Abstract
-
Purpose
To describe the process of systematically developing an integrated health promotion program for school-age children from vulnerable families.
-
Methods
In this study, we applied the first three steps—analysis, design, and development (ADD)—of the analysis, design, development, implementation, and evaluation (ADDIE) model. The analysis step involved a literature review and needs assessment. In the design step, program components were considered and a program draft was developed. The program content was modified based on expert validation in the development step. The preliminary program was administered in the implementation step, and the final program was confirmed in the evaluation step.
-
Results
The program contents were based on the literature review, needs assessment, and Ryan’s integrated theory of health behavior change. The content was valid, and the educational material was appropriate for school-age children from vulnerable families. The finalized program consists of six sessions to promote physical, psychological, and social health using individual/group and face-to-face/online methods, including two that involve both parents and children.
-
Conclusion
This study presents a detailed description of how the program was developed and illustrates the critical elements that should be considered during similar program development. The effect of this program on health promotion behavior should be examined in future research.
-
Key words: Child; Health promotion; Nursing methodology research; Program development; Vulnerable populations
INTRODUCTION
School-age is a critical stage in childhood which forms the lifestyles that determine the health status in adulthood [
1]. Since it establishes the foundation for long-term health, monitoring and managing lifestyles and health promotion behaviors in this phase are crucial [
1,
2]. Children from vulnerable families are more likely to face health risks than those from other families [
3]. In Korea, vulnerable families lack socioeconomic and human resources, considering both economic and structural factors [
4,
5]. Economically, these families include recipients of the National Basic Livelihood Security Program (BLSP) and households with incomes ≤50% of the median national income (second-lowest income bracket). Structurally, vulnerable families consist of children from single-parent households, grandparent-headed households, those without parental care, or multicultural families [
4-
6].
Building on previous research, this study defines children from vulnerable families using both economic and structural factors as criteria. Specifically, vulnerable children are identified as those from low-income households (e.g., recipients of BLSP or those in second-lowest income bracket), single-parent families, grandparent-headed families, or multicultural families [
4-
6].
Self-regulation is a key personal factor in inducing health-promoting behaviors and is highly predictive of the behavior [
7,
8]. School age is a crucial period for developing self-regulation [
9]. During this stage, children develop specific inhibitory controls (e.g., behavioral inhibition, cognitive and selective attention) that are components of self-regulation [
9]. Additionally, higher-level cognitive skills such as planning and problem-solving emerge, both of which are closely linked to the development of self-regulation [
7-
9]. Children with low self-regulation often adopt unhealthy lifestyles driven by immediate gratification caused by immature defense mechanisms, emotional dysregulation, and limited judgment. Previous studies have demonstrated that higher levels of self-regulation in children are directly associated with improved health outcomes [
7,
8,
10]. Furthermore, individuals who effectively manage healthy lifestyles during childhood are more likely to sustain good health throughout their lives [
7,
11]. Therefore, enhancing self-regulation skills in school-age children may serve as a cost-effective strategy for reducing the risk of chronic diseases associated with lifestyle choices [
7].
Self-efficacy is closely related to self-regulation; the lower the self-efficacy, the greater the inability to regulate oneself and the tendency to engage in inappropriate behavior [
12]. Even when short-term self-regulation is achieved, children with low self-efficacy are more likely to relapse into self-regulation failure. Therefore, enhancing self-efficacy is essential as a complementary strategy to achieve long-term success in self-regulation [
13]. Social support is a major environmental factor that maintains physical and mental health by regulating the degree of the impact of health crises [
8,
14]. In particular, family plays a crucial role in child health promotion as children acquire several health behaviors within the family environment [
14]. Peers are another significant source of social support; they can encourage positive healthy lifestyle habits but may also reinforce negative health behaviors through social interaction [
7,
8]. Thus, social support from both parents and peers is an essential factor in promoting children’s health behaviors [
8].
Many children from vulnerable families face heightened risk of physical (e.g., obesity due to fast food consumption), psychological (e.g., depression and anxiety), and social (e.g., bullying and lack of social skills) health problems [
3,
8,
14]. These risks stem from limited access to education and healthcare services, inadequate care at home, increased exposure to health risk factors, and a lack of protective factors such as family support [
5,
8]. Park [
8] emphasizes that promoting self-regulation, enhancing self-efficacy, and strengthening social support—including family support and positive peer relationships—are essential for improving the health behaviors of children from vulnerable families. Generally, health problems in one area lead to that in other areas, or gradually spread to other areas [
14,
15]. As a result, children in vulnerable contexts frequently experience physical, psychological, and social problems simultaneously [
14]. Addressing these interconnected health issues requires an integrated approach that considers their interrelations rather than isolating specific factors or areas [
4,
14]. However, most existing studies have developed interventions targeting physical, psychological, and social health separately [
16-
20].
Moreover, all existing health promotion programs focus on the intervention effects, and studies that systematically present the process of program development are scarce [
16-
20]. To address this gap, we present a detailed methodological description of the development of an integrated health promotion program using the first three steps—analysis, design, and development (ADD)—of the analysis, design, development, implementation, and evaluation (ADDIE) model [
21]. This model is a systematic and linear process represented by interacting steps in instructional design [
21]. It is one of the most commonly used instructional design methods that guides the development of programs in various disciplines. The systematic and elaborate description of the process of developing a health promotion program for children from vulnerable families may help healthcare professionals develop and apply customized health promotion programs based on various community environments.
The conceptual framework of this study was based on the integrated theory of the health-behavior change (ITHBC) developed by Ryan [
21]. It aims to maintain and improve people’s health status by changing their behavior. According to the ITHBC, health behavior changes can be enhanced by fostering knowledge and beliefs, increasing self-regulation skills and abilities, and enhancing social facilitation.
Knowledge and beliefs form the first construct. Knowledge is defined as condition-specific factual information and beliefs are personal perceptions about a specific health condition or behavior [
21]. This construct comprises behavior-specific knowledge, self-efficacy, outcome expectancy, and goal congruence [
21]. The second construct describes self-regulation skills and abilities. It encompasses goal setting, self-monitoring and reflective thinking, decision-making, planning for and engaging in specific behaviors, self-evaluation, and managing physical, emotional, and cognitive responses associated with health behavior change [
21]. The third construct, social facilitation, involves social support and active collaboration among individuals and families to promote health outcomes [
21].
Outcomes in this theory are categorized as proximal and distal. The proximal outcome is actual engagement in self-management behaviors specific to a condition or health behavior [
21]. Distal outcomes refer to the long-term effects of individual behavior on health status, with failure to engage in healthy behaviors potentially leading to the premature onset of diseases [
21]. Distal outcomes are partially dependent on the successful achievement of proximal outcomes [
21]. This study assumed that information on health promotion, self-efficacy in performing health-promoting behaviors, participation with parents and peers, and social support improve self-regulation of health-promoting behaviors, leading to participation in an integrated health promotion program and health promotion behavior. The relationships among the constructs, concepts, and variables according to the ITHBC model are shown in
Figure 1. An integrated health promotion program is an intervention designed to promote physical, psychological, and social health based on the holistic view that humans are biologically, mentally, and socially interconnected [
22]. In this study, the program is developed following the definition by Jung and Chin [
22] and incorporates key elements of the ITHBC [
21], including health knowledge, self-efficacy, social support, and self-regulation. Therefore, this study aimed to describe the process of systematically developing an integrated health promotion program for school-age children from vulnerable families.
METHODS
Ethical statements: This study was approved by the Institutional Review Board (IRB) of the Yonsei University Health System (IRB no., 4-2022-0484). Informed consent was obtained from all participants.
1. Study Design
A methodological study design was used to develop an integrated health promotion program for school-age children from vulnerable families. The reporting of this study was based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [
23].
The program was developed using the first three steps—analysis, design, and development—of the ADDIE model.
1) Step 1: analysis
(1) Literature review: health promotion interventions for children from vulnerable families
To develop the program, interventions to improve health promoting behaviors in school-age children from vulnerable families were evaluated. Relevant studies published in English or Korean in peer-reviewed journals between January 2012 and August 2022 were reviewed. A search of databases including PubMed, Web of Science, CINAHL, PsycINFO, and RISS databases was conducted using a combination of medical subject headings (MeSH) and keywords (
Supplement 1). The inclusion criteria for the selected articles were as follows: (1) studies with elementary school children aged 6–12 years from low-income households, single-parent families, grandparent-headed families, or multicultural families (including minority backgrounds); (2) implemented health promotion interventions; and (3) reported health-related outcomes. Eleven studies were selected based on the criteria. We have followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for the literature review. A flowchart of the selection process is shown in (
Supplement 2).
(2) Focus group interviews: needs assessment
To determine the content inclusion criteria, focus group interviews (FGIs) were conducted by a doctoral researcher with nearly 10 years of clinical experience in child health nursing to identify the health promotion needs of children. Dream Start, a representative institution that cares for vulnerable families, was considered by the researchers as a source of participants for the FGIs (e.g., BLSP recipients, second-lowest income bracket, and single parent). The participants were selected with the cooperation of five Dream Start centers in Seoul. Convenience sampling, in which the manager of the institution introduced the participants, was used to recruit participants. Three FGIs were conducted with elementary school children (grades 5–6) from vulnerable families, their mothers, and Dream Start case managers who directly managed the health and welfare of the vulnerable families. The FGIs were conducted between July 25 and August 5, 2022, with participants divided into three groups: children, parents, and Dream Start managers. Six children, five mothers (one mother refused to attend the FGI and withdrew participation), and five Dream Start managers (a total of 16 participants) participated in the FGIs via Zoom (Zoom Video Communications) because of the coronavirus disease 2019 (COVID-19) pandemic-related restrictions. Key interview questions used with the children are described. For parents and Dream Start managers, the same questions were used with slight modifications to the wording, referring to “your children” or “the children you care for” instead of “you.” (1) Have you ever experienced any health-related problems or difficulties? If yes, what kind of health-related problems or difficulties have you experienced? (2) What factors (both positive and negative) affect your health promotion efforts? (3) What kind of content should be included in health promotion education? (4) If you were to receive health promotion education, which method would you prefer: face-to-face or online?
2) Step 2: design
During the design step, a program draft was created based on the results of the previous steps. The number of sessions, components, and activities of the program were determined following the literature review and needs assessment.
3) Step 3: development
Six experts evaluated the content validity of the program using a content validity index (CVI). The expert group consisted of three child health nursing professors (PhDs), one social welfare professor (PhD) and two case managers (social workers with Master of Social Work degree) from Dream Start. Content validation was conducted from September 5 to 12, 2022. Between September 7 and 8, 2022, a preliminary review of the draft program was conducted at Dream Start with two managers and two fifth-grade elementary school students. Feedback was collected regarding difficult vocabulary and content that might be challenging for children to understand or implement in practice.
RESULTS
1. Analysis
1) Literature review: health promotion interventions for children from vulnerable families
All 11 selected studies included children from low-income families, one study included families with single-parent, and one included families belonging to minority communities [
3,
16-
20,
24-
28]. The intervention period ranged from 5–12 weeks, with each session lasting for 30–120 minutes. Seven studies (64%) included interventions designed to improve physical health, 3 (27%) to improve mental and social health, and 1 (9%) to promote physical, psychological, and social health. Various delivery methods were used, including face-to-face instructions, group activities, newsletters, and telephone counseling. To maintain children’s interests, mixed-mode interventions were delivered, such as group play and education, group activities, and counseling, rather than a single-mode ones. The details are provided in
Supplement 3.
Based on the literature review, the following intervention strategies were identified. First, in most interventions, education was provided for each subject and various activities such as cognitive behavioral therapy, play activities, peer activities, meditation, and gymnastics were conducted [
3,
16,
18,
20,
25,
28]. To deliver the intervention in a way that is easy to understand and arouses interest, considering the nature of children, a mixture of multiple approaches was used. As such, the interventions were established to include activities that would stimulate children’s interest and participation along with the necessary health education content.
Second, all studies were group interventions in which peers participated, but in some (18%), individual counseling was provided with group intervention to confirm the effectiveness of the intervention on health promotion [
3,
17]. Therefore, counseling for a child’s health promotion, along with education and activities for common health improvement, was selected as an intervention strategy.
Third, in four studies (36%), parents participated in interventions to improve the health of their children [
3,
17,
20,
27]. Considering that parents are an important source of social support for children and that children from relatively vulnerable families have fewer opportunities to interact with their parents, interventions involving parents were selected as a strategy [
29].
Finally, none of the 11 studies was theory-based. To generate high-quality evidence for the development of future programs, it was necessary to develop theory-based interventions and evaluate its effectiveness [
5].
2) Focus group interviews: needs assessment
In the children’s group, the average age was 11.83±0.41 years, and there were four male (66.7%) and two female students (33.3%). All 6 (100%) were eligible for basic livelihood support; 3 (50%) were from single-parent families. The participating mothers’ average age was 42.80±11.83 years. All belonged to families eligible for BLSP and 3 (60.0%) were single parents. The average age of the five case managers was 49.00±7.14 years. From the four main questions on the FGIs, 10 categories and 20 subcategories were identified (
Table 1).
(1) Key question 1: Health-related problems: physical, psychological, and social health problems
Children from vulnerable families often experienced complex health problems. The most common physical health problems in children were overweight and slow growth. In particular, issues emerged due to the consumption of instant food, which causes inadequate nutrient intake, and a lack of physical activity. Additionally, they were exposed to sensational content and secondary sexual characteristics and expressed concern about the difficulty in forming correct sexual values. Their psychological health problems were typically associated with excessive use of smartphone and games. They had a high level of stress as a result of schoolwork and peer relationships, and their psychological health problems worsened because of low self-esteem. Health problems associated with social problems appear as difficulties in peer relationships, with bullying at school being a prominent example. As a result of bullying, many children had difficulty forming interpersonal relationships and were passive in participating in school and after-school activities.
(2) Key question 2: Factors affecting health problems: facilitators and barriers
The health promotion behaviors of school-age children from vulnerable families were heavily influenced by their parents, who were their main support system. When parents were indifferent to their children’s health problems, the children experienced various issues because of inadequate formation of healthy habits. Most children mentioned that they did not have an adult to inform them about health-promoting behaviors or that they did not have a chance to consider their health.
(3) Key question 3: Contents for health promotion program: physical, psychological, and social health promotion and interesting components
As children from vulnerable families experience physical, psychological, and social health problems, the program’s demand for integrated healthcare was confirmed. The demands of the physical health promotion program were nutrition education along with cooking classes, sex education reflecting the modern era, such as addressing dating, and education to practice rejecting situations in which peers encouraged smoking and drinking. In psychological health promotion program, an educational program was needed to enhance self-esteem and the ability to discriminate between smartphone content. To promote social health, it was essential to develop positive relationships with peers through group activities. It was found that the health promotion program for school-age children from vulnerable families requires interesting educational content, such as child-friendly educational plans, positive feedback, and parent-involved content to promote children’s participation and positive outcomes. To achieve this, easy terms and familiar characters should be used in the education plan. The need for tailored interventions based on each child’s health status and habits was also identified. In addition, FGI participants recommended that their parents and peers participate together in preventing dropout by providing positive messages or appropriate rewards.
(4) Key question 4: Education methods: interactive face-to-face
Face-to-face delivery of interventions was more effective and interesting for children than online delivery. Most FGI participants were concerned about communication difficulties in online programs. A face-to-face program is required to achieve communication between researchers and children and positive health promotion results.
In summary, the FGIs revealed that school-aged children from vulnerable families experienced various physical, psychological, and social difficulties. In addition, parents’ health-related caring behavior for the child, stigma, and lack of opportunity to acquire health behaviors were factors influencing children’s health promotion behavior. Accordingly, the demand for an integrated health promotion program to improve children’s physical, mental, and social health was confirmed. Thus, parental and peer participation and positive feedback were found to be necessary intervention strategies.
2. Design
Based on the ITHBC, literature review, and needs assessment, the components of the program were organized in the design step (
Table 2). A program draft was created based on the findings of the previous steps (
Supplement 4). A literature review of interventions to improve children’s health revealed an implementation period of over 6 weeks. Moreover, the duration of children’s group programs should not exceed 8 weeks because they may not be able to complete a lengthy program [
30]. Therefore, the intervention in this study was planned for six sessions (6 weeks). Most studies in the literature review utilized group education; however, needs assessments suggested that individual interventions should be included based on each child’s health status. Therefore, a mix of group and individual education program was developed.
To promote “knowledge and self-efficacy,” the first construct of the ITHBC, a group education was planned to provide knowledge about physical, psychological, and social health (i.e., healthy eating habits and physical activity, sexual health, safety education, alcohol and smoking prevention, smartphone use control, and psychological health). To emphasize self-efficacy, the educational content included the definition of self-efficacy, methods for enhancing it, and the delivery of positive messages about health-promoting behaviors. The program also incorporated components to help children set health goals that they could independently achieve (ITHBC facilitators: goal congruence) and counseling sessions to discuss the expected health outcomes (ITHBC facilitators: outcome expectancy).
Individual interventions aimed to establish and evaluation health promotion goals based on each child’s health status to promote “self-regulation.” Children are to independently monitor their progress toward the individual health-promotion goals they have set (ITHBC facilitators: goal setting, self-monitoring and reflection, and self-evaluation), evaluate their achievements, and openly share their emotions and experiences during individual counseling sessions. Following the literature review and needs assessment that highlighted the importance of involving parents and peers in the program to foster “social support,” the program was designed to include interactive face-to-face peer group activities and family counseling sessions (ITHBC facilitator: social support). Furthermore, the program was designed to provide rewards (e.g., gift vouchers) to children for homework thereby promoting common physical activities. Although the preference for the face-to-face program was confirmed in the needs assessment, family counseling was conducted online to increase parental participation in the program.
3. Development
The item (I)–CVI was included in the program content through lesson plans and session-specific workbooks. The overall CVI was .97 and the I-CVI ranged from .83–1.00, which was considered valid [
31]. Several aspects of the program were revised and supplemented with feedback from the experts. Nutrition education was expanded to include information on junk food and methods for checking food nutrients. Second, coping methods were included in sexual health education when recommending pornography and online grooming. Third, there was an opinion that children should have the opportunity to fully share their experiences during each program session. Accordingly, in sessions 2–4, children were given 5–10 minutes or more to express their feelings regarding the intervention.
A preliminary review of the draft program found that the content of each session was appropriate. Reviewers noted that the program was easy to understand and engaging given its use of various visual materials.
However, they highlighted that some words, such as “promotion,” are difficult for fifth graders to understand. There was a comment about the 4-minute duration of the video on how to refuse smoking and drinking. The video was replaced with an another lasting approximately 2 minutes. In the fifth session, it was suggested that it would be helpful to have time to discuss and resolve concerns. Accordingly, a concern pocket was created to allow children to express their concerns anonymously in each session. In the fifth session, written concerns were incorporated into board game-style worry-counseling activities.
The final program was named Integrated HEalth pRomotion (I-HERO) (
Table 3, Supplement 5). The program consisted of six sessions of 40–60 minutes each, once a week, combining individual and group interventions. The program involved online intervention for the first and sixth sessions for children and parents of each family and face-to-face group intervention with peers from the second to fifth sessions. The first session provides an overview. In this session, the researcher, child, and parent discuss the child’s typical healthy habits, as well as those that require more effort. From these discussions, health promotion goals are established for each child. Next, the researcher sends a positive text message to the children and parents, specifying the goals that were set.
The second session focuses on physical activities and a healthy diet. To encourage physical activity for at least 30 minutes, 3 times per week, a free health app (Samsung Health, Samsung) is used to record physical activity time and homework steps. KakaoTalk group chat room (Kakao Corp.) is used to verify the time and degree of physical activity shared by participants in each group via the Together mission of the health app. Participants would also be able to communicate directly with the researcher through KakaoTalk. A group activity in this session involves creating healthy salads to increase fruit and vegetable consumption.
The third session is about sexual health education. Children could share their puberty experiences with each other. During the third session, children make warning signs of sexual violence, explain them to peers, and vote on them. The I-HERO awards are announced at the end of the session based on the results of the physical activity completed as homework from this session to the fifth.
Topics for the fourth session include safety accidents and smoking and drinking. Situational play is used to practice refusal when peers encourage smoking or drinking. A group activity allows participants to share their impressions after playing games such as walking along footprints while wearing drinking glasses.
The fifth session focuses on enhancing self-esteem, controlling emotions, and preventing media overdependence. Through meditation and stretching, children learn how to control their emotions, manage stress, and express their emotions effectively using I-message. Board games are used to discuss solutions to anonymously-submitted concerns. In this session, children write commendations on rolling paper for their peers.
The sixth session is conducted in the same manner as the first session. Health promotion goals outlined in the first session are discussed and evaluated by parents, children, and researchers. Children freely discuss their efforts to attain their health promotion goals, and parents discuss their efforts to ensure that their children maintain their health promotion goals.
DISCUSSION
Improving the effectiveness of health-promotion interventions requires logical and systematic development. This study systematically developed interventions following the ADD of the ADDIE model. To develop an integrated health promotion program for children from vulnerable families, this study adopted a holistic perspective, integrating the physical, psychological, and social dimensions of health promotion as proposed by Jung and Chin [
22]. Additionally, we applied the ITHBC model by Ryan [
21], highlighting that integrated health promotion—encompassing health knowledge, self-efficacy, and social support—enhances self-regulatory skills, in turn leading to health-promoting behaviors.
A literature review of health-promotion interventions for children from vulnerable families revealed that none of the studies applied a theoretical framework. A theoretical framework assists in developing hypotheses, identifying exogenous variables that may influence the effectiveness of experimental interventions, and facilitating the discussion of research findings [
32,
33]. The present study was based on the ITHBC model by Ryan [
21], program’s purpose, variables, and principal components were designed to reduce the gap between theory and practice through theoretical validation. To improve the health of children of vulnerable families, it is necessary to continuously verify and expand theories through development and application of theory-based interventions [
8].
Many children from vulnerable families struggle with multiple physical, psychological, and social health problems [
3,
5,
25,
27]. Nevertheless, existing studies have typically provided interventions for fragmentary health promotion, which may not solve complex and multidimensional health problems [
16,
17,
20]. Considering that the proposed program is an integrated health education program tailored to the characteristics of children’s health problems, it is expected to effectively address the complex and multidimensional nature of children’s health problems.
The duration and number of group intervention sessions for children must be carefully considered to ensure they are interested and can concentrate. Participation in a lengthy session may be challenging for children. Although short-term interventions may have high participation rates, their effectiveness may be difficult to determine. Therefore, studies have recommended group interventions lasting 6–8 weeks and 40–60 minutes per session for children [
30,
34]. The present study designed a 6-week integrated health promotion program, with sessions lasting approximately 40 minutes and breaks of more than 10 minutes between sessions. Research has noted the advantage of allowing participants to share their common concerns if they have an unusual experience with a group intervention [
35].
Individual interventions can also effectively reinforce children’s positive beliefs and elicit their emotions [
36]. A combination of individual family and group interventions was used in this study. According to the children participating in our study, both the program with peers and the time to discuss their health individually were beneficial. Providing face-to-face interventions to children increases their psychological stability and concentration through interaction with the provider [
37]. However, in situations such as the COVID-19 pandemic, online interventions are recommended for flexibility in terms of time and place and to increase research participation [
38]. The present study used a blended method of an online intervention in which children and parents participated together as families and a face-to-face one in which children received group education. Previous studies have demonstrated high satisfaction with education when both children and parents are involved using a blended intervention delivery method [
38]. Consequently, blended intervention delivery in education involving both parents and children can serve as a critical operational strategy to maximize intervention effectiveness and engagement [
38,
39].
This methodological study has some limitations. First, although this study described the program development process following the ADD steps of the ADDIE model, a systematic intervention development framework, we could not evaluate its effectiveness. Therefore, follow-up studies are needed to evaluate the effectiveness of this program.
Second, the program development process was relatively straightforward and could not consider complex issues or multiple variables. This may limit the program’s applicability and flexibility. Future study should design a program development that considers various variables and complex problems, thereby increasing the program's applicability and flexibility. This may enhance the practicality and generalizability of the program.
Third, this study primarily focused on children in the upper grades of elementary school, who came from vulnerable families. Although self-regulation abilities develop mainly during elementary school years, there are differences in how lower and upper grade elementary students understand health promotion. Therefore, future research should develop health promotion programs that are centered on self-regulation and tailored to children in the lower grades of elementary school, who come from vulnerable families.
Finally, this study developed an integrated health promotion program based on the ITHBC. While this theory has been applied to interventions promoting physical activity, weight management in children, and health behaviors in children with illnesses, it was not specifically designed for children from vulnerable families. Therefore, applying ITHBC to this population may be considered a limitation. Future research should aim to develop and validate theoretical frameworks specifically tailored to the health promotion needs of children from vulnerable backgrounds.
This study has significant implications for practice. The program developed in this research was created by experts in child healthcare, providing participants with practical advantages in terms of information and resources for addressing and managing children’s health issues. Moreover, these programs can be regularly taught and disseminated to healthcare professionals involved in children’s health at community institutions. A key strength of this study is its systematic approach to developing a health promotion program specifically designed for children from vulnerable families, distinguishing it from existing programs for school-aged children. By providing foundational data for health-related interventions tailored to this population, this study offers valuable insights with significant practical implications.
CONCLUSION
This study was conducted to develop an integrated health promotion program for school-age children from vulnerable families using the ADD steps of the ADDIE model. The literature review, needs assessment, and ITHBC were followed to develop the content of the program. The content of the program was valid, and the educational material was appropriate for school-age children from vulnerable families. The detailed description of the development process of the program illustrates the critical elements that should be considered in program development and implementation.
ARTICLE INFORMATION
Supplementary material
Supplement 2.
Data search using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram. RCT, randomized controlled trial.
Supplement 3.
Literature review: components and outcomes of the implemented health promotion program for children from vulnerable families.
Figure 1.Conceptual framework of this study.
Table 1.Results of the focus group interview
|
Domain |
Category |
Sub-category |
|
Health-related problems or difficulties |
Physical |
• Overweight and growth delays |
|
• Secondary sexual characteristics and sexual video exposure |
|
Psychological |
• Low self-esteem |
|
• Smartphone, game, and internet overdependence |
|
Social |
• Difficulty with peer relationships and bullying |
|
Factors affecting health promotion |
Parental health-related care |
• Parents’ willingness to care for their children's health |
|
• Communication between parents and children |
|
Environment for health-promoting behavior |
• Lack of opportunities to acquire health promotion behaviors |
|
Contents for the health promotion program |
Physical |
• Nutrition education with cooking |
|
• Sex education reflecting the modern era |
|
• Smoking and alcohol prevention education, including coping strategies |
|
• Easy-to-understand safety education |
|
Psychological |
• Compliments to improve self-esteem |
|
• Self-regulation on smartphone use |
|
Social |
• Group activities to promote peer relationships |
|
Interesting components of the program |
• Child-friendly educational content |
|
• Programs involving parents and peers |
|
• Positive messages and rewards to motivate health promotion |
|
• Individual and tailored health promotion intervention |
|
Preferred methods of education: face-to-face or online |
Interactive face-to-face program |
• The preference for face-to-face interventions which allow researchers and children to interact |
Table 2.Components of the integrated health promotion program based on theory, literature review, and needs assessment
|
Theoretical construct |
Facilitators of theorical construct |
Components based on the literature review |
Components based on the needs assessment |
|
Knowledge and self-efficacy |
• Condition-specific knowledge |
• Providing education on health promotion behavior (group education) |
• Providing education on health promotion behavior (face-to face) |
|
• Personal perception |
- Organizing education to promotes the interest and participation of children |
- Nutrition education with cooking |
|
- Self-efficacy |
• Motivation for health promotion |
- Sex education reflecting the times |
|
- Outcome expectancy |
- Individual counselling for health promotion behavior |
- Smoking and alcohol prevention including coping strategies |
|
- Goal congruence |
• Theory-based program |
- Easy to understand safety education |
|
|
- Self-regulation of smartphone use |
|
|
• Compliments to improve self-esteem |
|
|
• Positive messages and rewards to motivate health promotion |
|
Self-regulation |
• Goal setting |
- |
• Individualized and tailored health promotion intervention; setting, monitoring, and evaluating individual health promotion goals. |
|
• Self-monitoring and reflection |
|
• Planning and plan enactment |
|
• Self-evaluation |
|
Social support |
• Influence support |
• Providing support by involving parents in the program |
• Programs involving parents and peers |
|
• Group activities to promote peer relationship |
|
• Interactive face-to-face program |
REFERENCES
- 1. Hockenberry MJ, Wilson D, Rentfro AR, McCampbell LS. Study guide for Wong’s nursing care of infants and children. Elsevier Health Sciences; 2014.
- 2. Seo J, Kim G. [Influence of physical symptoms and lifestyle on suicidal ideation of senior grade students in elementary school]. Child Health Nurs Res. 2019;25(2):175-183. https://doi.org/10.4094/chnr.2019.25.2.175
- 3. Park N, Im M. Effectiveness of a combined obesity prevention program in South Korea for children from low-income families that included primary caregiver participation. Child Health Nurs Res. 2021;27(3):211-224. https://doi.org/10.4094/chnr.2021.27.3.211
- 4. Kim S, Choo J. Health behaviors and health-related quality of life among vulnerable children in a community. J Korean Acad Community Health Nurs. 2015;26(3):292-302. https://doi.org/10.12799/jkachn.2015.26.3.292
- 5. Park J, Baek S, Im M. Trends in health-related interventions on children attending community child care centers in South Korea. Child Health Nurs Res. 2018;24(2):241-251. https://doi.org/10.4094/chnr.2018.24.2.241
- 6. Lee H, Park Y, Yoo S, Jeong S, Ko J. Panel survey on children & youths in socially disadvantaged families and welfare facilities III: focusing on the Community Child Centers, after-school-academies and residential care facilities. National Youth Policy Institute; 2012.
- 7. Baker S, Morawska A, Mitchell A. Promoting children's healthy habits through self-regulation via parenting. Clin Child Fam Psychol Rev. 2019;22(1):52-62. https://doi.org/10.1007/s10567-019-00280-6
- 8. Park J. Predictors of health-promoting behaviors in children from low-income families: an ecological approach. Nurs Health Sci. 2018;20:60-68. https://doi.org/10.1111/nhs.12388
- 9. Choe DB, Kim KS. The development and validation of self-regulation scale for elementary school students. Korean J Elem Educ. 2015;26(4):59-81. https://doi.org/10.20972/kjee.26.4.201512.59
- 10. Bub KL, Robinson LE, Curtis DS. Longitudinal associations between self-regulation and health across childhood and adolescence. Health Psychol. 2016;35(11):1235-1245. https://doi.org/10.1037/hea0000401
- 11. Robson DA, Allen MS, Howard SJ. Self-regulation in childhood as a predictor of future outcomes: a meta-analytic review. Psychol Bull. 2020;146(4):324-354. https://doi.org/10.1037/bul0000227
- 12. Graham JD, Bray SR. Self-control strength depletion reduces self-efficacy and impairs exercise performance. J Sport Exerc Psychol. 2015;37(5):477-488. https://doi.org/10.1123/jsep.2015-0064
- 13. Yang SY, Kim HS. Effects of a prevention program for internet addiction among middle school students in South Korea. Public Health Nurs. 2018;35(3):246-255. https://doi.org/10.1111/phn.12394
- 14. Kang K, Kim S. Health problems and related factors of socially vulnerable school-age children in Seoul. J Korean Soc Sch Health. 2017;30(3):181-193. https://doi.org/10.15434/kssh.2017.30.3.181
- 15. Jarpe-Ratner E, Folkens S, Sharma S, Daro D, Edens NK. An experiential cooking and nutrition education program increases cooking self-efficacy and vegetable consumption in children in grades 3-8. J Nutr Educ Behav. 2016;48(10):697-705. https://doi.org/10.1016/j.jneb.2016.07.021
- 16. Jung IK, Kim JH, Woo SH. Verifying effectiveness on physical activity and nutrition program for obesity management of children from low income family. Korea J Sports Sci. 2019;28(3):547-557. https://doi.org/10.35159/kjss.2019.06.28.3.547
- 17. Wright K, Giger JN, Norris K, Suro Z. Impact of a nurse-directed, coordinated school health program to enhance physical activity behaviors and reduce body mass index among minority children: a parallel-group, randomized control trial. Int J Nurs Stud. 2013;50(6):727-737. https://doi.org/10.1016/j.ijnurstu.2012.09.004
- 18. Brusseau TA, Hannon J, Burns R. The effect of a comprehensive school physical activity program on physical activity and health-related fitness in children from low-income families. J Phys Act Health. 2016;13(8):888-894. https://doi.org/10.1123/jpah.2016-0028
- 19. Byun EK, Chang KO. The effects of oriental medicine qi gong program on the anxiety and self efficacy among children using community child center. J Korea Acad Ind Coop Soc. 2014;15(3):1623-1631. https://doi.org/10.5762/KAIS.2014.15.3.1623
- 20. Chen JL, Kwan M, Liu K, Yu F. The feasibility and efficacy of healthy weight management program for low income Chinese American overweight and obese children in a primary care clinic. J Pediatr Nurs. 2015;30(6):821-828. https://doi.org/10.1016/j.pedn.2015.01.026
- 21. Ryan P. Integrated theory of health behavior change: background and intervention development. Clin Nurse Spec. 2009;23(3):161-170. https://doi.org/10.1097/NUR.0b013e3181a42373
- 22. Jung GH, Chin YR. The effects of an integrated health care program on the physical, psychosocial, and spiritual health of people with mental disorder in community. J Korean Acad Community Health Nurs. 2015;26(2):69-78. https://doi.org/10.12799/jkachn.2015.26.2.69
- 23. Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Epidemiology. 2007;18(6):805-835. https://doi.org/10.1097/EDE.0b013e3181577511
- 24. Bang KS, Kim S, Song MK, Kang KI, Jeong Y. The effects of a health promotion program using urban forests and nursing student mentors on the perceived and psychological health of elementary school children in vulnerable populations. Int J Environ Res Public Health. 2018;15(9):1977. https://doi.org/10.3390/ijerph15091977
- 25. Jeon Y, Rho D. A study on the effect of psychoanalytic group art therapy on the promotion of self-esteem of children of community childcare centers. J Reg Stud. 2018;26(2):119-138. https://doi.org/10.22921/jrs.2018.26.2.007
- 26. Jung JH, Jin BH, Lee JN, Yu JY. Oral health promotion program application and effect for underprivileged lower grade students. J Korean Soc Sch Community Health Educ. 2015;16(3):41-50.
- 27. Overcash F, Ritter A, Mann T, Mykerezi E, Redden J, Rendahl A, et al. Impacts of a vegetable cooking skills program among low-income parents and children. J Nutr Educ Behav. 2018;50(8):795-802. https://doi.org/10.1016/j.jneb.2017.10.016
- 28. Kim SM, Kim JN. The effects of the cognitive-behavioral therapy on depression, automatic thought, and peer relationship for low-income group children and adolescents. Korean J Youth Stud. 2016;23(1):181-208. https://doi.org/10.21509/KJYS.2016.01.23.1.181
- 29. Kim SY, Kim Y. A study on the health inequality in childhood: the moderating effects of social support between the social economic level and health problems. Res Cent Korea Youth Cult. 2017;(50):7-30. https://doi.org/10.17854/ffyc.2017.04.50.7
- 30. Kang JR. Group counselling in practice [Internet]. Hakjisa; 2019 [cited 2025 Mar 20]. Available from: https://www.hakjisa.co.kr/mobile/subpage.html?page=book_book_info&bidx=4237
- 31. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable indicator of content validity?: appraisal and recommendations. Res Nurs Health. 2007;30(4):459-467. https://doi.org/10.1002/nur.20199
- 32. Rycroft-Malone J. Theory and knowledge translation: setting some coordinates. Nurs Res. 2007;56(4 Suppl):S78-S85. https://doi.org/10.1097/01.NNR.0000280631.48407.9b
- 33. Wallin L. Knowledge translation and implementation research in nursing. Int J Nurs Stud. 2009;46(4):576-587. https://doi.org/10.1016/j.ijnurstu.2008.05.006
- 34. Kim HS, Yang JH. A meta-analysis of effects of smartphone addiction prevention program for adolescents. Soc Sci Res Rev. 2016;32(1):259-281. https://doi.org/10.18859/ssrr.2016.02.32.1.259
- 35. Manne S, Mee L, Bartell A, Sands S, Kashy DA. A randomized clinical trial of a parent-focused social-cognitive processing intervention for caregivers of children undergoing hematopoetic stem cell transplantation. J Consult Clin Psychol. 2016;84(5):389-401. https://doi.org/10.1037/ccp0000087
- 36. Shekarabi-Ahari G, Younesi J, Borjali A, Ansari-Damavandi S. The effectiveness of group hope therapy on hope and depression of mothers with children suffering from cancer in Tehran. Iran J Cancer Prev. 2012;5(4):183-188.
- 37. Jones MK, Dickter B, Beard C, Perales R, Bunge EL. Meta-analysis on cognitive-behavioral treatment and behavioral intervention technologies for anxious youth: more than a BIT effective. Contemp Behav Health Care. 2016;2(1):1-9. https://doi.org/10.15761/CBHC.1000115
- 38. Wickberg F, Lenhard F, Aspvall K, Serlachius E, Andrén P, Johansson F, et al. Feasibility of internet-delivered cognitive-behavior therapy for obsessive-compulsive disorder in youth with autism spectrum disorder: a clinical benchmark study. Internet Interv. 2022;28:100520. https://doi.org/10.1016/j.invent.2022.100520
- 39. Lochman JE, Boxmeyer CL, Jones S, Qu L, Ewoldsen D, Nelson WM. 3rd. Testing the feasibility of a briefer school-based preventive intervention with aggressive children: a hybrid intervention with face-to-face and internet components. J Sch Psychol. 2017;62:33-50. https://doi.org/10.1016/j.jsp.2017.03.010
: online counseling for each family involving parents; 
: face-to-face group education and activity with peers; 
: recording physical activity (step count, activity time) with the free health app (Samsung Health); 
: certifying physical activity through the KakaoTalk group chat (Kakao Corp.). I-HERO, Integrated HEalth pROmotion.
