The Journal of School Nursing
The Author(s) 2020
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DOI: 10.1177/1059840520940377
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2022, Vol. 38(4) 368–379
The purpose of this study was to test the effects of a child sexual abuse prevention education program using a hybrid application (CSAPE-H) by examining fifth-grade students’ (a) knowledge for sexual abuse prevention and (b) self-protective behaviors against sexual abuse. A quasi-experimental, pretest/posttest design was used. Sixty-eight students from two schools participated. The intervention group (n = 48) received six sessions in CSA prevention education using the hybrid app, whereas the control group (n = 35) was taught using a lecture in a classroom environment. Between the two groups, there were significant differences in self-protective behaviors against CSA (t = 2.26, p = .027). In addition, educational satisfaction was significantly higher in the experimental group than the control group (t = 2.41, p = .019). A CSAPE-H may be effective for elementary school students, especially for self-protective behaviors.
Keywords
child abuse, education, school nursing, sexual
CSA is a significant global issue due to not only the issue itself but also the accompanying aftereffects it causes (Walsh et al., 2015, 2018). Previous studies estimated that before the age of 18, approximately 10%–20% of female children and 5%–10% of male children experience some form of CSA, worldwide (Barth et al., 2013; Ji et al., 2013; Walsh et al., 2015).
Sexual abuse experienced during childhood can have long-term adverse effects on physical and psychological well-being over the course of individuals’ lives (Jin et al., 2016). The robust research literature has demonstrated a variety of negative psychological outcomes from short- to long-term repercussions without the memory ever being erased (Berman & Knight, 2015; Choi et al., 2016). In addition, as the human rights of the victims have improved compared to the past, the help of health professionals rather than individual efforts has become more important to prevent secondary harm (Chae, 2016). Therefore, there is a need to strive for the prevention of CSA through education, so that the safety and well-being of the children may be guaranteed (Jin et al., 2016; Pulido et al., 2015).
A major component of any health-related program for elementary school children is school-based education (Li et al., 2015). Accordingly, an effective strategy for CSA prevention is an educational program performed in the school environment (Fryda & Hulme, 2015). In particular, young children benefited from a school-based CSA prevention program (Pulido et al., 2015). Because schools have the important primary function of providing essential education access to large populations of children, the schools are optimal institutions for teaching children about CSA prevention (Barron & Topping, 2013; Walsh et al., 2015, 2018). An effective prevention program for CSA should therefore be aligned with school health curricula.
A systemic review conducted by Walsh et al. (2015) showed evidence of an improvement in knowledge and protective behaviors among children exposed to school-based programs regardless of the program type. In an additional study by Walsh et al. (2018) that applied a systematic review and meta-analysis of school-based education programs for the prevention of CSA, the effects were positive. However, they noted that the number of program evaluations of school-based CSA prevention studies worldwide had declined since the 1980s and highlighted the need for more school-based program evaluations that can assess the effects of CSA (Barron et al., 2015).
The rapid development of smartphone-based applications and advancements in mobile technology has made huge amounts of data accessible and offers an unprecedented opportunity to help people in their daily lives (Morrison et al., 2014; Rickard et al., 2016). This trend can be considered as a timely and suitable delivery method to make content on health care education accessible to children and adults.
Hybrid application (app) refers to an operating system (OS) that enables simultaneous cross-platform access between web-based and smartphone-based applications (Lee et al., 2016). Therefore, a hybrid app is an alternative model to provide a package of web- and mobile-based access for a specific intervention (H. S. Kim & Kwon, 2016). A hybrid app can also improve accessibility, be more convenient, and better suited for providing information and education.
Nowadays, people’s preferences and pursuits have brought about a transformation in educational methods that can further increase a hybrid app’s effectiveness. In this respect, hybrid apps turned out to be not only convenient for use because of multiplatform production but also efficient by increasing accessibility beyond time and space. In addition, it is adapted to high-speed mobile communication (Lee et al., 2016) and has the advantage of being able to run on any smartphone platform (Do et al., 2013). Moreover, most general hospitals in Korea are already providing health education using hybrid app services for patients and their families (H. S. Kim & Kwon, 2016).
There are few studies that use hybrid apps for health education. Therefore, the attempts to take advantage of delivery of education programs using web and apps are needed. Regarding the prevention of CSA, Walsh et al. (2015) suggested that further study is required to evaluate and assess programs’ effectivity. In the past decade, sexual abuse among children below 13 years has increased by 27.4% in Korea (Supreme Prosecutors’ Office of Korea, 2019). Although the incidents of abuse have dramatically increased, the effects of CSA prevention education in Korea have not been explored enough (Choi et al., 2016). CSA prevention education contents can be integrated with a hybrid app to increase its practical utilization in everyday life, and the efficiency of education programs could be improved with increased accessibility using both mobile technology and the internet.
To examine the effects of CSA prevention education program using a hybrid application (CSAPE-H), Orem’s (1991) self-care theory was used as a theoretical framework for this study. We set the core concepts as (a) self-care, (b) self-care demands, (c) self-care ability, and (d) nursing agency (Figure 1). Self-care theory shows why humans care for themselves and how they keep their lives healthy by meeting self-care requisites. This consists of activities performed by oneself in order to maintain life and promote individual development and well-being continuously (Berbiglia & Banfield, 2018).
Self-care is an individual activity performed for oneself independently. In this study, self-care means the fifth-grade children’s acquisition of proper knowledge and self-protective behaviors against CSA. We regarded fifth-grade children as individuals having self-care demand against CSA. Self-care ability is an individual’s ability to engage in self-care activities. In this study, self-care ability means the students’ ability to acquire knowledge and self-protective behaviors to prevent CSA. Nursing agency helps people to fulfill self-care needs required to maintain and promote wellbeing. In this study, nursing agency refers to the application of the CSA prevention education using a hybrid app. The main focus of this study framework is to achieve health education that promotes and ensures the children’s safety through self-care. To achieve this, CSAPE-H is required.
The purpose of this study was to examine the effects of CSAPE-H by reporting on fifth-grade elementary school students’ (a) knowledge of CSA prevention and (b) self-protective behaviors against CSA. The hypothesis of this study is that in the CSA prevention education program, for fifth-grade students, using a hybrid application (CSAPE-H) would be more effective than a classroom lecture environment.
In this study, a pretest/posttest quasi-experimental design was used to examine the effects of CSAPE-H on fifth-grade children (Figure 2). For this, CSAPE-H was developed and evaluated based on the analysis, design, development, implementation, evaluation (ADDIE) model and includes the analysis, design, development (Kim et al., 2018), implementation, and evaluation phase (Figure 3). This study was approved by the university institutional review board (IRB No. HIRB-2018-017) to which one of this study’s authors is affiliated.
Phase 1: Analysis. Our first step was to formulate the study’s goal and two objectives. In order to analyze students’ educational needs, learning environment and the students’ characteristics were assessed and literature review related to CSA prevention education was conducted. In addition, we appointed an expert panel composed of three elementary school teachers, two school nurses, and three nursing professors who majored in child health nursing. The panel met 4 times for in-depth discussions, each lasting 2 hr. An analysis of earlier research showed that elementary school students do not have accurate knowledge about CSA and lack an awareness about CSA situations. In addition, the students want direct and concrete content such as coping method and care after a CSA incident. To meet the specific needs of the students, we composed the contents to include the required knowledge and self-protective behaviors. In addition, we considered the developmental characteristics and the level of understanding of school-age children and their willingness to learn. Therefore, we used educational methods such as puppet play to enhance the students’ attention and provoke interest.
Phase 2: Design for educational intervention. In this study, CSAPE-H focused on elementary school children as prevention targets. The program was designed to be a practical education program that was easy to understand and that would help children to cope with real-life situations, prevent CSA, and ultimately promote elementary school students’ health. CSAPE-H for knowledge and self-protective behaviors included three subcategories each. Knowledge for CSA preventions were “concept of CSA,” “causes and occurrence of CSA,” and “difficulties after the CSA.” Self-protective behaviors against CSA were “behavior in safe/unsafe situations,” “coping strategies,” and “self-assertiveness.” At the end of the session, the program was wrapped up with a summary and a quiz. The contents on the app were also connected to a mobile web and internet home page. In the app, users could access each subcategory by touching the menu of each table on their smartphones’ screen. The selected themes and related core topics are presented in Table 1.
In the “concept of CSA” session, the definition of CSA, the importance of CSA prevention, and the types and examples of CSA offenders were presented to increase the users’ understanding of CSA knowledge. “Causes and occurrence of CSA” allowed children to recognize factors related to CSA such as reasons for inducing CSA with reference to actual cases, reported and estimated frequencies, including unreported cases of CSA, environmental factors surrounding the children, and harmful cultures that provoke CSA.
In the “behavior in safe/unsafe situations” session, students developed the ability to identify and distinguish between safe/unsafe situations, what is permitted, and what children should not do. This session taught the students about the “safe rule” and how to avoid potential CSA situations.
In “coping strategies,” five examples that frequently occur to Korean children were discussed, such as “When a stranger comes to touch my body, while I am playing at the playground,” “When a stranger comes to me and offers to buy a delicious food on the way to and from school,” “When a stranger asks me to open the door when I’m alone,” “When a person who I don’t know asks me the way to the park,” and “When the man standing behind me in the elevator tries to touch me suddenly or forcefully.” In this session, the puppeteer showed 10 pictures and explained how to cope in each case and informed the students that “blowing a whistle against the perpetrator” is one of the most effective coping skills.
In the “self-assertiveness” session, the students’ ownership of their own body was emphasized. The students were informed that nobody should touch their body without their permission and to say “no” firmly, then get away from the place immediately. What happened could also not be kept a secret and the child needed to ask for help from a trustworthy person such as their parent or teacher.
In “difficulties after the CSA,” information was shared on what to do if a CSA has occurred. Immediate actions include immediately reporting the incident to the police. Some cautions and sequelae after the CSA were also discussed, as well as how to care for friends who have been sexually abused. In addition, giving information by setting up a “sexual offender notification website” was stressed upon, so that sexual offenders could be identified more easily. The students were also informed of links on the app’s home page that could be used to be automatically connected with the child protection unit’s phone number and the address of a childcare center, should they need help.
At the end of the session, a “wrap-up” session was followed by a simple quiz with 16 questions that required “yes” or “no” responses that were easy for the elementary school students to answer. Once the problem was presented and the student selected the “yes” or “no” icon, the screen showed whether the answer was correct or not, and if the answer was correct, the screen moved on to the next question.
Phase 3: Development. The development was done by registering on the Android-based Google Play Console, which is a general OS for smartphones. The screen was created using a distinctive color, font, and font size that was easy to understand and noticeable for elementary school students, using the Photoshop CS6 program (version.13.0). Considering the elementary school students’ reading comprehension ability, the contents were conveyed in concise and easy words. All content was developed by touch so that it can be checked easily. In addition, real puppets and video materials were used to teach the concepts. Checking for learning was made by selecting “yes” or “no” in a quiz format, like a game with visual processing. For the correct answer, the program was designed to respond verbally (“good job”) and for the wrong answer, the app gave a message to encourage the user to try and solve the quiz again in order to understand and remember the correct answer.
As a hybrid app, the program can be accessed from a mobile web using a smartphone and via the internet from a home page on a home computer. The address of the home page is as follows: https://svprevention.modoo.at/ (Figure 4).
Phase 4: Implementation. After the development phase, the expert group verified the validity of the app’s contents and revised the disputed parts until they all agreed. The validity of the CSAPE-H was examined based on the overall configuration (context, structure, interest, difficulty), screen (character, sequence order), system information (use of terminology, speed, location), and learning (reflection of learner’s needs, usefulness of quiz) using a 10-point scale. In the validity test, the content validity index (CVI) showed above .8, thus, it was proven valid. The aim of the implementation phase was to transfer the knowledge and self-protective behaviors taught to the children to real-life situations. Before implementation, a pretest was done on 10 fifth-grade students to identify the appropriateness of the program. The students for pretest were chosen from another elementary school and excluded students from both the experimental and control groups. Students attended an in-class session for each relevant content area.
In the experimental group, students were able to use the CSAPE-H to perform iterative learning anywhere throughout the app using either the mobile web or an internet home page. On the other hand, the control group also received the same content but by an in-class lecture. For both groups, CSA prevention education was presented in six in-class sessions; however, the experimental group was encouraged to use the web and app platform.
Phase 5: Evaluation. The effectiveness of the CSAPE-H was evaluated using pretest and posttest questionnaires. The students’ knowledge and self-protective behaviors of CSA were tested at the start (pretest) and at the end (posttest) of six classes on CSA prevention. On completion of the course, the participants’ satisfaction level of each educational method was also evaluated.
One hundred fifth-grade elementary school students aged 10–11 years were recruited from two schools in South Korea to participate in this study. We used convenience sampling: One class in the first school was assigned to the experimental group and another one class in the second school was assigned to the control group. Group assignment was determined by the students’ smartphone ownership rate: In the experimental group, it was 100% and in the control group, it was 99.6%.
Each group belonged to the same province but were located in different districts. The schools were similar with regard to the number of students and parents’ income levels. It took over 1 hr by car to reach the venue. Consequently, there was no risk of exposure to experimental treatment. A total of 17 students were excluded from the analysis because of infrequent attendance. In the end, 83 students (83%) were included in the study. To calculate the sample size, G*Power Version 3.1.7 (Faul et al., 2007) was used. It required 26 participants in each group to achieve a large effect size of .80, power of .95, and a significance level of .05 for the calculation of the t test. Therefore, 83 participants in this study were an appropriate number for the sample size.
After the potential participants received an explanation of their human rights, information about the purposes and procedures to be employed in the study, assurance that there would be no negative consequences related to nonparticipation, and assurance that data would be reported in the aggregate. Participation was limited to the students who obtained informed consent with the signed permission form from their parents.
Demographic characteristics. The items for demographic characteristics were generated with reference to previous studies on child sexual education (Ha & Lee, 2014; Im & Park, 2014; S.-J. Kim & Kang, 2017). Therefore, the participants’ age, gender, number of siblings, family type, birth order, and having experience of sexual education at school and by parents or not were included.
Knowledge for CSA. The assessment used to measure participants’ knowledge for CSA was revised by the authors of this study to accurately match the purpose of the study and was based on S.-J. Kim and Kang (2017) and information from the textbook published by the Korean Society of School Health (2014). Measures included three subcategories: “concept of CSA” (understanding CSA), “causes and occurrence of CSA” (recognizing factors related to CSA occurrence), and “difficulties after the CSA” (looking for help and related institutions). Subcategories consisted of 10 items with multiple-choice questions and students could choose one of four answers. Students received 1 point when they gave an accurate answer and no point for an incorrect answer. The possible scores ranged from 0 to 10 points. A high score indicated a high degree of knowledge about CSA.
Self-protective behaviors against CSA. The questionnaire was also revised by the authors of this study and based on S.-J. Kim and Kang (2017) and information from the textbook published by the Korean Society of School Health (2014). Self-protective behaviors were measured using a simulated abuse situation and scored according to the child’s response to the situation. Three subcategories were included: “behavior in safe/unsafe situations” (identify and avoid potentially abused situations), “coping strategies” (What to do), and “self-assertiveness” (take ownership of their own body). Each student’s self-protective behaviors against CSA were queried using multiple-choice questions, the possible scores ranged from 0 to 10. A high score indicated higher competence in self-protective behavior against CSA.
Satisfaction level of education. At the end of the course, participants’ level of satisfaction was assessed as well as feedback regarding the teaching. The scale consisted of 5 items scored on a 4-point Likert-type scale (1 = not at all, 2 = little, 3 = moderate, 4 = very). The participants’ satisfaction was evaluated on 5 items: “inducement of interest,” “helpfulness,” “well-understood,” “confidence to cope,” and “applicability.”
Validity. Validity was carried out using content validity. Eight experts including three nursing professors, two school nurses, and three elementary school teachers validated each question using a CVI. It can be said that the item is applicable when the CVI of the tool is 80% or more (Polit et al., 2007). Through the validity test, the items in this study were verified as valid.
The participants completed the pretest 1 week before the study intervention was conducted. Permission to conduct the study was obtained after the school nurse sent the official research cooperation letter to the parents of the participants. The questionnaire was provided twice to the participants: 1 week before the study and after the intervention. It took about 15–20 min for the students to answer the questions. The test was conducted by a research assistant not to be influenced by measurement bias. The comments related to the course and the students’ level of satisfaction regarding the program were also collected after the six sessions of the program were completed.
Analyses were performed using SPSS for Windows Version 21.0 (IBM Inc., Chicago, IL). Descriptive statistics were used to describe the demographic characteristics of the participants and their scores on the questionnaires. A χ2 test was administered to test the homogeneity between the experimental group and the control group. A t test was used to compare the difference in knowledge of CSA and self-protective behaviors against CSA, with significance of two-tailed, α of .05.
Eighty-three fifth-grade elementary school students in Korea participated in this study. Boys were 44.6% (n = 37) and girls were 55.4% (n = 46). Their ages ranged from 10 to 11 years, with an average of 10.49 (+.50). Most of the students belonged to a nuclear family (88.0%) rather than an extended family (12.0%). Almost all of the students (97.6%) received sexual education at school.
The homogeneity test was performed before the educational intervention was implemented to check whether the two groups were homogeneous or not. There was no significant difference between the two groups with regard to general characteristics, knowledge for CSA (t = –0.27, p = .788), and self-protective behaviors against CSA (t = –1.65, p = .103; Table 2). Therefore, the two groups were regarded as homogeneous.
There was no significant difference between the two groups in their knowledge for CSA (t = 0.17, p = .868). On the other hand, there was a significant difference between the two groups in self-protective behaviors against CSA (t = 2.34, p = .022; Table 3). Among the subcategories of self-protective behaviors, “understanding on how to distinguish” and “behavior in safe and unsafe situations” were significantly increased (t = 2.62, p = .010). These results indicate that CSAPE-H positively affects the self-protective behaviors against CSA in elementary school students.
After the intervention, the satisfaction level of the participants was examined. The difference between the two groups was significant (t = 4.90, p <.001; Table 4). The score of the experimental group (3.75 + 0.50) was higher than that of the control group (3.18 + 0.57) in 5-point satisfaction level.
The distinguishing feature of this study compared with other CSA studies is the development of a hybrid app as a CSA prevention education method and the examination of its effectiveness. Although meta-analysis revealed significant effects of previous CSA studies (Walsh et al., 2015, 2018), these were intervention studies using traditional teaching methods. In Korea, owing to the highly developed information technology, most elementary school students communicate via smartphones. Considering these factors, the effectiveness of a hybrid app to develop educational methods for CSA prevention must be evaluated. In addition, CSAPE-H may provide a more effective CSA prevention strategy for the current generation as elementary school students prefer technologies such as smartphone apps. Therefore, an educational method using the new technology, such as CSAPE-H, is needed to evaluate the effectiveness of CSA prevention.
The participants’ CSA knowledge in the current study was significantly increased in both groups and not significantly higher in the children provided with CSAPE-H than children who received traditional lectures. This result is in line with the Brilian application effect where the knowledge gains in both groups (hybrid-method group and lecture-based group) were increased among college students (Hariadi et al., 2019). It is thought that the knowledge would be acquired in various educational methods. The results of a meta-analysis study were confirmed by Walsh et al. (2018) and showed that the experimental group that received the education showed a significant difference in knowledge score compared to the control group who did not received the CSA prevention education. Therefore, the CSA prevention education needs to be done in various ways, and it is necessary to examine its effectiveness.
For children, providing knowledge for CSA prevention through education is considered very important in that it informs exactly what CSA is (Jin et al., 2016; Pulido et al., 2015). As children may not be sure about the definition of sexual abuse, establishing the correct concept for CSA prevention can give them the necessary tools to prevent sexual abuse (Fulgen, 2017; Walsh et al., 2015). In this study, the mean difference score between the two groups was not showed to be statistically significant. Through further study, there is a need to test the effects of education using web- or app-based CSA prevention methods.
The results in this study support the hypotheses that the children provided with CSAPE-H showed a significantly higher score in reported self-protective behaviors than the children receiving traditional lectures. As there was no previous study related to CSA using a hybrid app, we could not compare the effectiveness of CSA prevention education targeting the students using a hybrid app with other educational methods. In this context, previous research described the advantages of both app-based and web-based learning (Tuna et al., 2014). However, these studies suggested that to maximize the effects, intervention accompanying both a web-based and an app-based education program is better than applying a web-based or app-based intervention alone. Of the 18 studies included in the meta-analysis of Walsh et al. (2018), only 2 studies reported significant effects on self-protective behavior. Therefore, further study needs to verify through iterative research.
In this study, the satisfaction level of the experimental group was significantly higher than the control group. Morrison et al. (2014) reported that most participants viewed a hybrid app as a convenient means to access their desired information. The study of Patil et al. (2016) on medical undergraduate students found that 80% of students had a positive attitude toward mobile learning and perceived the importance of mobile learning. This study may have significance in terms of the development and testing of the educational method applied to a hybrid app for CSA prevention among elementary students.
Regarding the educational method, this study showed an experimental group applied hybrid app had more effective than control group in self-protective behavior. A previous study (Morrison et al., 2014) also reported that the effect was stronger among those who accessed both web- and app-based content compared to participants who only used the app. The participants also agreed that the hybrid app provided a constant reminder of their plans and established goals regarding personal eating and physical activity. Therefore, CSA prevention using hybrid apps that are accessible via the app and the web may be more effective in CSA prevention education if opportunities for self-directed repetitive learning are created.
In relation to self-care theory (Berbiglia & Banfield, 2018; Orem, 1991), these results showed that the fifth-grade children who have self-care demands against CSA took care of themselves and improved their self-protective behaviors. With the help of nursing agency (the application of CSAPE-H), children’s self-care ability was enhanced. Through self-care activities against CSA, their safety can be secured. Although a school-based CSAPE-H program is not viewed as a perfect solution to CSA but rather as a foundation that may enhance knowledge and self-protective behaviors for CSA prevention.
Given our findings, this study offers several implications for future studies using hybrid apps. The combination of the delivery of both web- and app-based intervention enhanced students’ self-protective behaviors. Therefore, educational intervention using a hybrid app may find a practical guide for prevention against CSA. Further study is needed to examine whether the same results are shown when applying hybrid app, web- or app-based intervention alone.
School nurses are specialized in health education who can apply school-based programs to prevent CSA (Fryda & Hulme, 2015). The goal of CSA preventive education should be to identify students’ needs and to develop appropriate knowledge and competencies for self-care. The CSAPE-H program, developed based on Orem’s (1991) self-care model, can be a valuable resource that school nurses can use more effectively.
This study emphasizes the value of using a hybrid app, a combination of web- and app-based intervention. However, in this study, we did not provide detailed explanations of why the combination method brought positive effects in self-protective behaviors. Therefore, a detailed understanding of the rational reason regarding the effectiveness of the hybrid app may be possible through further study.
With the benefits of mobile phone health technology that holds great potential through its ability to deliver flexible, user-oriented intervention, hybrid apps could be introduced as a learner-centered education method. In addition, it may improve the ability of teachers and students to adapt to the new technology as an effective teaching-learning method (Patil et al., 2016). Hence, the use of hybrid apps may enhance the accessibility of CSA education in a school setting.
A number of limitations of this study should be acknowledged. First, only fifth-grade Korean students from one province participated in the study. Future studies could include participants from various geographic areas and ethnic groups. Second, this study has no control group that can compare the effects of using web- or app-based intervention alone. Therefore, it is not clear whether the improved findings of using hybrid app originated from the combination or not. Additional studies using hybrid apps are needed to further examine both usage or not. Third, although we designed the simulated situations to measure self-protective behaviors, there may be differences between the responses to the questionnaire and behaving in real-life situations. Therefore, it is necessary to consider the possible ways to observe the children’s behaviors directly. Finally, although the outcomes were effective, the measurement was only one once after the 6-week intervention sessions. To better understand the retention effects of the hybrid app, it is necessary to follow up after the intervention in the longer term.
This study sought to investigate the effects of CSA prevention education on elementary school students. Based on the research results and discussion above, there was an increase in reported knowledge in both groups and significantly higher self-protect behaviors in the experimental group. In conclusion, this study showed that CSAPE-H was an effective strategy for the provision of school-based program to prevent CSA.
This article has not been published in whole or in part elsewhere and it is not currently being considered for publication elsewhere. All authors of this article have been personally and actively involved in substantive work leading to the report, and we will hold ourselves jointly and individually responsible for its content.
So Ra Kang and Shin-Jeong Kim contributed to the conception of this manuscript as well as acquisition, analysis, and interpretation of the data involved. All authors were involved in the drafting of the manuscript, critical revisions and gave final approval. They agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: Hallym University (Grant HRF-202004-014) and National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2015R1D1A1A01060257).
Shin-Jeong Kim, PhD, RN https://orcid.org/0000-0003-2582-3436
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So Ra Kang, PhD, RN, is a lecturer in the Division of Nursing at Ewha Womans University.
Shin-Jeong Kim, PhD, RN, is a professor in the School of Nursing at Hallym University.
Kyung-Ah Kang, PhD, RN, is a professor in the College of Nursing at Sahmyook University.
1 Division of Nursing, Ewha Womans University, Seoul, Korea
2 School of Nursing, Hallym University, Chunchon, Korea
3 College of Nursing, Sahmyook University, Seoul, Korea
Corresponding Author:
Shin-Jeong Kim, PhD, RN, Division of Nursing, Hallym University, 1 Hallymdaehak-gil, Chuncheon, Gangwon-do, 200-702, South Korea.Email: ksj@hallym.ac.kr
