This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Aging, is properly cited. The complete bibliographic information, a link to the original publication on https://aging.jmir.org, as well as this copyright and license information must be included.
Chinese American family caregivers of persons with dementia experience high rates of psychosocial distress and adverse health outcomes. Due to their immigrant and minority status, they face substantial obstacles to care and support, including stigma and misperception of dementia, limited knowledge and use of welfare and services, and poor social support. Few interventions have been developed or tested for this vulnerable population.
This study aims to pilot-test the Wellness Enhancement for Caregivers (WECARE) intervention, a culturally tailored program delivered via WeChat, a social media app highly popular in the Chinese population. The 7-week WECARE was designed specifically for Chinese American dementia caregivers to improve their caregiving skills, reduce stress, and enhance psychosocial well-being. Feasibility, acceptability, and preliminary efficacy of the WECARE were assessed in this pilot.
A total of 24 Chinese American family caregivers of persons with dementia were recruited for a pre-post 1-arm trial of the WECARE. By subscribing to the WECARE official account, participants received interactive multimedia programs on their WeChat account multiple times a week for 7 weeks. A backend database automatically delivered program components and tracked user activities. Three online group meetings were organized to facilitate social networking. Participants completed a baseline and a follow-up survey. Feasibility was assessed by the follow-up rate and curriculum completion rate; acceptability was assessed by user satisfaction and perceived usefulness of the program; and efficacy was assessed with pre-post differences in 2 primary outcomes of depressive symptoms and caregiving burden.
The intervention was completed by 23 participants with a retention rate of 96%. Most of them (n=20, 83%) were older than 50 years and the majority (n=17, 71%) were female. The backend database revealed that the mean curriculum completion rate was 67%. Participants also reported high rates of user satisfaction and perceived usefulness of the intervention and high ratings of weekly programs. The intervention led to significant improvement in participants’ psychosocial health outcomes; their depressive symptoms reduced from 5.74 to 3.35 with an effect size of −0.89 and caregiving burden decreased from 25.78 to 21.96 with an effect size of −0.48.
This pilot study suggests that WeChat-based WECARE intervention was feasible and acceptable; it also demonstrated initial efficacy in improving psychosocial well-being in Chinese American dementia caregivers. Further research with a control group is needed to assess its efficacy and effectiveness. The study highlights the need for more culturally appropriate mobile health interventions for Chinese American family caregivers of persons with dementia.
The American population is rapidly aging and becoming more diverse. The number of adults aged 65 years and older is projected to increase from 16.9% in 2020 to 22% in 2050, and the proportion of racial and ethnic minorities is expected to grow from 38.4% in 2020 to 50.3% in 2045 [
Family caregivers of persons with dementia face a myriad of challenges related to the length, complexity, and intensity of caregiving. As a result, they have reported high levels of physical and emotional stress [
Asian Americans are the fastest-growing racial group with a growth rate of 88% from 2000 to 2020 [
Despite these unique challenges and barriers, few caregiving interventions are tailored to the needs of Chinese American dementia caregivers [
Racial or ethnic minority populations are more likely to be smartphone-dependent for internet access (without computer or other mobile devices) and rely on social media as a primary source of health information [
To address the literature gaps and public health needs of culturally tailored intervention for Chinese American dementia caregivers, we developed a WeChat-based intervention called Wellness Enhancement for Caregivers (WECARE) to address their psychosocial distress [
This is a 1-arm, pre-post pilot trial. A total of 24 Chinese American dementia caregivers completed a baseline survey and received the 7-week WECARE intervention; their activities on WECARE were tracked by the backend database. Participants completed a follow-up survey 2 to 3 weeks after the intervention. Feasibility was assessed by the retention rate and curriculum completion rate. Acceptability was assessed by user satisfaction and perceived usefulness scale in the follow-up survey. Preliminary efficacy was evaluated by effect sizes of psychosocial health outcomes assessed at baseline and follow-up surveys.
Participation eligibility included (1) self-identifying as Chinese or Chinese Americans and can read Chinese, (2) at least 21 years old, (3) currently living in the United States, (4) using WeChat, and (5) providing care at least 12 hours a week for a family member or loved one with Alzheimer disease, dementia, or other neurodegenerative conditions. Exclusion criteria included (1) being cognitively impaired or has serious mental health problems and (2) care partner has less than 6 months of life expectancy or in hospice care. When a potential participant contacted, our research staff conducted the screening. Those who met the participation criteria were invited to participate. A separate Zoom meeting was scheduled to obtain informed consent.
Participants were recruited from 2 sources. One was through our community partner, a community-based organization that serves Chinese Americans in the greater Washington, DC metropolitan. A recruitment flyer was distributed through social media and email newsletters. The other source was the University of California San Francisco Collaborative Approach for Asian Americans, Native Hawaiians, and Pacific Islanders Research Education registry [
The study protocol was approved by the Institutional Review Board of George Mason University (IRB#1849712). All eligible participants had a one-on-one online meeting with a research staff who explained the study procedure and answered all questions. All participants provided verbal informed consent before they started the study.
The 7-week WECARE intervention was developed to reduce caregiving burden, decrease distress, and enhance psychosocial well-being of Chinese American family caregivers of persons with dementia. Its protocol development and key features were detailed elsewhere [
A total of 24 participants were enrolled in the study. After the informed consent, participants completed a web-based baseline survey and then subscribed to the WECARE official account via their WeChat app. WECARE automatically sent multimedia program components 4-6 times a week, at a prescheduled time Monday to Saturday, for 7 weeks. During the 7 weeks, participants’ activities on WECARE, including whether a program component was opened, how many times it was opened, and for how long, were tracked by the backend database. Participants who had not opened WECARE for a week would receive a friendly reminder via WeChat. Those who were not responsive to our reminders for 3 consecutive weeks were considered dropped out. A follow-up survey was administered 2 to 3 weeks after the intervention completion. Surveys were in Chinese, the links to the online surveys were sent to participants in their WeChat accounts or emails, and they could open the link in any browser.
Two sets of data were collected in the pilot study: (1) baseline and follow-up surveys administered online before and after the intervention (see
Data sets and domains of measures.
|
Baseline survey | Backend database | Follow-up survey | ||||
Demographics | ✓ |
|
|
||||
|
|||||||
|
Retention rate | ✓ |
|
✓ | |||
|
Curriculum completion rate |
|
✓ |
|
|||
|
User activities: total and weekly read counts; total and weekly reading minutes |
|
✓ |
|
|||
|
|||||||
|
User satisfaction |
|
|
✓ | |||
|
Perceived usefulness of WECAREa |
|
|
✓ | |||
|
Perceived usefulness of weekly program |
|
|
✓ | |||
|
|||||||
|
Depressive symptoms | ✓ |
|
✓ | |||
|
Caregiver’s burden | ✓ |
|
✓ | |||
|
Life satisfaction | ✓ |
|
✓ | |||
|
Perceived social support | ✓ |
|
✓ |
aWECARE: Wellness Enhancement for Caregivers.
Feasibility was measured by three indicators about how participants have completed the intervention trial: (1) retention rate was assessed by the percentage of participants who completed the follow-up survey. (2) Curriculum completion rate was assessed by the percentage of a participant’s completion of all 40 articles of the WECARE curriculum. For example, if a participant completed 20 articles, his or her curriculum completion rate was 50%. If an article was opened, it was considered read or completed, which was tracked by the backend database. We calculated the mean value of all curriculum completion rates of all participants. (3) User activity was assessed by read counts and reading minutes tracked by the backend database. A “read count” was the number of times a participant had opened an article; “weekly read count” was the sum of read counts on a week’s program; and “total read count” was the sum of all read counts. “Reading minutes” was the minutes a participant spent on an article; “weekly reading minutes” was the sum of reading minutes for a week’s program; and “total reading minutes” was the sum of all reading minutes. These indicators of user activity reflected user engagement.
Acceptability was measured by three indicators, all were drawn from our previous digital health intervention evaluation [
Intervention efficacy was measured by whether the 4 psychosocial health outcomes have meaningful effect sizes as a result of the intervention. The primary outcomes were depressive symptoms and caregiver’s perceived burden, and the secondary outcomes were life satisfaction and perceived social support. (1) Depressive symptoms were assessed by the Center for Epidemiologic Depression Scale (CES-D) 10-item [
Demographic characteristics of participants were assessed in the baseline survey. Caregivers’ characteristics assessed included age, sex, marital status, education, employment status, years of living in the United States, English proficiency, health status, and having difficulty paying for the basics. Care-partner characteristics assessed included age, sex, relationship to caregiver, living arrangement, and functional status measured by activity of daily living (ADL) [
First, descriptive statistics were used to describe the sample characteristics, feasibility and user engagement, acceptability, and user satisfaction. Cronbach α was used to calculate internal consistency of the scales. Then, paired
As shown in
Demographics of caregivers and care partners.
Characteristics | Values | |||
|
||||
|
Age (years), mean (SD) | 59.58 (11.99) | ||
|
Female sex, n (%) | 17 (71) | ||
|
Married or living with a partner, n (%) | 21 (88) | ||
|
Years of living in the United States, mean (SD) | 23.4 (10.5) | ||
|
Limited English proficiency, n (%) | 13 (54) | ||
|
Speaks Chinese or Mandarin at home, n (%) | 22 (92) | ||
|
Has difficulty paying for basics, n (%) | 11 (46) | ||
|
||||
|
Age (years), mean (SD) | 81.38 (8.65) | ||
|
Female sex, n (%) | 13 (54) | ||
|
CP and CG live together, n (%) | 16 (67) | ||
|
|
|||
|
|
Spouse, n (%) | 7 (29) | |
|
|
Child, n (%) | 16 (67) | |
|
|
Other relative or friend, n (%) | 1 (4) | |
|
ADLa score, mean (SD) | 11.54 (9.47) | ||
|
IADLb score, mean (SD) | 20.08 (5.64) |
aADL: activity of daily living.
bIADL: instrumental activities of daily living.
Three indicators were used to assess feasibility: (1) follow-up rate, (2) curriculum completion rate, and (3) user activities. Out of 24 participants who were enrolled at baseline, a total of 23 completed the intervention and follow-up survey, with a retention rate of 96%. The backend database revealed that out of the 23 participants in the follow-up, the curriculum completion rate ranged from 8% to 100% with a mean value of 67%. Participants’ total read counts of program components ranged from 5 to 154 with a mean of 54. Participants’ total reading minutes ranged from 1 to 7196 minutes with a mean of 465 minutes (see
Acceptability was assessed with four indicators, including (1) user satisfaction and (2) perceived usefulness of overall WECARE program, and (3) perceived usefulness and (4) user activity on the weekly program.
User satisfaction (N=23).
Item | Mean (SD) |
1. It was easy to use | 4.87 (0.34) |
2. It was useful for me | 4.70 (0.47) |
3. The time needed for the program was appropriate | 4.65 (0.49) |
4. It was boring to use (reversed score) | 4.48 (0.95) |
5. It was fun to use | 4.48 (0.67) |
6. I would recommend it to others | 4.70 (0.47) |
7. Overall, I’m satisfied with the program | 4.65 (0.49) |
Total score | 32.52 (2.54) |
Perceived usefulness (N=23).
Item | Mean (SD) |
1. WECAREa has helped me understand Alzheimer disease better | 4.74 (0.45) |
2. WECARE has motivated me to become a better caregiver | 4.78 (0.42) |
3. WECARE has helped me become a better caregiver | 4.65 (0.49) |
4. WECARE has helped me better manage stress and improve my psychosocial well-being | 4.48 (0.67) |
5. WECARE has helped me to better prepare the upcoming journey of caregiving | 4.52 (0.51) |
Total score | 23.17 (1.99) |
aWECARE: Wellness Enhancement for Caregivers.
Perceived usefulness and engagement by weekly program (N=23).
|
Usefulness (range 1-5), mean (SD) | Read counts by week, mean (SD) | Reading minutes by week, mean (SD) |
1. Week 1: Dementia facts and knowledge | 4.52 (0.59) | 10.6 (8.03) | 132.1 (465.15) |
2. Week 2: Caring for patients with dementia | 4.65 (0.49) | 8.3 (5.89) | 113.5 (400.76) |
3. Week 3: Effective communication | 4.43 (0.66) | 7.3 (6.46) | 22.5 (31.38) |
4. Week 4: Problem-solving in caregiving | 4.35 (0.65) | 7.1 (5.53) | 40.4 (118.16) |
5. Week 5: Stress reduction and depression prevention | 4.35 (0.65) | 8.7 (7.15) | 49.3 (135.38) |
6. Week 6: Becoming a healthy caregiver | 4.39 (0.72) | 6.5 (5.88) | 40.3 (126.20) |
7. Week 7: Course summary and local resources | 4.57 (0.59) | 8.2 (5.48) | 66.5 (210.90) |
8. Three group meetings online | 4.39 (0.78) | —a | — |
aNot available.
The intervention efficacy was assessed with pre-post differences of 4 psychosocial outcomes: depressive symptoms, caregivers’ burden, life satisfaction, and social support.
Caregivers’ psychosocial well-being pre- and postintervention comparison (N=23).
Outcome | Baseline, mean (SD) | Follow-up, mean (SD) | Change, mean (95% CI) | Effect size | |
Depressive symptoms (range 0-10) | 5.74 (2.56) | 3.35 (2.72) | −2.39 (−3.56 to −1.23) | −0.89 (−1.37 to −0.40) | <.001a |
Caregiving burden (range 0-48) | 25.78 (7.19) | 21.91 (6.69) | −3.87 (−7.38 to −0.36) | −0.48 (−0.90 to −0.04) | .03b |
Life satisfaction (range 0-30) | 11.35 (6.66) | 14.83 (7.11) | 3.48 (0.73 to 6.23) | 0.55 (0.10 to 0.98) | .02c |
Social support (range 0-30) | 14.78 (5.15) | 13.96 (6.39) | −0.83 (−3.39 to 1.74) | −0.14 (−0.55 to 0.27) | .51 |
a
b
c
Our data strongly suggest that WECARE was a feasible and acceptable intervention in Chinese American dementia caregivers; it also demonstrated preliminary efficacy in improving participants’ psychosocial well-being. First, the intervention was feasible. A total of 24 participants enrolled in the study and 23 completed the intervention with a retention rate of 96%. The backend database that tracked user activities showed that the mean curriculum completion rate was 67%; in other words, on average participants had completed 67% of all 40 multimedia papers in the 7-week program. The mean read counts was 57, and the mean total reading minutes was 465 minutes, suggesting a good level of user engagement. Second, the intervention had good acceptability. The follow-up survey indicated that participants reported high levels of user satisfaction (32 out of 35), high levels of perceived usefulness of the intervention (23 out of 25), and high levels of perceived usefulness of weekly programs (4.3-4.5 out of 5). Third, the intervention demonstrated preliminary efficacy. The pre-post analysis of psychosocial outcomes revealed that, despite a small sample size, 3 out of 4 health outcomes, that is, depressive symptoms, caregivers’ burden, and life satisfaction, had statistically significant changes after the intervention, and the effect sizes ranged from 0.55 to 0.89. However, perceived social support for caregiving remained unchanged.
To the best of our knowledge, the WECARE represents the first mHealth intervention for Chinese American dementia caregivers and one of the first for immigrant and racial minority dementia caregivers. The results from the trial were comparable to earlier in-person interventions for Chinese American dementia caregivers [
The feasibility, acceptability, and initial efficacy demonstrated in this study could be attributed to the following strengths of the WECARE. First, the curriculum of the WECARE was developed based on evidence-based interventions [
We noted that despite significant improvement in 3 out of the 4 health outcomes (depressive symptoms, caregiving burden, and life satisfaction), participants still reported high levels of depressive symptoms (mean 3.35) and caregiving burden (mean 21.91) at the follow-up, suggesting elevated psychosocial distress despite the intervention. More resources and continuous support are needed to meet the needs of this vulnerable population.
One of the 2 secondary outcomes for efficacy evaluation, perceived social support for caregiving, did not change significantly after the intervention. There were 2 possible explanations. One, it might be that the sample size was too small to detect the change. Two, the WECARE had minimal effect on improving perceived social support in caregiving, even though 3 moderated online meetings were organized and participants could use the built-in functions in WeChat like group chat and private chat to initiate additional contacts. Social support requires long-term trust building and tangible support to address daily needs. A 7-week online program with limited interactions might not be the most effective approach to improve social support.
An important feature of the WECARE was its backend database that automatically sent program components and tracked user activities, including whether and when an article was opened, how many times it was read, and for how long. User activity data such as curriculum completion rate, total read counts, and total reading minutes could be used as objective measure of user engagement. These data also complemented the self-report survey data on user satisfaction and perceived usefulness to provide a more comprehensive understanding of the program’s feasibility and acceptability and inform further revision of the intervention. For example, high levels of user engagement tracked by the backend database and high levels of perceived usefulness reported in the follow-up survey for a particular week’s program might indicate its good acceptability; otherwise, it might suggest the need for further revision.
This pilot study has several limitations. First, there was no control group, so we could not affirm whether the changes in health outcomes observed in this pre-post trial were a result of the intervention only instead of testing effects or other factors. The main purpose of the pilot study was to assess the feasibility, acceptability, and preliminary efficacy of the WECARE; thus, future research would need to test its efficacy through a rigorous randomized controlled trial. Second, all acceptability measures and health outcome measures were based on self-report, there were potential self-report biases. Third, the follow-up survey was administered 2-3 weeks after the intervention, so we were not able to observe the long-term effect of WECARE. A future study with long-term follow-ups is needed. Fourth, though the intervention retention rate was 96% with only 1 participant dropped out, the curriculum completion rate was suboptimal with 67%, suggesting some participants stayed in the intervention but did not complete the entire curriculum. However, these numbers were higher or comparable to other mHealth interventions for caregivers or other WeChat-based interventions [
The WECARE pilot study demonstrated that this WeChat-based intervention demonstrated a high level of feasibility and acceptability; it also showed promising efficacy in improving psychosocial well-being in Chinese American family caregivers of persons with dementia. It reduced participants’ depressive symptoms, decreased caregiving burden, and increased life satisfaction but had no effect on perceived social support for caregiving. Our next step is to conduct a randomized controlled trial with a larger sample and long-term follow-up to further test WECARE’s efficacy and effectiveness. Based on the promising results from this study, we call for more research on culturally tailored and digitally delivered interventions for immigrant and racial or ethnic minority family caregivers of persons with dementia.
WECARE project baseline and follow-up survey.
WECARE intervention frontend and backend screenshots.
User activities tracked by the backend database.
activity of daily living
Center for Epidemiologic Depression Scale
instrumental activities of daily living
mobile health
Social Support Scale
Satisfaction With Life Scale
Wellness Enhancement for Caregivers
Zarit Burden Interview
The study was funded by the Virginia Center for Alzheimer’s and Related Diseases Research Award Fund (PI: YAH). We thank Chinese Culture and Community Service Center, Inc for tremendous support in participant recruitment and WECARE program design and evaluation. Some participants were recruited with support from the Collaborative Approach for Asian Americans, Native Hawaiians and Pacific Islanders Research and Education (CARE), which is funded by the National Institute on Aging of the National Institutes of Health (R24AG063718, PI: VTP).
This pilot study has a sample size of 24 only, and all participants were underserved Chinese American dementia caregivers. Even deidentified day poses potential risks of tracing back to some participants. Per our institutional review board requirement, we do not submit the data to a repository. Any fellow researcher interested in this data set may contact the corresponding author directly.
None declared.