiritual well-being. It could be integrated into transitional care for cancer

patients in community. Future research with rigorous design is necessary to test the effects

on-line life reviews among cancer patients.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

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Accepted Article
Table 1 Patient demographic characteristics
Variable Total Control group Experimental
N=86 n=42 group χ2 P
n (%) n (%) n=44
n (%)
Age, n (%)
0-40years 11 （12.8） （ ）
3 7.1 （ ）
8 18.2 2.783 0.249 b
41-60years 45 （52.3） （ ）
22 52.4 （
23 52.3
61-80years 30 （34.9） （ ）
17 40.5 ）
13（29.5
）
Gender, n (%)
Male 63 （73.30） 29 （69.05） （
34 77.30 ） 35.724 0.418c
Female 23 （26.70） 13 （30.95） （
10 22.70 ）

Education, n (%)
Primary school 20（23.30） 12 (28.60) 8 (18.20) 5.594 0.232b
Secondary school 46（53.40） 18 (42.80) 28 (63.60)

Tertiary education 20（23.30） 12 (28.60) 8 (18.20)

Marital status, n(%)

Unmarried 4 (4.70) 2(4.80) 2(4.50) 4.497 0.195c
Married 76 (88.40) 35(83.30) 41(93.20)
Divorced 2 (2.30) 1 (2.40) 1(2.30)
Widowed 4 (4.70) 4 (9.50) 0(0.00)
Religion, n(%)
Yes 34(39.50) 14(33.30) 20(45.50) 1.321 0.250b
no 52(60.50) 28(66.70) 24(54.50)
Monthly income, n(%)
≤3000yuan 30(34.90) 19(45.20) 11(25.00) 3.875 0.05b
>3000yuan 56(65.10) 23(54.80) 33(75.00)
：
a: χ2 test; b Fisher’s exact test.

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 Table 2 Patient clinical characteristics
Accepted Article
Variable Total Control group Experimental group
N=86 n=42 n=44 χ2 P
n (%) n (%) n (%)

Cancer type 0.419 0.936a

Gastrointestinal 60(69.77) 29(69.05) 31(70.45)
Respiratory 17(19.77) 9(21.43) 8(18.18)
Urinary Reproductive 6(6.98) 3(7.14) 3(6.81)
others 3(3.48) 1(2.38) 2(4.56)
Surgery 2.935 0.087b
Yes 47(54.70) 19 (45.20) 28 (63.60)
no 39 (45.30) 23 (54.80) 16(36.40)
Metastasis 0.239 0.625b
yes 72 (83.70) 36(85.70) 36(81.80)
no 14 (16.30) 6(14.30) 8(18.20)
First time 0.966 0.326b
chemotherapy
Yes 1(1.20) 0(0.00) 1(2.30)
No 85(98.80) 42(100.0) 43(97.70)
KPS 0.765 0.435a
50~ 22(25.58) 10(23.81) 12(27.27)
60~ 22(25.58) 14(33.33) 8(18.18)
70~90 42(48.84) 18(42.86) 24(54.55)

a:χ2 test b ：Fisher’s exact test

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 Table 3 Landing on the WBLRP platform
Accepted Article Session Total Total
number of numbers Average
clicks of users
Cancer experience 57.82 49 1.18
Before the Adulthood 52.65 45 1.17
interview Childhood and 57.5 46 1.25
Adolescence
Summary of Life 48.4 44 1.1

Cancer experience 44 44 1
Adulthood 46 46 1
After the interview
Childhood and 94 47 2
Adolescence
Summary of Life 42 42 1

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Accepted Article Table 4 Comparison of outcome measures between groups at pretest and posttest

Measure Time Control group Experimental group t P

Mean SD（ ） Mean SD （ ）
pretest 31.50(6.515) 29.84(4.524) -1.833 0.710a
Anxiety
posttest 32.10(5.525) 25.93(3.738) 6.031 0.001b

pretest 36.83(8.097) 34.18(4.637) 1.852 0.069a

Depression
posttest 39.02(7.475) 30.48(4.369) 6.434 0.001b

pretest 43.05(6.105) 40.75(6.521) 1.685 0.096a

Self-transcendence
posttest 43.90(6.585) 53.48(4.583) -7.791 0.001b

pretest 50.52(7.747) 54.11(8.162) -2.090 0.04c

Meaning in life
posttest 49.43(8.642) 56.64(10.109) -3.546 0.001b

pretest 36.31(2.934) 35.86(3.092) 0.685 0.495a

Hope
posttest 35.14(3.482) 36.36(3.293) -1.671 0.098a

a: P >0.05

b: P <0.01

c: P <0.0

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 Table 5 Comparison of outcome measures within groups
Accepted Article Measure Group pretest posttest t P

control group 31.50(6.515) 29.84( 4.524) -0.726 0.472a

Anxiety
experimental group 29.84(4.524) 25.93(3.738) 5.330 0.001b

control group 36.83(8.097) 39.02(7.475) -2.054 0.046

Depression
experimental group 34.18(4.637) 30.48(4.369) 4.423 0.001b

control group 43.05(6.105) 43.90(6.585) -0.723 0.474a

Self-transcendence
experimental group 40.75(6.521) 53.48(4.583) -2.244 0.03c

control group 50.52(7.747) 49.43(8.642) 0.785 0.437

Meaning in life
experimental group 54.11(8.162) 56.64(10.109) -1.877 0.067

control group 36.31(2.934) 35.14(3.482) 2.042 0.048

Hope
experimental group 35.86(3.092) 36.36(3.293) -0.972 0.337a

a: P >0.05

b: P <0.01

c: P <0.05

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Accepted Article

Figure 1. Study flow diagram