WhatsApp-assisted Prehabilitation Programme for Adult Patient Undergoing Elective Colorectal Cancer Surgery - A Randomised Controlled Trial
Phase: NA
Conditions: Colorectal Cancer (Diagnosis)
Sponsor: Tseung Kwan O Hospital, Hong Kong

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Study Protocol 
 
WhatsApp-assisted prehabilitation programme for adult patient undergoing 
elective colorectal cancer surgery – A randomized controlled trial 
 
Principal Investigator: Miss. Sung Hoi Ling Shering, Registered Nurse (Specialty), 
Department of Surgery, Tseung Kwan O Hospital 
(TKOH), KEC 
 
Other Co-investigator: Dr. So Winnie Kwok Wei, Professor, The Nethersole 
School of Nursing, Faculty of Medicine, The Chinese 
University of Hong Kong 
 
Academic Supervisor: Dr. So Winnie Kwok Wei, Professor, The Nethersole 
School of Nursing, Faculty of Medicine, The Chinese 
University of Hong Kong 
 
Site Supervisor:  
Dr Yu Yin Li, Associate Consultant, Department of 
Surgery, TKOH, KEC 
 
BACKGROUND 
Colorectal cancer is a global health concern and ranks second most prevalent 
forms of cancer in Hong Kong. The incidence and mortality had increased by a 
substantial 15.3% and 20.7% over a decade, reaching 5899 and 2298 cases in 2021 
(Hong Kong Cancer Registry, 2023). Surgery is still the primary curative option in 
the management of colorectal cancer. Enhanced Recovery After Surgery (ERAS) 
protocol, a multimodal coordinated strategy with elements of preoperative education, 
enhanced surgical and anesthetic approach and postoperative rehabilitation, has been 
promulgated in the local public hospitals. Although compromising result of 
shortened general length of stay (LOS) (5 vs 10, p<0.05) in ERAS is illustrated, 
surgical complications such as postoperative ileus (POI) remain unresolved (Wong, 
2016). Significant burdens associated with POI including prolonged LOS (median 
LOS=14), physical deconditioning with extended rehabilitation services (68%), 
impaired lung function requiring invasive ventilator support (5%) and leading to 2% 
of mortality (Tseung Kwan O Hospital, 2022). The cause of POI is still inconclusive; 

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however, it is mediated by surgical approach and cardiopulmonary condition, in 
which the vulnerabilities could be modified and optimized (Lee et al., 2020; Wells et 
al., 2022). 
Prehabilitation refers to optimization in a single or multi-disciplinary approach of 
exercises training, nutritional therapy and psychological counseling, with aims to 
improve physical fitness, strengthen cardiopulmonary function and reduce mental 
distress, through lifestyle modification and better physiological reserve (Bojesen et 
al., 2023; Bousquet-Dion et al., 2018; Carli et al., 2020). Exercise training and 
nutritional counseling have demonstrated to keep physically active and improve 
nutritional status in reducing risks of postoperative respiratory and wound infections 
(Lee et al., 2023; Li et al., 2021; López-Rodríguez-Arias et al., 2021; Wang et al., 
2022). In the current clinical practices of a local public hospital, the concept of 
educations in form of preoperative exercises and nutritional counseling outweighs the 
purposes of actual prehabilitation. Moreover, the accessibility of regular outpatient 
supervised exercises and in-person nutritional counseling is limited in weekly and 
biweekly session respectively due to high caseloads of out-patient visits in context of 
short-handed physiotherapists and dietitian, and colorectal cancer patients are highly 
recommended to follow the unsupervised exercises and dietary regimen at home. 
Suboptimal regimen adherence toward these preoperative educations may result in 
poor surgical outcomes such as prolonged LOS (Barberan-Garcia et al., 2018).           
Mobile health (mHealth) has been all the rage in the recent research studies, 
especially in the pandemic of COVID-19, to deliver barrier-free health interventions 
at a reduced health cost (Baillot et al., 2017; Duarte-Rojo et al., 2021; Metcalf et al., 
2019; van der Meij et al., 2018). Behavior change is the common goal of mHealth 
interventions impacted on enhanced regimen adherence through self-monitoring, 

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prompt notification and customized educational content. A systematic review by 
Jakob et al. (2022) identified that effective behavior change with better regimen 
adherence contributed by mHealth apps in feature of personalized health content 
(Edney et al., 2019; Luhanga et al., 2018), positive reminders (Benze et al., 2019; 
Oftedal et al., 2019), user-friendly apps design (Hendrie et al., 2020; Orlemann et al., 
2018) and personal reinforcement (Chen et al., 2017; Svetkey et al., 2015). 
WhatsApp, one of the mobile apps supporting instant text, voice and video 
messaging, is widely utilized (77.6%) in Hong Kong (Datareportal, 2024) and 
identified as effective in delivering health interventions (Ferret et al., 2021). 
WhatsApp-delivered health promotion programmes have demonstrated positive 
impacts on healthy lifestyle in sedentary adults (Alghafri et al., 2018; Cavallo et al., 
2012; Durmaz et al., 2019) and raising awareness of cancer screening in developing 
countries (Bradway et al., 2017; Knaul et al., 2018; Pereira et al., 2020). 
In this study, concept of prehabilitation encompassing physical training, 
nutritional therapy and psychological counseling is embedded to align with the 
current ERAS protocol. mHealth in form of WhatsApp-assisted technology is 
incorporated into the proposed prehabilitation programme to deliver the health 
interventions to enhance the regimen adherence and thus patients’ outcomes on 
postoperative complications, LOS and mental well-being. 
THEORETICAL FRAMEWORK OF THE PROGRAMME 
Poor physical activity and malnutrition are the prognostic factors for 
postoperative complications and morbidity for colorectal cancer patient undergoing 
surgical procedure, of which could be modified though preoperative health education 
and lifestyle modification. Adherence is an essential component for effectiveness of 
a health promotion programme in the process of behavior change. Given the context 

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of this programme, concept of prehabilitation refers to a behavior change 
interventions for colorectal cancer patients to engage in a surgery school in 
optimizing physical functioning, nutritional status and psychological well-being. To 
design an evidence-based prehabilitation programme, it is crucial to have a better 
understanding of how engagement influencing behaviors. Grimmett et al. (2021) 
reviewed the input of behavioral science in the existing thirteen prehabilitation 
studies and identified mHealth strategies of skills and knowledge (capability), user-
friendly features (opportunity) and prompt notification (motivation) contributing the 
role of behavior change (Barberan-Garcia et al., 2020; Brahmbhatt et al., 2020; 
Szinay et al., 2021). Hence, the concept of this proposed programme is underpinned 
by a theoretical framework of the capability, opportunity, motivation and behaviour 
(COM-B) model of behavior change developed by Michie et al. (2011) (Figure 1). 
 
Figure 1. The COM-B model framework 
Capability refers to an individual’s physical and psychological capability to 
participate in the activities to achieve the designated outcomes. Given the high 
penetration of WhatsApp application in Hong Kong social media market, participants 
are expected to demonstrate a good knowledge of using WhatsApp without hesitation 
or with minimal guidance (physical capability). In the context of colorectal cancer, 

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specific educational content towards physical vulnerabilities and dietary advice on 
cancer-related symptoms promotes the knowledge input. Periodic evidence-based 
sharing on poor lifestyle increases the awareness on high-risk factors of surgical 
complications like sedentary lifestyle and complication-induced impacts such as 
prolonged hospitalization, result in enhancing psychological capabilities with 
perceived knowledge to perform healthy behavior (Beck et al., 2021; Wang et al. 
2022). WhatsApp reminder message provides prompt multimedia reinforcement and 
supports regular self- monitoring by memory attention with behavior regulation 
(Banerjee et al., 2021; Mooney et al., 2007). 
Opportunity is denoted as physical and social opportunities that influences the 
engagement. WhatsApp encompasses innovative features of instant text, voice 
and video message with easy and handy design which creates a better physical 
opportunity to sustain engagement. These features enhance personalized experiences 
in a health education with better interaction of communications in multifaceted health 
interventions on physical activities (e.g. exercises demonstration), psychological 
therapy (e.g. podcasting of meditation), nutritional advice (e.g. video of cooking 
recipes). Social influences in form of information exchange and experience sharing 
promotes the perceived psychological opportunity through practical support (Agasi-
Idenburg et al., 2020; Cooper et al., 2022; Parker et al., 2019). Virtual counselling 
(e.g. podcasting of peer-sharing on experiences and tips towards healthy lifestyle) 
encourages participants in engagement with the WhatsApp built-in professional 
support (Agasi-Idenburg et al., 2020; Beck et al., 2021; Wu et al., 2022).  
Motivation is defined as automatic and reflective motivation that facilitate the 
willingness toward engagement. WhatsApp-assisted health intervention with a 
concrete action with structured timeframe (e.g. 30-minute relaxation breathing 

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exercises) sustains the regular engagement through setting specific goal (e.g. sleep 
with at least 6 hours) and enhancing self- confidence (e.g. perform relaxation 
technique at least once per week) (Beck et al., 2021; Karlsson et al. 2020). In-app 
reinforcement with positive rewards (e.g. intangible appraisal of badges achievement 
on adherence to weekly exercises) is essential to motivate their journey (Brahmbhatt 
et al., 2020; Cooper et al., 2022). Anticipated improvement with progress evaluation 
also promotes the sustainability of engagement (e.g. maintain the optimal body 
weight without unintentional weight loss prior to surgery) (Daun et al., 2022; Ferreira 
et al., 2018) 
Given the context of engagement underpinned by COM-B model, WhatsApp-
assisted strategies with concrete information of surgery-related complications and 
benefit of preoperative physical and nutritional enhances, progress reinforcement, 
and virtual psychological support are incorporated in this prehabilitation protocol 
(Figure 2). 
 
Figure 2. Proposed programmed incorporated with theoretical framework of COM-B model. 
 
 

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TRIAL DESIGN 
It is a prospective randomized controlled study (For pilot and a full-scale study) 
PRIMARY OUTCOME 
Postoperative complication calculated as Comprehensive Complication Index (CCI) 
SECONDARY OUTCOMES 
Length of hospital stay (LOS); Gastrointestinal recovery; Physical activity; 
Psychological well-being; Perceptions toward prehabilitation; Sociodemographic 
characteristics 
AIM AND HYPOTHESIS 
This study aims to examine the effects of a technology-assisted prehabilitation 
for reducing postoperative complications and LOS with improved physical activity, 
nutritional status, gastrointestinal recovery and psychological well-being among 
patient with colorectal cancer receiving surgery. 
It is hypothesized that, compared with usual care, WhatsApp-assisted 
prehabilitation significantly reduce postoperative complications and LOS, and 
enhance physical activity, nutritional status, gastrointestinal recovery and 
psychological well-being with colorectal cancer patients receiving surgery during the 
postoperative period and after discharge. 
Prior to the full-scale RCT, a pilot study will be conducted to assess the 
feasibility, acceptability and preliminary effectiveness of the WhatsApp-assisted 
prehabilitation program.  
METHOD AND ANALYSIS 
DESIGN 
A single with assessor-blind, double-armed randomized controlled trial (RCT) 

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design approach will be conducted. Randomization will be done using a computer-
generated random sequence to ensure allocation concealment. Participants will 
be 
randomly 
assigned 
to intervention group with WhatsApp-assisted 
prehabilitation program and control group with standard preoperative program under 
ERAS protocol (Figure 3). 
 
Figure 3. The flow of study procedure. 
PARTICIPANTS (For pilot and a full-scale study) 
Participants will be recruited in the Department of Surgery in Tseung Kwan O 
Hospital by convenience sampling. The study hospital is a local tertiary care hospital 
in Hong Kong and study department provides services care to adult patients with 
gastrointestinal cancer. 
Inclusion Criteria: Patients (1) aged over 18, (2) scheduled for elective           
colorectal cancer surgery as primary treatment, (3) possess a smart technology with 
internet plan or WIFI access, (4) able to use WhatsApp application with read, write 
and interact, (5) can understand Chinese (Cantonese) and follow instructions. 
Exclusion Criteria: Patients with (1) expected surgery date less than 21 days, (2) 
identified cognitive disorder, (3) respiratory disease or (4) musculoskeletal problems, 
that is, showed difficulties in understanding the study procedures, providing 

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informed consent or following instructions, in their medical records, (5) requiring 
neoadjuvant therapy. Participants will be also excluded if their surgery is cancelled 
(as judged by surgeon or patient refused operation) after randomization. 
SAMPLING SIZE 
Sample size calculation was based on guidelines of pilot RCT (Julious, 2005; 
Lancaster et al., 2004; Whitehead et al., 2014), the need to assess feasibility and 
estimate variability and the context of the main study’s sample size planning. The 
pilot study with a sample size of 24 participants (12 per arm) will be conducted to 
evaluate the feasibility and preliminary effectiveness of the WhatsApp-
prehabilitation program. This sample size is sufficient to evaluate the recruitment, 
attrition, outcome measurement while accounting for potential attrition of 20%.  This 
will also align to the main study’s effect of primary outcome of comprehensive 
complication index. From Molennar et al. (2023) multicenter RCT study, the odd 
ratio was 0.47 with outcome incidence at 0.37. In our population from the study 
hospital (2022-2023), the incidence was 0.33 with mean of CCI at 22. Using power 
analysis software G*Power 3.1 and considering a decrease of the CCI by 30% as 
clinically meaningful with anticipating attrition rate of 20%, it is estimated total of 
100 patients (50 per arm) would be sufficient for a double-group RCT with 80% 
power at two-sided with a level of significance at 5% in the full-scale study. 
RANDOMIZATION AND BLINDING (For pilot and a full-scale study) 
This study consists of two groups: an intervention group that receives the 
digital prehabilitation with standard care and a control group that receives the 
standard care only. A computer-based randomization will be utilized to allocate 
patients into either one group. Eligible participants will be randomly assigned in a 
1:1 ratio to either control group or intervention group. Block randomization was 

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performed through a computer-generated sequence, and serial and opaque with sealed 
envelopes will be prepared in by independent staff not involved in clinical care or 
screening or assessment, in which will be used to conceal the sequence until the 
intervention as assigned at the outpatient preoperative clinic. Participant cannot 
request to change to other group. 
Given the nature of digital approach of intervention, it is difficult to conduct a 
double- blinded trial in this study. However, single blinded with outcome assessor will 
be conducted in both groups. 
CONTROL (STANDARD CARE) (For pilot and a full-scale study) 
Participants in the control group will receive the standard care without digital 
intervention prior to surgery. Standard care involves physical training, dietary and 
psychological advice. In addition, it may take approximate 10-15 minutes in doing 
the questionnaires at day of recruitment [Baseline (T0)], weekly before operation and 
on the day of discharge(T1). 
INTERVENTION (PREHABILITATION WITH STANDARD CARE) (For pilot 
and a full-scale study) 
In addition to standard care, participants will receive digital approach of 
WhatsApp-assisted prehabilitation programme and then start the home-based 
training for about 3-4 weeks prior to the surgery. The WhatsApp-assisted 
prehabilitation includes exercises training, dietary advice and psychological support. 
In support by the existing RCTs studies, prehabilitation duration ranges from 2 to 4 
weeks, considering the current clinical setting, it is recommended at least 3-week 
intervention should be conducted. Contents will contain elements of physical 
training (e.g. aerobic and resistance exericses) and psychological therapy (e.g. 
meditation) will be delivered through WhatsApp at three sessions (day 1, 3 & 5) per 

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week for 30 minutes and 15 minutes respectively, educational information associated 
with colorectal cancer surgery and prehabilitation(e.g. high risks factors towards 
surgical complications) and dietary advices (e.g. recipes) will be delivered on weekly 
basis (day 1) as follows: 
WhatsApp-assisted intervention – Week 1 (Day 1) 
Component 
Information provision, animation-assisted exercises, 
psychological support 
Content 
- Information related to surgery and prehabilitation 
- Animation-assisted demonstration on exercises (30 mins) 
- Dietary advice (e.g. low residue diet) 
- Psychological reinforcement (e.g. positive belief on 
anticipated goal) 
Length of session 
45-60 minutes 
Format 
Individual 
 
WhatsApp-assisted intervention – Weekly (Day 3) 
Component 
Animation-assisted demonstration, psychological support 
Content 
- Animation-assisted demonstration on exercises (30 mins) 
- Psychological reinforcement/ relaxation technique 
Length of session 
30-45 minutes 
Format 
Individual 
 
WhatsApp-assisted intervention – Weekly (Day 5) 
Component 
Animation-assisted demonstration, psychological support 
Content 
- Animation-assisted demonstration on exercises (30 mins) 
- Psychological reinforcement/ relaxation technique 
Length of session 
30-45 minutes 
Format 
 
      Individual 
 
In addition, it may take approximate 10-15 minutes in doing the questionnaires 

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at day of recruitment [Baseline (T0)], weekly after intervention and on the day of 
discharge(T1). 
 
DEVELOPMENT AND VALIDATION 
The content theme of WhatsApp message is developed and designed by a panel 
of healthcare team involving surgeon, nurse, and allied health professionals. 
Information comprises of impacts of colorectal cancer surgery with relevant statistics 
and identifying the common misconceptions towards colorectal cancer and 
preoperative optimization through multimedia interaction and active manner. Expert 
panel of multidisciplinary health professionals in the study hospital will also validate 
the final content. 
IMPLEMENTATION(For pilot and a full-scale study) 
The study is mainly delivered through a digital platform through WhatsApp. 
Designated trained research assistants are responsible for the digital prehabilitation 
programme and it is expected to commence approximately four weeks prior to the 
scheduled colorectal cancer surgery. Basic training of using WhatsApp function such 
as video or voice playing and message texting will be provided to all participants at 
the first approach in the outpatient clinic after randomization. The designated 
WhatsApp message will be delivered three time per week (Monday, Wednesday and 
Friday) in the morning session. The purposes of WhatsApp-assisted interventions are 
to enhance the cognitive understanding in surgery-related risks and complication with 
structured knowledge on beneficial impacts in preoperative physical and nutritional 
strengthening through multimedia interaction. The message also provides prompts 
and cues to action with promoting adherence to exercises intervention and reinforcing 
the sustainability through progress measures and emotional support. Psychological 
supportive podcasting shares experience and skills on lifestyle modifications, in 

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which enhances the competency and positive commitment in behavioral changes. 
Participants will also receive the message to evaluate the progress of the training 
on the same day of the intervention in the evening by the trained research assistants. 
FIDELITY OF INTERVENTION 
The fidelity of the intervention is ensured by recruiting three part-time research 
assistants (RA1, RA2, RA3) with background of current studying in nursing 
programme, of proficiency in using WhatsApp function. The principal investigator 
will provide one day training to RAs in (1) site visit of study venue; (2) introduction 
and evidence of benefit of prehabilitation; (3) application of WhatsApp; (4) 
procedure of intervention; (5) knowledge about confidentiality and privacy. A 
standardized manual will be used to guide the delivery of WhatsApp intervention. In 
addition, the message delivered will be randomly selected by principal investigator 
to assess the compliance with intervention protocol at least one session per month. 
Regular monthly meeting with RA will be provided in the first three month of 
commencement 
of 
study 
to 
maintain 
effective 
communication, 
clarify 
misunderstanding and solve the problem encountered. 
OUTCOME MEASUREMENTS 
The outcome measures will be collected by trained research assistants, who are not 
involved in clinical care, delivery of intervention and allocation of participants. 
Primary Outcomes 
Postoperative complications 
Comprehensive complication index (CCI) is our primary outcome in this study. 
It is a validated and reliable calculated index used to measure the postoperative 
complications regarding to the severities (Amaro-Gahete et al., 2022; Slankamenac 
et al., 2014). It is more comprehensive and sensitive in colorectal cancer surgery and 

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the scales ranges from 0 (no complication) to 100 (death associated with 
complication) (Tamini et al., 2021). The online version of CCI will be utilized from 
a certified online platform (www.assessurgery.com) and the relevant data will be 
collected by the study investigator from the hospital record and translated into CCI 
through the calculator. 
Secondary Outcomes 
Length of hospital stay (LOS) 
Length of hospital stay (LOS) will be measured in number of days in hospital 
from the day of operation to discharge. This outcome data will be retrieved by the 
designated nurse from the hospital record. 
Gastrointestinal recovery 
Gastrointestinal recovery will be measured as time to first flatus (in hours), time 
to first bowel (in hours), occurrence of associated events (reinsertion of nasogastric 
tube, gastrograffin study), to identify the impacts of POI. Data will be collected by a 
designated nurse and project assistant(s). 
Physical activity 
Physical activity (PA) will be assessed by International Physical Activity 
Questionnaire Short Form (Chinese version) (IPAQ-SF) at baseline, weekly before 
operation and upon discharge. Sedentary lifestyle contributes to lower functional 
status after surgery, which associated with postoperative complication such as chest 
infection and prolonged length of stay due to optimal patients’ recovery (Collins et 
al., 1999; Santa Mina et al., 2015). Recent systematic review revealed that higher 
preoperative activity level was associated to shortened length of stay and improved 
quality of life among cancer patient receiving surgery (Steffens et al., 2018). In 
addition, low physical activity has been demonstrated relationship with increased 

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postoperative complication in gastrointestinal cancer surgery (Tatematsu et al., 2013; 
Whelan et al., 2021; Yanagisawa et al., 2020). IPAQ-SF (Chinese version) is a 
validated and reliable tool that has been widely used to assess the physical activity 
for cancer patients receiving surgery in research studies with good reliability of 
intraclass correlation coefficient ranging from 0.81-0.89 (Craig et al., 2003; Deng e 
al., 2008). Data will be collected by training research assistant and designated nurse. 
Psychological well-being 
Psychological well-being in terms of anxiety and depression and quality of life 
(QoL) will be measured. The Chinese version of Hospital Anxiety and Depression 
Scale (C-HADS) and the Short Form 12 Health Survey (SF-12 version 2 (Hong 
Kong)) are both widely used validated tools with high reliability of Cronbach’s alpha 
at 0.85 and 0.84 with good internal consistency respectively. Data will be collected 
by project assistant(s) at baseline and on day of discharge day by case nurses. 
Perception towards prehabilitation 
Patient-report perception towards digital prehabilitation will be collected after 
discharge through WhatsApp platform by research assistant(s) with a 5-point-likert-
scale survey validated by an expert panel in the study department. Survey in content 
of usability (5- point Likert-scale), satisfaction (5-point Likert-scale), acceptability 
(5-point Likert-scale) will be assessed. Adherence to interventions by percentage 
(self-reported on progress evaluation) will be also evaluated. 
Sociodemographic characteristics 
Sociodemographic characteristics will be collected by the trained research 
assistant(s) with a simple interview on the day of recruitment, involving gender, sex, 
medical history, diagnosis of cancer, marital status, anthropometric measures, 
educational background, smoking status, history of surgery or chemotherapy or 

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radiation therapy, exercises habit, use of supplements, current physical or 
psychological illness. 
DATA COLLECTION PROCEDURES 
A colorectal surgeon working in the study department will screen for eligibility 
for all patients scheduling for colorectal cancer surgery. If the patients meet the 
inclusion criteria, the surgeon will refer them to the designated trained research 
assistant(s). The trained research assistant (RA4) will introduce the study purposes 
and explain the intervention procedures will an information sheet. If patients agree to 
join the study, the trained research assistant will obtain the written informed consent 
and then acquire the sociodemographic characteristics and perform baseline 
assessment (T0) of patients before randomization. Patients in the control group will 
receive the standard care while those in the intervention group will receive the digital 
prehabilitation plus standard care according to the allocation. 
During the intervention period, progress evaluation on treatment adherence 
from the intervention group will be collected by trained research assistant weekly. 
Trained research assistant will also collect the data of physical activity level weekly 
from both intervention and control group.  
On the day of discharge, a set of data (anxiety and depression, quality of life) 
(T1) will be collected from the patients by nurses working in the study unit, who are 
blinded to the subject allocation. Designated nurse in the study team will collect the 
clinical data from the medical record (CCI, LOS, gastrointestinal recovery) after 
discharge. 
After discharge, trained research assistant(s) (RA1, RA2, RA3) will collect 
the data of perception towards prehabilitation through WhatsApp message. 

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DATA MANAGMENET 
To protect patient privacy, all research data would be handled in line with 
HA/Hospital’s policy in handling/storage/destruction of patients’ medical records. 
All collected data will be kept strictly confidential and for research purposes only. 
Anonymity will be ensured for all data collected, with the whole investigator team, 
the employed research staff and IRB/REC have exclusive access to the datasets. 
Integrity and reliability of data derived will be ensured. The storage period will be 6 
years including the period of study. A new electronic device (Smartphone) and a new SIM 
card will be purchased for this study. This SIM card will be verified and completed with the 
real name registration under study investigator according to the Telecommunication 
(Registration of SIM Cards) Regulation in Hong Kong and the phone number of this SIM card 
will be used to register for the WhatsApp Business Account. During these periods, the 
electronic device (mobile) used for digital intervention and the informed consent will 
be kept in a specific locked cabinet. The electronic device is also encrypted with a 
password and the password will be changed regularly in every 3 months. Trusted and 
encrypted network is used to deliver the WhatsApp intervention. After completion of 
aforesaid storage period, the mobile SIM card and the WhatsApp account will be 
destroyed and reset. All hard copy of data will also be discarded as confidential waste 
6 years after the completion of study. The Principal Investigator, and the coordinating 
investigator will be responsible for safekeeping of the personal data and study data 
during and after the study.  
PATIENTS AND PUBLIC INVOLVEMENT 
Patients and the public will not be involved in the study design nor 
development of interventions. Only participants in the intervention group will receive 
the WhatsApp message to explore their perceptions in content of satisfaction, 

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usefulness and acceptability towards the interventions. However, all study 
participants will receive a plain language summary of the results after the completion 
of study as part of the knowledge translation approach. 
DATA ANALYSIS 
All analyses will be performed using IBM SPSS statistics (Version. 29) with 
level of significance set at 0.05 (2-tailed). Descriptive statistics will be used to 
summarize baseline characteristics and outcome measures. Normality of continuous 
variables will be assessed based on their skewness and kurtosis statistics and normal 
Q-Q plots. Appropriate transformations will be made on skewed continuous variables 
to render them normally distributed. Homogeneity of baseline characteristics 
between groups will be assessed by using independent t-test, Mann-Whitney U test, 
chi-squared test or Fisher’s exact test. Those baseline characteristics showing 
statistically significant difference between groups (p<0.05) will be considered as 
potential confounding covariates and adjusted in subsequent outcome analyses. The 
outcomes of LOS and CCI will be compared between groups using multiple 
regressions with adjustment for the potential confounding covariates identified above. 
GEE models will be used to compare the repeated measure outcomes (e.g. QoL) 
across study time points between groups with adjustment for the covariates. The 
occurrence of associated events will be compared by using logistic regression with 
adjustment for the covariates. 
ETHICS AND DISSEMINATION 
The research team will protect participants' rights and safety by adhering to 
local laws, the Hong Kong Personal Data (Privacy) Ordinance, institutional policies, 
Declaration of Helsinki, and the International Conference on Harmonization – Good 
Clinical Practice (ICH- GCP). Ethical approval will be obtained from Central 

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Institutional Review Board (IRB). Principal investigator passed CUHK CRMO 
Online training for Declaration of Helsinki & GCP Workshop for Investigator and Site 
Personnel (2.0) (recognised by TransCelerate BioPharma). Permission to use the 
indicated instruments will be obtained from the original authors. 
Agreement will be made in advance with personnel in charge of the study 
venues for arranging participants recruitment. A colorectal surgeon working in the 
study department will screen for eligibility for all patients scheduling for colorectal 
cancer surgery. If the patients meet the inclusion criteria, the surgeon will refer them 
to the designated trained research assistant(s). The trained research assistant (RA4) 
will introduce the study purposes and explain the intervention procedures will a 
detailed information sheet including the study purpose and all potential benefits and 
risks regarding to the study intervention. If patients agree to join the study, the trained 
research assistant will obtain the written informed consent. All study participants will 
be rewarded a value of HK$100 voucher for the travel and time expenses in this 
study. 
All collected data will only be used for research. Patients will be informed of 
the right to refuse to participate in the study or to withdraw consent to participate at 
any time without giving any reason, loss of benefit or impacts on the care they are 
receiving. Anonymity will be always ensured, and the findings will only be published 
as part of the fulfillment of thesis dissertation and in a peer-reviewed journal in local 
and international conference journals. Any protocol modification will be 
communicated to the local research ethics committees in a timely manner. 
DISCUSSION 
Leveraging technology in health interventions has been rapidly spreading. This 
multifaceted innovative approach incorporating technology to provide opportunities 

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for all patients in accessing barrier-free health interventions at their convenience and 
result in better patients’ outcome. In addition, the incidence of colorectal cancer 
(CRC) still demonstrates an upward trend and the complexity of care becomes 
demanding. Prehabilitation could improve the physiological reserve among CRC 
patients, of promoting physical activity, faster recovery and reducing complications 
and psychological distress. However, the benefits of leveraging technology in 
prehabilitation programme to enhance patients’ outcomes of postoperative 
complications, LOS and mental health remains limited Therefore, this study aims to 
evaluate the feasibility and effect of digital prehabilitation delivered by WhatsApp, 
where an novel and convenient intervention for colorectal cancer patients undergoing 
surgery at any time and place. The result will provide insights of the use of digital 
approach. To our knowledge, this is the very first trial of digital prehabilitation for 
CRC patients in Hong Kong public hospitals. Therefore, it provides positive 
contribution and acts as an important quality benchmark for patients’ outcomes. The 
findings will also generate knowledge on the optimalization of care provided to CRC 
patients prior to surgery and assist to develop a structured and effective health system 
in our community. This innovation may have implications to other research studies 
and extends the potential clinical practices to related subspecialities such as gastric 
cancer. The study engages different stakeholders with universities, health 
organization and patients and provides a high quality of knowledge exchange during 
the process. 
FUNDING AND INSURANCE  
This project is funded by the Y. K. Pao Foundation Centre for Nursing 
Excellence in Chronic Illness Care, The Nethersole School of Nursing, Faculty of 
Medicine, The Chinese University of Hong Kong. The study will not consume any 

WhatsApp-assisted prehabilitation programme for adult patient undergoing elective colorectal cancer surgery 
Study Protocol dated 12Jan2026 
 
P.21/31 
resources from the Hospital Authority and the subjects will not be charged for the 
study. All study participants will be rewarded a value of HK$100 one-off voucher 
for the travel and time expenses in this study. 
The issue of insurance is not applicable in this study. 
CONFLICT OF INTERETST 
No direct conflict of interest to declare. 
 
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