The influence of WeChat education and care program on anxiety, depression, insomnia, and general state of health in parents of pediatric acute lymphoblastic leukemia patients

Purpose WeChat-based education and care program serves as a promising nursing method for relieving mental stress in parents of pediatric patients. This study purposed to explore the influence of the WeChat education and care program (WECP) on mental health, insomnia, and general state of health in parents of pediatric acute lymphoblastic leukemia (ALL) patients. Methods Totally, 146 parents of 73 primary pediatric ALL patients were randomized into the WECP group (74 parents of 37 patients) and standard care (SC) group (72 parents of 36 patients) to receive a 6-month corresponding intervention. Self-rating anxiety scale (SAS), self-rating depression scale (SDS), Athens insomnia scale (AIS), and 12-item general health questionnaire (GHQ-12) were assessed in parents of patients. Results SAS scores at the third month (M3) (P = 0.041) and M6 (P = 0.032) were reduced in WECP group versus SC group. SAS-defined anxiety rate at M6 (P = 0.035) was declined in WECP group versus SC group. SDS score at M6 was descended in WECP group versus SC group (P = 0.024). However, there was no discrepancy in SDS-defined depression rate at any time point between groups (all P > 0.05). AIS scores at M1 (P = 0.015) and M6 (P = 0.021), as well as GHQ-12 scores at M3 (P = 0.007) and M6 (P = 0.001) were decreased in WECP group versus SC group. By subgroup analyses, WECP exhibited good effects at M6 in mothers, but not in fathers. Conclusion WECP is a feasible and efficacy intervention to improve mental stress and health status among parents of pediatric ALL patients, especially in mothers.


Introduction
Acute lymphoblastic leukemia (ALL) is a hematological malignant tumor characterized by the overgrowth of immature lymphoid cells, which is the most frequent type of malignancy in children (Chang et al. 2021).Currently, the advancement of chemotherapy protocols and the development of supportive care have improved the prognosis of pediatric ALL patients, with a 5-year overall survival (OS) rate of 79.9%-90.4% (Hunger et al. 2012;Gunes et al. 2014;Ma H et al. 2014;Inaba and Pui 2021).However, the diagnosis of pediatric ALL imposes a serious burden on the physical and psychological health of patients' parents (Mogensen et al. 2022;Ferraz et al. 2023).Evidence shows that a considerable proportion of parents of pediatric ALL patients suffer from mental distress, sleep problems, and reduced quality of life (Iqbal and Siddiqui 2002;Wang J et al. 2017;Rensen et al. 2022).Therefore, searching for effective interventions is a notable issue to relieve these symptoms in parents of pediatric ALL patients.
WeChat-based education and care program offers a promising nursing mode through the network platform, which addresses the spatial and temporal limitations of medical services (Xu et al. 2021;Wang Z et al. 2023).Notably, the application of WeChat-based education and care programs in the field of parents of child patients has been vastly explored (Yang et al. 2021;Wu et al. 2022).For example, one study illustrates that a WeChat-platform-based education and care program is effective in decreasing anxiety, depression, and post-traumatic stress disorder in parents of pediatric and adolescent patients with osteosarcoma (Wu et al. 2022).Another study suggests that WeChat follow-up management achieves the reduction of anxiety and depression, as well as the improvement of quality of life in parents of premature infants with patent ductus arteriosus (Yang et al. 2021).According to these studies, one hypothesis is proposed that nursing interventions based on WeChat may improve the physical and psychological health status of parents of pediatric ALL patients.However, no relevant studies have been conducted.
Therefore, the present study designed a WeChat education and care program (WECP), intending to investigate its effect on mental stress, insomnia, and the general state of health in parents of pediatric ALL patients.

Patients and parents
This randomized controlled study consecutively enrolled 146 parents of 73 primary pediatric ALL patients who were visited between May 2020 and June 2022.The inclusion criteria were: (1) patients were diagnosed as primary ALL; (2) patients were aged ≤ 18 years; (3) both parents were able to participate in this study (to remove the bias of parent's gender); and (4) both parents were skilled in using the WeChat (Tencent, China) application.The exclusion criteria were: (1) parents or patients who participated in other therapeutic interventions or clinical studies at the same time; (2) parents who had a documented mental illness; (3) mother who was pregnant or breastfeeding; and (4) parents who were reluctant to participate in this intervention method and had no commitment.This study was approved by the Ethics Committee.The written informed consent was signed by all parents.The written informed consent was required to be signed by the patient and his/her guardians if the patient was older than or equal to 8 years, and only by the guardians if the patient was younger than 8 years.

Randomization of parents
The randomization of parents was based on the family (1 family had 1 patient and 2 parents).A block randomization method was used, and the block size was 4. The parents of each family were randomly divided into two groups in a ratio of 1:1.The parents obtained a randomized serial number (parents from the same family had the same serial number) which was placed in an opaque envelope with the grouping information.The above process was carried out by two uninformed nurses.Parents received their envelope after discharge.There were 72 parents of 36 patients in the standard care (SC) group and 74 parents of 37 patients in the WECP group.

Treatment and interventions
This study did not intervene in the treatment of the patients.The treatment was chosen based on the patient's condition and willingness, as well as the doctor's recommendations, and the specific treatment regimen was mainly based on Chinese Childhood Leukemia Group (CCLG)-ALL-2008 or Chinese Childhood Cancer Group (CCCG)-ALL-2015.
After the patient was discharged, SC or WECP intervention was administered to their parents.Parents in the SC group were divided into different teams (8-10 parents per team) for SC, and each team was handled by 1-2 specialized nurses.The SC lasted a total of 6 months, and the main sections were as follows: (1) Pre-discharge education.Before discharge from the hospital, a 1-h offline education was provided by the nurses.The nurses distributed educational brochures to parents and provided them with psychological guidance.The nurses advised the parents to meditate, listen to music, jog, or read regularly to relieve their emotions.(2) Offline psychological and health support.The parents came to the hospital's rehabilitation training room every two weeks for 1-h face-to-face care.Nurses provided parents with relaxation exercises, including 20 min of massage, 20 min of meditation, and 20 min of free communication.(3) Telephone follow-up.The nurses conducted a weekly telephone follow-up with the parents via the phone numbers they left behind.The nurse would ask the parents about the current problems they were facing and provide them timely support.
Parents in the WECP group were divided into different teams (8-10 parents per team) for WECP, and each team was handled by 1-2 specialized nurses.The WECP lasted a total of 6 months.Parents in the WECP group received the same care as parents in the SC group, at the same time, parents in the WECP group received WeChat-based mental and physical health education.The main contents of WECP were as follows: (1) Followed the online public account.The nurses created a public account to upload the full content of the study materials, including educational articles and training videos (instructional videos on meditation and deep breathing).Parents who needed it could learn from the public account at any time.( 2
SAS scores and SAS-defined anxiety were used to measure the level of anxiety of the patients.The SAS score ranged from 25 to 100.Higher SAS scores indicated that the parent was more anxious.When the score was greater than or equal to 50, the parent was considered to be the anxiety.SDS scores and SDS-defined depression were used to measure the level of depression of the parents.The SDS score was ranged from 25 to 100.Higher SDS scores indicated that the parent was more depressed.When the score was greater than or equal to 50, the parent was considered to be the depression (Wang X et al. 2022).The AIS score measured the insomnia of the parents.The AIS score range was 0 to 24, with higher scores indicating more severe insomnia (Wang X et al. 2022).The GHQ-12 score measured the general state of health of the parents.The GHQ-12 score range was 0-12, with higher scores indicating a poorer state of health (Jin et al. 2020).

Data analysis
The calculation of the minimum sample size was based on clinical experience.The SAS score at M6 in the SC group was predicted to be 45, and in the WECP group was predicted to be 50.The standard deviation (SD) was 10.The significance (α) level was 0.05 with a power of 80%.The minimum sample size was calculated to be 64.The study took into account that 10% of patients were lost to followup or disengaged, and the sample size was 72 per group.For data analysis, SPSS 24.0 (IBM Corp., New York, USA) software was used.Continuous variables were displayed by median (range), median and interquartile range (IQR), or mean ± SD.Categorical variables were demonstrated by numbers (percentages).Comparisons between the two groups were used with the Mann-Whitney U, Student's t, Chi-square, and Fischer's exact tests.P < 0.05 were considered statistically different.

Study flow
In total, 160 parents of 80 pediatric ALL patients were selected, among which, 14 parents of 7 patients were excluded (including 10 parents who were not willing to join, 2 parents whose child was not primary ALL, and 2 parents of a patient due to a documented history of mental illness in one of the parents).Then, the eligible 146 parents of 73 pediatric ALL patients were enrolled and divided randomly into the WECP group (74 parents of 37 patients) and the SC group (72 parents of 36 patients) in a ratio of 1:1.In the WECP group, parents received WECP intervention for 6 months, and there were 6 parents who lost to follow-up.In the SC group, parents received SC intervention for 6 months, and there were 2 parents who lost to follow-up.SAS score and SAS-defined anxiety, SDS score and SDS-defined anxiety, AIS score, and GHQ-12 score were assessed at M0, M1, M3, and M6 (Fig. 1).

Clinical traits between the two groups
The patients in the WECP group included 15 (40.5%) females and 22 (59.5%)males, and the median (range) age of patients was 4.0 (2.0-12.0)years.The patients in the SC group included 11 (30.6%)females and 25 (69.4%)males, and the median (range) age of patients was 4.0 (1.0-11.0)years.Regarding parents, the median (range) age of parents in the WECP group was 33.0 (26.0-44.0)years, and the median (range) age of parents in the SC group was 31.0 (25.0-44.0)years.There was no difference in all clinical traits of patients or parents between groups (all P > 0.05).
More detailed clinical traits of patients and their parents are listed in Table 1.

Anxiety and depression of parents in the two groups
SAS scores at M3 (44.8 ± 10.1 vs. 48.8± 12.3) (P = 0.041) and M6 (43.3 ± 9.3 vs. 47.3 ± 12.1) (P = 0.032) were decreased in the WECP group in comparison with the SC group.The SAS-defined anxiety rate at M3 tended to be lower in the WECP group in comparison with the SC group (30.9% vs. 47.1%)(P = 0.050).Notably, the SAS-defined anxiety rate at M6 was declined in the WECP group versus the SC group (29.2% vs. 47.1%)(P = 0.035) (Table 2).
SDS score at M6 was descended in the WECP group compared to the SC group (42.7 ± 9.1 vs. 46.5 ± 10.0) (P = 0.024).While no discrepancy was found in the SDSdefined depression rate at any time point between the two groups (all P > 0.05) (Table 2).

Discussion
Parents of children with malignancies often inevitably develop a series of psychological problems (Agbayani et al. 2022).One previous study shows that anxiety and depression rates among parents of pediatric ALL patients are 45.4 and 57.7%, respectively (Wang et al. 2017).Another research illustrates that depression is observed among 56.7% of parents of pediatric ALL patients (Iqbal and Siddiqui 2002).In our study, baseline SAS/SDS-defined anxiety and depression rates in parents of pediatric ALL patients were 54.1-55.6% and 41.9-43.1%,respectively.The baseline anxiety and depression rates in our study differed slightly from previous studies (Iqbal and Siddiqui 2002;Wang et al. 2017), which was possible because: (1) All patients in the previous study have high school education or above (Wang J et al. 2017), while a proportion of 44.4% parents in our study had less than a high school education.Thus, the differences in the included population might lead to different results.( 2 Therefore, the different results in depression rates might be due to the differences in assessment scales.In any case, searching for effective nursing interventions is a key issue in relieving the anxiety and depression of parents of pediatric ALL patients (Wang et al. 2018).
As the main communication tool of contemporary people, WeChat has broken the limitations of time and space required by ordinary nursing, which provides a more convenient nursing mode (Xu et al. 2021;Huang et al. 2023).In our study, WECP effectively achieved the reduction of SAS/ SDS-defined anxiety and depression versus SC in parents of pediatric ALL patients.There were several possible explanations: (1) WECP strengthened psychological education for parents through the online public account, which enabled  parents to understand their mental problems conveniently and take corresponding measures timely (Hu et al. 2021).( 2) WECP provided a platform for parents to consult nurses oneon-one when they encountered psychological issues, and the pressure might be relieved effectively under the guidance of nurses (Ma C et al. 2021;Wu et al. 2022).
(3) WECP promoted communication among parents, which made parents share learning experiences, release negative emotions, and gain encouragement from each other (Luo et al. 2019).Thus, WECP improved the mental health of parents of pediatric ALL patients.In addition, our study also found that WECP relieved insomnia and improved the general state of health in parents of pediatric ALL patients.These findings were probably due to the fact that: (1) WECP provided instructional videos through the online public account, which encouraged parents to train without the constraints of time and space, thus increasing the training efficacy.Meanwhile, meditation and deep breathing training relieved the pressure on parents by regulating the autonomic nervous system, thereby reducing insomnia (Jerath et al. 2018).( 2) In WECP, the nurses checked parent's training regularly to ensure the training quality and quantity, which enhanced the parent's self-care ability and physical status, thus improving the general state of health (Ma D et al. 2018;Luo et al. 2019).( 3) Based on the results of our study, WECP alleviated the pressure and elevated the sleep quality of parents, which might contribute to the improvement of the general state of health (Schneiderman et al. 2005;Matsui et al. 2021).
In addition, subgroup analyses exhibited that the WECP yielded better outcomes versus SC in mothers of pediatric ALL patients, while there was no difference in outcomes in fathers between the two groups.These findings indicated that WECP might be more applicable to mothers of pediatric ALL patients versus fathers.This result might be attributed to the following points: (1) Compared with fathers, mothers might have a greater need for emotional venting and social support (Clarke et al. 2009;Wan Ghazali et al. 2023), and WECP satisfied their needs by building an online platform.Thus, WECP might be more effective for mothers of pediatric ALL patients.(2) Compared with men, women might be more willing to actively seek for help through social media when facing psychological or physical problems (Judd et al. 2008;Smail-Crevier et al. 2019).Therefore, WECP worked better among mothers of pediatric ALL patients.However, more studies were needed for verification.
Notably, our study excluded parents who had a documented mental illness and mothers who were pregnant or breastfeeding.The reasons were as follows: (1) Parents who had a documented mental illness might not be suitable to participate in therapeutic interventions or clinical studies; meanwhile, their mental illness might bias the results to a certain extent.Moreover, previous studies also excluded  parents who have a documented mental illness (Ma et al. 2021;Xu et al. 2021;Wu et al. 2022).( 2) Clinical studies usually exclude mothers who are pregnant or breastfeeding due to concerns about possible harm to these mothers and their infants (Ma et al. 2021;Kang and Li 2022;Leung et al. 2023).Thus, our study also excluded mothers who were pregnant or breastfeeding.
Our study had some limitations: (1) Data show that parents of pediatric ALL patients may report mental stress, sleep problems, and reduced quality of life in the long term (Rensen et al. 2022), while the intervention and follow-up period of our study was only 6 months.Therefore, the longterm effect of WECP on parents of pediatric ALL patients was required to be investigated.(2) Parents of pediatric ALL patients were easily aware of their grouping during the intervention period, which might cause biased results.(3) The assessment scales were single in our study, and further studies with multiple assessment scales were needed to comprehensively evaluate physical and psychological symptoms in parents of pediatric ALL patients.

Conclusion
In conclusion, WECP is helpful for parents of pediatric ALL patients to relieve anxiety, depression, and insomnia, as well as improve health status, whose effects are better for mothers.
) Joined the online WeChat group.Through the WeChat group, parents could add the nurse's account, and if they encountered problems, they could communicate with the nurse oneon-one at any time.(3) Regular feedback on training.Each parent regularly uploaded videos of his/her meditation and deep breathing training to the assigned nurses, which was urged and checked by the nurses to ensure that the training was completed in a quality and quantity manner.(4) Parents communicated with each other in the WeChat group.Deep communication between parents started once a week in the WeChat group for at least an hour.Parents could share what they learned from the study, how they took care of their patients, or what troubles they had recently in their lives and work.The main purpose of the program was to let parents help each other.In addition to the professional education from doctors and nurses, parents could receive emotional support from other parents.

Fig. 1
Fig. 1 Study flow chart ) The previous study assesses depression through the Mini Mental State Examination (MMSE) and Structured Clinical Interview according to the Diagnostic and Statistical Manual of Mental Disorders-fourth version (SCID-IV) (Iqbal and Siddiqui 2002), while our study evaluated depression by SDS.

Fig. 2
Fig. 2 Comparison of AIS score of parents between groups

Fig. 3
Fig. 3 Comparison of GHQ-12 score of parents between groups

Table 1
Characteristics of pediatric ALL patients and their parents ALL acute lymphoblastic leukemia, SC standard care, WECP WeChat education and care program, IQR interquartile range, T-ALL T-cell acute lymphoblastic leukemia, B-ALL B-cell acute lymphoblastic leukemia, FAB French-American-British classification systems, WBC white blood cell, PPR prednisone poor response, PGR prednisone good response, CNY Chinese Yuan a 73 patients were analyzed

Table 2
Comparison of outcomes for parents between SC and WECP groups SC standard care, WECP WeChat education and care program, SAS self-rating anxiety scale, SD standard deviation, SDS self-rating depression scale, M0 before intervention, M1 first month after intervention, M3 third month after intervention, M6 sixth month after intervention

Table 3
Subgroup analysis of the outcomes at M6 for parents based on the relationship with pediatric ALL patients M6 sixth month after intervention, ALL acute lymphoblastic leukemia, SC standard care, WECP WeChat education and care program, SAS self-rating anxiety scale, SD standard deviation, SDS self-rating depression scale, AIS Athens insomnia scale, GHQ-12 12-item general health questionnaire