eHealth interventions to support colorectal cancer patients’ self-management after discharge from surgery—an integrative literature review

Introduction Colorectal cancer (CRC) creates elevated self-management demands and unmet support needs post-discharge. Follow-up care through eHealth post-primary surgery may be an effective means of supporting patients’ needs. This integrative review describes the evidence regarding eHealth interventions post-hospital discharge focusing on delivery mode, user-interface and content, patient intervention adherence, impact on patient-reported outcomes and experiences of eHealth. Methods A university librarian performed literature searches in 2021 using four databases. After screening 1149 records, the authors read 30 full-text papers and included and extracted data from 26 papers. Two authors analysed the extracted data using the ‘framework synthesis approach’. Results The 26 papers were published between 2012 and 2022. The eHealth interventions were mainly delivered by telephone with the assistance of healthcare professionals, combined with text messages or video conferencing. The user interfaces included websites, applications and physical activity (PA) trackers. The interventions comprised the monitoring of symptoms or health behaviours, patient information, education and counselling. Evidence showed a better psychological state and improved PA. Patients reported high satisfaction with eHealth. However, patient adherence was inadequately reported. Conclusions eHealth interventions may positively impact CRC patients’ anxiety and PA regardless of the user interface. Patients prefer technology combined with a human element.


Background
Colorectal cancer (CRC) is the third most common cancer globally [1].Cancer stages I-III (i.e.nonmetastatic disease) dominate among CRC cases, with curative surgery being the cornerstone of treatment [2].Patients with CRC are prone to comorbidities [3].The impact of surgery, in combination with comorbidities, is found to be highest in the first year following surgery [4].Most CRC patients are currently managed within enhanced recovery schemes [5], including early discharge to home post-surgery, when physiological functions such as oral intake of nutrients or bowel functions may not be fully restored [6].About half of anastomotic leakages after bowel resection occur after discharge from hospital, with serious consequences for the patient [7].Consequently, the period of transition from hospital to home may represent a vulnerable time, prone to issues that can contribute to readmission.Readmission rates for CRC range from 9 to 25% [8] and are deemed markers of quality of care [9].
Following discharge, many CRC patients may struggle with navigating the healthcare system and adopting recommended self-management behaviours.The self-management of CRC includes monitoring health, accessing health information [10] and initiating health behaviour changes, such as exercising more [11].Moreover, CRC patients may struggle with self-management tasks like finding medical information, monitoring health and interacting with healthcare services, which may result in physical and mental fatigue [10].
eHealth is defined as 'the use of information and communication technologies (ICT) for health' [12].eHealth support deployed post-hospitalisation may promote selfmanagement among people with severe conditions [13].However, further insight is needed into how a more seamless eHealth service during the transition from inpatient to outpatient care may enable patients to obtain adequate self-management support, feel safe and recover well [14].
There is some evidence that eHealth can support cancer survivors in the self-management of treatment side effects and complications and increase their quality of life (QOL) [15].Recent reviews of eHealth in the context of CRC populations are sparse.In an overview of reviews on telemedicine (e.g.eHealth) in post-treatment cancer survivorship, none of the 29 included systematic reviews focused on CRC patients only [16].A systematic review aiming to study eHealth support directed at CRC survivors' followup needs upon discharge from the hospital addressed the interventions' service content, outcomes and software infrastructure [17].The findings demonstrated that eHealth was useful for CRC survivors in supporting physiological, psychological and cognitive needs and enabling better symptom management and QOL [17].Nevertheless, there is a knowledge gap concerning technology acceptance and how patients adhere to eHealth interventions.Adherence is defined as 'the extent to which a person's behaviour corresponds with agreed recommendations from a healthcare provider' [18] (p.3), but little is known about how eHealth may promote adherence to recommended CRC self-care [19].
This study aimed to (1) explore the user interface, content and delivery mode of CRC eHealth interventions following discharge after surgery, (2) investigate patient adherence to the interventions, (3) establish intervention effects on patientreported outcome measures (PROMs) and ( 4) describe patients' experiences of eHealth follow-up interventions.

Methods
The study was conducted according to Whittemore and Knafl's five-step framework for integrative reviews [20] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [21].
Step 1: literature search Comprehensive literature searches were performed by a university librarian in October 2021 using the Embase, Medline, CINAHL and Cochrane Library databases, as well as by manually searching reference lists.The search terms, limitations and search results are displayed in Table 1.
Step 2: study selection Endnote™ Version X9 [22] was used to manage the generated records from Search no. 3 (Table 1).After removing duplicates (N=471), a blinded screening of 1373 titles and abstracts was performed using the web application Rayyan [232] and a priori inclusion and exclusion criteria (Table 2).Following the blinded screening, a comparison of the decisions showed discrepancies for 37 records (4.5%), resolved through discussions among the authors.Fifty-nine full-text articles were distributed among the authors and assessed for final inclusion, with conflicting opinions being resolved through discussions among the authors.The results of the study selection process are displayed in a PRISMA flow chart [23].

Step 3: data extraction
To achieve consistency in data extraction, an extraction tool was constructed, including publication identifiers, study design, study context and participants, eHealth program, program adherence and patient outcomes and experiences.Any inconsistencies among co-authors were resolved via the assessment of a second reviewer.

Step 4: critical assessment of articles
The authors used the mixed methods appraisal tool (MMAT) [24] in teams of two to establish the risk of bias in the included studies.Here, the MMAT checklists for randomised controlled trials (RCTs) and non-randomised, descriptive, qualitative and mixed methods were used.Each study was assigned an overall quality score, varying from 25% when one criterion was met to 100% when all criteria were met.The MMAT was used as a summarising tool, with methodological quality considered according to the design of each study.The MMAT score was not used for exclusion decisions [24].Studies were not excluded based on methodological quality.The strength of evidence was summarised as part of the review's limitations.

Step 5: data synthesis
To analyse and synthesise data, the 'framework synthesis approach' was used, which includes five analytical stages: familiarisation with the data content, identification of themes, indexing, charting and mapping and interpretation [25].Data from the extraction table allowed the authors to familiarise themselves with the findings.Coding of the data was performed by one author according to key issues, concepts and themes, namely the outcomes and practices of eHealth follow-up programs, including content, delivery mode and user interface, patient adherence, impact of eHealth interventions and patient experience.The synthesis of the findings was then reviewed by a second author and finally examined by the co-authors.

Results
After the full-text assessment of the 30 records, four were excluded based on the eligibility criteria resulting in a total of 26 included papers  (Fig. 1).

Risk of bias
Among the 12 RCTs, two achieved full scores (7/7 points) [30,51], four achieved 6/7 points [35,42,46,49], five scored 5/7 points [38,40,43,47,48] and one scored 4/7 points [28].Across the MMAT domains, seven of 12 RCTs did not report the blinding of outcome assessors.Nearly all the nonrandomised studies scored 5/6 points, while one achieved 4/6 points [26].Here, the less reported item referred to administration of the intervention as intended (5/8 studies).Only one of the three descriptive achieved the full score of 7 points [45] as the authors of the other two did not report on sample representativeness, risk of non-response bias and appropriate statistical analysis [33,44].The only mixedmethods study scored 5/7 points as it lacked reporting on sample representativeness and an adequate rationale for using a mixed-methods design to address the research question [36].Both qualitative studies [31,50] demonstrated good methodological quality, scoring 7/7 points.

Overview of study characteristics
The studies were published between 2012 and 2022 (Table 3), and most were of European origin.Three studies were performed by the same Swedish research team [31][32][33], while three Dutch studies involved the same eHealth application (i.e.Oncokompas) [47][48][49].Fourteen studies applied RCT or quasi-experimental study methods, seven used observational designs, two were qualitative, two used mixed methods, and one used a case-study design.The study populations ranged from 1 to 756 participants (median number of participants, n=118).In one study, presented in two publications, the CRC patient population accounted for 25% of the participants [47,48].All studies recruited adult CRC patients (18-81 years of age).Median age, based on 21 of 26 studies that provided information on mean or median Fig. 1 PRISMA flowchart of study selection process age was 65 years of age [26-39, 41-44, 46-49, 51].In four studies, most of the participants were female [29,30,35,41,42].Only two studies addressed the importance of a diverse sample as to provide eHealth services to demographically (e.g.education and income) and geographically (e.g.rural areas) diverse groups [42,46].In all the studies, patients were enrolled during the post-operative care trajectory.In eight studies, patients received the eHealth intervention during adjuvant chemotherapy [26, 28-33, 38, 39].
Patient education and information were included as intervention content in 13 of the eHealth programs, six of which provided education and information on PA behaviour change [29,35,36,42,43,46].In four studies, CRC patients received a digital educational program aiming to strengthen patients' self-management skills [34,[47][48][49], while Soh et al. included health education in their mobile care system to support CRC patients' QOL [45].Avci et al. provided patients with education and counselling to lower anxiety levels and chemotherapy-based symptoms [26], while Young et al. delivered educational material to meet the emotional needs of CRC patients following surgery [51].
All the intervention studies comprised an element of monitoring of health condition and symptoms.Eight studies monitored the patient's health condition and treatment side effects by using checklists that the patients responded to electronically [26, 29-31, 35, 39, 41, 44-49].A pedometer or accelerometer was used to monitor daily PA (e.g.number of steps, walking distance, intensity) in six studies [29,35,36,42,43,46], while Cheong et al. applied an activity tracker, like a Fitbit, to monitor the patient's PA and heart rate [29].One study used home telemonitoring to follow up with post-operative patients by monitoring vital signs (using an oximeter, thermometer, sphygmomanometer and echocardiogram) and changes in the surgical wound [49].In one study, CRC patients' health condition was monitored through a video consultation clinic by the surgeon in charge [27].
Eleven studies used a telephone to provide intervention content comprising counselling, therapy or psychosocial support.Four of those studies offered counselling on managing treatment symptoms and late effects [26,39], healthy eating [36] or enhancing self-management [37].Three studies provided supportive calls delivered by nurses focusing on psychosocial support to meet the CRC patients' emotional and informational needs [27,38,50].Two interventions comprised telephone-delivered reminiscence therapy [30] and cognitive behavioural therapy [34] to reduce mental health symptoms of stress, depression and anxiety.In two studies, health coaching to support PA and dietary issues was part of the telephone-based interventions [40,43].In Lynch et al., the eleven 30-min sessions were delivered by nurses, physiologists or health coaches [40], while in Pinto et al., the patients received 12 sessions from research staff based on behavioural cognitive theories to promote exercise self-efficacy [43] (Table 4).

The effects of eHealth interventions on PROMs
A summary of findings on effects from eHealth interventions can be found in Table 3. Sixteen studies included QOL patient outcomes (i.e.health-related quality of life (HRQoL), QOL, subjective well-being, self-efficacy, and sense of coherence) [28-30, 33-38, 42, 44, 45, 47-49].Only, the study by Kim et al. [35] found strong evidence for a significantly improved QOL (p=.000) and selfefficacy (p=0.0075)following the use of the combined       telephonic and mobile app intervention offered to CRC patients for 6 months following primary cancer surgery.
Another study found that HRQoL and sense of coherence levels remained stable throughout the chemotherapy cycles, with no statistically significant change [33].
Psychological morbidities, such as anxiety, depression, fear of cancer recurrence (FCR), distress and fatigue, were reported in eight studies.Both Avci et al. [26] and Beaver et al. [28] used the State-Trait Anxiety Inventory to measure CRC patients' anxiety levels during eHealth followup.They found that receiving a web-and telephone-based eHealth educational intervention, counselling and support [26] and a nurse-led telephone-based intervention comprising CRC care information and inquiring symptoms and emotional concern had significant effects [28].Anxiety and depression were measured by the Hospital Anxiety and Depression Scale (HADS) in the context of a telephone-based intervention of education and support, and both anxiety and depression levels decreased significantly, with p=.07 and .037,respectively, compared with controls [38].A similar telephone-based intervention significantly reduced depression levels (p≤.05) in CRC patients who received reminiscence therapy in addition to telephonebased support, but this result was not achieved with standard care and telephone support only [30].FCR was included as a PROM in one pre-post-longitudinal intervention using telemedicine applications and showed no statistically significant differences from baseline to the 12-week timepoint [34].In one telephone-support-based study [51] and one using a range of remote follow-up approaches (e.g.smartphone app, messaging) [29], no significant time or group differences in distress were observed.Only one study included fatigue as a PROM, measured by the Functional Assessment of Cancer Therapy-Fatigue (FACT-F) scale.Fatigue changed in the hypothesised direction but did not reach statistical significance [36].
Three studies reported on how eHealth may ease cancer treatment side effects.The two quantitative studies by Drott et al. [32,33] measured neurotoxicity from chemotherapy with oxaliplatin.The authors found that none of the participants returned to baseline function after the self-reporting of symptoms on a mobile phone-based system.Avci et al. [26] found that the intervention group experienced chemotherapy side effects significantly less frequently compared with the control group (p≤.05), as well as less severe side effects of infection, hair loss and mouth and throat problems (p≤.05), after receiving a web-and telephone-based eHealth intervention of education, counselling and support.
In six studies, health behaviours such as PA, sedentary behaviour and a healthy diet were studied as outcomes of eHealth interventions.Self-reported PA was included in five of them.All five found significant improvements in PA after CRC patients received eHealth interventions in the form of smartphone applications with information, real-time communication and monitoring [29,35,42] or telephone consultations and written information [36,43].Sedentary behaviour was explored in the RCT by Lynch et al. [40].They found that telephone-based counselling, including exercise instructions and regular support from intervention staff, did significantly reduce sedentary behaviour in a sample of CRC patients.However, no significant differences were observed between the intervention and control groups [40].Two studies investigated the benefits of eHealth interventions regarding patient diet or nutritional status using a smartphone application [29] or telephone consultations and written information [36].Only Grimmett et al. [36] succeeded in proving that the eHealth intervention was beneficial, showing significant increases in self-reported fruit and vegetable consumption (p<.001), with the mean intake exceeding seven portions a day at follow-up.In addition, red meat intake was significantly reduced (p<.013).
Self-management was reported in three of the included articles, representing two studies [47][48][49].Here, the authors used the patient activation measure to study CRC patients' self-management knowledge, skills and confidence.They found no statistical difference between the intervention group following the Oncokompas intervention for 6 months and the control group [47][48][49].Four studies described the eHealth intervention as promoting the self-management of CRC patients but did not include self-management as an outcome [33,36,37,49].In Qaderi et al., self-management information was included as part of a cost overview and as a measurement of CRC patients' satisfaction with the selfmanagement content of a remote follow-up service following surgery [44].

Patient experiences of eHealth follow-up interventions
A total of five studies explored CRC patients' experiences with using eHealth as part of follow-up during or after cancer treatment [27,32,44,46,50].Van Blarigan et al. [46] assessed the acceptability of a PA intervention by surveying the participants' access rates to a Fitbit website and use of interactive text messages.In this study, the intervention was perceived as highly acceptable, and the text messages were found to motivate the participants to exercise.In two other studies, video consultations were used as part of remote follow-up care for CRC patients.Barsom et al. [27] found that video consultations were highly valued for being easy and convenient to use and that the majority of participants wanted to use video consultations in the future.In Qaderi et al. [44], CRC patients expressed high levels of satisfaction with receiving remote follow-up that resulted in fewer hospital visits, saved time and costs, increased healthcare accessibility and efficiency and better communication with healthcare 11 Page 20 of 24 professionals.The perceived disadvantages included less frequent face-to-face contact with healthcare professionals.
The only aim of both qualitative studies was to explore CRC patients' experiences with eHealth.In Drott et al. [32], CRC patients' experiences of using a mobile phone-based system to report symptoms were identified and constructed as the patients being involved in their own care by observing treatment side effects, being able to choose the time and place they answer the questions, and gaining knowledge on how side effects can vary during the cycles of treatment.All the patients in Williamson et al. [50] found telephone follow-up (TFU) to be a positive experience, and all stated a preference for continuing with TFU.They experienced TFU as being accessible, convenient and personalised, and their relationship with the specialist nurse was well taken care of through the telephone consultations.A summary of findings on patient experience with eHealth interventions is displayed in Table 3.

Discussion
This integrative review aimed to review the research on eHealth interventions in the context of CRC survivorship published over the past 10 years to evaluate the mode of delivery, user interface and content of various eHealth interventions, patient adherence to the intervention, effects of eHealth interventions on PROMs and patients' experiences of eHealth follow-up interventions.
Post-surgery eHealth interventions for the follow-up of CRC patients largely revolved around a telephone-based user interface, mainly delivering information, advice or support.For patients with low digital competence or without access to technology, simple solutions like the telephone appear preferable.Meanwhile, it is important to continue to develop more advanced technology that requires patients to play an active role in its application.A substantial number of smartphone subscriptions worldwide enable the use of mHealth applications to support and guide patients with cancer towards better self-management and improved health literacy [52].
The monitoring of health, symptoms or health behaviours was included in all the studies, while over 50% of them provided remote education and information through eHealth.CRC patients report extensive information needs post-surgery and need self-management support to avoid complications and restore normalcy [10].To support CRC patients' self-management needs, a blended approach to eHealth is suggested, with more involvement and attention from healthcare professionals in combination with the technology to ensure successful implementation [53].
Eleven of the studies addressed patients' adherence to the eHealth interventions, and the range among those that calculated adherence rates was 62 to 100% [29, 32, 35, 36, 40-42, 44, 46, 49, 51].This is in line with earlier research on cancer patients' encounters with digital health interventions, which showed adherence rates between 70 and 100% [14].The included studies that reported on patients' adherence to eHealth interventions mainly focused on patient uptake of the intervention, and none of them provided a definition based on a theoretical understanding of adherence.The successful implementation of eHealth services relies on systematic evaluations founded on theoretical frameworks [54].Moreover, uptake of eHealth interventions is aided by the fact that approximately 85% of the global population are connected through mobile networks, with a 5-year increase in smartphone users of 5% [55].
A clear link between eHealth adherence and technology acceptance is predicted by perceived usefulness and perceived ease of use [56].In this review, patients were found to perceive eHealth interventions as highly acceptable and valuable, with both intervention-related factors and patients' personal gains applying to the CRC patients' opinions.Among the intervention-related factors that may positively influence cancer patients' adherence to eHealth are content tailored to meet the patient's needs, customised reminders and real-time contact with healthcare professionals [57].
A cancer diagnosis threatens a patient's emotional health.We found evidence for improved mental health outcomes resulting from eHealth follow-up, mainly decreased anxiety and depression levels [28,30].As confirmed in earlier reviews, eHealth approaches can manage psychological distress among cancer patients [58].An essential finding of this review is the lack of follow-up on FCR among CRC patients, studied in only two of the eHealth interventions.Healthcare professionals need to recognise and support CRC patients' FCR in the early post-treatment stages.eHealth interventions offered during the transition from hospital to home may provide strategies to manage fear and improve the patient's help-seeking behaviour [59].
Many cancer survivors experience physical symptoms that limit their daily life activities and decrease their QOL, and the integration of survivorship-centred care is crucial throughout the cancer care trajectory [60].In the current review, evidence of the efficiency of eHealth in ameliorating chemotherapy side effects was weak.Interestingly, benefits of eHealth follow-up were observed when web-based counselling and education were paired with TFU, involving human contact [26].Considering the finding that CRC patients highly appreciate the combination of personalised care via eHealth programs and sufficient communication with healthcare professionals through eHealth, we argue that eHealth solutions without any human interaction may prove less valuable.This statement is supported by an overview of 15 reviews during post-treatment cancer survivorship care, recommending hybrid approaches combining telemedicine with face-to-face support [16].Cancer patients may experience a 'teachable moment' in the wake of a cancer diagnosis, leading to a change in health behaviours [61] that depends on motivational support from healthcare professionals [62].We found that eHealth interventions containing information, monitoring and realtime communication from healthcare professionals improved CRC patients' engagement in PA.The monitoring of behaviour is the cornerstone of a health behaviour change and is often associated with a positive result [63].In addition, eHealth may facilitate participation for cancer patients who lack access to or cannot conveniently access PA programs in their community [64].

Strengths and limitations
This review clearly describes the methods and outlines the process of data identification and selection as well as steps to synthesise the results from individual studies and evaluate the evidence, all of which create a robust and meaningful review.The inclusion of studies with different study designs enabled a more comprehensive approach to meeting the study aims.On the other hand, even though we employed a rigorous literature search overseen by a highly experienced librarian and used a digital sorting tool for the screening of records, relevant records may have been missed.We did not exclude inadequately reported studies as doing so would not affect the findings in any meaningful way [64].

Conclusion
In this review, we identified 26 studies of eHealth interventions following the discharge of patients from the hospital after curative surgery for CRC.eHealth interventions upon hospital discharge can offer support during a critical period.This review demonstrated that eHealth interventions were mainly telephone-based, delivering education, counselling or support and monitoring symptoms or health behaviours.However, there was a lack of focus on CRC patients' adherence to eHealth.More research is needed on adherence to eHealth programs and its relationship with the implementation of eHealth in CRC populations.
eHealth follow-up may mitigate anxiety and depression in CRC patients, while the proof of its impact on other psychological morbidities or QOL is less clear.We also did not find strong evidence of the ameliorating effects of eHealth programs regarding the side effects of cancer treatment.eHealth interventions may have a positive influence on CRC patients' PA behaviours regardless of the user interface, but the combination of technology and human interaction appears important.In general, remote, digital follow-up was experienced as positive, accessible and usable and as an improvement to healthcare services delivery.
This review can inform future intervention research on discharge planning in CRC care.In addition, it may support clinicians working towards ensuring the uneventful and swift recovery of CRC patients.Furthermore, the findings may have value in the development of eHealth services for other cancer patient populations.

Table 2
Inclusion and exclusion criteria Original and empirical studies using quantitative, qualitative or mixed methods Reviews, syntheses, meta-analyses, book chapters, study protocols, conference papers, grey literature Adult patient populations with CRC Child and adolescent patients eHealth interventions to support CRC patients following primary surgery eHealth studies targeting CRC patients in the pre-surgical phase Studies on screening or surveillance of the development of CRC eHealth studies not reporting on CRC patient outcomes Studies reporting on the development phase of eHealth

Table 3
A summary of findings on included studies' origin, publication year, study design, study participants, patient outcomes, patient adherence, findings and quality assessment score Author (year)