Caregivers of veterans enrolled in the Caregiver Support Program were eligible for the pilot study as these caregivers all had an electronic health record, a requirement for Annie registration. The pilot study was publicized to the national network of Caregiver Support Program teams of VA located at each facility. Caregiver Support Program staff from each VA facility sent a flyer about the study to each of their caregivers enrolled in the VA Caregiver Support Program. If a caregiver was interested in participating, staff registered the caregiver in Annie and then sent the caregiver’s information to the Caregiver Center Annie coordinator. The Annie coordinator then reached out to the caregiver and completed a short screening interview to ensure that the caregivers could receive text messages and were willing to participate. Once a caregiver agreed to participate, the Annie coordinator mailed consent forms and scheduled a time to go over them over the phone. Caregivers then received messages to help reduce stress for 1 month. After the month was over, the Annie coordinator completed a program evaluation with the caregivers to obtain their feedback on the messages.

The pilot evaluation was reviewed and approved by the Memphis VA Medical Center institutional review board (IRBNet #1415769). It was conducted from July 11 to November 1, 2019, to evaluate caregivers’ use and satisfaction with the messages and format.

The Annie Stress Management protocol for caregivers, used in the pilot and the national rollout, is based on the Resources for Enhancing All Caregivers Health (REACH) caregiver intervention used in the Department of VA and the community [4,29,30]. REACH and the text messages are based on the stress health process model [31,32]. As conceptualized by the model, caregivers have challenges and demands placed on them (eg, care of their loved one, lack of help, and their own physical health) and cognitive and emotional responses to these challenges (eg, grief, feeling alone, and viewing events from a negative perspective) [32]. If caregivers do not believe they have resources and the capacity to manage their demands, they experience stress, which can lead to physical and psychological distress and illness [31]. Following the model, the Annie Stress Management text messages focus on knowledge, strategies, and actions that caregivers can take to cope with demands and their responses to them and manage stressors. The goal is to help the caregiver intervene at multiple points in the stress health process (Table 1).

The pilot protocol included two types of text messages, those that Annie sent without any caregiver involvement focusing on motivation and education and messages that were requested by the caregiver after a series of prompts by the system and caregiver responses. For the pilot messaging workflow, motivational or educational messages were sent twice a week without any caregiver involvement. The requested messages offered an optional activity to the caregiver. Caregivers were contacted to ask if they were stressed twice a week (on days when a motivational message did not come). If they replied yes, they received a query to ask if they would like to do an activity to help. Caregivers could respond to this activity-requested query to receive content about stress-relieving strategies, breathing, give yourself a break, setting boundaries, and mindfulness. Annie then sent messages to help with stress. For example, for breathing, one stress-relieving strategy was “Annie says to breathe deeply, hold it for 3 seconds. Breathe out slowly. Say a calming word to yourself. Let your jaw, shoulders, and arms go limp. Repeat twice.” Caregivers could contact the text program at any time as many times as they wanted for stress-relieving messages. Each time they texted the appropriate prompt to the system (eg, Activity BREATHING), a message was sent until the bank of 10 to 12 texts for each topic was exhausted and began again. Therefore, caregivers could receive none, one, or several activity messages. Annie provided instructions each time to help the caregivers remember how to request assistance.

At the end of a month, caregivers were contacted by telephone to evaluate acceptability of the program’s texts by the coordinator. Questions were focused on technical aspects (eg, easy to read and problems requesting texts) and perceptions of benefit (eg, helped me take better care of myself, made me feel cared for, and made me feel confused). Each question was answered on a scale from 1 (completely disagree) to 5 (completely agree). Data were analyzed using descriptive statistics, including frequencies and means. Open-ended questions asked caregivers what they enjoyed about the messages and why, usefulness of the messages, most helpful messages, use of the messages, and confidence about managing stress after the messages. Caregivers were also asked whether they liked the request prompt messages (responding yes to being stressed and receiving an activity message).

Quotes were examined individually by 2 anthropologist authors, both with prior experience in coding of qualitative data. Each reviewer sorted the descriptions, concepts, and central ideas into potential themes [33] looking for repetitions, similarities, and differences [34]. Topics that occurred repeatedly were linked to verbatim quotes [33]. Themes were discussed and finalized by these authors.

On the basis of the positive response to the messages by caregivers in the pilot study, a national rollout of the Annie caregiver stress management protocol was approved by the VA’s Office of Connected Care for the VA system on October 1, 2019. As the caregivers from the pilot study had expressed a strong preference for being given an activity instead of requesting it, modifications to the protocol were made to have Annie offer messages without the necessity of caregivers replying as shown in Figure 1.

The program was initially publicized through the Caregiver Support Program and the Office of Connected Care of the VA. The eligible candidates were caregivers of veterans enrolled in the VA health care system who had a VA electronic health record or a veteran who was a caregiver. Any VA staff member could register a caregiver from their facility in Annie. Staff at VA facilities determined whether a caregiver was interested in receiving the Annie text messages. If the caregiver was interested, staff then ensured that caregivers had a VA electronic health record, which was a requirement for Annie services, registered the caregiver in Annie, and sent a referral to the Caregiver Center for the caregiver to be entered into the Annie protocol. The Caregiver Center offered training to staff who did not know how to use Annie, and as of February 2022, a total of 592 staff members had been trained.

The Annie caregiver stress management protocol was lengthened to include a year’s worth of messages. On the basis of pilot findings, 3 messages per week, education, motivation or inspiration, and activity were sent with no response required from the caregiver.

In the current version of the protocol, messages are sent 3 times a week on different days and focus on education, motivation or inspiration, and strategies or skills (Table 3). Educational texts provide information about stress and responses to it. Motivational texts, often quotes from famous people, were included on caregiver request and were validating and inspiring. Activities focusing on stress-relieving strategies, breathing, giving yourself a break, taking care of yourself, setting boundaries, and mindfulness are strategies suggested for caregivers to try. General messages were sent to all caregivers in addition to the protocol messages. Messages offering an email link for help or questions and links to the national Caregiver Support Program staff and resources were sent every 3 weeks. Caregivers were registered in Annie by clinical staff at their local VA facility; each caregiver must have an electronic health record. After registration, a referral was sent to the Caregiver Center, which enrolled the caregiver in the requested protocol.

At the end of 6 months, caregivers were asked to fill out a brief evaluation survey through a SurveyMonkey (Momentive Inc) link in an Annie message. All data were anonymous. Six questions asked caregivers’ opinions about the texting program using a 5-point Likert scale ranging from completely disagree (score=1) to completely agree (score=5), and data were analyzed with descriptive statistics, including frequencies and means. Caregivers were asked whether the texts had helped manage stress, increase confidence, and take better care of self and loved one. They were also asked whether the texts had made them feel like someone cared about their well-being and whether they would recommend the program.

Two open-ended questions about additional topics and anything caregivers wanted to add were asked. Quotes were examined individually by 2 anthropologist authors, both with prior experience in coding of qualitative data. Each reviewer sorted the descriptions, concepts, and central ideas into potential themes [33] looking for repetitions, similarities, and differences [34]. Topics that occurred repeatedly were linked to verbatim quotes [33]. Themes were discussed and finalized by these authors.

In total, 4401 caregivers were enrolled in the stress protocol as of the end of February 2022. All had not been in the protocol for 6 months and were therefore not eligible to receive the evaluation link, with 3522 caregivers eligible. Figure 2 shows the responses from the 781 caregivers who answered the link, a 22.17% (781/3522) response.

Caregivers endorsed 3 messages per week as the right amount (679/778, 87.2%). The mean scores for each question indicated that the caregivers felt that the messages had been useful in increasing their confidence (mean 4.1, SD 0.9), managing their stress (mean 4.3, SD 0.8), and helping them take care of themselves (mean 4.3, SD 0.8) and their loved ones (mean 4.2, SD 0.8). The messages also helped them feel cared for (mean 4.5, SD 0.8). Finally, caregivers would recommend the program to other caregivers (mean 4.5, SD 0.8). In fact, several caregivers reported sharing Annie even on social media. Furthermore, 23.1% (180/778) of the caregivers tried all the strategies, an additional 42% (329/778) tried most strategies, and 26.9% (210/778) tried some strategies. Less than 10% (49/778, 6.3%) tried a few strategies and only 1.3% (10/778) of the caregivers tried none of the strategies.

In their open-ended comments, the caregivers identified 5 general themes, as shown in Table 4. There were only 16 negative comments; most wanted to respond and have Annie answer them (ie, wanted a real person checking on them), and 2 caregivers thought there were too many texts.

Because caregivers shared the protocol with their veterans, and staff were asking whether veterans could be put on the protocol, a year-long Annie Stress Management protocol for veterans was developed, which is similar in format and types of messages. In February 2022, this protocol enrolled 294 veterans, making it one of the top 10 protocols according to the number of users.

On the basis of the success of the stress management protocol, several new protocols have been developed: bereavement; taking care of you, which focuses on healthy lifestyle and emotions; dementia behaviors, which combines stress management and management of behaviors; and PTSD behaviors, which focuses on coping with behaviors. Similar to the stress management protocol, education and strategies for all these protocols are also taken from the REACH VA behavioral intervention. All protocols except bereavement last for a year. Caregivers can also be enrolled in the VA’s Coronavirus Precautions protocol.

The Annie caregiver protocols had a cumulative total of 7274 caregiver enrollments as of February 2022 with 7062 current users, and each month about 250 caregivers are referred to the Caregiver Center for enrollment in an Annie protocol, showing the feasibility of incorporating SMS text messaging into a large health care system. The Annie caregiver protocols have been extremely successful with more users than many Annie Veteran protocols. For example, in February 2022, among the top 10 Annie protocols based on users, 3 were caregiver protocols. Of the 6386 users in the top 10 protocols, 56.34% (3598) were enrolled in caregiver protocols with 31.99% (2043) of the users enrolled in stress management.