Using Group Chats to Drive Behavior Change in Digital Health Interventions: Scoping Review and Realist Synthesis

Clinical Snapshot

Key Findings

• P Value: Not applicable - descriptive and theoretical analysis

• Effect Size: Not applicable - qualitative synthesis of mechanisms rather than quantitative effect estimation

• Primary Outcome: Identification of 12 recurring context-mechanism-outcome configurations across 5 domains driving behavior change in group chat interventions

• Nnt Or Sensitivity: Program theory sensitivity depends on facilitation quality, group composition, cultural alignment, technological access, and social norms

• Confidence Interval: Not applicable - realist synthesis methodology

Clinical Application

High feasibility given widespread WhatsApp usage in Australia and integration potential with existing telehealth infrastructure Highly relevant to Australian digital health strategy, particularly for rural/remote populations and culturally diverse communities. Aligns with PBS digital health initiatives and RACGP telehealth guidelines for group-based interventions Broad applicability to Australian healthcare including chronic disease management, maternal health, mental health, and culturally diverse communities

Abstract

BACKGROUND: Group chats on platforms such as WhatsApp (Meta Platforms, Inc), WeChat (Tencent Holdings Limited), and Telegram (Telegram FZ-LLC) are central to everyday communication in many settings, including across low- and middle-income countries and among groups often overlooked by one-to-one or app-based digital health tools. Yet their roles and underlying mechanisms as intentionally designed health interventions have not been comprehensively examined. OBJECTIVE: This scoping review with realist synthesis aimed to map the characteristics and reported outcomes of group chat-based health interventions and contextual conditions shaping their outcomes. It mapped intervention characteristics and identified context-mechanism-outcome (CMO) configurations driving behavior change. METHODS: We included empirical studies in which group chats were the primary digital component of the health intervention. Searches of PubMed, Embase, MEDLINE, Web of Science, and Scopus (2005-2026) and reference screening identified eligible studies. Data were extracted on study characteristics, health domains, settings, participants, platform, intervention features, and outcome domains. For the realist synthesis, CMO configurations were analyzed using reflexive thematic analysis informed by social cognitive theory and synthesized into a final program theory. RESULTS: Eighty-one studies were included. Publications increased sharply after 2020, with evidence clustering in mental health (25/81, 30.9%) and maternal and child health (20/81, 24.7%). Most studies enrolled adult participants, including pregnant or postpartum women, caregivers, and people managing chronic conditions. WhatsApp (38/81, 46.9%) and WeChat (21/81, 25.9%) were the most frequently studied platforms. Interventions were commonly delivered in clinical or community settings and typically involved mixed membership groups that included health professionals alongside participants (68/81, 84.0%). The realist synthesis identified 12 recurring CMO configurations across 5 domains: capability and actionability, confidence and motivation, modeling and norms, safe and supportive environment and access, and self-regulation and maintenance. These mechanisms were activated or suppressed by facilitation quality, group composition, cultural alignment, technological access, and social norms. The final program theory depicts group chats as dynamic systems where access, facilitation, and group structure shape how the domains amplify or dampen one another, explaining shifts from low engagement to high trust spaces sustaining behavior change. CONCLUSIONS: This review integrates descriptive mapping of interventions with realist program theory to explain how context and facilitation activate mechanisms of change, unlike prior reviews that have focused narrowly on effectiveness of digital modalities. This dual approach provides a practical, mechanism-focused basis for designing and scaling group chat interventions in practice, particularly given their potential as a low-cost, high-reach strategy embeddable within broader digital health programs. Realizing this potential depends on treating group chats as purposefully designed social environments, with deliberate attention to facilitation quality, equity-oriented access, and alignment between group structure, norms, and communication practices.

References

1. 1.Thu, H., Chan, F. J. H., Hashim, J., & Ali, S. H. (2026). Using group chats to drive behavior change in digital health interventions: Scoping review and realist synthesis. Journal of Medical Internet Research, 28(4), e88911. https://doi.org/10.2196/88911