Subjects
Twenty-five 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 five 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 reflect the efficacy of the intervention. The three health topics were specifically 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, non-essential 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, qualified 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 find it difficult to differentiate between right and wrong health information.
2. 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.
3. Students’ feedback survey
Likewise, to evaluate the impacts of the intervention on involved students, student volunteers were invited to fill 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).
4. 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.
5. 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 flow of the study was summarized in Table 1.
Table 1
Time
|
Tasks
|
Before week 1
|
● Training session on intervention protocol and communication techniques
|
Week 1
|
● Self-introduction
● GDS-15 survey
● Pre-test and explanations on theme 1: Medication safety
|
Week 2
|
● Pre-test and explanations on theme 2: Health Care Voucher
|
Week 3
|
● Pre-test and explanations on theme 3: COVID-19 myths debunking (First 5 questions)
|
Week 4
|
● Pre-test and explanations on theme 3: COVID-19 myths debunking (Later 5 questions)
|
Week 5
|
● Posttest on theme 1, 2, and 3
● Subject feedback survey
|
After Week 5
|
● Student feedback survey
|
During week 1, students first 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 justifications. 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 five 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 efficacy of program and was not part of the intervention.
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 efficacy 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 efficacy of intervention based on the differences in proportion of subjects answering each question in questionnaires correctly. The level of significance 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.