Ecacy And Feasibility of Telephone-Delivered Educational Intervention in Knowledge Transfer of COVID-19 Related Information to Elderly in Hong Kong: A Pilot Study

Background Educational interventions were necessary to clarify COVID-19 related misconceptions among Hong Kong older adults. Yet, face-to-face interventions were infeasible under the pandemic. The primary objective of the present study was to evaluate the ecacy of a healthcare student-led, telephone-delivered intervention in educating older adults on COVID-19 related health topics. Feasibility, satisfaction level in subjects and impacts on volunteer students of the intervention were also explored. Our pilot study offered initial evidence to suggest the ecacy and feasibility of telephone-delivered educational intervention in educating Hong Kong older adults and its benets on student volunteers. Future studies should include a larger sample size and evaluate the ability of phone calls in improving subjects’ mental well-being.


Introduction Background
Since early January, the outbreak of COVID-19 affected multiple aspects of Hong Kong society tremendously, such as the tourism and retail industry. While COVID-19 itself can be deadly and fatal, the spread of misinformation amid the pandemic should not be overlooked. As the World Health Organization stated, the spread of false information such as fake remedies and conspiracy theories has hampered efforts to ght against COVID-19 [1].
In particular, a recent study revealed that older adults aged 65 or above were more likely to hold COVID-19 related conspiracy beliefs than younger age groups [2]. In fact, it was suggested that older age groups were usually more susceptible to health misinformation due to memory and cognitive decline as a result of ageing [3]. For instance, a 2016 study found that users over 65 years old shared seven times as many fake news articles as the youngest age group [4]. It was also found that health literacy was generally lower in older age groups [5,6], especially those with lower educational and socioeconomical levels [5,6].
Apart from low educational level, the popularization of social media also contributed to the spread of COVID-19 related health misinformation [7]. Further, social distancing led to the stop of social welfare services in Hong Kong, making it more di cult for old adults to seek advice from healthcare professionals [8], rendering them more reliant on inaccurate online information.
In Hong Kong, the well-being of older adults was negatively affected by the spread of COVID-19 related misinformation. Without proper understanding of COVID-19, old adults were unable to protect themselves correctly, thus increasing their susceptibility to the disease. For example, some older adults believed that face masks could be reused after washing with detergent [9]. Second, older adults might panic and become anxious after listening to exaggerated rumors [10]. In fact, frequent exposure to misinformation and conspiracy theories was associated with higher risk of depression during the COVID-19 pandemic [11]. Hence, it is possible that COVID-19 misinformation could negatively affect the well-being of older adults in Hong Kong.
Given the potential impacts of COVID-19 related misconceptions on older adults, educational interventions are of paramount importance to clarify these misunderstandings. Apart from educational purposes, such interventions are important in providing elderly with a supporting net to improve their psychological well-being amid the pandemic. Previous systematic reviews suggested that face-to-face educational programs such as seminars and Q&A sessions were effective in improving health literacy among older adults [12,13]. Yet, under social distancing policies, it is di cult to organize large-scale and face-to-face health educational programs. Therefore, virtual educational programs through mobile applications, telephone calls, internet, etc., seemed more feasible.
Among the various types of virtual intervention programs, telephone-delivered interventions appeared to be more appropriate under the pandemic because it was di cult to educate older adults on the use of mobile and web-based applications without any prior face-to-face instruction classes. Moreover, the use of mobile applications was not popular among Hong Kong elderly population given that only 57% of elderly owned a smart phone in 2019 [14]. In contrast, telephone is easier to use and more popular among elderly population, suggesting that telephone-delivered educational interventions more practical and suitable.
Previous studies suggested the effectiveness of telephone-delivered educational interventions in multiple health-related issues such as smoking cessation [15] and diabetes management [16]. Yet, studies focusing on COVID-19 related health issues were limited. Previous programs were commonly conducted by healthcare professionals while our present intervention was run by healthcare students from various healthcare disciplines, which enabled interprofessional collaboration among students. Therefore, the present study proposed a student-led, telephone-delivered program to educate older adults in Hong Kong.
The primary objective of this pilot study was to evaluate the e cacy of a university student-led, telephone-delivered intervention in educating Hong Kong older adults on COVID-19 related health knowledge. The secondary objectives were to evaluate the feasibility and satisfaction level of the telephone-delivered intervention within subjects and to evaluate the impacts of a telephone-delivered intervention on the student volunteers.

Study design
The study was a longitudinal pilot study which compared subjects' knowledge level concerning COVID-19 before and after the 5-week intervention. Pre-tests and post-tests based on COVID-19 related topics including medication safety, healthcare voucher, and COVID myth debunking were carried out to re ect the effectiveness of educational interventions. No control group was involved in this study.

Subjects
Twenty-ve older adults aged 65 or above were recruited from a local elderly district community centre in Hong Kong. Participants aged 65 years old or above, able to communicate in Cantonese and able to communicate in mobile phones for subsequent telephone-delivered interventions were recruited. Participants were excluded if they were cognitive or hearing impaired. Participants who failed to attend all ve sessions of the intervention and evaluation were also excluded in data analysis. Materials 1. COVID-19 related knowledge questionnaires A pre-test and post-test questionnaires were designed to evaluate the knowledge level relating to COVID-19 of subjects. The pre-test questionnaire included a total of 20 True or False questions. The pre-test questionnaire was composed of three themes where each theme focused on one COVID-19 related health topic. The questions in the post-test questionnaire were all the same as the pre-test questionnaire. The difference in scores between pre-test and post-test questionnaires was taken to re ect the e cacy of the intervention. The three health topics were speci cally included in the knowledge questionnaires to better cater for the health needs of older adults in Hong Kong.
Theme 1 included 5 questions and focused on medication safety. Under the COVID-19 pandemic, nonessential healthcare services at public hospitals were reduced. As follow-up appointments were postponed, some chronic patients might experience shortage of medications. Instead of consulting healthcare professionals, some of them might discontinue their medications [17]. Hence, medication safety education is of paramount importance to ensure drug adherence amid the pandemic.

Theme 2 included 5 questions and focused on Healthcare Vouchers. To subsidize older adults in Hong
Kong to use private healthcare services, quali ed older adults are currently provided with HKD $2000 worth of health care vouchers by the government. Although these vouchers aimed to subsidize private healthcare services only, some older adults might wrongly believe that these vouchers could be used to purchase sanitizing products and facemasks. Further, scams and disputes related to health care vouchers occurred occasionally during the pandemic [18]. It was therefore important to educate subjects on health care voucher to better protect their rights.
Although questions in themes 1 and 2 were not directly about COVID-19, they were included since related health issues may arise during the pandemic as mentioned. As current health advertisements focused primarily on COVID-19, educating subjects on other important health issues became necessary. Theme 3 included 10 questions focusing on COVID-19 myths debunking. As said, COVID-19 related fake news and misinformation were extremely prevalent. Some older adults might nd it di cult to differentiate between right and wrong health information.

Subjects' feedback survey
By the end of the 5-week program, every subject was invited to complete a feedback survey comprised of a few yes-no questions and open-ended questions. The feedback survey aimed to investigate subjects' opinions and overall satisfaction level towards the intervention program. Feedbacks and satisfaction level of subjects were crucial in evaluating the feasibility of the intervention.

Students' feedback survey
Likewise, to evaluate the impacts of the intervention on involved students, student volunteers were invited to ll in a survey consisted of 8 open-ended questions regarding the most and least enjoyable parts of the program, major challenges encountered, new skills acquired and preferred mode of service learning (phone-delivered versus face-to-face).

Focus group interview with students
Apart from students' feedback survey, a focus group interview was conducted after the program to better understand students' perceptions of interprofessional collaboration during the intervention. A total of 21 students, divided into 7 groups with 3 students in each group, were interviewed. Each interview lasted for 45 minutes.

Geriatric Depression Scale (GDS-15) survey
To evaluate depression risks of subjects during COVID-19, the Chinese version of the Geriatric Depression Scale (GDS-15) was adopted [19]. The questionnaire included 15 questions as a self-report assessment used to evaluate depression risks in subjects. The total score of the GDS-15 survey was 15 marks. A total mark of 5 or above indicates low to moderate risk of depression while 8 marks or above indicates high risk of depression.
Intervention and experimental procedure The study was designed and carried out by undergraduate students in health disciplines (Medicine, Nursing, Nutritional Science, etc.) under supervision of two registered pharmacists in Hong Kong. Oral consent from study subjects and students were attained prior to the start of intervention. Each subject participant was paired up with one student during the intervention. The student was also required to write a phone call summary after each intervention session. The overall logistic ow of the study was summarized in Table 1. Week 5 • Posttest on theme 1, 2, and 3 • Subject feedback survey After Week 5 • Student feedback survey During week 1, students rst introduced themselves and provided the subject with an overview of the telephone-delivered educational program. Subjects were also asked to provide their preferred time to conduct phone calls. Also, the GDS-15 survey was done to determine the mental wellbeing of subjects.
During week 1 to 4, pre-test questionnaire of the three aforementioned health topics were conducted at the start of each phone call session to measure subjects' health knowledge level before any interventions. All the True or False questions were asked verbally via phone by students. Answers of the subjects were then marked down by students. 1 mark will be awarded if the subject answered correctly and was able to justify his answers correctly. Marks will not be awarded for wrong answers or answers without reasonable justi cations. The total scores for pre-test and post-test questionnaire were 20 marks.
As part of our intervention, the student would provide the subject with correct answers and standardized explanations after completing the pre-test questionnaire. The subject was also invited to raise other health-related questions which were then answered by the student during the phone call. Each phone call was expected to last for 10 minutes on average.
Several measures were taken to reduce variability between interventions delivered by different students.
First, students were provided with standardized answers for the questionnaires. Further, prior to the program, students were required to attend training sessions organized by pharmacists and social workers, where the intervention protocol and tips for improving communication with older adults were introduced. To ensure fairness, students were also told not to offer any hints when conducting the pre-test and post-test. Further, students should only contact the subject during the ve scheduled intervention sessions.
Post-test questionnaire comprised of 20 questions covering all three health themes was done in week 5.
Unlike the pre-test questionnaire, correct answers and explanations would not be given if the subject answered incorrectly because the post-test questionnaire aimed to evaluate the e cacy of program and was not part of the intervention.

Study population
Twenty-ve subjects were recruited from community centers in the pilot scheme. Each subject was paired up with a student. Background information including education level, gender and age of subjects were also collected.
Data processing and statistical analysis The primary outcome was the differences in questionnaire scores between pre-test and post-test.
Differences between pre-test and post-test scores measured the effectiveness of the intervention. The mean, standard deviation and range of tests scores were considered.
Paired t-test was used to evaluate the e cacy of intervention based on the differences in pre-test and post-test mean scores of the three topics. McNemar's test was used to evaluate the e cacy of intervention based on the differences in proportion of subjects answering each question in questionnaires correctly. The level of signi cance was set at 0.05.
The secondary outcome was the feasibility and satisfaction level of intervention among subjects and the impact of intervention on students. Descriptive statistics was run to analyze results from yes-no questions while qualitative analysis was done for open-ended questions. Data collected were then recorded in Microsoft Excel. SPSS was used for statistical analysis.

Results
A total of 25 participants were recruited at the aforementioned community center. Phone calls were made between October and November in 2020. All the subjects completed the study and their sociodemographic characteristics at baseline were summarized in Table 2.   Table 4.

Feasibility and satisfaction level of telephone-delivered intervention
Overall, subjects were highly satis ed with various aspects of the intervention program. Our satisfaction survey showed that almost all subjects agreed that the duration of phone calls (96%) and di culty of questions were appropriate (88%). Only three subjects (12%) found the questions too easy. Further, many subjects agreed that this program was useful and greatly enhanced their understanding about COVID-19 (96%). Apart from knowledge enhancement, a number of subjects agreed that they felt cared for and became more hopeful after the program (92%): 'It's nice that I got to talk to young people via this program' [6] 'I felt happier and learnt a lot after the program' [13] 'It's nice and heartwarming that I got to talk to the same person during every phone call session' [17] Although telephone-delivered approach reduced face-to-face interactions, all subjects agreed that telephone-based interventions were exible and convenient (100%). In fact, 18 subjects (72%) preferred telephone-based over face-to-face programs because phone calls were more convenient and personalized. A few subjects (28%) preferred face-to-face programs because it offered more authentic and genuine interactions.
When asked about the shortcomings of the program, around 4 (16%) of them hoped that face-to-face seminars could be incorporated into the intervention while another 3 (12%) hoped that they could be noti ed of the phone call schedule earlier such that they could better arrange their plans. The remaining 17 (72%) did not think that the program had any signi cant de ciencies.

Impacts of telephone-delivered intervention on students
A total of 25 student volunteers were recruited and all of them completed the program. Their demographic characteristics at baseline were summarized in Table 5. Overall, students commented positively on the intervention. Students' feedback surveys showed that 14 students (56%) enjoyed the exibility of the program. Other students found the program meaningful (16%) and the duration of program appropriate (32%). Only 2 students (8%) did not nd any parts of the program enjoyable. Most students also believed that they were able to apply skills taught at class in the program. 12 students (48%) believed that they were able to apply medical knowledge taught at class. Another 4 students (16%) mentioned other skills such as communication skills and bioethics knowledge. The remaining 11 students (44%) did not think that they were able to apply any skills acquired at school during the program.
Regarding major obstacles encountered during phone call sessions, a number of them (46%) found it di cult to communicate with subjects via phone calls solely. Another 5 students (20%) had di culties in contacting subjects while 3 students (12%) found it di cult to sustain conversations with subject. Around 5 students (20%) did not encounter any di culties throughout the program.
When asked about the major bene ts of program, 23 students (92%) believed that their communication skills improved signi cantly. While it was previously mentioned that students found it di cult to bond with subjects under the absence of face-to-face interactions, many believed that they became more sensitive and cautious about verbal cues. Also, 19 students (76%) believed the program deepened their understanding about older adults in Hong Kong as they realized older adults were more knowledgeable than expected.
Despite the bene ts associated with the program, only 7 students (28%) preferred telephone-based while 17 (68%) liked face-to-face interventions more. The remaining 1 student did not have any strong preferences.

Students' perceptions of interprofessional collaboration
During the focus group interview, all students agreed that interprofessional collaboration played an important role in providing subjects with quality content. For example, one student pointed out that he could turn to other pharmacy students for help when the subject asked him questions related to medications.
Apart from collaboration between healthcare students, most student helpers agreed that (92%) collaboration between healthcare and non-healthcare students should be promoted when conducting similar interventions in the future. For example, some students pointed out that students majoring in education might offer insights in better ways to interact and educate subjects. The remaining two students (8%) disagreed, claiming that non-healthcare students might not be su ciently capable to educate subjects on health-related issues.

E cacy of intervention
Our ndings suggested that telephone-delivered educational intervention was effective in knowledge transfer as the improvement in test scores were statistically signi cant. A similar pilot study found that telephone-delivered educational intervention was effective in improving knowledge of older adults during the Hong Kong SARS epidemic in 2007 [20]. In contrast to the present study, only two phone calls, instead of ve, were conducted in the previously mentioned study to avoid information overloading. Nonetheless, our ndings suggested that increasing the quantity of content delivered did not reduce intervention e cacy.
Multiple factors might have contributed to the high e cacy of intervention. First, the educational contents delivered in the program was easy to understand as most subjects deemed the di culty level appropriate.
Second, the educational program was personalized and able to address different questions raised by individual subject because our phone calls were made on a one-on-one basis.
However, our current ndings might not be applicable to other population groups. A meta-analysis published in 2014 analyzed 5 randomized controlled trials and concluded that phone call interventions were not more effective than standard care in glycemic control of diabetes patients [21]. This occurred because the included studies were mostly conducted in rural areas where diabetic patients typically had lower economic and education level, leading to poorer medication adherence [21,22]. Given that, high e cacy of intervention was found in the present study potentially because Hong Kong was a welldeveloped city and that all our subjects received at least primary education.
Nonetheless, this does not imply that phone call interventions were not useful in rural areas. Rather, phone-based interventions are particularly useful in remote areas because health education in these regions are limited [23]. Also, intervention content should be adjusted based on based on subjects' education and knowledge level to maximize e cacy.
Of note, it was found that age was negatively correlated with the e cacy of intervention. This nding was consistent previous studies as information retention was generally lower in older people [24]. Further, multiple studies suggested that age was negatively correlated with knowledge level concerning COVID-19 and older adults at large had inadequate knowledge about COVID-19 [25]. Also, elderly of younger age were more likely to engage in social activities and interact with other individuals [26], resulting in increased exposure to COVID-19 related knowledge [27].
Despite improvement in correct response rate for all questions (except for Q7), not all of them were statistically signi cant. For one, the correct response rate in some of the pre-test questions were already very high (>80%). Thus, even if all subjects answered correctly in the post-test, improvements would remain statistically insigni cant due to insu cient statistical power.
Yet, for pre-test questions with poorer performance (<80%), those with greater relevance to COVID-19 were more likely to show signi cant improvement in correct response rate. For instance, question 2 and 3 were related to the use of healthcare vouchers in COVID-19 related services like COVID-19 testing and showed signi cant improvement in correct response rate. Likewise, questions in topic 3 were related to COVID-19 myth busting and almost all of their correct response rate increased signi cantly. Conversely, other questions in theme 2 (Q1, 4, 5) were related to the general guidelines of healthcare vouchers and their correct response rate did not improve signi cantly.
Under extensive media coverage and public health promotion, people's knowledge towards COVID-19 generally improved as the pandemic continued [28,29] regardless of the intervention. Current study results suggested that such improvement was further enhanced by the intervention. Meanwhile, subjects appeared to be less well informed about other health topics these topics were generally less heavily emphasized in health promotion programs during the pandemic, indicating that these health issues should not be overlooked in future interventions.

Satisfaction level of subjects
Furthermore, subjects were highly satis ed with the phone-based intervention due to its usefulness and ability to improve their mood. Due to social distancing policies, many older adults felt isolated [30] and GDS survey suggested that around one-third of subjects were at risk of developing depression.
Meanwhile, results of the subject satisfaction survey showed that many of them felt cared for and became more positive after the program. Although our subjects did not undergo any rigorous training in communication, our results suggested that phone-based interventions had the potential to improve subjects' psychological well-being during the pandemic. A similar study conducted recently also showed that lay-person delivered phone calls were able to reduce loneliness and depression within subjects during the pandemic [31].

Impacts on students
Apart from its positive impacts on subjects, the telephone-based intervention also bene tted the students.
First, students were able to practice their phone-based communication skills and the use of verbal cues. While face-to-face patient communication was heavily emphasized in health-related disciplines, phonebased communication skills were equally important in scenarios such as patient referral, telephone consultation services and breaking bad news [32,33]. Telephone communication skills acquired through the present study were of paramount importance for health-related students in future practice.
Second, the program improved students' understanding about elderly people in Hong Kong. Students realized that older adults in Hong Kong were more knowledgeable than expected. Although students' attitudes towards older adults were not formally accessed in the present study, misconceptions and negative prejudices against older people remained prevalent in health professionals and students of health-related disciplines [34]. When students with negative attitudes towards elderly became health professionals, they were more likely to offer poor patient care [35]. Meanwhile, students in the present study found that older adults were more knowledgeable than expected, suggesting that their perceptions on older adults became more positive. This suggested that elderly related volunteering work had the potential to improve students' attitudes towards older adults.
Moreover, interdisciplinary collaboration between students bene tted both students and subjects in the program. For one, students were able to learn from each other and share their expertise. During the design of COVID-19 knowledge questionnaires, healthcare students from different majors were responsible for setting different questions. For instance, pharmacy and public health students helped to design questions for 'Medication Safety' and 'Healthcare Vouchers' respectively. Also, the questionnaires were crosschecked by students before the program.
Also, interprofessional engagement bene tted the subjects by improving the quality of intervention delivered. For example, when public health students were asked about medication problems by subjects during phone calls, other pharmacy students were able to assist. Our results suggested that interprofessional collaboration ensured information accuracy during phone calls and were in line with previous studies [36,37].

Implications: Telehealth in Hong Kong
Given the high e cacy and satisfaction level of intervention, the present study offered preliminary evidence about the feasibility of telehealth implementation in Hong Kong. Telehealth refers to the provision of health services remotely via digital communication tools such as phone calls, video conferencing and short messaging services (SMS) [38]. Under the pandemic, many medical appointments and patient education seminars were canceled while telehealth had the potential to address this issue. While studies in USA [39] and Canada [40] showed that telehealth was feasible and able to supplement traditional care, studies in Hong Kong were lacking. Hence, the present study suggested that phone calls were well accepted by elderly subjects in delivering health education.
However, the intervention still had room for improvement. First, video-conferencing could be incorporated in future interventions. Satisfaction survey suggested that some subjects who felt socially isolated hoped that face-to-face interventions could be incorporated for more genuine and natural interactions. However, face-to-face activities were unlikely due to social distancing policies. Hence, videoconferencing could be a feasible substitution to enhance authenticity of communication and wellbeing of elderly in Hong Kong [41] without increasing the risk of COVID-19 infection. Also, it was previously found that videoconferencing was well accepted within Hong Kong elderly populations [42].
Apart from videoconferencing, SMS might also be useful in future interventions and telehealth services. As reported in feedback surveys, some students were unable to contact the subjects while some subjects were unable to answer the call as scheduled because they were busy with other activities. To address this issue, SMS could be useful as subjects could read the messages based on their schedules. Although educators and subjects were unable to have real-time interactions through SMS, previous systematic reviews suggested that SMS-based interventions were able to improve clinical outcomes in diabetes patients thanks to the personalized nature of SMS [43,44]. For instance, subjects involved in these interventions were often provided with tailored dietary and lifestyle advice based on individual blood glucose level, medical history, insulin dose, etc. Hence, SMS might be able to offer health information regularly and future studies should investigate the e cacy of various forms of telehealth tools.

Limitations
There are several limitations in the current study. This study was unable to measure the effect size due to small sample size and a lack of control group. However, inclusion of control group remained di cult as community centers typically hope that all of their subjects are able to receive interventions.
Also, improvement in subjects' knowledge level might not be long-lasting owing to the short study period.
Further, since the pre-test and post-test questions were identical, the improvement in questionnaire scores might be in ated.
Moreover, sample size was low, and subjects were not recruited in a random basis but from one district community center only. For instance, around 56% of subjects received secondary education, compared to the Hong Kong elderly average of 39.6% [45]. Therefore, our ndings might not be applicable to other older adults in Hong Kong. To address this issue, the investigators has launched a similar yet larger-scale program with a sample size of 300. This ongoing study may offer insights into its feasibility and impacts when carried out with more participants.
Finally, no pre-and post-questionnaires were done to measure the impacts of interventions on subjects' depression level and mood. Future studies should include relevant surveys to quantify the impacts of interventions on subjects' mental well-being.

Conclusion
In conclusion, our pilot study offered initial evidence to suggest the e cacy and feasibility of telephonebased interventions in educating Hong Kong elderly on COVID-19 related information. Also, our study suggested that the intervention improved student volunteers' communication skills and understandings about elderly in Hong Kong.

Declarations
Ethics approval The current study was approved by the Survey and Behavioural Research Ethics Committee at the Chinese University of Hong Kong (Reference number: SBRE-20-048). All subjects had provided their informed consent before enrolment.

Funding
The study did not receive any nancial funding.

Con ict of interests
The authors declare that they have no competing interests.

Data availability statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. All authors have approved the manuscript for submission. The content of manuscript has not been published, or submitted for publication elsewhere. The authors declare no con icts of interest.