The Journal of School Nursing2025, Vol. 41(5) 579–592© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405241228448journals.sagepub.com/home/jsn
Abstract
COVID-19 brought significant changes to the role of school nurses, necessitating the development of remote health education programs. However, there is a lack of evidence and pedagogical lessons for digitally transforming education for socially vulnerable children. This qualitative study analyzes the health educational needs and barriers faced by children and service providers in a childcare-based obesity prevention program during the pandemic in South Korea. Through a thematic content analysis, four core themes emerged: (a) heightened concerns about obesity and the pandemic’s impact on facilities, (b) unexpected positive outcomes of the program, (c) digital readiness gaps, and (d) insufficient program satisfaction (better than nothing). When designing a digital-based health education program for vulnerable children, assessing individual readiness and facility suitability is crucial. Additionally, school nurses should incorporate hybrid pedagogy, integrating technology-mediated activities. By leveraging technology effectively and considering individual and environmental factors, educators can provide comprehensive and accessible health education.
Keywords
childhood obesity, COVID-19, digital technology, health status disparities, school nurse
The COVID-19 pandemic intensified health disparities globally, presenting a significant health challenge (Bambra et al., 2020; Lopez et al., 2021). Recent studies have consistently reported on lifestyle changes, and physical and mental health problems among children from socioeconomically vulnerable groups, which ultimately contribute to socioeconomic disparities in childhood obesity (Miregård et al., 2023). A cohort study conducted in the United States found that children’s body mass index increased by 0.24 kg/m2 per year compared to prepandemic levels, with particularly notable increases observed among children who were obese and from low-income backgrounds (Knapp et al., 2022). Additionally, the temporary closure of schools and childcare centers, coupled with social distancing measures during the pandemic, led to a significant decrease in physical activity levels, and a rise in sedentary behaviors such as excessive screen time and increased consumption of snacks and sugary drinks (Medrano et al., 2021). Furthermore, while prevalence varies globally, most countries have reported a negative impact of the pandemic on children’s mental health, including increased rates of anxiety, depression, stress, posttraumatic stress disorder, and suicidal thoughts (Oliveira et al., 2022). These obesity-related issues disproportionately affect children from socioeconomically disadvantaged backgrounds, including those from low-income families with limited parental income and education levels, and those belonging to minority ethnic groups (Medrano et al., 2021; Miregård et al., 2023). One of the significant contributing factors to these disparities is the temporary closure of schools and childcare centers, which serve as crucial determinants of health for vulnerable children (Blundell et al., 2020).
In response to the pandemic, the use of innovative information and communication technologies (ICT) has gained momentum in nursing education and counseling for children and adolescents in community settings. The implementation of these technologies has been accelerated by the social distancing measures and temporary lockdowns imposed on schools and childcare centers during the COVID-19 pandemic (Mielgo-Conde et al., 2021). For instance, schools have provided remote counseling services (Yoshikawa et al., 2020) and programs to prevent child abuse (Haas, 2021). In addition, school nurses have engaged in online health education, connecting students and families to health services considering their health needs, and remotely monitoring students with chronic conditions to ensure their well-being at home (Fauteux, 2021; Marrapese et al., 2021). Despite these efforts of school and school nurses, there were some points overlooked when applying new technology. Individual competencies and environmental readiness for digital technology are significant determinants that affect program performance outcomes and the effectiveness of such programs (Haleem et al., 2022). Unfortunately, children from vulnerable populations often lack digital literacy and preparation for the digital era, leading to a digital divide (Mascheroni et al., 2022; Masters et al., 2020), which ultimately exacerbates childhood health disparities (Radesky et al., 2020). In fact, over 50% of primary school students in the United Kingdom did not have a dedicated space for studying at home and more than 20% lacked access to essential tools such as online learning platforms and classes during lockdowns. Socioeconomic disparity among families resulted in unequal access to learning resources for children, significantly impacting their learning time and academic achievement (Andrew et al., 2020). In addition, Schulz and Robinson (2022) reported that 30% of disadvantaged secondary school students have not acquired the skills necessary to search, access, and stream content that can be informative for educational purposes including digital distance learning. Therefore, it is essential to assess the barriers and educational needs of socially vulnerable children before planning and developing nursing education programs using ICT.
The COVID-19 pandemic brought radical changes, significantly altering the roles and responsibilities of school nurses in community settings, where they directly care for children (Lowe et al., 2023). These unprecedented circumstances demanded an expanded role for school nurses in the community, making them key figures in the pandemic era (Jenkins et al., 2023). They oversaw a myriad of pandemic-related and unfamiliar tasks, including disease surveillance, disaster preparedness, vaccination efforts, and the development of guidelines and protocols to prevent the spread of COVID-19 in schools and communities (Barbee-Lee et al., 2021; Fauteux, 2021; Lowe et al., 2023; Marrapese et al., 2021). Among these responsibilities, providing education and counseling in a remote environment has been identified as one of the most challenging aspects faced by nurses (Sammut et al., 2022). Despite the sudden changes in their roles and responsibilities, most previous studies on school nurses in community settings have primarily focused on pandemic-related tasks such as enforcing social distancing, monitoring COVID-19 cases, contact tracing, vaccination, supporting isolated students and their families, and developing plans for school closures and reopening (Cook et al., 2023; Lee et al., 2021; Lowe et al., 2023). Consequently, there is a relative scarcity of evidence regarding pedagogical approaches that examine the effects and limitations of remote health education and prepare nurses for the active digital transformation era that lies ahead. Moreover, there has been limited research on health educational needs and barriers faced by socially vulnerable children from the perspective of health disparities.
This study aims to fill the gaps in knowledge by analyzing the experiences of participants in a childcare-based obesity prevention program for vulnerable families during the COVID-19 pandemic. Although childcare facilities are not identical to school circumstances, the childcare center for the disadvantaged populations in South Korea provides an optimal environment for identifying the characteristics of vulnerable children from the perspective of place-based intervention and initiatives (Park, Baek, et al., 2023). As the era of infectious diseases continues (even though the World Health Organization recently declared an end to COVID-19 as a public health emergency), school nurses and nursing researchers must consistently monitor changes in the community nursing education environment (Schwerdtle et al., 2020). Understanding the needs of socially disadvantaged children who are more vulnerable to these disasters can help school nurses develop strategies for effective nursing education in the digital era, and ultimately alleviate childhood health disparities.
The remainder of the article is structured as follows: the methods used in the study are stated, including a description of the study design, participants, and data collection and analysis. Then, the study results are stated, focusing on the four core themes that emerged from the thematic content analysis. Next, the results are discussed in relation to those of previous studies, and then the study limitations are stated with recommendations for future research. The study implications for nurses are documented, concluding with a summary of our study, the findings, and further practical implications.
This qualitative research aimed to investigate the experiences of participants of a childcare-based obesity prevention program for vulnerable families. Focus group interviews (FGI) with children and service providers (SPs) at childcare facilities were conducted, and participation experience reports were analyzed. Through the study, we strictly adhered to the consolidated criteria for reporting qualitative research (COREQ; Tong et al., 2007; see Appendix 1).
The “Let’s Eat Healthy & Move” program, implemented in South Korea in 2015, is a place-based obesity-prevention intervention for vulnerable children. The program adopts a comprehensive approach, including anthropometric and lifestyle assessments of children, as well as obesity prevention education and cooking classes for children, caregivers, and SPs in community childcare (CCC) centers. These centers serve as a vital part of the Korean child welfare policy, providing after-school care for vulnerable children. Previous evaluations of the program have demonstrated positive effects on children’s lifestyle, weight status, and quality of life (Park, 2019).
However, with restricted access to CCC centers due to the COVID-19 pandemic, the “Let’s Eat Healthy & Move” program had to adapt to the new circumstances in 2021. To effectively deliver remote obesity prevention education, the program incorporated the use of a blog platform, and most programs, including cooking classes, were transitioned to remote formats. Appendix 2 provides a detailed description of the program structure and components. This community-based participatory program was implemented in collaboration with a healthcare center in a specific community, involving the participation of 319 children and 52 SPs across 16 centers from June to November in 2021.
As part of the evaluation, two focus groups comprising seven children and three groups with nine SPs were organized using purposive sampling methods. The general characteristics are outlined in Table 1. Additionally, following the completion of the program, one SP from each center wrote a participation report, expressing their thoughts and providing further suggestions for program improvement. A total of 11 reports were submitted from 16 centers, and these statements were included in the analysis (total length of the paper: 29 pages).
Initially, the purpose and methodology of the FGI were communicated to the SPs through detailed e-mail and phone discussions. They were asked to recommend children who could effectively express their experiences in the program on a voluntary basis. Among them, children whose voluntary participation was confirmed by children and their caregivers participated in the interviews. The FGIs were conducted in January and February 2022 using remote video interviews through zoom. The research team extensively reviewed previous studies and held several meetings to learn how to effectively conduct remote interviews and address potential issues that may arise during the FGI. One day prior to the interview, detailed instructions on accessing zoom and the purpose and methodology of the interview were provided. Participants were requested to fill out a questionnaire containing general characteristics and submit it before the interview through the email. Additionally, before starting the interview, thorough checks were conducted to ensure the interview environment and readiness, including internet connectivity and minimizing background noise.
The interview was conducted in Korean by one moderator and one research assistant who were experts on the topic and had previous experience with FGI. The moderator was a PhD and university professor, and the research assistant was a doctoral student, all of whom are women. The interviewer established a relationship with the participants by doing the research. Semistructured open-ended questions (Appendix 3) were used during the interviews and we used a field note during the interview. The interview participants consisted of three groups of SPs and two groups of children, and no participants were dropped. Each group interview lasted approximately 1–1.5 h, and the entire interview was recorded using zoom after obtaining consent from the participants. The researcher determined that data saturation had been reached with the initially recruited participants, therefore, no further data collection was conducted. The criterion for data saturation was the point at which new meanings and experiences could not be discovered during the interviews. This study was approved by the Institutional Review Board (IRB) of the reseacher’s university (IRB number: INJE 2022-07-015). Participants were given an honorarium (approximately 40 U.S. dollars) as a token of appreciation for their participation in the interviews.
The FGIs were digitally recorded and subsequently transcribed in Korean. The transcriptions were then transferred to NVivo R1 (Park, 2020; Saldana, 2009) for analysis. Three researchers individually generated initial codes based on the interview sequence. Subsequently, the codes were compared. To ensure validity, the coding and corresponding texts were repeatedly reviewed by the researchers in a series of eight research meetings. To enhance the trustworthiness of the results, a member check was conducted with one SP who participated in the FGI. This member confirmed that the results of this study accurately reflected the experiences shared by the participants. Finally, the study results were translated into English, and two researchers who are bilingual both Korean and English reviewed and confirmed the translation process.
Through a thematic content analysis of participant experience, four core themes emerged from the data: (a) escalated tension in facilities during the pandemic and obesity concerns, (b) serendipitous and unexpected effects of the program, (c) digital readiness gaps for the digital transformation era, and (d) insufficient program satisfaction: better than nothing.
The daily lives of both children and SPs were tightly regulated, leading to physical and psychological constraints. The reduced interactions between people further intensified the psychological tension within the centers. To prevent the spread of COVID-19, the centers strictly adhered to unfamiliar infection prevention measures, such as installing partitions between desks and maintaining a physical distance. This unusual environment placed a considerable mental burden and heightened tension on both children and SPs.
What we told the children the most during the day was to wear their masks properly, up to their nose (…), not getting too close to other children, not talking too much. Children felt cramped and under a lot of stress (…). (Interview 1, SP 3)
The controlled routines and escalated tension in childcare facilities due to COVID-19 not only increased the psychological burden of children but also brought significant changes to their lifestyle.
Psychological Burden on Children Due to Controlled Routines. The prolonged social distancing measures during the COVID-19 pandemic resulted in extremely limited interactions among peers, leading to boredom, stress, irritation, and dissatisfaction among children. A SP described this as early puberty brought on by COVID-19.
There are so many restrictions that we don’t know what to do, such as how to release all the pent-up energy that the children have. Puberty came so quickly and severely for these children. The impact of COVID-19 is evident in this type of change. (Interview 1, SP 1)
Lifestyle Changes in Response to the Pandemic. The COVID-19 pandemic resulted in a significant decrease in physical activity among children, mainly due to the restrictions imposed during this period. SPs expressed concern about the increased risk of obesity resulting from reduced physical activity levels. Additionally, the pandemic led to changes in the eating environment, with meal services being replaced by lunchboxes and children having to eat alone. These changes along with decreased physical activity further contribute to the challenges surrounding healthy eating habits and weight management among children during the pandemic.
Children move so little because of COVID-19, and they gain so much weight that you can see they got heavier. (Participation Report 1)
It’s a shame that children can’t eat together because of COVID-19. I hope the pandemic ends soon so that children can freely share meals together. (Participation Report 2)
In the past, there were things like yoga that were physically active, singing, or exercising. But with COVID-19, I think I’m doing programs that are less active and they move less than before…. (Interview 1, Children 2)
The digitally transformed childcare-based obesity prevention program had several unexpected effects that were reported by the participants. Firstly, it was found that the program successfully enhanced participants’ knowledge and awareness of healthy lifestyles, translating into practical behaviors. SPs took the initiative to promote physical activity and healthy eating habits among children, caregivers, and colleagues, aligning with the program goals outlined in Appendix 2.
One significant outcome was the acquisition of digital literacy skills by both SPs and children. Prior to the program, most employees lacked proficiency in using digital devices, and children had limited exposure to computers despite attending online classes during the pandemic. However, through the program, participants gained digital literacy skills, and the centers started actively using digital devices for online education aimed at parents. Furthermore, the program included interactive live cooking sessions conducted through zoom, allowing children to greet each other on the screen and witness the happenings in other centers. This unique experience provided an opportunity for children and SPs to interact digitally, fostering increased communication and connection.
These unexpected effects demonstrate the program’s ability to not only address obesity prevention but also contribute to digital literacy skill development and promotion of social interaction among children and SPs.
It was interesting to learn how to use the device in a zoom meeting. (Interview 1, Children 1)
Children’s activities have been too limited; however, children in different regions or the same community who could not see each other could meet remotely and communicate, although it was only online. (Interview 2, SP 2)
The participants expressed a significant gap in personal readiness and environmental preparation for digital use, which emerged as a major obstacle in implementing the digitally transformed obesity prevention program. Specifically, the study revealed a noticeable lack of digital readiness among caregivers of children from vulnerable groups, such as grandparents, single parents, and immigrant families. Grandparents, in particular, faced challenges using digital media and navigating appropriate digital platforms, especially in cases where the family consisted solely of grandparents and grandchildren. Furthermore, even among parents who possessed the necessary digital skills, some reported a lack of sufficient time to guide and supervise their children during digital activities. This time constraint hindered their ability to actively engage and support their children in utilizing digital devices effectively.
The parents struggle with zoom access at first. (…) If you have an ID, you can just click on it to start, but some parents are confused with even that. (Interview 2, SP 2)
Most adults are used to using these devices, but it’s not the case for grandparents or single-parent families. Children use the devices, and their parents should monitor them to help them learn to use the devices. (…) The parents’ lives are hard enough as it is, so it’s not easy to help their children with this, too. (Interview 3, SP 1)
In addition, significant variations were observed among the centers in terms of equipment preparation, such as beam projectors, internet stability, and adequate space, which are fundamental requirements for program operation. Most of the centers faced challenges due to their vulnerable environment, making it difficult for them to fully participate in remote programs.
Using zoom was somewhat inconvenient because the internet connection wasn’t so good, and the screen would sometimes freeze when disconnected. (Interview 1, Children 4)
There were some issues, such as small space and insufficient equipment. It would have been more effective if we could set up a big beam projector, but we couldn’t(…). (Interview 2, SP 3)
Participants in this study expressed several limitations of unfamiliar remote methods when compared to existing face-to-face delivery methods. One limitation was the difficulty of interactive communication, which is inherently more challenging in video-based education and remote settings.
Some things could have been done smoothly without any trouble if they were done face-to-face. However, because two-way communication could not be done in real-time, the teachers would just move at their pace, and the children could not keep up. (Interview 1, SP 3)
Moreover, participants recognized that the remote method had a lower educational effect than the face-to-face because it was difficult to experience directly and the level of concentration was low.
The problem with remote methods is that we only watch it, whereas with face-to-face methods, we can actually experience it in the flesh. We can see each other’s faces (…). Face-to-face methods produce long-lasting memories and experiences. That’s the difference, and we can’t help that. (Interview 1, SP 1)
With remote methods, we lack focus or concentration, same as the children, unlike during face-to-face methods. (Interview 1, SP 3)
Conversely, some expressed the advantages of remote methods that have accessibility to the materials at any time and are repeatable and availability of lively and visible video material.
I like the fact that the teaching materials are always posted on the blog and available to see anytime, [so I could check them] when I don’t remember something. (Participation Report 2)
The materials that the instructors or teachers brought were illegible. (…) However, online materials were more direct and clearly visible, which is better for understanding. (Interview 1, SP 3)
In summary, most participants thought that remote delivery methods were suitable during the COVID-19 pandemic. However, some participants stated that these types of programs are not necessarily effective but rather better than not having any programs at all, as existing programs were canceled or discontinued during the COVID-19 pandemic.
Recent studies have shed light on the socioeconomic disparities in childhood obesity during COVID-19, analyzing its impact on the prevalence of obesity among children (Anderson et al., 2023; Jenssen et al., 2021, 2023; Miregård et al., 2023). In this study, we found that the COVID-19 pandemic brought radical changes in the primary environment in which vulnerable children live and grow. In turn, these changes have the potential to affect their likelihood of developing obesity. Specifically, the psychological burden associated with the pandemic and the resulting lifestyle changes can interact and amplify the risk of obesity. Previous research consistently highlights that disadvantaged groups are particularly susceptible to pandemic-related stress, which can be a contributing factor to obesity (Medrano et al., 2021; Miregård et al., 2023). It is an unexpected finding that the places meant to support vulnerable children can inadvertently become environments that contribute to and worsen obesity. Therefore, it is crucial to proactively understand the circumstances and dynamics between vulnerable children and their key environments from a social determinants of health perspective (CSDH, 2008; Solar & Irwin, 2010). This understanding will serve as a pivotal factor in the development and planning of effective health education programs tailored to the needs of vulnerable children.
The study findings not only revealed the intended effects of the program, but also unforeseen benefits associated with the acquisition of digital literacy skills, increased utilization of digital devices in educational centers, and enhanced interaction among children. Recent studies have also highlighted the additional effects of digital-based health education programs, including the acquisition of digital technology skills and the transition to a digital environment (Haleem et al., 2022). Traditionally, digital devices have been perceived as barriers to interpersonal interaction in face-to-face environments (Kaihlanen et al., 2022). In contrast, recent studies have shown that such interventions can promote interpersonal interaction, and alleviate depression and anxiety, especially in situations such as the COVID-19 pandemic, where physical interaction is severely limited (Kim et al., 2023; Vandelanotte et al., 2022). Hence, future development of digital-based health education programs incorporating new ICTs should systematically integrate digital technology-related content, such as the advantages and uses of ICT, along with strategies to foster interpersonal communication. Furthermore, it is important to measure participants’ digital skills and their interpersonal interactions related to this content as potential program outcomes. Thus, we can ensure a comprehensive approach to designing effective digital-based health education programs that harness the potential of ICT while prioritizing interpersonal connections.
In a digital-based health education program, the participants’ digital readiness plays a crucial role in determining the program’s success and outcomes (Haleem et al., 2022). Specifically, participants require digital literacy encompassing technical skills in using devices and accessing platforms, as well as cognitive capabilities to understand and critically evaluate digital information (Chetty et al., 2018; UNESCO, 2017). Moreover, the environment in which the program is implemented should be optimized to support the delivery of digitally based interventions (Haleem et al., 2022). This is particularly relevant when considering children, as the readiness of the human and physical environment surrounding them can significantly influence the effectiveness and outcomes of the program (Kracht et al., 2023). In this study, we confirmed that personal readiness and environmental preparation for digital use present major obstacles in implementing a digitally transformed obesity prevention program. Vulnerable groups, such as grandparents and single-parent families, are known to be generally unprepared for the digital era (Mascheroni et al., 2022; Masters et al., 2020), which was prominently observed in this study. The digital divide has emerged as a major predictor of individuals’ digital capabilities, and health behaviors and disparities (Adedinsewo et al., 2023). Therefore, before implementing a digital-based health education program for vulnerable children, it is essential to thoroughly assess individual readiness and parental preparedness in utilizing digital technology, as well as to evaluate the suitability of the facility environment.
Study participants shared their experience with the digitally transformed program, highlighting the differences compared to the familiar face-to-face delivery methods. While acknowledging the unavoidable shift to remote methods prompted by the unexpected pandemic, several participants expressed concern about the limitations of such approaches and suggested the development of more suitable delivery methods for future pandemic eras. Pedagogical research has highlighted various limitations of remote education, including difficulties in interactive communication, limited direct experience, and reduced participant concentration (Alsubaie, 2022; Zarei & Mohammadi, 2022). However, unlike many school education methods for imparting simple knowledge, nursing and health education aims to change human behavior. It is essential to induce change in various determinants such as skills and awareness (Johnson & May, 2015; Park, Baek, et al., 2023; Park, Chung, et al., 2023). Therefore, when planning and developing health education initiatives, it is crucial to tailor the delivery method to the specific educational content and the needs of the target populations. Nurse educators require a comprehensive understanding of the advantages and disadvantages of both remote and face-to-face delivery methods, and should strive to devise an optimal approach that leverages the strengths of each method. In addition, in preparation for recurring pandemic eras, it is essential to activate hybrid pedagogy (Linder, 2017), integrating technology-mediated activities such as artificial intelligence, Internet of Things, robot technology, and virtual reality into nursing education. Continual monitoring and updating of these strategies will be necessary to ensure their effectiveness in adapting to changing circumstances.
In this study, we did not include voices from other important stakeholders, such as caregivers, school nurses, teachers, and policymakers. To obtain a more comprehensive understanding of the health educational needs and barriers in nursing and health education, it is necessary to gather input from these diverse stakeholders. Further research should strive to collect the opinions of various stakeholders who have the potential to influence the educational needs and barriers faced by vulnerable children, employing an ecological model as a framework. In addition, it is essential for school nurses to utilize these findings as a basis for developing tailored health education programs that consider the unique circumstances and challenges faced by vulnerable children. Thus, they can ensure that the programs are customized and sensitive to the needs of these individuals, promoting their overall well-being and health outcomes.
Students and teachers in schools are gradually getting used to remote teaching environments and must remain prepared for the possibility of recurring pandemics. Even beyond pandemic scenarios, it is necessary to embrace remote teaching delivery methods that offer various advantages. When developing and planning health education programs for vulnerable children, it is necessary to actively understand the dynamics between vulnerable children and their key environments considering the social determinants of health. In future endeavors, the development of digital-based health education programs utilizing new ICTs should systematically incorporate digital technology-related elements. To successfully operate digital-based health education programs for vulnerable children, it is essential to strengthen their digital capabilities and enhance facility readiness to utilize digital technology more effectively. School nurses should have a comprehensive understanding of the strengths and weaknesses of remote and face-to-face delivery methods, and aim to devise an optimal approach that maximizes the benefits of each method. Active preparation and exploration of alternatives to the aforementioned challenges are necessary. By doing so, the effectiveness of health education will be enhanced and the health outcomes of vulnerable children will improve, contributing to a reduction of health inequalities.
This study aimed to identify the health educational needs and barriers for vulnerable children in the digital transformation era by analyzing the participation experience of children and SPs in a childcare-based obesity prevention program during the COVID-19 pandemic. Considering the predicted recurring pandemics, nursing educators and researchers face the task of adjusting to the evolving landscape of remote education (Torous et al., 2020). Consequently, the study results hold significant value as they provide a vital framework for the development of tailored programs aimed at benefiting socially disadvantaged children. Ultimately, these efforts will contribute to the overarching goal of mitigating health disparities.
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, authorship, and/or publication of this article: This work was supported by a grant from Research year of Inje University in 2022 (Grant Nos. 20220025).
Jiyoung Park, PhD, RN https://orcid.org/0000-0003-1374-9187
Gahui Hwang, PhD https://orcid.org/0000-0002-4298-5763
Adedinsewo, D., Eberly, L., Sokumbi, O., Rodriguez, J. A., Patten, C. A., & Brewer, L. C. (2023). Health disparities, clinical trials, and the digital divide thematic reviews on forward thinking on clinical trials in clinical practice. Mayo Clinic Proceedings, 98(12), 1875–1887. https://doi.org/10.1016/j.mayocp.2023.05.003
Alsubaie, M. A. (2022). Distance education and the social literacy of elementary school students during the COVID-19 pandemic. Heliyon, 8(7), Article e09811. https://doi.org/10.1016/j.heliyon.2022.e09811
Anderson, L. N., Yoshida-Montezuma, Y., Dewart, N., Jalil, E., Khattar, J., De Rubeis, V., Carsley, S., Griffith, L. E., & Mbuagbaw, L. (2023). Obesity and weight change during the COVID-19 pandemic in children and adults: A systematic review and meta-analysis. Obesity Reviews, 24(5), Article e13550. https://doi.org/10.1111/obr.13550
Andrew, A., Cattan, S., Costa Dias, M., Farquharson, C., Kraftman, L., Krutikova, S., Phimister, A., & Sevilla, A. (2020). Inequalities in children’s experiences of home learning during the COVID-19 lockdown in England. Fiscal Studies, 41(3), 653–683. https://doi.org/10.1111/1475-5890.12240
Bambra, C., Riordan, R., Ford, J., & Matthews, F. (2020). The COVID-19 pandemic and health inequalities. Journal of Epidemiology and Community Health, 74(11), 964–968. https://doi.org/10.1136/jech-2020-214401
Barbee-Lee, M., Seymour, K., Hett, A. L., Norris, G., Stack, S., Cartier, A., Haycox, P., Armstrong, L., & Herbert, L. (2021). School nursing in a pandemic: Striving for excellence in Santa Fe Public Schools. NASN School Nurse, 36(5), 276–283. https://doi.org/10.1177/1942602X211005166
Blundell, R., Costa Dias, M., Joyce, R., & Xu, X. (2020). COVID-19 and inequalities. Fiscal Studies, 41(2), 291–319. https://doi.org/10.1111/1475-5890.12232
Chetty, K., Qigui, L., Gcora, N., Josie, J., Wenwei, L., & Fang, C. (2018). Bridging the digital divide: Measuring digital literacy. Economics, 12(1). https://doi.org/10.5018/economics-ejournal.ja.2018-23
Commission on Social Determinants of Health (CSDH). (2008). closing the gap in a generation: Health equity through action on the social determinants of health—Final Report of the Commission on Social Determinants of Health. World Health Organization. https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1
Cook, G., Appleton, J. V., Bekaert, S., Harrold, T., Taylor, J., & Sammut, D. (2023). School nursing: New ways of working with children and young people during the COVID-19 pandemic: A scoping review. Journal of Advanced Nursing, 79(2), 471–501. https://doi.org/10.1111/jan.15504
Fauteux, N. (2021). School nursing during a pandemic. American Journal of Nursing, 121(8), 17–19. https://doi.org/10.1097/01.NAJ.0000767776.98974.e7
Haas, J. J. (2021). The role of the school nurse in detecting and preventing child abuse during this age of online education. NASN School Nurse, 36(1), 16–19. https://doi.org/10.1177/1942602X20958064
Haleem, A., Javaid, M., Qadri, M. A., & Suman, R. (2022). Understanding the role of digital technologies in education: A review. Sustainable Operations and Computers, 3, 275–285. https://doi.org/10.1016/j.susoc.2022.05.004
Jenkins, C., Geisthardt, C., & Day, J. K. (2023). Supporting children and families in medical settings: Insights from child life specialists during the COVID-19 pandemic. Journal of Child and Family Studies, 32(6), 1599–1616. https://doi.org/10.1007/s10826-023-02537-9
Jenssen, B. P., Kelly, M. K., Powell, M., Bouchelle, Z., Mayne, S. L., & Fiks, A. G. (2021). COVID-19 and changes in child obesity. Pediatrics, 147(5), Article e2021050123. https://doi.org/10.1542/peds.2021-050123
Jenssen, B. P., Kelly, M. K., Shu, D., Dalembert, G., McPeak, K. E., Powell, M., Mayne, S. L., & Fiks, A. G. (2023). Trends and persistent disparities in child obesity during the COVID-19 pandemic. Childhood Obesity. https://doi.org/10.1089/chi.2022.0205
Johnson, M. J., & May, C. R. (2015). Promoting professional behavior change in healthcare: What interventions work, and why? A theory-led overview of systematic reviews. BMJ open, 5(9), Article e008592. https://doi.org/10.1136/bmjopen-2015-008592
Kaihlanen, A. M., Virtanen, L., Buchert, U., Safarov, N., Valkonen, P., Hietapakka, L., Hörhammer, I., Kujala, S., Kouvonen, A., & Heponiemi, T. (2022). Towards digital health equity – a qualitative study of the challenges experienced by vulnerable groups in using digital health services in the COVID-19 era. BMC Health Services Research, 22, 188. https://doi.org/10.1186/s12913-022-07584-4
Kim, H., Lee, K., Lee, Y. H., Park, Y., Park, Y., Yu, Y., Park, J., & Noh, S. (2023). The effectiveness of a mobile phone–based physical activity program for treating depression, stress, psychological well-being, and quality of life among adults: Quantitative study. JMIR mHealth and UHealth, 11, Article e46286. https://doi.org/10.2196/46286
Knapp, E. A., Dong, Y., Dunlop, A. L., Aschner, J. L., Stanford, J. B., Hartert, T., Teitelbaum, S. L., Hudak, M., Carroll, K., O’Connor, T., McEvoy, C. T., O’Shea, T., Carnell, S., Karagas, M. R., Herstman, J. B., Dabelea, D., Ganiban, J. M., Ferrara, A., & Hedderson, … Environmental Influences on Child Health Outcomes. (2022). Changes in BMI during the COVID-19 pandemic. Pediatrics, 150(3), Article e2022056552. https://doi.org/10.1542/peds.2022-056552
Kracht, C. L., Burkart, S., Flanagan, E. W., Melnick, E., Luecking, C., & Neshteruk, C. (2023). Policy, system, and environmental interventions addressing obesity and diet-related outcomes in early childhood education settings: A systematic review. Obesity Reviews, 24(4), Article e13547. https://doi.org/10.1111/obr.13547
Lee, R. L. T., West, S., Tang, A. C. Y., Cheng, H. Y., Chong, C. Y. Y., Chien, W. T., & Chan, S. W. C. (2021). A qualitative exploration of the experiences of school nurses during COVID-19 pandemic as the frontline primary health care professionals. Nursing Outlook, 69(3), 399–408. https://doi.org/10.1016/j.outlook.2020.12.003
Linder, K. E. (2017). Fundamentals of hybrid teaching and learning. New directions for teaching and learning, 2017(149), 11–18. https://doi.org/10.1002/tl.20222
Lopez, L. 3rd, Hart, L. H. 3rd, & Katz, M. H. (2021). Racial and ethnic health disparities related to COVID-19. JAMA, 325(8), 719–720. https://doi.org/10.1001/jama.2020.26443
Lowe, A. A., Ravi, P., Gerald, L. B., & Wilson, A. M. (2023). The changing job of school nurses during the COVID-19 pandemic: A media content analysis of contributions to stress. Annals of Work Exposures and Health, 67(1), 101–117. https://doi.org/10.1093/annweh/wxac053
Marrapese, B., Gormley, J. M., & Deschene, K. (2021). Reimagining school nursing: Lessons learned from a virtual school nurse. NASN School Nurse, 36(4), 218–225. https://doi.org/10.1177/1942602X21996432
Mascheroni, G., Cino, D., Mikuška, J., & Smahel, D. (2022). Explaining inequalities in vulnerable children’s digital skills: The effect of individual and social discrimination. New Media & Society, 24(2), 437–457. https://doi.org/10.1177/14614448211063184
Masters, G. N., Taylor-Guy, P., Fraillon, J., & Chase, A. M. (2020). Ministerial briefing paper on evidence of the likely impact on educational outcomes of vulnerable children learning at home during COVID-19. Australian Council for Educational Research.
Medrano, M., Cadenas-Sanchez, C., Oses, M., Arenaza, L., Amasene, M., & Labayen, I. (2021). Changes in lifestyle behaviours during the COVID-19 confinement in Spanish children: A longitudinal analysis from the MUGI project. Pediatric Obesity, 16(4), Article e12731. https://doi.org/10.1111/ijpo.12731
Mielgo-Conde, I., Seijas-Santos, S., & Grande-de-Prado, M. (2021). Review about online educational guidance during the COVID-19 pandemic. Education Sciences, 11(8), 411. https://doi.org/10.3390/educsci11080411
Miregård, J., Nowicka, P., & Nylander, C. (2023). National data showed an increased prevalence of overweight and obesity among four-year-old Swedish children during the first year of COVID-19. Acta Paediatrica, 112(6), 1269–1274. https://doi.org/10.1111/apa.16707
Oliveira, J. M. D., Butini, L., Pauletto, P., Lehmkuhl, K. M., Stefani, C. M., Bolan, M., Guerra, E., Dick, B., De Luca Canto, G., & Massignan, C. (2022). Mental health effects prevalence in children and adolescents during the COVID-19 pandemic: A systematic review. Worldviews on Evidence-Based Nursing, 19(2), 130–137. https://doi.org/10.1111/wvn.12566
Park, C. (2020). NVivo R1: NVivo release 1: Matters of how to conduct CAQDAS. Global Contents.
Park, J. (2019, August 30). Strategies for reducing health disparities in childhood obesity: messages from community-based participatory research. Paper presented at the 2019 International Congress on Obesity and Metabolic Syndrome & Asia-Oceania Conference on Obesity, Seoul, South Korea.
Park, J., Baek, S., Hwang, G., Park, C., & Hwang, S. (2023). Diet-related disparities and childcare food environments for vulnerable children in South Korea: A mixed-methods study. Nutrients, 15(8), 1940. https://doi.org/10.3390/nu15081940
Park, S., Chung, C., & Kim, G. (2023). Effects of health education using virtual reality for adolescents: A systematic review and meta-analysis. Journal of Korean Academy of Nursing, 53(2), 177–190. https://doi.org/10.4040/jkan.23003
Radesky, J., Chassiakos, Y. L. R., Ameenuddin, N., & Navsaria, D., & Council on Communication and Media. (2020). Digital advertising to children. Pediatrics, 146(1), Article e20201681. https://doi.org/10.1542/peds.2020-1681
Saldana, J. (2009). The coding manual for qualitative researchers. Sage.
Sammut, D., Cook, G., Taylor, J., Harrold, T., Appleton, J., & Bekaert, S. (2022). School nurse perspectives of working with children and young people in the United Kingdom during the COVID-19 pandemic: An online survey study. International Journal of Environmental Research and Public Health, 20(1), 481. https://doi.org/10.3390/ijerph20010481
Schulz, J., & Robinson, L. (2022). Distance learning, digital inequality, and COVID-19: Visualizing learning channels among California public school students. First Monday, 27(4), https://doi.org/10.5210/fm.v27i4.12585
Schwerdtle, P. N., Connell, C. J., Lee, S., Plummer, V., Russo, P. L., Endacott, R., & Kuhn, L. (2020). Nurse expertise: A critical resource in the COVID-19 pandemic response. Annals of Global Health, 86(1), 49. https://doi.org/10.5334/aogh.2898
Solar, O., & Irwin, A. A. (2010). Conceptual framework for action on the social determinants of health. World Health Organization. https://www.who.int/publications/i/item/9789241500852
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Journal of the International Society for Quality in Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042
Torous, J., Jän Myrick, K., Rauseo-Ricupero, N., & Firth, J. (2020). Digital mental health and COVID-19: Using technology today to accelerate the curve on access and quality tomorrow. JMIR Mental Health, 7(3), Article e18848. https://doi.org/10.2196/18848
UNESCO. (2017). Working group on education: Digital skills for life and work. In: Broadband Commission for Sustainable Development. https://unesdoc.unesco.org/ark:/48223/pf0000259013
Vandelanotte, C., Duncan, M. J., Plotnikoff, R. C., Rebar, A., Alley, S., Schoeppe, S., ,To, Q., , Mummery, W. K., & , &Short, C. E. (2022). Impact of a web-based personally tailored physical activity intervention on depression, anxiety, stress and quality of life: Secondary outcomes from a randomized controlled trial. Mental Health and Physical Activity, 23(2), Article 100477. https://doi.org/10.1016/j.mhpa.2022.100477
Yoshikawa, H., Wuermli, A. J., Britto, P. R., Dreyer, B., Leckman, J. F., Lye, S. J., Ponguta, L. A., Richter, L. M., & Stein, A. (2020). Effects of the global coronavirus disease-2019 pandemic on early childhood development: Short- and long-term risks and mitigating program and policy actions. The Journal of Pediatrics, 223, 188–193. https://doi.org/10.1016/j.jpeds.2020.05.020
Zarei, S., & Mohammadi, S. (2022). Challenges of higher education related to e-learning in developing countries during COVID-19 spread: A review of the perspectives of students, instructors, policymakers, and ICT experts. Environmental Science and Pollution Research International, 29(57), 85562–85568. https://doi.org/10.1007/s11356-021-14647-2
Jiyoung Park, PhD, RN, is an associate professor at the College of Nursing, Institute for Health Science Research, Inje University, Busan, South Korea, and a visiting scholar at the Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Gill ten Hoor, PhD, is an assistant professor at the Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands.
Seohyun Won, MSN, RN, is a doctoral student at the College of Nursing, Inje University, Busan, South Korea.
Gahui Hwang, MSN, RN, is a doctoral student at the College of Nursing, Yonsei University, Seoul, South Korea.
Sein Hwang, PhD, is an assistant professor at the Department of Social Welfare, College of Social Science, Inje University, Gimhae-si, South Korea.
Siew Tiang Lau, PhD, MHS, BHS, RN, is an associate professor at the Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
1 College of Nursing, Institute for Health Science Research, Inje University, Busan, South Korea
2 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
3 Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
4 College of Nursing, Inje University, Busan, South Korea
5 College of Nursing, Yonsei University, Seoul, South Korea
6 Department of Social Welfare, College of Social Science, Inje University, Gimhae-si, South Korea
Corresponding Author: Gahui Hwang, MSN, RN, College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, South Korea. Email: hwang_dawn@naver.com
