The Journal of School Nursing2021, Vol. 37(6) 460–469© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519901165journals.sagepub.com/home/jsn
The purposes of this study were to compare the use of contraception by monocultural and multicultural adolescents and identify the multidimensional factors in an ecological model. This study was cross-sectional design with a secondary data analysis using national data from the 2018 Korea Youth Risk Behavior Survey, including 3,031 participants (81 multicultural and 2,950 monocultural adolescents with sexual activity). The monocultural adolescents reported significantly higher rates of contraceptive use (61.66%) than multicultural adolescents (39.39%, p < .001). Monocultural adolescents’ contraception use was significantly associated with intrapersonal factors (gender, drinking, and using substances) and school factors (school location, grade, and sex education). School factors also associated with multicultural adolescents’ contraception use. To promote contraception use by multicultural adolescents with sexual activity, sex education should be tailored to meet specific cultural needs. In addition, risky behavior prevention should be part of comprehensive health promotion and sex education for monocultural adolescents.
contraception, cultural diversity, ecological model, multicultural adolescent, school nursing, sex education
Sexual activities vary among sociodemographic subgroups. Previous studies have reported that there are racial and ethnic differences in sexual experiences and contraception use (Centers for Disease Control and Prevention [CDC], 2018; Jackson et al., 2016). Most studies on the health disparity on this topic have been conducted in Western countries (CDC, 2012, 2018; Jackson et al., 2016), and many previous studies have emphasized the significance of investigating racial and ethnic differences within a country. However, racial and ethnic differences in contraception use have been supported by both individual and cultural preferences for features of contraceptive methods, potential side effects, ease of use, and effectiveness (Hatcher, 2008); thus, more cultural aspects should be considered for this issues.
Recently, this research topic of adolescent sexual health has gained attention in Korea in connection with recent societal change and relevant health consequences (Park, 2015; Yu & Kim, 2015). The relative proportion of multicultural adolescents has been increasing in Korea (Yu & Kim, 2015). The school-age population in general has decreased from 10,882,052 in 2010 to 9,633,308 in 2015. However, the number of children in multicultural families has sharply increased from 121,935 in 2010 to 197,550 in 2015, accounting for about 2.1% of the total number of Korean children (Korean Statistical Information Service, 2019). Despite accelerating diversity among Korean students, migrants and their children have had challenges related to health inequalities and disparities. Multicultural adolescents experience various psychological difficulties secondary to low language competence, difficulties learning or forming peer relationships, differences in appearance from the majority population, and depression due to social prejudice and discrimination against foreigners (Park, 2015; Yu & Kim, 2015). The discrimination experience and Kwon et al. 461 psychosocial maladjustment are widely known to be associated with increases in psychological distress, negative response behavior (Pascoe & Smart Richman, 2009; Yu & Kim, 2015), and risky activities such as smoking, alcohol or drug use, and sexual activity (Caldwell & Takahashi, 2014; Flores et al., 2010; Pascoe & Smart Richman, 2009).
Sex education in Korean schools started in the 1980s as a response to general sexual trends and a social demand for sex education for adolescents (Korean Ministry of Education, 2015). In 2015, the Korean Ministry of Education developed a sex education standard for schools and mandated that students receive 15 hours of sex education. However, schools can change the content of their sex education programs according to the discretion of school principals and school conditions (K. Lee, 2019). Although sexual experience is influenced by a multitude of cultural factors (Park, 2015; Schwartz et al., 2014), there is some evidence that it only reflects social changes, such as cultural diversity, to a limited degree.
There are also several types of community-based institutions that provide sexual health education, such as public health centers, regional medical institutions, social welfare facilities, and sexual violence relief centers (Y. J. Cho et al., 2018). Those institutions offer sex counseling and sex education to adolescents and their parents according to the adolescents’ level of development as part of a national public health promotion project. In addition, 58 Korean youth sexuality culture centers, sex-specialized institutions, have recently founded in 16 regions across the country with the government’s financial support (Hwang et al., 2017). The centers provide self-directed sex education learning modules through the use of multimedia, given adolescents’ familiarity with technology. These centers also make various other efforts such as sex counseling, peer-support groups, and training informal experts (Hwang et al., 2017). Nevertheless, community-based services are also limited in their ability to overcome inequality in sexual health services among different subgroups given the racial differences and cultural values of Korean adolescents. Thus, it is important to know the similarities and differences of sexual experiences among culturally diverse adolescents to develop effective programs based on cultural differences.
Therefore, this study compared the use of contraception among sexually active adolescents in monocultural and multicultural families and identified the multidimensional factors associated with using contraception based on an ecological model using the 14th Korea Youth Risk Behavior Survey (KYRBS).
The study was cross-sectional and correlational in design with a secondary data analysis using the 14th KYRBS (Korean Ministry of Education [KmoE], Korean Ministry of Health and Welfare [KMoH], & Korean Centers for Disease Control and Prevention [KCDC], 2018a). To perform the secondary data analysis study, institutional review board (IRB) exemption approval was obtained from the affiliated university (IRB approval number: Y-2019-0044).
The 14th KYRBS was developed by the KCDC in collaboration with the Ministry of Education and the Ministry of Health and Welfare in Korea (KMoE, KMoH, & KCDC, 2018a). The purpose of this survey was to examine healthrisk behaviors among adolescents, monitor progress based on the Korea’s National Health Plan 2020 indicators, and provide fundamental data for the development and evaluation of adolescents’ health promotion policies and programs. The overall contents of KYRBS were examined through 103 items in 15 domains of health-risk behaviors including sexual behaviors, using substances, and mental health (Kim et al., 2016).
The 14th KYRBS used a stratified multistage cluster sampling design. A three-stage cluster sample design was used to produce a nationally representative sample of students in middle and high schools. The first-stage sampling frame consisted of 117 strata according to province and school type. Secondary sampling units were defined as middle or high school to cover all grades. The third stage of sampling consisted of random sampling in each grade. For the KYRBS, weight was calculated with student gender, grade, and response rate.
Health-related risky behaviors such as smoking, drinking, and sexual experiences are difficult to assess because there is a possibility of self-reporting bias. In general, paper-andpencil questionnaires have more missing answers than online surveys on some sensitive measures (Wood et al., 2006). Specifically, paper-and-pencil questionnaires have approximately 7 times more missing values compared to that in online surveys of sexual behaviors (Jaspan et al., 2007). Moreover, multicultural adolescents are minority which is difficult to recruit for the small scaled survey. Therefore, it was beneficial to conduct the secondary data analysis using nationally representative data from the web-based KYRBS to investigate sexually active adolescents.
The secondary data analysis included 3,031 sexually active adolescents. Eligible students were enrolled in Grades 7–12. Excluded students were those who (1) did not report their parents’ nationality and (2) had never experienced sexual intercourse. According to the Multicultural Family Support Act (Ministry of Gender Equality and Family, 2017), the definition of a multicultural family is one composed of immigrants by marriage and those who have acquired. To identify multicultural adolescents for this study, researchers selected 976 students who answered “no” to the questions, “Was your father born in Korea?” and/or “Was your mother born in Korea?” based on the Multicultural Family Support Act (Ministry of Gender Equality and Family, 2017). The others who answered “yes” to both questions were identified as monocultural. Adolescents who are sexually active were identified as those answering “yes” to the question, “Have you ever were sexually active?” Finally, researchers selected 81 multicultural adolescents and 2,950 monocultural adolescents who were sexually active (see Figure 1).
Dependent variables. Use of contraception was the dependent variable of this study by identifying the question, “Did you use contraception to prevent pregnancy when you had sexual intercourse?” The “use” group was coded as 1 combining always or almost always and the “no use” group was coded as 0 combining no, very rarely, or never according to the KCDC’s definition (KMoE, KMoH, & KCDC, 2018a).
Individual factors. Individual factors included gender, smoking, drinking, and using substances. Gender was selfreported as either boys or girls. Two categorical variables were identified “Have you ever smoked a cigarette, even one or two puffs?” and “Have you ever taken substances such as drugs, butane gas, or glue-sniffing habitually or intentionally?” Participants responded “yes” or “no.” Drinking modified the response to the question “In the last 30 days, how many days have you been drunk?” Participants responding with “1 or 2 days of the month,” “3 or 4 days of the month,” or “more than 5 days of the month” were coded as “yes” and “never had a drink in the last 30 days” was coded as “no.”
Family factors. Family factors included whether the respondent was living with their family and perceived socioeconomic status (SES) of the household. Living with family modified the response to the question “What is your living situations?” Participants who responded that they were “living with their family” were coded as “yes” and living with relatives or in dormitories, orphanages, or so on was coded as “no.” SES modified the response to the question “How would you perceive your household SES?” The available responses were “affluent,” “average,” or “poor.”
School factors. School factors included the location and grade as well as the extent of sex education at school. The locations of schools were classified as metropolitan, urban, or rural. Grade was classified as middle (Grades 7–9) and high school (Grades 10–12). Receiving sex education at school was evaluated as follows: “In the last 12 months, have you ever received sex education at school?” The available responses were “yes” or “no.”
According to the user guidelines provided alongside the KYRBS, this study utilized the complex sample design elements strata, cluster, weight, and finite population correction factor (KMoE, KMoH, & KCDC, 2018a). All statistical analyses were conducted using IBM SPSS Version 25.0 with the significance level set at .05, two-tailed. First, the differences in the rates and methods of contraception use were analyzed via a χ2 test on weighted percentages comparing rates of sexual activity between monocultural and multicultural adolescents. Although the sample size for multicultural adolescent with sexual activity was quite small, using weighting enables us to examine the prevalence of contraceptive use in adolescent to ensure national-level representativeness. Second, a binary logistic regression of complex samples was performed to identify individual, family, and school factors associated with using contraception among monocultural and multicultural adolescents.
The KYRBS is an annual nationwide survey sponsored by the Korean government and developed by the KCDC in collaboration with the Ministry of Education and the Ministry of Health and Welfare in Korea. The 14th KYRBS was officially approved by the Statistics in Korea (Approval No. 117058). Procedure for the 14th KYRBS was designed to protect students’ privacy by ensuring anonymous and voluntary participation. Students who agreed to an online form of informed consent completed an anonymous, selfadministered web-based questionnaire during one class.
Table 1 shows differences in the rates and methods of contraception use in sexually active adolescents between monocultural and multicultural families. The monocultural adolescents reported significantly higher rates of using contraception (61.66%) than multicultural adolescents did (39.39%, p < .001). The methods of contraception were significantly different between monocultural and multicultural adolescents (p = .002). Condoms were the most frequent method for both groups (84.12% and 75.02%, respectively), followed by withdrawal prior to ejaculation (7.43%) in monocultural adolescents and oral contraceptive pills (6.57%) in multicultural adolescents. However, multicultural adolescents used more diverse types of methods including the rhythm method, emergency contraceptive pills (ECP), and intrauterine devices (IUDs) compared to the monocultural adolescents.
Table 2 shows the differences in multidimensional factors associated with contraception use between monocultural and multicultural adolescents. First, among individual factors, high proportions of no contraception use were found in monocultural boys (χ2 = 7.89, p = .003), drinkers in both adolescent groups (χ2 = 15.04, p < .001 for the monocultural group and χ2 = 2.65, p = .034 for the multicultural group), and substance users in both groups (χ2 = 32.71, p < .001 for the monocultural group and χ2 = 2.65, p = .004 for the multicultural group). Larger differences were identified in multicultural adolescents in terms of drinking (72.01% vs. 46.74%) and using substances (73.02% vs. 61.27%) compared to the monocultural. Second, among family factors, high proportions of no contraception use were found in multicultural adolescents not living with their families (χ2 = 6.30, p = .002) and monocultural adolescents of poor SES (χ2 = 8.68, p = .025). Third, among school factors, high proportions of no contraception use were found in middle school in both groups (χ2 = 29.88, p < .001 for the monocultural group and χ2 = 2.49, p = .009 for the multicultural group) and in those having sex education at school in both groups (χ2 = 24.80, p < .001 for the monocultural and χ2 = 3.72, p = .022 for the multicultural). Larger differences were identified among multicultural adolescents than the monocultural adolescents in terms of grade (76.48% vs. 48.07%) and having sex education at school (50.69% vs. 35.74%), respectively.
Table 3 shows the factors associated with adolescent contraception use. The values of Cox and Snell R2 and Nagelkerke R2, which indicate the goodness of fit of the model (Walker & Smith, 2016), were .036 and .049 for monocultural adolescents and .167 and .226 for multicultural adolescents, respectively. Significant factors associated with monocultural adolescent contraception use were gender, drinking, using substances, school location, grade, and sex education at school. Grade and sex education at school were also significant factors of using contraception in multicultural adolescents.
For using contraception, the adjusted odds ratio (aOR) was significantly lower in boys than girls (aOR = 0.83; 95% confidence interval [CI] [0.71, 0.97]). The aOR of those drinking and using substances was 0.74 and 0.44 (95% CI [0.59, 0.93] and [0.30, 0.65], respectively) regarding contraception use. However, those factors were not statistically significant in multicultural adolescents.
Regarding school factors, school location, grade and sex education at school were significant factors associated with using contraception. The aOR was significantly lower for middle school adolescents than high school adolescents (aOR = 0.60, 95% CI [0.49, 0.72] for the monocultural group and aOR = 0.41, 95% CI [0.20, 0.84] for the multicultural). However, the aOR was significantly higher for those receiving sex education at school than those not receiving any (aOR = 1.50, 95% CI [1.23, 1.83] for the monocultural group and aOR = 2.15, 95% CI [1.08, 4.26] for the multicultural).
Our study findings provide fundamental information about widely varying characteristics of contraception use among Korean adolescents based on national survey data. Multicultural adolescents with sexual activity were less likely to use contraception compared to monocultural adolescents. For monocultural adolescents, using contraception was significantly lower with boys, experiences of drinking, using substances, urban schools, lower grades, and with no experience of sex education at school. Grade and sex education at school were also significant factors of using contraception in multicultural adolescents.
The rates and methods of using contraception differed significantly between monocultural and multicultural adolescents. Our study found that multicultural adolescents are less likely to use contraception compared to monocultural adolescents. The U.S. Youth Risk Behavior Surveillance reported that 90% of boys and 84% of girls use contraception during sexual activity (CDC, 2018), but the rate for monocultural adolescents living in Korea was much lower. It was also lower than Switzerland’s rate of 90% and Canada’s rate of 82.3% for adolescents in general (Godeau et al., 2008). It is difficult to make a direct comparison because there are differences in definition and measurement of contraception use among countries. However, the significantly lower uses of contraception of Korean adolescents seem to be problematic (KMoE, KMoH, &, KCDC, 2018b) and specifically the contraceptive rate for multicultural adolescents was much lower at 39.39%. Compared to monocultural adolescents, multicultural adolescents had lower average SES and parents’ education levels, which may negatively influence sexual experience and risky behaviors (Park, 2015). Previous studies have found that cultural beliefs or social norms influence condom use, for example, native Spanish adolescents reported more positive attitudes regarding condom use than multicultural Latin American adolescents in Spain (Bermúdez et al., 2011).
Multicultural and monocultural adolescents used condoms as the most common contraceptive method. It is consistent with previous research reporting condoms as the main contraceptive method of Korean (H. J. Lee & Kang, 2011), United States (CDC, 2018), and Greek adolescents (Godeau et al., 2008). Overall, educational programs (Chung-Park, 2008; Kim et al., 2017), which promote the use of condoms as a convenient and safe contraceptive method, would have increased condom use. However, contraceptive rates and use of condoms in multicultural adolescents are similar to Korea’s statistics from 10 years ago (H. J. Lee & Kang, 2011). A similar situation was also found in a previous study by Ellawela et al. (2017); Sri Lankan immigrants were less likely to use contraception or have heard of effective contraceptive methods and were more likely to report that it was difficult to access useful contraceptive counseling than Australian women and men.
In addition, 9.31% of monocultural and 15.25% of multicultural adolescents used other methods such as withdrawal prior to ejaculation, ECP, and the rhythm method. In particular, withdrawal prior to ejaculation was used with a false belief that it is safe, makes condoms unnecessary, and hides sexual activity from parents (H. J. Lee & Kang, 2011). The rhythm method and ECP were used 5 times more by multicultural adolescents than monocultural adolescents. The rhythm method is not effective because adolescents’ hormones are changing and menses are not consistent because the menstrual cycle easily changes in response to physical and psychological stress or external environmental factors (Hatcher, 2008). In the National Survey of Family Growth report, among girls who had had sexual intercourse, 59.8% used a highly effective contraceptive method (i.e., IUD or hormonal methods), 16.3% used a moderately effective method (i.e., condoms alone), 6.1% used a less effective method, and 17.9% did not use any contraception during 2006–2010 (CDC, 2012). When sex education is implemented for adolescents, school nurses should provide pros and cons about various contraceptive methods and offer a contraception solution that is appropriate for an individual’s situation. In addition, learning the correct uses of contraception is important to maintain safe sex and reduce the risk of sexually transmitted diseases (STDs).
While multicultural adolescents were significantly affected by school factors such as grade and sex education at school, the individual factors that significantly affected only monocultural adolescents were more diverse and related to gender, drinking, and using substances. Drinking, smoking, and using substances are well known to reduce the use of contraception during sexual intercourse (Hooshyar et al., 2018). According to previous studies of factors associated with using contraception in Korean adolescents, significant personal factors include the first age of sexual intercourse and post-drinking sexual intercourse (Y. H. Cho & Ra, 2014). These risky behaviors may prompt failure to use contraception correctly or at the right time due to reduced perception of risk through neurocognitive impairment (Herbeck & Brecht, 2013).
However, in the case of multicultural adolescents, sex education at school is a stronger factor of their sex-related experiences than personal factors. Consistent with the previous report (Kim et al., 2017), adolescents receiving sex education at school reported higher rates of contraception use than those without sex education. Hooshyar et al. (2018) found a similar result in an Indian population-based study in which adolescents reported that knowledge of condoms and STDs equated to a higher incidence of condom use. In addition, it reported that Dominican girls receiving sex education have 2.52 times higher contraception use than those not receiving sex education (Minaya et al., 2008). Korean sex education in schools is highly focused on delivering didactic knowledge in the classroom about various topics such as puberty and secondary sex characteristics (K. Lee, 2019). In spite of this limitation, this study’s findings show that such education is helpful for multicultural adolescents because it serves as their important opportunity to learn about safe sex. Therefore, sex education learning modules for multicultural adolescents should be diversified to reflect their cultural values about sexuality. Web-based and selfdirected sex education have been recommended as useful ways to deliver sex education to adolescents because they are increasingly popular educational platforms that protect students’ privacy and increase their accessibility to information (Scull et al., 2016).
In addition, early school education is important for multicultural adolescents; thus, early and continuing education should be provided across school systems. Consistent with a previous report (Cho & Ra, 2014), middle school adolescents had a very low rate of contraception use compared to high school adolescents. This may be related to a decline in the age of first sexual intercourse (KMoE, KMoH, & KCDC, 2018b), and at younger ages, a lack of contraceptive knowledge may result in low rates of contraception use (Sokkary et al., 2013). The findings indirectly suggest that sexual activity in adolescents becomes a health concern earlier than ever; thus, it is necessary to introduce contraception for adolescents before middle school. In France, sexuality education is mandatory at the age of 6 and must integrate biological knowledge and social, psychological, cultural, and ethical dimensions of sexuality based on the growth of migrant populations (Parker et al., 2009). In addition, the Sexuality Information and Education Council of the United States categorizes those who receive sex education into first through fourth stages and emphasizes that continuous and systematic education should be provided from early school age to the final year of high school (Sexuality Information and Education Council of the United States, 2004). Greater concerns about STD infections encourage a proper and timely use of condoms and increased awareness of HIV and the risks of a possible infection (Bermúdez et al., 2011).
School nurses play an important role in comprehensive and tailored sex education planning in schools. Our study findings have clinical implication for school nursing practice when designing effective education and service programs for adolescent sexual health.
First, comprehensive sex education should include teaching how to properly use contraception. School nurses should provide clear information about various contraceptive methods and offer contraception solutions that are appropriate for given situations. Students should understand the pros and cons of each contraceptive method and the importance of practicing each method accurately. In addition, school nurses should prepare to provide accurate information about each contraception use. Adolescents may access a variety of media resources to fill in gaps in the sex education which they receive at school, in their communities, and from their parents that influence their self-protective sexual health.
Second, school nurses must consider multidimensional factors, specifically cultural differences arising from diverse types of families. It is necessary to develop culturally tailored sex education to meet the needs of multicultural adolescents, so school nurses should review their own cultural beliefs or social norms related to sexuality as these may influence how adolescents think about sexual health decisions, including whether to engage in protective sexual behaviors (Deardorff et al., 2008). Thus, school nurses must develop culturally sensitive sex education based on an understanding of the values of multicultural adolescents, including their cultural traditions, terminology, and expressions (Kreuter et al., 2003), to enhance their awareness of and ability to practice safe contraception methods. In addition, it is necessary to encourage parental involvement in sex education because the sexual experiences of multicultural adolescents have been reported to be strongly affected by their parents (Nam, 2015) and to cooperate with communitybased institutions such as health centers and Korean youth sexuality culture centers.
Third, receiving sex education early was shown to be important for both groups of adolescents; thus, school nurses should begin providing sex education early and continue to do so throughout students’ education. In our study, monocultural adolescents were more likely to be affected by individual factors, while multicultural adolescents were more likely to be affected only by school factors. School nurses are able to identify at-risk groups through interviews or structured questionnaires regarding unexpected and unplanned sexual activity due to drinking or using substances. Such programs should be appropriate with regard to age, developmental level, and school level and are particularly important to implement for multicultural adolescents. Thus, sex education should not only focus on the prevention of unintended pregnancy and STIs but also developing communication, decision-making, and critical-thinking skills to help adolescents have healthy sexual relationships depending on their developmental level. In addition, it suggests that web-based sex education programs that reflect the experiences and unique characteristics of multicultural adolescents increase their privacy and access to timely education.
There were several study limitations. First, some data were missing, as adolescents without parents were unable to reflect their parents’ nationalities. In this study, those without identified parents were excluded because it was not possible to classify them into monocultural versus multicultural groups. Since adolescents without any parent may be more socially and economically vulnerable, a comparative study of sexual health is recommended for parentless adolescents. Second, this study did not compare multicultural adolescents in detail based on their parents’ race or nationality. However, as beliefs about sexual health can be influenced by culture, race, or nationality, the further analysis of adolescents from multicultural families separated by race or nationality in detail may provide more practical basic data on sexual health education. Third, it was not possible to directly compare associated factors due to a wide disparity in the sizes of the monocultural and multicultural adolescent samples. Therefore, future studies should consider using propensity score matching based on the covariates found in this study.
The multicultural adolescents had significantly lower rates of using contraception than monocultural adolescents did. In addition, there were differences in factors associated with using contraception among monocultural and multicultural adolescents. In general, grade and sex education at school are associated with using contraception. However, gender, drinking, and using substances were important influences on contraception use for only monocultural adolescents. Our study findings emphasize that sex education at school should be tailored to cultural and specific needs. In addition, preventing risky behaviors such as drinking and using substances should be part of comprehensive health promotion and sex education for monocultural adolescents.
All authors contributed to the conception of the article, acquisition, and interpretation of data, and revisions; drafting of the article; and final approval as well as agree 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) received no financial support for the research, authorship, and/or publication of this article.
Eunji Kwon, RN https://orcid.org/0000-0001-5213-288X
Myungsuk Kang, MSN, RN https://orcid.org/0000-0001-9067-0144
Heejung Kim, PhD, RN, GNP https://orcid.org/0000-0003-3719-0111
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Eunji Kwon, MSN, RN, is a lecturer at Korea Armed Forces Nursing Academy, Daejeon, Republic of Korea and also a graduate student at College of Nursing, Graduate School, Yonsei University, Seoul, Republic of Korea.
Myungsuk Kang, MSN, RN, is an assistant professor at Korea Armed Forces Nursing Academy, Daejeon, Republic of Korea, and also a doctoral student at College of Nursing, Yonsei University, Seoul, Republic of Korea.
Heejung Kim, PhD, RN, GNP, is an assistant professor at College of Nursing, Yonsei University, Seoul, Republic of Korea and also a principal researcher at Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea.
1 College of Nursing, Graduate School, Yonsei University, Seoul, Republic of Korea
2 Army Cadet Military School, Goesan, Chungcheongbuk-do, Republic of Korea
3 Korea Armed Forces Nursing Academy, Daejeon, Republic of Korea
4 Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
Corresponding Author:Heejung Kim, PhD, RN, GNP, College of Nursing, Yonsei University, Room #603, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea.Email: hkim80@yuhs.ac
