Assessment of a digital intervention program with Holocaust survivors

Abstract Objective This study evaluated a digital intervention program with aging Holocaust survivors. Participants received a tablet device and were coupled with a volunteer who assisted them to use the tablet. The study aimed to assess which characteristics of the Holocaust survivors are linked with more frequent use of digital communication at the end of the program. Methods Information was collected by telephone interviews with 91 survivors before and 54 after participating in the program. We combined this data with digital usage data from the tablets. Regression models examined the characteristics of Holocaust survivors that were related to higher frequency of using digital communication technologies during the intervention. Results The Holocaust survivors expressed high satisfaction with the program. They increased their frequency of using digital communication technologies—text correspondence and video chats with friends and family. Regressions showed that Holocaust survivors who reported increased digital communication were characterized at the start of the intervention by having fewer post-traumatic stress symptoms, higher levels of flourishing (reflecting a more meaningful life and higher well-being), being lonelier, and were also more satisfied with the program at follow-up. Conclusion The pilot program benefited the aging Holocaust survivors. Further programs should be developed to increase the digital communication of vulnerable older populations, such as trauma survivors.


Introduction
There are currently fewer than 150,000 Holocaust survivors in Israel.They are aged 75 years old and older, with the vast majority being older old (80+ years; Israel Ministry of Social Equality, 2023).Holocaust survivors were exposed to especially difficult and horrific events during World War II and came to Israel as indigent refugees.They can be an especially vulnerable group due to their old age and past traumas, and are indeed found to have, on average, worse mental and physical health and to be lonelier compared to older adults who did not experience the Holocaust, both in 'regular' times and during the COVID-19 pandemic (Barel et al., 2010;Carmel et al., 2022;O'Rourke et al., 2018;Shrira et al., 2020).Nevertheless, there are some indications of their resilience in terms of certain physical or mental resources (Bachner et al., 2018;Carmel et al., 2022), and higher levels of resilience among survivors are associated with experiencing better quality of life and more positive aging.For example, Holocaust survivors who had reported higher resilience also had better subjective successful aging and lower psychological distress (Diamond & Shrira, 2018).Moreover, among survivors who underwent open heart surgery, lower levels of posttraumatic symptoms were related to better quality of life (Schreiber et al., 2004).It is therefore crucial to find effective ways to improve the lives and aging experiences of Holocaust survivors.
One promising avenue for improving the mental health and social connections of older persons in general, and perhaps Holocaust survivors in particular, is via information and communication technologies (ICT) such as tablets (Czaja, 2017).Several benefits for mental health and wellbeing were found to be associated with use of ICTs, such as improvement in cognitive abilities, perceived quality of life, social support (Chen & Chan, 2014), as well as decrease in the sense of loneliness and depression states (Cotten et al., 2014) and increase in wellbeing (Czaja et al., 2018).Additionally, participating in designated tablet interventions may have the benefits of increasing digital participation (Czaja et al., 2018) and facilitating contact with family and friends (Vaportzis et al., 2018).
Nevertheless, the process of technology acceptance by older persons (i.e. the behavioral intention to use technology), may be complex (Peek et al., 2014).Mitzner et al. (2019) tested an intervention using a computer system developed for older persons and found that its use on the mid-and long-term was predicted by previous use, executive function, computer efficacy and female gender.In a study by Tsai et al. (2015), it was found that the acquisition of tablets was often done by others in the social network, and tablet use was strongly facilitated by seeing others use the tablet and having a meaningful social network.In a different intervention, tablet use was facilitated when participants underwent training as part of a group (Vaportzis et al., 2018).Importantly, lack of social interaction, knowledge, and proper guidance may pose a barrier to novel technology acceptance, as found with tablets in particular (Vaportzis et al., 2017).Mental health might also act as a predictor of technology acceptance and use, although this premise is less often examined (Mitzner et al., 2019).An additional barrier to understanding ICT acceptance and use is that research of technology acceptance and interventions tends to involve mainly younger, relatively healthy, highly educated and techsavvy older persons (Mannheim et al., 2019;Mitzner et al., 2019;Williams et al., 2015), and often overlooks diverse and specific populations, for example people with experiences of trauma.
However, to our knowledge, no research has specifically targeted Holocaust survivors.It is necessary to examine this vulnerable older population and to understand what are the characteristics of Holocaust survivors who will benefit to a greater extent from a digital intervention program.Holocaust survivors may suffer from social isolation-for example they are less likely to live with a partner and report worse social support compared to other older adults who were not in the Holocaust (Ohana et al., 2014;Stessman et al., 2008).Use of digital communication could help improve their social connections, which can ultimately improve their mental health (Schwarzbach et al., 2014).The conservation of resources (COR) theory posits that personal resources, (e. g., mental health) and social resources (e.g.assistance from others) can buffer against the potential negative impact of stressful life events (Alvaro et al., 2010;Hobfoll, 2002).We will apply this framework to examining resources related to technology use, which can help the survivors cope with some of the effects of their past traumas, as well as the stressors of old age.
Thus, the current study set out to investigate a pilot digital intervention program which aimed to foster digital orientation and digital communication skills for Holocaust survivors via volunteers who taught survivors to use tablets.We will assess which characteristics of the Holocaust survivors are linked with more frequent use of ICT at the end of the program, examining both personal resources of mental health, and social resources as seen in the involvement of the volunteer.We will examine both subjective assessments of social communication and objective usage data from the tablets themselves.We hypothesize that: (1) At the end of the program, survivors will report more frequent digital communication with family and friends, and tablet data will also indicate usage of the tablets.(2) In accordance with the conservation of resources theory, survivors who have better initial mental health will report more frequent use at the end of the program.

The program
The digital intervention pilot program was initiated by the Foundation for the Welfare of Holocaust Victims in Israel.This foundation is a non-profit organization in Israel (headquartered in Tel-Aviv), and it provides programs and services to Holocaust survivors across the country who require assistance.Participants in the program were recruited in several ways: by approaching Holocaust survivors who are registered as receiving services from the foundation, via advertisements in social media, a snowball technique through other survivors who participated in the program and by referral of social workers and healthcare workers in the community, municipalities and health maintenance organizations (HMOs) who thought that their clients could benefit from the program.Participants were recruited from all over the country.
As part of the program, the participants were provided with a tablet and the cost of internet connection was covered for one year.The tablets were installed with a software that made them more accessible for older adults, for example with large buttons.Each Holocaust survivor was assigned a volunteer, who underwent training before the program started and had weekly meetings with the survivor for a period of approximately four months.During the weekly meetings, the volunteers taught the survivors basic computer skills and how to use the tablets.
The eligibility criteria to participate in the program were as follows: a willingness to learn to use the tablet, which was assessed in the intake interview by asking the survivor whether he or she was interested in learning to use the tablet and planned to use the tablet over time.They also needed to agree to receive visits from the volunteer, as well as to speak Hebrew, Russian or English, which were the languages that the volunteers spoke.The participating survivors also needed to be without major cognitive impairments.During the intake interview they were asked whether they had advanced dementia, as well as asked for their ID number, date of birth and address.If the survivors could not answer these questions, the program coordinator inquired with a family member about any major cognitive impairments.In addition, at the beginning of the two study interviews, the participating survivors underwent a brief cognitive questionnaire in which they were asked for the day of the week, the current month and current year.If they responded to at least two questions correctly, they were forwarded to the interview itself.

Data collection
Data was collected from the survivors.They underwent an initial intake over the phone by the program coordinator to determine their fit to the program, provide information about the program and collect information about socio-demographic characteristics.The coordinator also obtained informed consent from the survivors to participate in the research surveys and to share the information collected during the intake with the research team.The coordinator also asked for survivors' agreement to have their tablet use patterns collected and shared with the research team.A program was installed on the tablets provided to survivors and collected information on the number of actions and length of time they used the tablet.Data collection from survivors took place over the telephone before the first meeting with the volunteer (T1) and 4 months later, after the end of the program (T2).At the beginning of each of the two phone interviews, the interviewer obtained oral consent to participate in the study.The interviewer asked the survivor whether they were willing to participate in the interview, and explained that the data is anonymous, only the study team will have access to it and that the survivor can terminate the interview at any time.The same informed consent was obtained at the beginning of the follow-up interview.Issues of potential harm from the interview were dealt with by the interviewer explaining to the survivor that they do not have to respond to any questions that make them feel uncomfortable and by giving the telephone number of the main investigator.In addition, if the interviewer identified any potential issues, such as the survivor expressing harmful thoughts, this was forwarded to the program coordinator who was in continuous contact with the survivors and if needed also with their family.An outline of the study design can be seen in Supplementary Figure 1.Ethics approval for the study was obtained from the Ben gurion university ethics committee.

Participants
Data was collected from 91 Holocaust survivors who were interviewed over the phone at baseline.The follow-up (T2) interviews were conducted with 54 survivors.Those who weren't interviewed again either dropped out of the program, couldn't be reached over the telephone or didn't agree to be interviewed for the second time.Tablet usage data was available for 70 survivors.Attrition analyses indicated that those who weren't interviewed again didn't differ from those who were interviewed (p > .05) in terms of age, gender, digital communication with family or baseline mental health.They reported more frequent text communication with friends (p = 0.02).

Measures
Digital communication with family and friends was measured by asking participants about contact frequency with family and friends using the modalities of (1) video calls and (2) text messages (e.g. using the online platform of WhatsApp).Responses ranged between 1 (not at all) and 5 (several times a day).These were measured at baseline and at follow-up.
Data from the tablets themselves was provided by the tablet software and indicated, for each tablet, for each time it was used the duration of time (in seconds) this usage lasted.Based on this, we calculated for each participant the average hours each day that they used the tablet.
Flourishing refers to social-psychological prosperity and encompasses having a meaningful life, self-respect, optimism, and having rewarding relationships.It was measured with the Flourishing Scale (Diener et al., 2010).The scale consists of eight items describing various aspects of human functioning such as positive relationships, feelings of competence, and having meaning and purpose in life.Responses ranged between 1 (completely disagree) and 5 (completely agree).All items are phrased in a positive direction, they were averaged and higher scores indicate greater flourishing.The scale had good reliability in the current sample (α = 0.83).
Posttraumatic stress symptoms were assessed via the short version of the International Trauma Scale, which includes six items (Fox et al., 2020).The scale inquires into a series of posttraumatic stress symptoms, and participants were asked to describe the frequency of experiencing various symptoms related to their experiences during the Holocaust, in the last two weeks, for example: 'Felt that you were jumpy or was scared easily' .Responses ranged between 1 (not at all) and 5 (very much).The score was based on an average of the scale items and higher scores indicate more posttraumatic stress symptoms.The scale had good reliability in the current sample (α = 0.81).
Loneliness was measured using the UCLA short scale for measuring loneliness.It was an average score of four items: three items which examined 'how often' respondents felt one of the following: 'a lack of companionship' , 'left out' or 'isolated from others' , in addition to one item measuring general feelings of loneliness: 'In general, do you feel lonely?' (Hughes et al., 2004).The response categories ranged between 1 (hardly ever), and 3 (often).The responses were averaged, with higher scores indicated greater loneliness.The scale had good reliability in the current sample (α = 0.83).
Satisfaction from the program was measured after the program's end, at T2, using a six-item scale for evaluating technological intervention (SER; Bakas et al., 2018).We modified the scale to inquire about tablet use, and it included the following items: 'It was easy for me to use the tablet'; 'The tablet use worked well for me'; 'I learned things I wanted to know'; 'The volunteer visits helped me with the learning'; 'I plan to continue using the tablet'; 'I liked using the tablet' .Each response ranged between 1 (not at all) and 5 (very much), and the final score is an average of the scale items.The scale had good reliability in the current sample (α = 0.80).The interview consisted mostly of close-ended questions.At the end of the follow-up interview, the participants were also asked an open-ended question: 'Is there anything else that you'd like to add about the program?' .This was done to support the quantitative data with qualitative input.
Covariates assessed age and gender.

Data analysis
The analysis starts with a description of the participating Holocaust survivors, based on data from the intake and the first interview.It also shows the survivors' evaluation of the program in their response to close-ended questionnaires and an openended question after the end of the program.The analyses provide a comparison of the digital communication with family and friends of the survivors before and after the program, and present Pearson correlations of baseline characteristics with outcome variables and usage data of the survivors.Finally, regression models identify usage of ICT at the end of the program, using various mental health indicators at baseline as predictors.We used full information maximum likelihood (FIML) to address issues regarding missing data.FIML estimates population parameters that maximize the likelihood function based on incomplete data, and can reduce selective attrition biases using all available data (graham, 2009;Kline, 2011).When conducting statistical tests, because of the relatively small sample size, p-value of below 0.10 are also considered statistically significant.For the analysis of the open-ended questions, we conducted a thematic analysis (Braun & Clarke, 2012) with an inductive approach to examine participants' perspectives on the program.Responses were open-coded and further grouped into categories with similar meaning.

Results
The characteristics of the Holocaust survivors who participated in the program are presented in Table 1.It shows percentages for gender, which is a dichotomous variable.Other study variables (including loneliness) are continuous, and thus Table 1 shows their mean score, standard deviation (SD) and range.The study participants were 83-years-old on average and almost two thirds (61%) were women.About a third (29%) had academic education, and 31% had elementary education.A majority of participants (84%) had a computer and\or a laptop before the program.On average, participants reported high levels of flourishing (M = 3.92 on a 5-point scale) and lower levels of posttraumatic stress symptoms (M = 1.99 on a 5-point scale).They reported relatively high loneliness scores, with reporting feeling lonely 'some of the time' (a score of 2 of 3).The survivors used the internet most frequently for sending text messages, especially with family members.They were the least likely to do video calls with friends.At the end of the program, we asked the survivors to evaluate their experience in the program (also Table 1).The survivors reported overall high satisfaction with the program (4.6 out of 5).Usage data from the tablet, showed that the participants used the tablet for 1.2 hours on an average day.
We next compared the Holocaust survivors at baseline and follow-up, after the program ended, in terms of their frequency of digital communication.The comparisons are presented in Table 2.The differences were examined via t-tests comparing the scores at baseline and follow-up.The results indicate that the program achieved its goals, and participating Holocaust survivors reported an increase in the frequency of communicating by text (e.g. using the online platform of WhatsApp) for contact with family members and with friends, and for communicating via video calls with family members.Additional analyses (Supplementary Table S1) showed fewer changes over time in communication that cannot be done via the tablet.Specifically, there were no significant changes in communicating with family face-to-face or via the phone or in communicating with friends face-to-face, and only improvements in phone calls with friends (from 2.5 to 2.7, p = 0.03).
The next stage examined which factors are related to more frequent communication after participating in the program and more tablet use.For that purpose, we calculated Pearson correlations which are presented in Table 3. Higher flourishing scores at baseline were related to higher levels of texting with family and friends and video calls with family at follow-up.More posttraumatic stress symptoms at baseline were related to fewer video calls with family and friends at follow-up.Those who were younger also reported more frequent texting with friends at follow-up.Those who were satisfied with the program after it ended reported higher frequency of texting with family and friends.They also had higher posttraumatic stress symptoms at baseline.
Our final analyses included regression models which predicted digital communication frequencies at the end of the program, using baseline mental health characteristics, as well as age, gender and overall satisfaction from the program as independent variables (see Table 4).The first model predicted text messages with family.Those who reported an increase in such messages also had higher flourishing scores at baseline, reported higher loneliness, and at follow-up were more satisfied with the program.We next predicted text messages with friends at follow-up.These were related to younger age, higher baseline flourishing and higher satisfaction with the program.The third model examined video calls with family at follow-up, which were related to lower baseline posttraumatic stress symptoms, higher flourishing scores and higher satisfaction with the program.The fourth model predicted video calls with friends at follow-up.These were associated with lower baseline  posttraumatic stress symptoms.The final model inspected usage data, which was related to younger age, and higher satisfaction with the program.
Of the sample, 18 participants answered the open-ended question about whether they want to add anything else regarding the program.Because this question came at the end of a closed-ended telephone interview, participants who responded provided brief answers of a single sentence or a few sentences.The interviewers did not further probe these responses.Most of the survivors who chose to respond expressed their satisfaction with the program and with the volunteers.For example: 'I'm very satisfied with the volunteer, she was lovely!'; 'The volunteer helped me a lot during the learning process' .One survivor said that he ' …loves and uses the tablet a lot' .
Some survivors related to aspects of usability.For example, explaining how the program helped them to learn to use the tablet.One participant said that he 'learned a lot of things, before the program I didn't know how to use the tablet at all.' He added that he is 'very pleased, uses the tablet a lot to communicate with the grandchildren and children, video calls, sending messages, reading things' .Another remarked that 'using the tablet was complicated, mostly because of my poor eyesight.The volunteer was lovely, helped a lot' .Some explained how the tablet helped them stay in touch with loved ones: 'I have a son who lives abroad, thanks to the tablet I was able to contact him, especially with video calls.I'm very satisfied and I like the meetings with the volunteer, he helped me a lot in the learning process.' An additional aspect in participants' answers related to suggestions for improving the program.Some expressed a wish for more training after the end of the program: 'I'm interested in more lectures'; 'I would like to learn more about the software and using the tablet.I need extra teaching, the volunteer that came didn't know how to provide adequate assistance.' One of the survivors asked that the tablet be modified to his Ultra-Orthodox way of life by blocking some of the content.

Discussion
The current study investigated a pilot program that provided Holocaust survivors with tablets and matched them with a volunteer who regularly came over to help them learn how to operate the tablet.Holocaust survivors are a particularly vulnerable population and it is imperative to find ways to help them feel connected and improve their lives as they grow older.Such an investigation is especially warranted due to the scarcity of research on interventions involving diverse samples of older persons (Mannheim et al., 2019;Mitzner et al., 2019;Williams et al., 2015).Overall, the Holocaust survivors expressed satisfaction with the program.Results from this pilot program indicate that following the program, the survivors have increased their frequency of using ICT for communicating with family and friends.Higher satisfaction with the program was related to higher usage as measured subjectively and objectively with actual usage data.Importantly, increased ICT use was related to having better initial mental health (i.e.fewer posttraumatic stress symptoms and higher flourishing), while also related to feeling lonelier at baseline.
The program held several advantages for the participating Holocaust survivors.Data from the tablet usage indicates that the survivors used the tablet frequently, with an average utilization of over an hour a day.The survivors reported an increase in their frequency of sending text messages (e.g. via WhatsApp) Table 4. Regression models predicting digital contact with family and friends at follow-up (t2) and mean usage scores.to family and friends and in using video calls to communicate with friends.The additional findings of fewer changes in communication that cannot be done via the tablet (i.e.face-to-face and over the phone), suggest that the improvements were related to the program as the increased contacts were such that can be carried out with the tablet, while non-tablet related communication changed to a lesser degree.In their verbal feedback some of them also mentioned that they used the tablet for communicating with family and friends.Holocaust survivors can face social isolation as they age (Barel et al., 2010;Ohana et al., 2014;Schreiber et al., 2004) and such programs can help them in connecting with others when it can become more difficult to leave the house for social interactions (Wrzus et al., 2013).Furthermore, these findings can indicate that such programs can help other vulnerable older adults who have been through traumatic experiences and suffer from posttraumatic stress symptoms.Such populations have been under-investigated in the development of interventions and can benefit from more attention, as they face greater risks of loneliness and isolation, while increased connections can protect against some of the negative effects of trauma exposure (Schwartz & Litwin, 2019).
Such findings are encouraging as they show that even very old adults, aged 75+, can benefit from a digital intervention program and learn how to use tablets.They counter some of the prevalent stereotypes that portray older adults, and very-old adults in particular, as having lower technological abilities than younger age groups (Köttl et al., 2021;Mannheim et al., 2019).Moreover, age was only partly associated with increased use of the ICT, further indicating that chronological age is not necessarily a large barrier as often considered in technology acceptance models (Hauk et al., 2018).Since stereotypes can impact policy toward older adults (Bugental & Hehman, 2007), these results can encourage policy makers to promote digital intervention programs aimed at very-old adults.The regular visits by the volunteer, have likely facilitated the acceptance of the tablets and their prolonged usage for digital communication, and volunteers should be incorporated into future interventions aimed at very-old adults.Indeed, positive intergenerational interactions may facilitate use and acceptance of ICTs (Luijkx et al., 2015), whereas negative experiences or exposure to ageism during such communications might hinder use (Mannheim et al., 2023;Xi et al., 2022).Importantly, experiences of ageism and negative perceptions of aging can have harmful implications for wellbeing (Wurm & Benyamini, 2014), as well as for using technology (Köttl et al., 2021).Thus, training of the volunteers and emphasis on positive intergenerational interaction may be key to future interventions.
The current study also identified those who were more likely to benefit from the pilot program by increasing their ICT use.In accordance with the conservation of resources theory (Hobfoll, 2002), personal resources of better initial mental health were related to more frequent use of ICT.Adults who had lower posttraumatic stress symptoms were more likely to increase their video calls with family and friends.These findings especially warrant attention since they can indicate that people with high posttraumatic stress, who would be targeted by such programs for Holocaust survivors and survivors of trauma in general, face the danger of benefiting less from them.Perhaps they suffer more from social withdrawal and thus, practitioners and coordinators of such programs should particularly focus on those survivors that present high posttraumatic stress and invest more resources and attention on helping them utilize ICTs for fostering connections.
Higher utilization was also related to higher flourishing scores at baseline.Survivors who reported higher flourishing, which reflects a more meaningful life and higher well-being, could be more willing to learn about and implement the use of tablets.On the other hand, adults who were lonely tended to increase their frequency of sending text messages to family members, potentially reflecting their greater need for contacts and their ability to benefit from such a program (Pikhartova et al., 2016).The factor which was most consistently related to greater use, as reflected in both objective and subjective evaluations, was satisfaction with the program.This can indicate that positive evaluations of the program, and perhaps positive interactions with the volunteers, do reflect receiving benefits from it.These findings attest to the importance of satisfaction from the program and positive experience of intergenerational interaction which was an imperative part of it.
This study has several strengths, including a unique understudied sample of persons with a traumatic past, and implementation of a holistic digital intervention program.There are also limitations that should be acknowledged.The sample size is relatively small, due to this being a pilot program with a unique very-old population.While our findings are encouraging, efficacy should be further validated with a larger sample and with the addition of a control group that will not undergo the intervention (Chen & Schulz, 2016).However, the results can provide impetus to future studies who could expand the current results to a larger sample of Holocaust survivors or older survivors of traumas.Such future studies could, for example, assess an intervention program that will extend over longer periods of time, such as a year, or focus on other vulnerable older populations such as old veterans.
To conclude, Holocaust survivors who underwent a pilot digital intervention program indeed increased their digital communication with family and friends.Survivors who benefited the most reported fewer posttraumatic stress symptoms and greater flourishing at baseline, while also reporting higher baseline loneliness, and they were satisfied with the program.The innovation of this study lies in its focus on a particularly vulnerable older population of Holocaust survivors, and its findings highlight the need to develop ICT interventions for this population and for older trauma survivors in general.Future programs should also emphasize the involvement of a person that can facilitate and help the older adult to learn, as well as making the ICT more accessible to older adults and involving them in its design.

Family
Baseline contact refers to the baseline frequency of contact corresponding to the follow-up variable, e.g. for 'Family: text t2' baseline contact is 'Family: text t1'; 1 PtSS = Posttraumatic stress symptoms.

Table 1 .
Characteristics of the Holocaust survivors.

Table 2 .
Comparison of baseline and follow-up digital contact with family and

Table 3 .
Pearson correlations between participants characteristics at baseline and digital contact with family and friends at follow-up (t2) and mean usage scores.