The effect of technology-based interventions on child and parent outcomes in pediatric oncology: A systemic review of experimental evidence

Abstract

Objective

In recent years, childhood cancers have become an increasingly important health problem worldwide. Evidence shows that technology-based interventions in pediatric oncology are effective, feasible, and acceptable. However, studies in this field are limited. This systematic review was planned to examine the available evidence for the impact of technology-based interventions on children, adolescents with cancer patients, and their parents.

Methods

In the systematic review, studies published between 2014 and 2023 from The Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with Full Text, Cochrane Library, PsycINFO, ProQuest PubMed, Science Direct, Scopus, and Web of Science databases were identified using a search strategy. Six studies by the criteria were examined in terms of the technology-based intervention, the intervention's duration, the follow-up period, significant findings, and the theory used in the intervention. The Joanna Briggs Institute (JBI) critical appraisal tools were used to evaluate the quality of the studies. In this systematic review, preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed.

Results

A total of six studies met the inclusion criteria: five randomized controlled trials and one quasi-experimental study. In studies for children with cancer, it was determined that the children were between the ages of 6 and 18. It has been determined that technology-based interventions mostly consist of electronic health interventions such as web-based interventions, virtual reality, and digital and mobile health interventions such as messaging, phone contact, and smartphone applications. In the studies, the intervention period ranged from 1 to 1.5 ​h and 10 weeks, and the follow-up periods ranged from 12 weeks to 6 months. In studies for parents, it was observed that the intervention durations ranged from 8 to 12 weeks, and the follow-up periods varied between 3 and 12 months. In most of the studies, technology-based applications have positive effects on the physical and psychological (symptom management, anxiety, stress, coping, and quality of life) problems of children and adolescents. Technology-based interventions affect parents' knowledge levels and coping skills, psychosocial symptoms (anxiety, post-traumatic stress disorder, depression, and caregiver burden), resilience, social support, and self-efficacy.

Conclusions

Technology-based interventions have been effective in improving physical and psychological symptoms in children with cancer, and parents' coping and psychosocial symptoms. These results should be interpreted with caution due to the limited number of studies, small sample sizes, and high heterogeneity. Comprehensive and high-quality randomized controlled trials are needed to obtain the best evidence for the effectiveness of technology-based interventions in pediatric oncology.

Systematic review registration

PROSPERO registration number was CRD42022297664.

Introduction

Today, the incidence of childhood cancers has become an important health problem increasing gradually all over the world and in our country.^1,2 Every year, approximately 300,000 children and adolescents aged 0–19 are diagnosed with cancer in the world.² In our country, it is known that the incidence of childhood cancer is approximately 2500–3000 per year.³ In recent years, with the developments in the treatment processes of childhood cancers, positive developments have been observed in the prognosis of childhood cancers.¹ However, there is strong evidence that children, adolescents, and parents experience many physical, emotional, and psychosocial symptoms during active treatment, home care, or survivorship during their cancer experience, which includes intensive treatment protocols4, 5, 6.

It is seen that technology-based interventions are planned in current research on children with cancer and their parents6, 7, 8. Technology-based interventions consist of electronic health (e-health) applications and mobile health (m-health) applications;^9,10 E-health applications include web-based applications, digital applications, and virtual reality, while m-health applications include mobile and wireless applications such as messaging, mobile applications, wearable technologies, and social media11, 12, 13. Technology-based health interventions for children and adolescents provide information, feedback, and assessment; facilitate child-health professional communication; offer supportive networking and real-time health problem detection.^9,10,14 Moreover, technology-based interventions are easy, accessible, cost-effective, and feasible in terms of supporting, communicating, and monitoring families15, 16, 17, 18. In the literature, technology-based interventions in pediatric oncology are related to physical care such as monitoring health status and symptom management. It has been determined that it is used to provide psychosocial support to improve psychosocial well-being, coping skills, resilience, and self-efficacy in children and parents^7,8,19, 20, 21.

In recent years, research has been ongoing in pediatric oncology nursing to improve child and parents’ outcomes in physical and psychosocial areas during childhood cancer experience.^15,21 In the current literature, it has been determined that research on children with cancer patients and their parents is mostly planned based on technology.^8,13,14,22 Pediatric oncology nurses can provide physical and psychosocial support to children with cancer and their parents through technology-based programs.^14,23 They also have an important role in determining the care needs of children with cancer and empowering children and parents with evidence-based and family-centered care.^6,24,25 While there are systematic reviews and meta-analyses evaluating the effect of technology-based programs for children with cancer patients or their families,^9,11,16,26 there is a need for studies that will contribute to the evidence-based knowledge in this field. In recent years, when the existing evidence in pediatric oncology is examined, it is seen that technology-based applications are used in a wide variety (such as symptom management and psychosocial support). However, there is a lack of synthesized evidence regarding the effects of technology-based interventions on children undergoing cancer treatment or survivors and their parents. This gap may affect understanding the impact of technology-based interventions for children with cancer and their parents in pediatric oncology. This systematic review will contribute to the field by providing evidence for the effectiveness of technology-based interventions to support and empower children with cancer and their parents.

This systematic review was planned to examine the available evidence for the effect of technology-based interventions on children with cancer and their parents. Therefore, answers to the following questions were sought.

• 1.What kind of technology-based interventions have been used in research on children with cancer and their parents?
• 2.What is the duration of technology-based interventions for children with cancer and their parents?
• 3.What is the follow-up period of technology-based interventions for children with cancer and their parents?
• 4.What are the important outcomes of technology-based interventions for children with cancer and their parents?
• 5.What are the theories or models used in technology-based studies for children with cancer and their parents?

Methods

Study design

This research was designed as a systematic review. The protocol of the study was registered on the PROSPERO database (CRD42022297664). In this systematic review, PRISMA (preferred reporting items for systematic reviews and meta-analyses) guideline was followed.²⁷

Eligibility criteria for the study

The inclusion criteria of this study were based on the population, intervention, comparison, outcome, study design method.

Inclusion criteria

• -Population: Studies whose sample consists of children, adolescents with cancer up to the age of 18 (including active treatment process and survivor period), or their parents.
• -Intervention: Technology-based interventions
• -Comparison: Control group or standard care
• -Outcome: Children's physical (symptom management) and psychological (stress, coping, etc.) outcomes

Parents' psychosocial (depression, coping skills, resilience, and self-efficacy) outcomes.

• -Study type: Experimental studies (randomized controlled trials (RCTs) and quasi-experimental studies with a control group)

Exclusion criteria

• -Studies on children with advanced, relapsed, or refractory cancer and their parents
• -Interventions for children with cancer including end-of-life, death period, and interventions for parents after the death of a child
• -Studies on aged ≥ 18 years adolescents and young adults and adult cancer patients
• -Studies for children with a psychiatric diagnosis and their parents
• -Face-to-face studies
• -Descriptive, cross-sectional, case–control, cohort studies, pretest–post-test experimental studies with a control group, discontinuous time series, qualitative studies, feasibility studies, cost-effectiveness studies, study protocols, conference proceedings, or abstracts

Search methods

Two reviewers independently analyzed research articles published between 2014 and 2023 in eight databases from baseline to November 20, 2022: PubMed, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with Full Text, Cochrane Library, PsycINFO, ProQuest, Science Direct, Scopus, and Web of Science. Additional records were identified through hand searching. The literature review was carried out using a systematic search strategy based on research questions in line with medical subject headings terms and combinations of synonyms with subjects on all items using Boolean (‘AND’ and ‘OR’) operators for each database. The reviews were analyzed using a search strategy from the identified databases as follows.

• -(Child OR children OR pediatric OR adolescent OR pediatric) AND (cancer OR neoplasm OR “childhood cancer” OR “children with cancer” OR “pediatric oncology” OR “pediatric cancer” OR “childhood cancer survivors” OR “adolescents and young adults survivors” OR “childhood cancer survivors” OR “pediatric cancer survivors” OR “adolescent cancer survivors”) AND (families OR parents OR caregivers OR “parents of children with cancer” OR “family of children with cancer”) AND (“ web-based interventions” OR “technology-based interventions” OR “mHealth interventions” OR “eHealth” OR “connected health interventions” OR “digital health interventions” OR “smartphone app” OR “smartphone-based interventions” OR “wearable technologies” OR “technology-assisted interventions” OR “technology-based psychosocial interventions” OR “telehealth support” OR “videoconference-based” OR “virtual reality” OR “web-based supportive interventions” OR “digital health interventions”)
• -EndNote X9 reference management program was used to save the studies obtained as a result of scanning from databases to eliminate duplications. The flow chart created in line with the PRISMA 2020 writing guide in the search strategy is given in Fig. 1.

Fig. 1.

Flow diagram of the studies included in the review in line with the PRISMA. PRISMA, preferred reporting items for systematic reviews and meta-analyses.

Study selection and data extraction

All search results were imported into the reference management software Endnote X9 for data management. After all duplicate articles were deleted, two reviewers independently screened the articles and cross-checked them. Any disagreements about whether to include an article were resolved through consultation with a third reviewer. As a result of the evaluation, a consensus was reached between the two researchers. The selection process of the studies in the research consisted of three steps. These steps were the evaluation of the study as title, abstract, and full text. First, the studies were evaluated in terms of the suitability of the study title by the first researcher who screened the database. Studies that did not meet the inclusion criteria in terms of the title were eliminated at this step.

Studies that met the inclusion criteria in titles and abstracts were recorded through the EndNote X9 program, and the full texts were accessed. Full texts were analyzed by two independent researchers in terms of meeting the inclusion criteria and their methodological quality and transferred to the data extraction table. The same two reviewers extracted the information from each article, including the year, place of the study, the design of the study, the number of samples and their characteristics, the characteristics of the technology-based interventions applied, the duration of the intervention, the duration of the follow-up, the important results obtained, and the theories used in the intervention. The study was conducted in line with the PRISMA writing guide published in 2021 for systematic review and meta-analysis studies.²⁷

Quality assessment

Two reviewers independently evaluated the methodological quality of the included studies using the Joanna Briggs Institute (JBI) critical appraisal tools (JBI for experimental design and JBI for quasi-experimental design).^28,29 Selection bias, performance bias, detection bias, and reduction bias of the studies were evaluated with JBI quality assessment tools. JBI for randomized controlled studies consists of 13 questions. Questions have four answers: ‘Yes’, ‘No’, ‘Unclear’ (If it does not present facts about a particular topic), and ‘Not applicable (NA)’ (If a question is not performed). Each question is scored as ‘Yes’ (1 point), ‘No’ (0 point), ‘Unclear’ (0 point), or ‘Not applicable’ (0 point). The total score varies between 0 and 13²⁸. JBI for quasi-experimental studies consists of 9 questions. Each question is scored as ‘Yes’ (1 point), ‘No’ (0 point), ‘Unclear’ (0 point), or ‘Not applicable’ (0 point). The total score ranged from 0 to 9 points.²⁹ The high scores obtained from both tools indicate that the research is of methodological quality.^28,29 Studies that scored less than or equal to half of the items examined were considered to have significant bias, resulting in low methodological quality. The Turkish validity and reliability of the quality assessment tool developed by the JBI critical appraisal tools for experimental and quasi-experimental designs were adapted by Nahcivan and Seckinli^30. The evaluations of the studies through the JBI checklists created for experimental and quasi-experimental designs are given in Table 1.

Table 1.

Main characteristics of the studies included in the systematic review (n ​= ​6).

Author/Year/Country	Study design	Sample characteristics	Aim	Intervention/intervention and follow-up period	Outcome measures	Primary outcomes	Theory/model
Cheng and Than 2021/Canada	Randomized controlled trial	10–18 years of age with cancer diagnosis (n = 50) n = 25 (intervention) n = 25 (control)	To evaluate the effect of a home-based multimodal symptom-management program for decrease of nausea and vomiting, fatigue, pain, mucositis, and anxiety in children and adolescents undergoing chemotherapy for hematological malignancies or solid tumors	The key feature of the symptom-management program was its inclusion of a home or visit and regular phone contact (mHealth) Intervention period: Intervention before or during the first 2 weeks of the first chemotherapy cycle (1–1.5 h) Follow-up period: The targeted symptoms were measured at baseline (after diagnosis), at the first 2 weeks of each cycle of chemotherapy, and at 6 months after baseline	-Symptom assessment (Nausea and vomiting, fatigue, pain, mucositis) -Anxiety	A comparison between the groups showed that the intervention group had a significant less fatigue over time (P < 0.05). However, no differences were found with respect to nausea and vomiting, pain, mucositis, and anxiety between groups.	The home-based multimodal symptom-management program was underpinned by the Social Cognitive Theory (self-efficacy and empowering to make positive behavior change) and the Symptom Cluster Concept
Wong et al., 2021/China	Randomized controlled trial	Pediatric cancer patients aged 6–17 years (n = 108) n = 54 (intervention) n = 54 (control)	To determine whether virtual reality (VR) distraction intervention can alleviate pain and anxiety and reduce length of procedure among pediatric cancer patients undergoing peripheral intravenous cannulation (PIC).	VR intervention was offered to patients 5 min before and during PIC. During the intervention, patients experienced a sense of immersion through the device delivering the VR sounds and images. VR videos for these patients to choose from, and all of them prefer VR cartoons over VR museum or VR water worlds (where users explore famous sceneries in the virtual world) Intervention period: Measurements were conducted at 5 min before, during, and immediately after the procedure. Follow-up period: None	The primary outcome; -Child-reported pain. Secondary outcomes; -Child-reported anxiety, -Pulse rate, -Length of procedure	Pediatric cancer patients in the intervention group demonstrated a significantly greater reduction in pain (P = 0.007), and anxiety levels (P < 0.01) compared with the control group. The mean duration (in minutes) for the PIC procedure was significantly shorter among participants receiving virtual reality intervention compared with the control counterparts (P = 0.02). However, no significant difference was observed in pulse rate during and after the procedure between groups.	The Gate Control Theory of pain was adopted as a conceptual framework to guide this trial
Arpaci et al., 2023/Turkey	Randomized controlled trial	Adolescent survivors of childhood leukemia who were between the ages of 12 and 18 (n = 55) n = 24 (intervention) n = 31 (control)	To evaluate the efficacy of the technology-based, psychosocial education and counseling program on survivors' QOL, self-efficacy, and coping skills within the scope of a health promotion model for adolescent survivors of childhood leukemia	Web-based program included 10 weeks of education and counseling on the web and 3 months of follow-up, which consisted of 5 modules and mobile messages were sent to motivate them to practice recommendations in each module Intervention period: 10 week Follow-up period: Post-intervention, 1 month, and 3 months post-intervention	-Quality of Life (QoL) -Self-efficacy -Coping skills	The 3 month post-intervention QoL total and psychosocial subscale scores in the intervention group were significantly higher than the control group (P < 0.05). The emotional self-efficacy subscale scores and the active coping scores of the intervention group adolescents were significantly higher than those in the control group (P < 0.05). Negative coping scores were lower in the intervention group than in the control group (P < 0.05)	Pender's Health Promotion Model
Wang et al, 2018/Canada–China	Quasi-experimental design	Parents of children with cancer (n = 92) n = 43 (intervention) n = 49 (control)	To evaluate the efficacy of m-health supportive care intervention in parents of children with Acute Lymphoblastic Leukemia (ALL)	Parents in the intervention group received the m-health supportive care intervention with standard health education. Parents in the control group received standard education and were followed for 3 months. The intervention consists of 2 parts -- Android smartphone app “Care Assistant (CA)” and - WeChat account - WeChat was used to update parents' information, while the CA smartphone application was the main intervention application, consisting of 8 modules Intervention period: 3 months Follow-up period: 3 months	-Anxiety -Social support -Caregiver burden -Parents' perception of uncertainty in diseases -Quality of life -Parents' knowledge levels and needs	Parents' uncertainty about anxiety (P = 0.03) and illness (P = 0.01) decreased, parents' social functions improved (P = 0.01), parents' knowledge levels on ALL and care increased (P < 0.001), and knowledge levels and needs decreased (P < 0.001).	Theory or Model not used
Luo et al, 2021/China	Randomized controlled trial	Parents of children with cancer (n = 103) n = 52 (intervention) n = 51 (control)	To evaluate the effectiveness of a mobile application-based resilience program on depressive symptoms, resilience, and quality of life in parents of children with cancer	In line with the resilience model aimed at reducing depressive symptoms and increasing resilience and quality of life, the program is applied to the parents of children diagnosed with cancer through a mobile application consisting of 8 modules. Intervention period: 8 weeks Follow-up period: 2 nd month and 6th month follow-up	-Resilience -Depressive symptoms -Quality of life	In the sixth month follow-up; It was determined that resilience level was higher (P < 0.01) and depressive symptoms were lower (P < 0.01) in the intervention group. In the 6-month follow-up, the quality of life score in the intervention group was found to be higher than the control group, but it did not have a significant effect (P = 0.07)	ResilienceM odel
Cernvall et al., 2017/Sweden	Randomized controlled trial	Parents of children with cancer (n = 58) n = 31 (intervention) n = 27 (control)	To evaluate the long-term effectiveness of e-health-based, guided support for parents of children diagnosed with cancer	Technology-based support program focusing on psycho-education and coping skills based on cognitive behavioral theory Intervention period: 10 weeks Follow-up period: 12 months	Primary outcome; -Post-traumatic stress disorder (PTSD) Secondary outcome; Depression, anxiety, health care use	The program was found to be effective on PTSD in the post-intervention evaluation (P = 0.01) and 12-month follow-up (P = 0.03). Depression (P < 0.001) and anxiety (P = 0.006) results were significantly reduced in the intervention group	Cognitive Behavioral Theory

Data synthesis and analysis

The data extraction form was made by two independent researchers using the following parameters: (1) author/year/country, (2) study design, (3) sample size, characteristics, (4) characteristics of technology-based interventions, duration of intervention, duration of follow-up, (5) assessment measures, (6) primary outcomes, and (7) intervention theories used. Due to the heterogeneity of technology-based interventions (m-health and e-health), intervention times, primary outcomes, and sample group (child or parent), the results could not be analyzed statistically and meta-analysis could not be performed. As a result, the outcomes of this review were reported with a systematic methodology.

Results

Characteristics of studies

A total of 6 studies including five RCTs^{8,13,14,22,24} and one quasi-experimental study²⁵ were included in the study. Included studies were carried out in Canada, China, Turkey, and Sweden. The publication dates of the studies were between 2017 and 2023. The sample of the studies examined consisted of children with cancer (a heterogeneous group in terms of the type of childhood cancer) and their parents.

The sample of the studies examined consisted of 213 children with a cancer diagnosis or who were in the survivor periods.^13,14,22 It was observed that the age range of children and adolescents included in the sample of the studies was 6–18 years.^13,14,22 Studies on parents consisted of 253 parents whose children were diagnosed with cancer.^8,24,25 In a study examined, the sample consisted of parents whose children were treated for acute lymphoblastic leukemia,²⁵ whereas in another study, parents of children with heterogeneous childhood cancer types such as leukemia, sarcoma, lymphoma, central nervous system tumors, and other varieties were included.^8,24 The author, year and country of the studies, study design, sample size and characteristics, technology-based interventions, duration of intervention and follow-up period, primer outcomes, and theory or model used in the intervention are shown in Table 1.

Outcome assessment

It was determined that pediatric symptom assessment, anxiety, self-efficacy, quality of life, and pediatric cancer coping assessment tools were used as an assessment for children in the studies.^13,14,22 In parents, anxiety and depression inventories, uncertainty in diseases, caregiver burden, resilience, social support, self-efficacy, and quality of life assessment tools were used.^8,24,25

Risk of bias within studies

The evaluations of the studies through the JBI Critical Appraisal Checklist for RCTs and quasi-experimental designs are given in Table 2.

Table 2.

Results of JBI critical appraisal tools for randomized controlled trials and quasi-experimental designs.

JBI Critical Appraisal Checklist for	Arpaci et al.	Cheng and Tan	Wong et al.	Cernvall et al.	Luo et al.
Randomized Controlled Trials	2022	2021	2021	2017	2021
1.Was true randomization used for the assignment of participants to treatment groups?	Yes	Yes	Yes	Yes	Yes
2.Was allocation to treatment groups concealed?	Yes	Yes	Yes	Yes	Yes
3.Were treatment groups similar at the baseline?	Yes	Yes	Yes	Yes	Yes
4.Were participants blind to treatment assignment?	Unclear	Yes	NA	No	No
5.Were those delivering treatment blind to treatment assignment?	Unclear	Yes	NA	No	Yes
6.Were outcomes assessors blind to treatment assignment?	Unclear	Unclear	Unclear	Unclear	Unclear
7.Were treatment groups treated identically other than the intervention of interest?	Yes	Yes	Yes	Yes	Yes
8.Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed?	Yes	Yes	Yes	Yes	Yes
9.Were participants analyzed in the groups to which they were randomized?	Yes	Yes	Yes	Yes	Yes
10.Were outcomes measured in the same way for treatment groups?	Yes	Yes	Yes	Yes	Yes
11.Were outcomes measured in a reliable way?	Yes	Yes	Yes	Yes	Yes
12.Was appropriate statistical analysis used?	Yes	Yes	Yes	Yes	Yes
13.Was the trial design appropriate, and were any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?	Yes	Yes	Yes	Yes	Yes

JBI Critical Appraisal Checklist For	Wang et al.
Quasi-Experimental Studies	2018
1.Is it clear in the study what is the ‘cause’ and what is the ‘effect’ (ie, there is no confusion about which variable comes first)?	Yes
2.Were the participants included in any comparisons similar?	Yes
3.Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?	Yes
4.Was there a control group?	Yes
5.Were there multiple measurements of the outcome both pre and post the intervention/exposure?	Yes
6.Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed?	Yes
7.Were the outcomes of participants included in any comparisons measured in the same way?	Yes
8.Were outcomes measured in a reliable way?	Yes
9.Was appropriate statistical analysis used?	Yes

∗ NA: Not Applicable.

Characteristics of technology-based interventions, intervention, and follow-up period

In this systematic review, among technology-based interventions for children, there were e-health interventions such as web-based psychosocial education and counseling interventions for self-efficacy, quality of life, and coping; virtual reality-based distraction intervention for anxiety and pain; m-health interventions such as messaging, phone contact, for home-based symptom management. In the studies, it was determined that the intervention period ranged from 1 to 1.5 ​h and 10 weeks and the follow-up periods ranged from 12 weeks to 6 months.^13,14,22

In this systematic review, among technology-based interventions for parents, there were e-health interventions such as web-based psycho-educational interventions for coping skills, and m-health interventions such as mobile applications for supportive care, and mobile application-based programs on psychologic symptoms, resilience, and quality of life in parents of children with cancer. In studies for parents, it was observed that the intervention durations ranged from 8 to 12 weeks and the follow-up periods varied between 3 and 12 months.^8,24,25 Technology-based interventions, duration of intervention, and follow-up period are shown in Table 1.

Primary outcomes

Primary outcomes of technology-based interventions for children with cancer are symptom management (nausea and vomiting, fatigue, pain, mucositis),^13,14 anxiety,^13,14 quality of life,²² coping skills,²² and self-efficacy.²² The primary outcomes in parents are psychological symptoms (anxiety, depression, caregiver burden),^8,24,25 social support,²⁵ quality of life,^8,25 uncertainty about diseases,²⁵ resilience,²⁴ and parents' knowledge.²⁵

Theories–models used in the intervention

It was determined that Social cognitive theory, symptom cluster concept, the gate control theory, and Pender's health promotion model were used in studies on children and adolescents,^13,14,22 and cognitive behavioral theory and resilience model were used in studies for parents.^8,24

Discussion

In recent years, technology has become widespread in every field, and it has brought essential transformations in the diagnosis, treatment, and follow-up processes of diseases, especially in health systems.^7,12 In addition, technology-based interventions in pediatric oncology are increasing.^5,7 It has been determined that technology-based interventions are e-health and m-health interventions for children receiving active cancer treatment or survivors in pediatric cancer patients or their parents.^9,10 In a systematic review by Ramsey et al. to examine e-health and m-health interventions in pediatric cancers, technology-based monitoring has been found to be an important component in influencing health-related outcomes.⁶ In the study by Linder et al. evaluating the game-based symptom assessment application for children with a cancer diagnosis at school age, it is stated that children mostly like the aspects of the application that support their creativity and offer options, while parents like the interactive nature of the application and its ease of use.¹⁵ In the meta-analysis of Sari Ozturk and Toruner, technology-based psychosocial interventions are effective in reducing anger, anxiety, and depression in children with cancer.³⁴ Also, in the meta-analysis of Contreras et al., technology-based parenting programs have positive effects on emotional well-being of parents of children with cancer.³¹ In this context, technology-based interventions are considered to be an effective approach to support children with cancer and their parents.

In our study, it is determined that the intervention time of technology-based interventions applied to children with cancer varied between 1.5 ​h and 10 weeks, and follow-up periods ranged from 12 weeks to 6 months. Similarly in the literature, in Ramsey et al.’s (2020) systematic review to examine e-health and m-health interventions in pediatric cancers, it is stated that the intervention period varies between 2 weeks and 12 months.⁶ In technology-based studies for the parents of children diagnosed with cancer, intervention periods ranged from 8 to 12 weeks^8,21 and follow-up periods ranged from 3 months to 12 months.^8,24,25 In the meta-analysis study of Flujas-Contreras et al. in which they evaluated the effects of technology-based programs on the psychological health of parents, it is stated that the intervention period varies between 2 and 16 weeks.³¹ The most important finding is that technology-based studies on children with cancer and their parents showed variability in terms of the nature of the intervention (during active treatment, home care or survivor period, etc.), the duration of the intervention, and the follow-up period. In pediatric oncology, the duration and follow-up (to assess how long the effect lasts) of technology-based interventions for children and parents are important. For this reason, it is thought that evidence-based studies will guide the intervention and follow-up period of the studies to be carried out.

One of the other important findings in this systematic review is that technology-based interventions for children are e-health interventions such as web-based interventions, virtual reality, and m-health interventions such as messaging, phone contact, and smartphone applications for symptom management (nausea and vomiting, fatigue, pain, mucositis), symptom management (nausea and vomiting, fatigue, pain, mucositis), anxiety, quality of life, coping skills, and self-efficacy.^13,14,22 In a systematic review by Cheng et al. to identify qualitative research evidence for digital health interventions with adolescent survivors, digital health interventions were found to be an acceptable and appropriate approach to providing care for adolescent survivors.¹¹ In light of these findings, technology-based interventions are thought to be an appropriate approach for this period because of their compatibility with the visual, auditory, and kinesthetic thought processes of children and adolescents, and their interactive nature that supports their self-efficacy and creativity. In the literature, technology-based interventions for parents are e-health interventions such as web-based interventions and m-health interventions such as smartphone applications for psychosocial support (quality of life, resilience, coping strategies, and parents' self-efficacy, etc.). In a systematic review by Delemere and Maquire in which they evaluated the effects of “Connected Health” technologies in supporting families affected by pediatric cancer, it was found that technology-based interventions reduced parents' anxiety, uncertainty, and information needs and improved social functioning.¹⁶ In line with these results, it is thought that technology-based interventions can be effective in meeting the information needs of parents during the cancer experience, developing coping mechanisms, being aware of their emotions and enabling them to manage them effectively, and supporting and empowering parents psychosocially.

Studies on children diagnosed with cancer and their parents are based on theories and models such as self-determination theory, social cognitive theory, cognitive behavioral theory, Lazarus and Folkman's model for coping with stress, Pender's health promotion model, and resilience model.^8,22,32 Planning research based on theories and models provides a systematic approach to evaluating the effectiveness of the intervention.³³ For this reason, it is thought that the theory or model-based planning of technology-based studies in pediatric oncology will guide researchers.

Limitations

There are some limitations in this systematic review. In this study, technology-based interventions for children with cancer and their parents were examined. The studies reviewed showed high variability in terms of intervention types and follow-up periods. Therefore, homogeneity cannot be achieved in the outcome parameters, and further analyses such as effect size calculation could not be performed. The study is limited to synthesizing research findings included in the systematic review.

Implications for practice

Pediatric oncology nurses have an important role in determining the care needs of children and adolescents with cancer or survivors and their parents, through evidence-based, family-centered care, and empowering children and parents accordingly. It is thought that this systematic review will guide technology-based studies to be planned in pediatric oncology in terms of the interventions applied, the duration of the interventions, the duration of the follow-up, the essential results obtained, and the theories used in the intervention. Also, studies evaluating the effectiveness, feasibility, acceptability, possible difficulties in use and user experiences of technology-based interventions are needed to identify the best practices for applying technology in pediatric oncology and to improve patient outcomes.

Conclusions

Technology-based interventions are important in integrating many aspects of cancer treatment (education, communication, and follow-up) into the lifestyles of children with cancer and their parents. As a result of this systematic review, technology-based interventions have been effective in improving physical and psychological symptoms in children with cancer and in improving parents' coping and psychosocial symptoms. These results should be interpreted with caution due to the limited number of studies, small sample sizes, and high heterogeneity. Comprehensive and high-quality RCTs are needed to obtain the best evidence for the effectiveness of technology-based interventions in pediatric oncology.

Credit author statement

Hazal Ozdemir Koyu: Conceptualization, Methodology, Data Extraction, Data Synthesis and Analysis, Writing, and Original and Revised Draft Preparation. Ebru Kilicarslan Törüner: Conceptualization, Methodology, Data Extraction, Data Synthesis and Analysis, and Revised Draft Preparation. All authors had full access to all the data in the study, and the corresponding author had final responsibility for the decision to submit for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Declaration of competing interest

All authors have none to declare.

Funding

This study received no external funding.

Ethics statement

Not required.

Data availability statement

Data available on request from the authors.

Appendix A. Supplementary data

The following is the Supplementary data to this article.