Abstract
Objectives:
To examine the associations between participant intensity of engagement with a text message intervention, CuidaTEXT, and socio-demographic factors, acceptability measures, and clinical outcomes among Latino/a caregivers of individuals with dementia.
Methods:
CuidaTEXT is a six-month, bilingual, and bidirectional intervention. We enrolled 24 Latino/a caregivers in a one-arm feasibility trial. Participants received approximately one automatic daily text message and could engage with the intervention by texting specific keywords (e.g., STRESS to receive messages about stress-coping), and by chat-texting with a live coach. We used metrics and psychometric scales to quantify variables.
Results:
Participants sent a total of 1,847 messages to CuidaTEXT. Higher intensity of engagement was associated with higher intervention satisfaction (r = 0.6, p = 0.007), as were several other acceptability outcomes. We found no associations between intensity of engagement with CuidaTEXT and sociodemographic or clinical outcomes (p > 0.05).
Conclusion:
Encouraging more intense engagement with CuidaTEXT might lead to higher levels of satisfaction with the intervention. However, it is possible that those who are highly satisfied, engage more intensely with CuidaTEXT. Future research should determine the directionality of these associations to optimize text message interventions.
Clinical Implications:
Creating more opportunities to increase intensity of text message engagement with caregiver support interventions may improve caregiver satisfaction with them.
Keywords: Latino/a, caregiver, mHealth, intervention, dementia, engagement
Sustainable Development Goals: SDG 3: Good health and well-being, SDG 10: Reduced inequalities
Introduction
Mobile health technologies (mHealth) encompass a range of digital tools and platforms to deliver healthcare support remotely.1 mHealth includes telephone calls, video calls, and text messages, offering effective resources for family caregivers of individuals with Alzheimer’s disease and related dementias (ADRD). Family caregivers of individuals with ADRD often face challenges that have a considerable impact on their mental health, leading to higher rates of depression and other negative health outcomes.2–9 However, accessing caregiver support can be hindered by barriers such as time constraints, transportation limitations, and limited intervention availability.10 To address these challenges, mHealth interventions have surfaced as effective resources.
Latino/a family caregivers, in particular, experience higher rates of depression and have less access to ADRD caregiver support interventions compared to non-Latino/a Whites.11,12 mHealth interventions may be accessible to many Latinos who are unable to attend in-person caregiver support. However, Latinos/as’ low use of most of these modalities would perpetuate their disparities in access to caregiving support.13 Text messaging is an ideal modality to deliver caregiver interventions to Latinos/as, as most Latinos/as own a cell phone and they use them for texting more frequently than non- Latino/a Whites.14 Text message interventions offer several advantages: 1) they are effective in treating various health disorders, 2) can be used anywhere at any time, 3) are more cost-effective compared to other delivery systems and 4) can be tailored to caregiver preferences and characteristics including language, culture and needs.15–18
Despite being one of the oldest mHealth modalities, evidence for text messaging interventions in ADRD caregiver support is still in its early stages. To our knowledge, there is only one text message intervention providing ADRD caregiver support, namely CuidaTEXT.19,20 This intervention specifically targeted Latino/a caregivers, and has shown promising feasibility (e.g., recruitment in a short amount of time), acceptability (e.g., satisfaction with the intervention and no discontinuation), and preliminary efficacy (reduced depressive symptoms and distress) by providing crucial resources, information, and emotional support to this specific population.19
While the fully-powered efficacy of this intervention is yet to be explored, the potential of caregiver intensity of engagement (how often caregivers send text messages) with ADRD caregiver support text message interventions remains to be fully utilized.
This study aimed to explore participant intensity of engagement with a text message intervention for ADRD caregiver support and its associations with sociodemographic, acceptability, and clinical variables. To achieve this aim, we analyzed data from our feasibility study.19 We hypothesized that higher intensity of engagement with CuidaTEXT would be associated with increases in caregiver satisfaction with the intervention and decreases in depressive symptoms. Increased intensity of engagement with the program may address a greater number of unmet needs, enhance caregivers’ sense of support, and consequently, increase caregiver satisfaction while reducing depressive symptoms.
Methods
We present a secondary analysis of a one-arm pre-post-intervention trial design with assessments conducted at baseline and six months after intervention, in addition to text messaging metrics of engagement (e.g., number of messages, type of messages). We have described the details about the design, procedures, and participants of this study in a previous publication.19 In short, we enrolled 24 informal caregivers in August 2021 using a variety of recruitment techniques including research registries, community promotion, and advertisements in national organization registries and websites, outreach at health fairs, and word of mouth. Eligibility criteria included speaking Spanish or English, being 18 or older, identifying as Latino/a, owning a cellphone with a flat fee, being able to read and write, and providing hands-on care for a relative with a clinical or research dementia diagnosis who also tested positive in a cognitive videocall/phone screener with the research team. For the current paper, we analyzed the data as a mixed-methods sequential study, in which qualitative data were used to define variables that were subsequently analyzed quantitatively. The quantitative method dominates, while the qualitative method is nested within. The quantitative method included descriptive statistics and correlations whereas the qualitative method included a qualitative descriptive approach. All study procedures were approved by the Institutional Review Board of the University of Kansas Medical Center (STUDY00144478). All participants gave written informed consent in their preferred language. The significance level was set at p < 0.025 by applying a Bonferroni correction for the two hypothesized comparisons in line with previous research.21 The significance level for secondary comparisons was set at p < 0.05, but no corrections were applied to these given the secondary role of these and given that the priority in this case was consistency of associations by type of outcome (e.g., sociodemographic, clinical, acceptability).
Intervention
CuidaTEXT is a bilingual, six-month intervention tailored to caregiver needs via SMS text messages. CuidaTEXT is bidirectional, as participants receive scheduled text messages, but they can also text to receive on-demand messages. An in-depth description of the intervention and its development has been previously reported.19,20 The intervention was designed from the beginning with and for Latino/a caregivers with the support of a team including bicultural, bilingual researchers, and informed by the Stress Process Framework and Social Cognitive Theory.22,23 These theoretical foundations influenced the aims and methods of the intervention, shaping its content and bidirectional communication approach.
The Stress Process Framework informed the intervention’s focus on identifying barriers to desired behaviors, leading to the inclusion of messages addressing problem-solving, relaxation techniques, and exercising. Moreover, participants are encouraged to set realistic goals, engage in gradual practice to increase healthy behaviors, and receive support through scheduled messages on various caregiving aspects. To incorporate elements from Social Cognitive Theory, CuidaTEXT integrates testimonials and videos to promote vicarious learning. The encouragement of gradual practice aligns with the theory’s emphasis on self-efficacy, while the integration of praise, social support, and educational content aims to increase dementia knowledge among caregivers.
CuidaTEXT includes approximately one scheduled daily automatic message (n=244 over six months) about logistics, dementia education, self-care, social support, end-of-life care, care of the person with dementia, behavioral symptoms, and problem-solving strategies. Participants can also text two types of messages to receive on-demand assistance via: 1) up to 783 keyword-driven text messages providing on-demand help for the above topics; 2) live chat interaction with a coach from the research team for further help upon request. Before enrollment, staff mail participants a 19-page reference booklet summarizing the purpose and functions of the intervention in their preferred language. The comprehensive approach of CuidaTEXT’s components underscores the commitment to addressing the multifaceted challenges faced by Latino/a caregivers in the context of ADRD.
Assessment
The research team collected information from three sources: baseline survey, six-month follow-up survey, and metrics of text message engagement. The research team published the description of baseline characteristics of the sample previously.19 We also collected cell phone characteristics in the baseline survey, which include questions developed by the team about whether the participant was the account holder of the cellphone (yes/no), the self-reported number of SMS text messages sent and received by the participants per day previous to the program, whether participants share the cellphone with family members (yes/no), the frequency with which participants check their cell phones for messages (5-item Likert scale ranging from every 1–4 minutes to less than once a day), whether participants had ever signed up for SMS text message reminders (yes/no), and whether participants use Wi-Fi, data or none to access internet on their phones.
Variables included engagement with CuidaTEXT, sociodemographic characteristics, acceptability outcomes, and clinical characteristics:
Intensity of engagement with CuidaTEXT included metrics on the number of each type of text messages sent by participants, which we categorized as total, keyword-driven (and their subgroups, prespecified during intervention development), and chat text (specified based on the qualitative analyses described in this manuscript). These data were obtained from a spreadsheet automatically downloadable from the SMS messaging software. These spreadsheets included information about the participant ID number, content of the message, date, and time the message was sent.
Sociodemographic characteristics included the following binomial variables: gender (women/men), ever signing up for SMS text message reminders (yes/no), caregiver insurance status (yes/no), marital status (yes/no), and Spanish as preferred language (yes/no). We also included the following ordinal and continuous variables: age (in years), number of texts sent and received per day before the program, frequency of checking for text messages before the program, number of days a week participants saw their loved one with ADRD in person, financial stability (5-point Likert scale ranging from very easy to very difficult), and the number of hours a day participants felt they were on caregiving duty.
Acceptability outcomes were based on previous text message health research24,25 and were all collected in the follow-up survey. These outcomes included nine four-point Likert scale questions on satisfaction with CuidaTEXT and its components (Not at All-Extremely). Three additional four-point Likert scale questions asked about their perceived helpfulness of CuidaTEXT in: caring for the individual with dementia, caring for themselves, and enhancing their understanding of dementia (Not at All-A Lot).
Clinical characteristics included scales administered at baseline and follow-up, which we have described previously.19 In the pursuit of a comprehensive understanding of the impact of CuidaTEXT on caregivers dealing with ADRD, our assessment of clinical characteristics included both negative and positive dimensions of caregiving, acknowledging the experiences of caregivers beyond the negative impacts. These scales include the full version of the following scales: Neuropsychiatric Inventory–Questionnaire (caregiver distress; NPI-Q-D),26,27 Modified Caregiver Strain Index (CSI),28 Zarit Burden Interview-6 (ZBI-6),29 Positive aspects of caregiving scale (PAC),30 Epidemiology/Etiology Disease Scale (EEDS),31,32 Interpersonal Support Evaluation List (ISEL-12),33 Coping Orientation to Problems Experienced Inventory (COPE-28),34,35 Center for Epidemiologic Studies Depression Scale (CES-D-10),36,37 Scale of Positive and Negative Experience (SPANE),38,39 Preparedness for Caregiving Scale (PCS),40,41 and Self-perceived health.42 We used Spanish validated or adapted versions when available, and translated those that were not available using standard guidelines. Internal consistency reliability for these scales in the current study was: NPI-Q-D: 0.872; CSI: 0.797; ZBI-6: 0.824; PAC: 0.839; ISEL-12 Appraisal: 0.753; ISEL-12 Belonging: 0.750; ISEL-12 Tangible: 0.559; COPE-Problem: 0.825; COPE-Emotion: 0.362; COPE-Avoidant: 0.565; CES-D-10: 0.565; SPANE-Positive: 0.873: SPANE-Negative: 0.768; and PCS: 0.768.
Analysis
We used descriptive statistics to summarize demographic, clinical and cellphone-related baseline characteristics of caregivers, and participants’ engagement. To analyze the chat text messages, we used a qualitative description design, which is a vehicle to present and treat research methods as living entities that resist simple classification, and thematic analysis, which emphasizes identifying, analyzing, and interpreting patterns of meaning within qualitative data.43–45 The content of the spreadsheet was coded by categorizing them into themes. Two researchers (JPP and MFC) conducted the coding, contrasted, and resolved coding disagreements through discussion and consensus. We excluded in the qualitative analysis any chat text messages that related to reminders for the follow-up assessment.
We analyzed associations between participant engagement and the following variables: (1) sociodemographic characteristics, (2) baseline clinical characteristics, (3) acceptability outcomes, (4) change in clinical characteristics from baseline to follow-up. Since participant engagement was not distributed normally, we conducted non-parametric analyses in all cases. These included Wilcoxon Rank sum tests for binomial variables and Spearman correlations ordinal and quantitative variables. We used SPSS v20.0 for all calculations46. The significance level was set at p < 0.05. Tables present the main findings whereas Appendices include findings from all analyses.
Results
A total of 24 caregivers participated in this study. Among them, 20 (83%) were women, 10 (41.7%) were born in the USA, 6 (25.0%) were born in Mexico, and 8 (33.3%) were born in another Latin American country. An overview of participant characteristics is presented in Table 1. The average age of caregiver participants was 52.6 years (SD = 13.2) and ranged from 26–81 years. Approximately half of the caregivers were married or had a partner 13 (54.2%). On average, caregivers had completed 14.7 (SD = 3.8) years of education. Of the participants, 20 (83%) were adult children or child-in-laws of an individual with dementia, while 4 (16.7%) were spouses or partners. The average score for depressive symptoms using the CES-D-10 was 9.1 (SD = 4.4). Most participants (75.0%) reported being the cellphone account holder, and they reported checking their phones at different intervals, with 41.7% checking every 5–59 minutes and 33.3% checking every few hours.
Table 1.
Description of demographic, clinical and cellphone-related characteristics of the sample
| Total (n=24) | |
|---|---|
| Age in years, mean (SD) | 52.6 (13.2) |
| Women, % (n) | 83.3% (20) |
| Country of birth, % (n) | |
| US, % (n) | 41.7% (10) |
| Mexico, % (n) | 25.0% (6) |
| Other, % (n) | 33.3% (8) |
| Years of education, m (SD) | 14.7 (3.8) |
| Spanish only as primary language, % (n) | 41.7% (10) |
| Relation to care recipient | |
| Children, % (n) | 75.0% (18) |
| Children-in-law, % (n) | 8.3% (2) |
| Partner, % (n) | 16.7% (4) |
| CES-D-10 depression (range 0–30), mean (SD) | 9.1 (4.4) |
| Participant is account holder of cellphone, % (n) | 75.0% (18) |
| Number of text messages sent daily, median (IQR) | 10.0 (4.3–20.0) |
| Number of text messages received daily, median (IQR) | 17.5 (4.3–37.5) |
| Shares cellphone with family members, % (n) | 8.3% (2) |
| Frequency of checking for text messages | |
| Every 1–4 minutes, % (n) | 12.5% (3) |
| Every 5–59 minutes, % (n) | 41.7% (10) |
| Every few hours, % (n) | 33.3% (8) |
| A couple of times a day, % (n) | 8.3% (2) |
| Less than once a day, % (n) | 4.2% (1) |
| Ever signed up for text message reminders, % (n) | 66.7% (16) |
| Uses Wi-Fi, data or non on their phone | |
| Both, % (n) | 95.8% (23) |
| None, % (n) | 4.2% (1) |
Table 2 shows the themes and examples from the qualitative data analysis of text messages sent by caregivers. This analysis yielded eight distinct themes. Definitions for each theme are as follows: 1) Expressions of Gratitude: Messages that thanked the program and/or coach for the information, support, or resources shared with participants or complemented a specific message. 2) Acknowledgment: Messages acknowledging that participants are experiencing a situation similar to the one discussed in a text message. 3) Logistics: Messages to test the program, to ask how the program works, asking for clarification about a message they received from the program, or typos that led to a keyword not working. 4) Education: Messages requesting information about ADRD beyond the information sent to that moment. 5) Behavior: Messages that explain a behavioral symptom of dementia and request help in addressing them. 6) Care: Messages that explain care recipient health needs other than behavioral symptoms and request help in addressing. 7) Caregiver: Messages that explain caregiver social or health-related needs and request help in addressing. 8) Other: Messages not included in the above themes.
Table 2.
Themes abstracted from participants’ text chat engagements and representative excerpts
| Theme | Excerpt |
|---|---|
| Gratitude | “Thank you for an incredible 6 months of support… I will miss you!”, “Thank God and yourself for the help you provide!”, “Thanks for the unconditional support. I am grateful for the daily texts to reinforce my caregiver role”, “Hello. May I share the video link above on Alz/Dementia with my mother? It’s so well-presented and quite informative”, “Thank you very much. It’s been very helpful to hear other talk about their experiences with their loved ones”. |
| Acknowledgement | “When my mother is sad, I call her sister or friends in her home country. They talk to her about fun things they experienced together”, “Thanks, I have called the Alzheimer’s Association on 3 occasions these last 3 years”, “I use my calendar to keep track of everything”, “It’s a blessing for me to take care of my mom. She sacrificed her whole life for her kids abs now I can do something for her - by taking care of her!”, “When she does something wrong, it works to be patient and understand that it’s not their fault”, “My little dog, she is always with me. She makes my days less stressful”. |
| Logistics | “I got the booklet. Have a nice day!”, “BEHAVIOR and SUPPORT”, “Alzheimer’s Association in Spanish”, “F”, “[after texting several words] I am just testing out this program with what I know”, “Can I recommend books that help me along my journey?”, ”Did the keyword not work because I didn’t use upper case? I’ll try again”, “Am I texting to an individual or to a group?”, We’re going to Mexico tomorrow, we have arranged to be able to receive messages there, thanks!”, “Yes, I am receiving the text messages (SMS). However, I cannot receive images (MMS), due to the settings of my plan”, “I don’t understand this message very well”. |
| Education | “Is the treatment much varied among the different types?”, “Is there a definitive exam/test to identify which type is affecting a patient?”, “Could eating/hunger issues be dependent on the areas of the brain affected by the disease?”, “What are the typical complications that people with Alzheimer’s die of?”, “Does anyone with Alzheimer’s ever get better?”, “I’d be interested in finding information about legal aspects”. |
| Behavior | “Just brought Mom home from hospital and rehab after three weeks. She can no longer live alone so she’s living with us. She said, ‘I want to go home.’ Over 30 times yesterday and started up again this morning. We try to change the subject to distract her, try to do an activity with her but she persists ‘I want to go home!’”, “I’m worried about my loved one’s anger. It’s hard to help him because he refuses help”. |
| Care | “My mother won’t stop scratching her head. I worried she’ll break her skin”, “I’d like to find a good daycare facility that has Spanish-speaking staff in our city”, “What kind of stool or step can I get so my loved one can get into my can?”, “My loved one’s doctor is retiring so I’m looking for a doctor that is good with elderly patients with Alzheimer’s Disease”, “Please let me know when you’re available to call me and help me fill the request for a respite grant for my husband”, “My mother is the other way round. I need to know how to get her to stop taking so many showers”. |
| Caregiver | “I’d like help explaining to my husband how tired I am from caring for my mother, and that we need to find help to be financially ready for when she gets worse. Are there social workers or specialists to guide couples about these topics?”, “I have not heard back from the respite grant to care for my husband”, “Hi there, can you please remind me where I can find psychological help for myself?”. |
| Other | “Merry Christmas to you!”, “Happy Thanksgiving!”, “Happy New Year to CuidaTEXT Support!”, “[Responding to a scheduled question about relaxation needing to be practiced to learn the skill] Yes/No”, “I do have a question regarding your study. May I ask the thesis of your research if it will not compromise your results?”. |
Participants sent a total of 1,847 messages to CuidaTEXT. The intensity of engagement varied among participants, with two (8.3%) showing no engagement (no messages sent), three (12.5%) demonstrating low intensity of engagement (sent <10 messages), six (25.0%) displaying medium intensity of engagement (sent between10 and 49 messages), seven (29.2%) exhibiting high intensity of engagement (sent between 50 and 99 messages), and six (25.0%) demonstrating very high intensity of engagement (sent more than 100 messages). Table 3 shows the descriptive statistics of each type and theme of text messages.
Table 3.
Description of participants’ intensity of engagement with the different types of messages
| Median | Minimum | Percentile 25 | Percentile 75 | Maximum | |
|---|---|---|---|---|---|
| Total number of messages | 51.0 | 0 | 14.3 | 97.5 | 392 |
| Total number of keywords | 14.5 | 0 | 5.0 | 30.8 | 309 |
| Total number of chat text messages | 30.5 | 0 | 5.0 | 52.0 | 177 |
| Keyword messages; Care domain | 3.0 | 0 | 2.0 | 7.0 | 80 |
| Keyword messages; Caregiver domain | 1.5 | 0 | 0.3 | 8.3 | 98 |
| Keyword messages; Support domain | 3.0 | 0 | 0.0 | 5.8 | 132 |
| Keyword messages; Behavior domain | 4.0 | 0 | 0.0 | 7.8 | 69 |
| Chat text messages; Gratitude domain | 9.0 | 0 | 1.5 | 17.3 | 144 |
| Chat text messages; Acknowledgement domain | 2.0 | 0 | 0.0 | 15.0 | 42 |
| Chat text messages; Logistics domain | 1.0 | 0 | 0.0 | 2.8 | 8 |
| Chat text messages; Education domain | 0.0 | 0 | 0.0 | 1.0 | 7 |
| Chat text messages; Behavior domain | 0.0 | 0 | 0.0 | 0.0 | 7 |
| Chat text messages; Care domain | 0.0 | 0 | 0.0 | 9.5 | 156 |
| Chat text messages; Caregiver domain | 0.0 | 0 | 0.0 | 0.0 | 3 |
| Chat text messages; Other domain | 1.0 | 0 | 0.0 | 1.8 | 2 |
Intensity of engagement with CuidaTEXT was generally not associated with the baseline sociodemographic or clinical characteristics (Table 4; Appendix 2). The few exceptions were associations with preferred language (Spanish-speakers were more engaged with total [mean rank difference = 8.4; p = 0.004] and keyword messages [mean rank difference = 7.8; p = 0.007]), and hours a day on caregiving duty (the more hours of caregiving, the more engaged with total [r = 0.43; p = 0.036] and chat text messages [r = 0.58; p = 0.003]).
Table 4.
Association between intensity of engagement with CuidaTEXT and baseline sociodemographic and clinical characteristics.
| Total number of messages | Total number of keywords | Total number of chat text messages | |
|---|---|---|---|
| Women (Mean rank difference) | −2.85 | −4.35 | 0.45 |
| Ever signed up for text message reminders (Mean rank difference) | −1.69 | 0.84 | −4.5 |
| Caregiver insurance (Mean rank difference) | −5.43 | −4.67 | −4.04 |
| Spanish as preferred language (Mean rank difference) | 8.40* | 7.81* | 5.54 |
| Age (Rho) | 0.19 | 0.07 | 0.24 |
| Years of education (Rho) | −0.25 | −0.08 | −0.36 |
| Number of text messages received daily (Rho) | −0.36 | −0.26 | −0.23 |
| Financial stability (Rho) | 0.18 | 0.23 | 0.11 |
| Hours a day on caregiving duty (Rho) | 0.43* | 0.17 | 0.58* |
| NPI-Q Distress (Rho) | −0.076 | −0.070 | 0.021 |
| Caregiver Strain Index (Rho) | 0.224 | 0.085 | 0.365 |
| ZBI Burden (Rho) | −0.129 | −0.244 | 0.002 |
| CES-D-10 depression (Rho) | −0.14 | −0.18 | −0.07 |
| SPANE-Positive affect (Rho) | 0.32 | 0.33 | 0.19 |
| SPANE-Negative affect (Rho) | −0.31 | −0.09 | −0.23 |
| Perceived health (Rho) | 0.20 | 0.36 | −0.11 |
Note. Spearman’s Rho: statistical dependence between the rankings of two variables;
p<0.05
Intensity of engagement with CuidaTEXT was significantly associated with several acceptability outcomes (Table 5; Appendix 3). For example, higher total intensity of engagement was positively correlated with intervention satisfaction (r = 0.6, p = 0.007), participant perceptions that CuidaTEXT provided help for their loved one with ADRD (r = 0.6, p = 0.003), and increased understanding of ADRD (r = 0.6, p = 0.008). One of the few associations that did not reach statistical significance includes the correlation between total intensity of engagement and participant perceptions that CuidaTEXT provided help for themselves as caregivers (r = 0.3, p = 0.173).
Table 5.
Association between intensity of engagement with CuidaTEXT and acceptability outcomes.
| Total number of messages | Total number of keywords | Total number of chat text messages | |
|---|---|---|---|
| Satisfaction with CuidaTEXT (Rho) | 0.57** | 0.56* | 0.41 |
| Satisfaction with CuidaTEXT’s duration (Rho) | 0.49* | 0.49* | 0.28 |
| CareTEXT helped care for loved one with ADRD (Rho) | 0.61* | 0.54* | 0.42 |
| CareTEXT helped care for themselves (Rho) | 0.30 | 0.47* | 0.20 |
| CareTEXT helped understanding the disease better (Rho) | 0.56* | 0.32 | 0.56* |
p<0.05
p<0.025
Intensity of engagement with CuidaTEXT was generally not associated with the change in clinical outcomes from baseline to follow-up (Table 6; Appendix 4). For example, total intensity of engagement with CuidaTEXT did not show a statistically significant correlation with changes in caregiver depressive symptoms (r = −0.0, p = 0.922). Other examples that showed no statistically significant correlation with total intensity of engagement with CuidaTEXT include caregiver self-rated symptoms (r = −0.0, p = 0.863) or burden (r = −0.1, p = 0.765).
Table 6.
Association between intensity of engagement with CuidaTEXT and baseline to follow-up change in clinical characteristics.
| Total number of messages | Total number of keywords | Total number of chat text messages | |
|---|---|---|---|
| NPI-Q Distress (Rho) | 0.43 | 0.37 | 0.06 |
| Caregiver Strain Index (Rho) | 0.04 | −0.12 | 0.16 |
| ZBI Burden (Rho) | 0.07 | −0.03 | 0.13 |
| CES-D-10 depression (Rho) | −0.00 | −0.01 | −0.12 |
| SPANE-Positive affect (Rho) | −0.33 | −0.16 | −0.25 |
| SPANE-Negative affect (Rho) | 0.10 | −0.00 | 0.16 |
| Perceived health (Rho) | −0.04 | −0.03 | 0.04 |
p<0.05
Discussion
This study aimed to explore participant intensity of engagement with a text message intervention for ADRD caregiver support among Latinos/as, and its association with demographic characteristics, and acceptability and clinical outcomes. This represents the first text message intervention for caregiver support of individuals with ADRD among Latinos/as or any other ethnic group, and has previously shown high levels of acceptability, and preliminary efficacy.19,20 Given CuidaTEXT’s previous successful outcomes, investigating the associations between intensity of engagement levels with the intervention and these outcomes is crucial. Our hypothesis proposed that higher intensity of engagement with CuidaTEXT would contribute to higher satisfaction levels and decreased depressive symptoms. Our findings support the satisfaction hypothesis but not the depressive symptoms hypothesis. In general, intensity of engagement with CuidaTEXT was associated with positive acceptability outcomes but showed no significant associations with demographic and clinical characteristics or change in clinical outcomes.
Participants in our study who engaged more intensely with the program reported higher levels of satisfaction with the intervention, along with several other acceptability outcomes. Findings align with a study that found that texting frequency was associated with relational satisfaction among college students.47 Similarly, in non-texting interventions, greater engagement and adherence to interventions (e.g., cognitive behavioral therapy for eating disorders) have shown to increase therapeutic alliance or connection between patient and therapist.48,49 While drawing parallels to face-to-face interventions, where higher adherence often correlates with a stronger therapeutic alliance, is tempting, it is crucial to acknowledge the unique nature of text-based interventions like CuidaTEXT. The comparison with face-to-face interventions involves assumptions that warrant careful consideration. Unlike in-person interactions, text-based communication lacks certain non-verbal cues and the immediate responsiveness intrinsic in face-to-face therapy. These distinctions underscore the need for better understanding these dynamics. A potential interpretation of our findings is that engaging more intensely with CuidaTEXT may have resulted in greater emotional closeness with the intervention and, in turn, led to positive acceptability outcomes.
The intensity of engagement was generally not associated with change in clinical outcomes. This finding is not consistent with our hypothesis, where we expected more improvement in depressive symptoms among those with a higher intensity of engagement. For example, a study where 28 consecutive patients with obsessive compulsive disorder were treated with exposure and response prevention found that compliance with in-session and homework exposure instructions was significantly related to posttreatment symptom severity.50 Another study where patients with depression received cognitive behavioral therapy found that those who did more homework improved more than those who did little or no homework.51 However, it is important to note that the intensity of engagement in our study mostly refers expressing gratitude and asking for help vs adhering to the intervention, completing homework and attending therapy sessions, which are related yet different concepts.
We also found that most demographic and clinical baseline characteristics were unrelated with the intensity of engagement with CuidaTEXT. This finding is in line with the literature on technological adjuncts to increase client adherence to psychotherapy, which suggests that baseline characteristics like symptom severity, educational background, or levels of coping skills are not associated with engagement between therapy sessions.48 The lack of a profile for more vs less intense engagement caregivers suggests that there is no need to adapt the intervention to increase engagement and potentially intervention acceptability, among specific groups.
In comparison to two studies assessing the effectiveness and user experiences of text messaging interventions, Latinos/as participating in this study exhibited a higher level of intensity of engagement, sending on average 83.95 text messages over a six-month period. Cartujano-Barrera et al (2019) found that among a mostly Latino/a sample of smokers, those who interacted with the program at least once sent on average 31.8 text messages during a 12-week period. Sosa et al. (2017) found that among a mostly non-Hispanic sample of head and neck cancer patients, participants sent 12 text messages during a one-week period.52 Much like the study conducted with Latino/a smokers, participants in this study showed a preference for composing their own text messages rather than relying on predefined keywords from the intervention for a response. This implies that depending solely on keywords may not provide adequate support for Latino/a caregivers through text messaging. Therefore, there might be supplementary expenses associated with deploying trained personnel to respond to participants’ text messages, as observed in our study.
While our study provided valuable insights, several limitations should be considered when interpreting the findings. Firstly, the variation in the number of messages could be influenced by factors such as individual caregiver needs, the effectiveness of automatic messages, and overall intensity or time spent on caregiving issues during the intervention. However, it is noteworthy that specific measures of the time or intensity of caregiving are not explicitly captured in this study, and the nuances behind these variations are not explicitly measured. Additionally, the levels of depression expressed by participants at baseline were relatively low. However, there was no requirement for a minimum level of depressive symptoms or stress for participants to be included in the study as it was a feasibility study. Despite caregivers’ relatively low levels of depressive symptoms, we have previously shown that these caregivers’ levels of depression declined after 6 months of CuidaTEXT.19 This study included a small sample size (n=24), did not have a control group, and only included two timepoints, which hinders our ability to establish directionality and causality between the intensity of engagement with CuidaTEXT intervention and other outcomes. The composition of the sample included primarily middle-aged Latino/a women with some college education, who were already familiar with text messages. While the most common profile of Latino/a family caregivers of people with ADRD is the daughter, our sample could have included a larger number of men and spouses, which might differ in their engagement with caregiver support interventions and text messaging. Lastly, neither the participants, the assessment staff, nor the data analyst were blinded, potentially introducing bias into the results.
The study has implications for clinical practice and research. With regards to clinical practice, it is encouraging to see that CuidaTEXT may contribute to reducing depressive symptoms and other clinical outcomes independently of caregiver intensity of engagement19. The association of intensity of engagement with acceptability outcomes highlights the importance of planning interventions to enhance caregivers’ willingness to engage for increased satisfaction and related outcomes. Researchers can conduct qualitative work to understand how to best encourage more intense engagement without adding burden to caregivers. The lack of association between intensity of engagement and most baseline variables, but existence of an association with acceptability outcomes suggests that people from diverse profiles may experience satisfaction and acceptability in general with the intervention. Also, the themes and examples of participants’ text messages found in our qualitative analyses can inform the development of future daily automatic or keyword messages, or a section for coaches on how to respond to specific messages in a protocolized way. Some interventions might propose more specialized answers to these messages, whereas others might refer caregivers to a resource who can help them responds to their needs. With regards to future research, text message studies on caregiving and other health and social issues should conduct similar research to explore whether their findings are comparable to ours. Research should include additional assessment points to explore the directionality of associations. For example, in our study we found an association between intensity of engagement with CuidaTEXT and acceptability outcomes (e.g., satisfaction with the intervention). However, it remains unclear whether intensity of engagement drove the satisfaction or those who were more satisfied engaged more intensely in sending text messages to CuidaTEXT. Including mediators of these associations may also help understand this relationship. Finally, the lack of association between intensity of engagement and change in clinical outcomes reduces the chance for bias related to differential intensity of engagement with the intervention in a future randomized controlled study.
Text messaging provides a unique opportunity to increase access and improve clinical outcomes among Latino/a family caregivers of people with ADRD. However, little is known about how features of these interventions such as intensity of engagement with their text messages can benefit them. In this study we found that intensity of engagement with CuidaTEXT, was generally associated with acceptability outcomes, but not with baseline characteristics nor change in clinical outcomes. Encouraging more intense engagement with caregiver support interventions might lead to higher levels of satisfaction with the intervention. However, future studies need to explore directionality of these associations.
Clinical Implications.
While CuidaTEXT shows promise in reducing depressive symptoms independently of caregiver intensity of engagement, the association between intensity of engagement and acceptability outcomes underscores the importance of planning interventions to enhance caregivers’ willingness to engage for increased satisfaction and related outcomes.
Future researchers may consider the clinical significance of customizing interventions based on caregiver engagement and preferences, drawing on insights from qualitative analyses.
Acknowledgements
The research team thanks research participants included in all stages of this research as well as anyone who has contributed directly and indirectly to this research. We also thank the UsAgainstAlzheimer’s A-List and the Alzheimer’s Association’s TrialMatch for sharing the opportunity to participate in CuidaTEXT with their registries and website visitors. The ideas and opinions expressed herein are those of the authors alone, and endorsement by the authors’ institutions or the funding agency is not intended and should not be inferred.
Appendix 1. Association between intensity of engagement with CuidaTEXT and sociodemographic characteristics
| Total number of messages | Total number of keywords | Total number of chat text messages | Keyword messages; Care domain | Keyword messages; Caregiver domain | Keyword messages; Support domain | Keyword messages; Behavior domain | Chat text messages; Gratitude domain | Chat text messages; Acknowledgement domain | Chat text messages; Logistics domain | Chat text messages; Education domain | Chat text messages; Behavior domain | Chat text messages; Care domain | Chat text messages; Caregiver domain | Chat text messages; Other domain | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Women (Mean rank difference) | −2.85 | −4.35 | 0.45 | 1.65 | −4.80 | −4.05 | −4.35 | 3.3 | −0.75 | −3.15 | 0.45 | 1.2 | 4.8 | 1.8 | −0.45 |
| Ever signed up for text message reminders (Mean rank difference) | −1.69 | 0.84 | −4.5 | 1.41 | 2.25 | 2.25 | 1.97 | −4.41 | −0.19 | 2.63 | 1.03 | −0.84 | −1.78 | −0.09 | −0.57 |
| Caregiver insurance (Mean rank difference) | −5.43 | −4.67 | −4.04 | −3.41 | −3.28 | −3.66 | −3.41 | −2.65 | 2.78 | −5.18 | 1.26 | 1.26 | −5.94* | −1.26 | 1.77 |
| Married (Mean rank difference) | 1.76 | −0.83 | 1.01 | −1.35 | −0.67 | −1.35 | −0.76 | −2.18 | −0.33 | 1.51 | −0.50 | 1.85 | 1.76 | 0.67 | −2.1 |
| Spanish as preferred language (Mean rank difference) | 8.40* | 7.81* | 5.54 | 5.87* | 7.05* | 6.80* | 5.37 | 4.19 | −0.17 | 3.02 | −1.85 | 0.09 | 5.37* | 3.27* | 0.67 |
| Age (Rho) | 0.19 | 0.07 | 0.24 | 0.09 | −0.06 | −0.013 | 0.12 | 0.29 | 0.25 | −0.05 | 0.08 | 0.27 | −0.07 | −0.09 | 0.41* |
| Years of education (Rho) | −0.25 | −0.08 | −0.36 | −0.04 | 0.06 | −0.04 | −0.15 | −0.42* | 0.01 | −0.31 | −0.01 | 0.18 | −0.28 | −0.01 | 0.01 |
| Number of text messages received daily (Rho) | −0.36 | −0.26 | −0.23 | −0.15 | −0.18 | −0.10 | −0.24 | −0.23 | −0.01 | −0.37 | −0.00 | −0.09 | −0.12 | 0.13 | 0.01 |
| Frequency of checking for text messages (Rho) | 0.77 | 0.01 | 0.05 | −0.01 | 0.08 | −0.05 | 0.08 | 0.03 | 0.15 | 0.02 | −0.28 | 0.01 | −0.10 | 0.11 | 0.23 |
| Number of days a week of seeing loved one with dementia in person (Rho) | 0.26 | 0.12 | 0.33 | −0.07 | −0.06 | 0.07 | 0.22 | 0.36 | 0.13 | 0.02 | 0.15 | 0.15 | 0.19 | −0.08 | 0.08 |
| Financial stability (Rho) | 0.18 | 0.23 | 0.11 | 0.29 | 0.25 | 0.19 | 0.09 | 0.01 | −0.18 | 0.33 | −0.27 | −0.05 | 0.29 | 0.42* | −0.14 |
| Hours a day on caregiving duty (Rho) | 0.43* | 0.17 | 0.58* | 0.21 | −0.03 | 0.14 | 0.24 | 0.47* | 0.29 | 0.48* | 0.18 | −0.03 | 0.39 | 0.08 | 0.50* |
p<0.05
Appendix 2. Association between intensity of engagement with CuidaTEXT and baseline clinical characteristics
| Total number of messages | Total number of keywords | Total number of chat text messages | Keyword messages; Care domain | Keyword messages; Caregiver domain | Keyword messages; Support domain | Keyword messages; Behavior domain | Chat text messages; Gratitude domain | Chat text messages; Acknowledgement domain | Chat text messages; Logistics domain | Chat text messages; Education domain | Chat text messages; Behavior domain | Chat text messages; Care domain | Chat text messages; Caregiver domain | Chat text messages; Other domain | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI-Q Distress (Rho) | −0.076 | −0.070 | 0.021 | 0.074 | −0.076 | −0.067 | 0.097 | 0.14 | 0.06 | −0.06 | −0.17 | 0.03 | 0.22 | 0.33 | −0.32 |
| Caregiver Strain Index (Rho) | 0.224 | 0.085 | 0.365 | 0.299 | −0.046 | 0.080 | 0.006 | 0.31 | 0.12 | 0.15 | −0.22 | −0.05 | 0.43* | 0.39 | 0.08 |
| ZBI Burden (Rho) | −0.129 | −0.244 | 0.002 | −0.076 | −0.225 | −0.239 | −0.279 | −0.03 | −0.07 | 0.08 | −0.15 | −0.13 | 0.08 | 0.12 | −0.17 |
| Positive aspects of caregiving (Rho) | −.406* | −0.357 | −0.246 | −0.219 | −.467* | −0.280 | −0.280 | −0.13 | −0.07 | −0.00 | −0.04 | −0.01 | −0.26 | −0.28 | 0.33 |
| EEDS dementia knowledge (Rho) | −0.174 | −0.128 | −0.016 | 0.022 | −0.098 | −0.028 | −0.082 | −0.06 | 0.19 | 0.18 | 0.27 | 0.43* | −0.03 | 0.00 | 0.30 |
| ISEL-12 appraisal support (Rho) | −0.158 | −0.240 | −0.147 | −0.277 | −0.317 | −0.292 | −0.218 | −0.05 | −0.06 | −0.17 | 0.11 | −0.16 | −0.25 | −030 | −0.20 |
| ISEL-12 belonging support (Rho) | −0.05 | −0.38 | 0.04 | −.44* | −0.31 | −0.37 | −0.31 | 0.11 | 0.19 | −0.10 | 0.26 | −0.18 | −0.30 | −0.33 | −0.20 |
| ISEL-12 tangible support (Rho) | −0.14 | −0.06 | −0.12 | −0.16 | 0.00 | −0.10 | −0.15 | −0.08 | −0.06 | −0.24 | 0.16 | −0.15 | −0.22 | −0.17 | −0.33 |
| COPE 28 problem focused (Rho) | 0.27 | 0.16 | 0.16 | 0.14 | 0.21 | 0.31 | 0.09 | −0.07 | 0.22 | 0.03 | −0.15 | 0.23 | 0.22 | 0.38 | −0.09 |
| COPE 28 emotion focused (Rho) | 0.24 | 0.06 | 0.20 | 0.12 | 0.01 | 0.08 | 0.03 | 0.18 | 0.34 | −0.11 | −0.05 | −0.28 | 0.02 | 0.16 | 0.32 |
| COPE 28 avoidant focused (Rho) | −0.02 | −0.18 | 0.01 | −0.03 | −0.22 | −0.12 | −0.11 | −0.03 | −0.05 | 0.09 | −0.24 | −0.27 | 0.12 | 0.06 | −0.25 |
| CES-D-10 depression (Rho) | −0.14 | −0.18 | −0.07 | −0.07 | −0.15 | −0.16 | −0.24 | −0.27 | −0.09 | 0.25 | −0.01 | −0.12 | 0.10 | −0.04 | −0.30 |
| SPANE-Positive affect (Rho) | 0.32 | 0.33 | 0.19 | 0.30 | 0.15 | 0.39 | 0.36 | 0.13 | −0.01 | 0.11 | −0.21 | 0.07 | 0.28 | 0.16 | 0.10 |
| SPANE-Negative affect (Rho) | −0.31 | −0.09 | −0.23 | 0.00 | −0.09 | 0.03 | −0.13 | −0.34 | −0.20 | 0.09 | −0.39 | −0.03 | 0.05 | 0.26 | −0.01 |
| PCS Competence (Rho) | −0.15 | −0.17 | −0.18 | −013 | −0.14 | −0.17 | −0.12 | −0.14 | 0.21 | −0.12 | −0.11 | 0.22 | −0.28 | −0.12 | −0.08 |
| Perceived health (Rho) | 0.20 | 0.36 | −0.11 | 0.27 | 0.35 | 0.35 | 0.40 | −0.13 | 0.10 | −0.24 | 0.07 | 0.26 | 0.06 | 0.12 | 0.21 |
p<0.05
Appendix 3. Association between intensity of engagement with CuidaTEXT and acceptability outcomes
| Total number of messages | Total number of keywords | Total number of chat text messages | Keyword messages; Care domain | Keyword messages; Caregiver domain | Keyword messages; Support domain | Keyword messages; Behavior domain | Chat text messages; Gratitude domain | Chat text messages; Acknowledgement domain | Chat text messages; Logistics domain | Chat text messages; Education domain | Chat text messages; Behavior domain | Chat text messages; Care domain | Chat text messages; Caregiver domain | Chat text messages; Other domain | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Satisfaction with CuidaTEXT (Rho) | 0.57** | 0.56* | 0.41 | 0.30 | 0.41 | 0.45* | 0.67* | 0.08 | 0.10 | 0.11 | 0.10 | 0.28 | 0.53* | 0.35 | 0.00 |
| Satisfaction with text message frequency (Rho) | 0.31 | 0.16 | 0.59* | 0.15 | −0.07 | 0.05 | 0.25 | 0.59* | 0.27 | −0.10 | 0.23 | −0.00 | 0.33 | −0.13 | 0.19 |
| Satisfaction with keyword options (Rho) | 0.52* | 0.30 | 0.41 | 0.10 | 0.17 | 0.12 | 0.49* | 0.38 | 0.38 | 0.19 | 0.06 | −0.21 | 0.20 | 0.26 | 0.05 |
| Satisfaction with phone contacts (Rho) | 0.60* | 0.42 | 0.53* | 0.34 | 0.25 | 0.31 | 0.47 | 0.33 | 0.32 | 0.44 | 0.16 | 0.29 | 0.47 | −0.05 | 0.03 |
| Satisfaction with links to websites (Rho) | 0.17 | 0.11 | 0.35 | −0.24 | −0.02 | 0.02 | 0.02 | 0.46 | −0.01 | 0.18 | 0.03 | −0.34 | −0.04 | −0.10 | −0.07 |
| Satisfaction with CuidaTEXT’s duration (Rho) | 0.49* | 0.49* | 0.28 | 0.35 | 0.26 | 0.44 | 0.40 | 0.28 | 0.02 | 0.14 | −0.09 | −0.14 | 0.32 | 0.27 | 0.10 |
| Enjoyment of CuidaTEXT (Rho) | 0.37 | 0.24 | 0.33 | 0.34 | 0.10 | 0.13 | 0.29 | 0.38 | 0.18 | 0.06 | −0.16 | −0.15 | 0.40 | 0.33 | −0.01 |
| CareTEXT helped care for loved one with ADRD (Rho) | 0.61* | 0.54* | 0.42 | 0.62* | 0.42 | 0.48* | 0.49* | 0.26 | 0.20 | 0.53* | 0.05 | 0.20 | 0.47* | 0.26 | −0.04 |
| CareTEXT helped care for themselves (Rho) | 0.30 | 0.47* | 0.20 | 0.39 | 0.28 | 0.42 | 0.49* | 0.34 | −0.05 | −0.11 | −0.06 | −0.20 | 0.30 | 0.29 | 0.00 |
| CareTEXT helped understanding the disease better (Rho) | 0.56* | 0.32 | 0.56* | 0.28 | 0.25 | 0.20 | 0.35 | 0.48* | 0.48* | 0.35 | 0.28 | 0.13 | 0.31 | 0.17 | −0.03 |
p<0.05
p<0.025
Appendix 4. Association between intensity of engagement with CuidaTEXT and baseline to follow-up change in clinical characteristics
| Total number of messages | Total number of keywords | Total number of chat text messages | Keyword messages; Care domain | Keyword messages; Caregiver domain | Keyword messages; Support domain | Keyword messages; Behavior domain | Chat text messages; Gratitude domain | Chat text messages; Acknowledgement domain | Chat text messages; Logistics domain | Chat text messages; Education domain | Chat text messages; Behavior domain | Chat text messages; Care domain | Chat text messages; Caregiver domain | Chat text messages; Other domain | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI-Q Distress (Rho) | 0.43 | 0.37 | 0.06 | 0.28 | 0.31 | 0.31 | 0.32 | −0.15 | 0.07 | −0.12 | −0.02 | 0.25 | 0.19 | 0.20 | 0.33 |
| Caregiver Strain Index (Rho) | 0.04 | −0.12 | 0.16 | −0.04 | −0.19 | 0.02 | −0.14 | −0.01 | 0.13 | 0.35 | −0.02 | 0.22 | - | - | - |
| ZBI Burden (Rho) | 0.07 | −0.03 | 0.13 | 0.15 | 0.01 | 0.10 | −0.07 | −0.02 | 0.11 | 0.45* | −0.10 | −0.00 | 0.11 | 0.02 | 0.28 |
| Positive aspects of caregiving (Rho) | 0.25 | 0.23 | 0.36 | 0.30 | 0.15 | 0.13 | 0.13 | 0.21 | −0.02 | 0.01 | 0.00 | 0.11 | 0.56* | 0.32 | −0.47* |
| EEDS dementia knowledge (Rho) | 0.18 | 0.17 | −0.04 | 0.05 | 0.14 | 0.10 | 0.12 | −0.13 | −0.18 | −0.05 | −0.12 | −0.21 | 0.20 | 0.12 | −0.50* |
| ISEL-12 appraisal support (Rho) | −0.23 | 0.10 | −0.17 | 0.14 | 0.06 | 0.19 | 0.03 | −0.15 | −0.23 | −0.13 | −0.17 | −0.23 | 0.08 | 0.28 | 0.19 |
| ISEL-12 belonging support (Rho) | −0.20 | −0.04 | −0.06 | 0.01 | −0.18 | −0.04 | 0.10 | 0.00 | −0.11 | −0.27 | −0.38 | 0.39 | 0.18 | 0.34 | 0.04 |
| ISEL-12 tangible support (Rho) | −0.15 | −0.10 | 0.02 | −0.08 | −0.25 | −0.07 | 0.06 | 0.12 | −0.13 | 0.03 | −0.18 | 0.23 | 0.17 | 0.18 | 0.01 |
| COPE 28 problem focused (Rho) | −0.16 | −0.13 | −0.15 | 0.03 | −0.16 | −0.25 | −0.06 | −0.12 | −0.19 | 0.31 | 0.08 | 0.09 | −0.03 | −0.45* | −0.15 |
| COPE 28 emotion focused (Rho) | −0.10 | −0.10 | −0.08 | 0.10 | −0.05 | −0.08 | −0.04 | −0.18 | −0.20 | 0.51* | 0.25 | 0.11 | 0.16 | −0.29 | −0.03 |
| COPE 28 avoidant focused (Rho) | 0.52* | 0.26 | 0.29 | 0.36 | 0.30 | 0.19 | 0.34 | 0.26 | 0.56* | 0.19 | 0.22 | 0.35 | 0.06 | 0.04 | 0.35 |
| CES-D-10 depression (Rho) | −0.00 | −0.01 | −0.12 | 0.07 | −0.01 | 0.06 | 0.17 | 0.14 | 0.23 | −0.18 | −0.23 | 0.10 | −0.15 | 0.36 | 0.52* |
| SPANE-Positive affect (Rho) | −0.33 | −0.16 | −0.25 | −0.21 | −0.02 | −0.29 | −0.19 | −0.13 | 0.01 | −0.26 | 0.09 | −0.06 | −0.32 | −0.20 | −0.23 |
| SPANE-Negative affect (Rho) | 0.10 | −0.00 | 0.16 | 0.12 | 0.02 | −0.01 | 0.06 | 0.27 | 0.17 | 0.00 | 0.57* | 0.09 | 0.11 | −0.13 | 0.42 |
| PCS Competence (Rho) | 0.37 | 0.55* | −0.00 | 0.35 | 0.60* | 0.51* | 0.36 | −0.29 | −0.30 | 0.08 | 0.06 | 0.06 | 0.34 | 0.16 | −0.56* |
| Perceived health (Rho) | −0.04 | −0.03 | 0.04 | −0.19 | −0.04 | 0.01 | −0.04 | −0.10 | −0.09 | 0.32 | 0.13 | −0.28 | −0.07 | 0.00 | −0.22 |
p<0.05
Footnotes
Disclosure statement: The authors report there are no competing interests to declare.
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