healthcare

Article
Effects of School-Based Exercise Program on Obesity and
Physical Fitness of Urban Youth: A Quasi-Experiment
Ji Hwan Song 1,† , Ho Hyun Song 2,† and Sukwon Kim 3, *

1 Department of Physical Education, Jeonju National University of Education, Jeonju-si 55101, Korea;
[email protected]
2 Ho-Sung Middle School, Jeollabukdo Office of Education, Jeonju-si 54817, Korea; [email protected]
3 Department of Physical Education, Jeonbuk National University, Jeonju-si 54896, Korea
* Correspondence: [email protected]; Tel.: +82-63-270-2860; Fax: +82-63-270-2850
† The first two authors (Ji Hwan Song and Ho Hyun Song) contributed equally to this work.

Abstract: (1) Purpose: The purpose of this study was to evaluate if an after-school intervention
program could prevent obesity and promote the physical fitness of urban sedentary school children.
(2) Methods: A 16-week after-school physical fitness program was provided to 36 middle school
students (7th, 8th, and 9th graders) recruited from a middle school for three days a week. They
were high-risk youth showing poor health status (level 4 or 5) in the regular physical fitness evalu-
ation conducted. Their body mass index (BMI), cardiovascular endurance, muscular strength and
endurance, quickness, and flexibility were evaluated. (3) Results: A paired sample t-test was used
(α = 0.05). There were statistical differences ((x ± s), p < 0.05) between the pre-Progressive Aerobic
Cardiovascular Endurance Run (PACER) (13.36 ± 4.98 (# of laps)) and post-PACER (18.64 ± 6.31





 (# of laps)) (p < 0.001), between the pre-sit-up (18.06 ± 7.22 (# of sit-ups)) and post-sit-up (24.89 ± 7.52
(# of sit-ups)) (p < 0.001), and between the pre-Trunk Flexion (2.64 ± 3.49 ((cm))) and post-Trunk
Citation: Song, J.H.; Song, H.H.;
Flexion (5.97 ± 2.78 ((cm)) (p < 0.001). There was no statistical difference between the pre-50m-Run
Kim, S. Effects of School-Based
(10.74 ± 1.30 ((sec))) and post-50m-Run results (10.69 ± 1.25 (sec)) (p = 0.063) or between the pre-BMI
Exercise Program on Obesity and
Physical Fitness of Urban Youth: A
(24.84 ± 3.97 (kg/m2 )) and post-BMI (24.76 ± 3.61 (kg/m2 )) (p = 0.458). Overall, the physical fitness
Quasi-Experiment. Healthcare 2021, 9, measures improved, whereas BMI did not change after 16 weeks. (4) Conclusion: Sixteen weeks
358. https://doi.org/10.3390/ of the school-based Health-related Physical Fitness (HrPF) program can be effective in improving
healthcare9030358 overall physical fitness levels of adolescents, although additional treatments would be required to
change BMI, which showed no improvement in the present study. It is concluded that in order for
Academic Editor: adolescents to maintain and promote physical fitness and health, participation in a school-based
Cristina Lidón-Moyano HrPF program is recommended for at least 30 min a day, three days a week. In addition, schools
should provide high-risk youth with easy access to physical activities that are similar to the objectives
Received: 9 February 2021
of the physical education curriculum. In order to promote the health of school-age children, each
Accepted: 18 March 2021
school should establish and operate school-based systematic intervention programs.
Published: 22 March 2021

Keywords: Physical Activity Promotion System; physical fitness; BMI; adolescents; school health
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iations.
1. Introduction
Regular participation in physical activity (PA) has numerous physical benefits in
adolescents, promoting bone and muscle growth, helping maintain proper weight and
Copyright: © 2021 by the authors.
body composition, and contributing to disease prevention such as high blood pressure,
Licensee MDPI, Basel, Switzerland.
diabetes, and obesity [1–3]. It also has mental health benefits, as it activates various
This article is an open access article
areas of the brain, promotes self-efficacy, and improves resilience against, among other
distributed under the terms and things, stress, anxiety, and depression. [4,5]. Adolescents who maintain an appropriate
conditions of the Creative Commons level of physical activity increase their likelihood of remaining active into adulthood [6–9].
Attribution (CC BY) license (https:// On the other hand, inactivity may lead to the development of chronic diseases such as
creativecommons.org/licenses/by/ high blood pressure and diabetes during adulthood [9]. Adolescents with poor physical
4.0/). health status can benefit more from regular participation in PA [1,8]. To achieve health

Healthcare 2021, 9, 358. https://doi.org/10.3390/healthcare9030358 https://www.mdpi.com/journal/healthcare

Healthcare 2021, 9, 358 2 of 11

benefits for high-risk youth or school-age children, it is important to encourage them to be

physically active.
As mobile devices such as smartphones, computers, tablets, video games, and social
media are incorporated into the lives of youths, the PA level has begun to gradually
decrease and will continue to decline [1,6,8]. Schoolchildren and adolescents spend most
of their time each day at school, so the role of school should have a great influence on
their health [1,6,8]. However, the scope, quantity, quality, and participation rate in physical
education courses are currently not at the desired levels in most of schools [1,6,8]. Schools
should offer good educational support that results in the positive attitudes necessary for
lifelong PA habits [1,6]. To meet the exigency of improving adolescent health and physical
fitness, a measurement and evaluation system that emphasizes physical fitness testing and
physical activity related education should be provided [8]. The Physical Activity Promotion
System (PAPS) was employed in accordance with these needs in Korea [10,11].
The ministry of Education in Korea enforced PAPS at all public and private elementary
schools nationwide in 2009, then all public and private junior high schools in 2010 and all
public and private high schools in 2012. PAPS evaluates quickness, muscular strength and
endurance, flexibility, cardiovascular endurance, and BMI of all students from 1st to 12th
grade once a year (Figure 1). Levels between 1 and 5 are set for each component (1 being
“Excellent”, 5 being “Very Poor”), and the Ministry of Education encourages students in
levels 4 and 5 to plan and engage in physical fitness programs at schools, and all schools
implement their own physical fitness programs based on the PAPS results (Figure 1, see
Supplementary Materials File S1)

Figure 1. Schematic Diagram of Physical Activity Promotion System (PAPS).

The evaluation components of PAPS include a comprehensive approach to monitoring

Health-related Physical Fitness (HrPF), including assessments of body composition (with
an eye towards early intervention in cases of obesity) and posture, as well as a thorough
psychological test [10]. Prescriptions for physical activity levels are provided after the
comprehensive PAPS assessments are completed. For purposes of the PAPS evaluation,
a student’s HrPF level is ranked on a scale of 1 through 5 for each assessment area, with
the most physically fit students placed in the 1st level, and less fit students falling within
levels 4 and 5. Less fit students are encouraged to increase their physical activity [11].
According to publicly available data from a school information disclosure site, the
number of students who received PAPS scores in levels 1 and 2 have decreased over the pre-
vious three years among elementary, middle and high school students, while the number of
students who fall within levels 4 and 5 have increased in Seoul [12]. Among middle school
students, those who fall within levels 1 and 2 made up 5.6% and 35.7%, respectively, of the
student population in 2018, a decrease of 0.1% and 1.0% from the previous year. Meanwhile,
Healthcare 2021, 9, 358 3 of 11

students with scores between levels 4 and 5 made up 13.7% and 1.7%, respectively, of the
middle school population in 2018, an increase of 1.0% and 0.2% from the prior year in
Seoul [12]. The overall decrease in physical activities may be a result of a lack of individual
participation in physical fitness or exercise activities, or a lack of appropriate exercise
programs in physical education classes at their schools. It is recommended for children
or adolescents between 5 and 17 years of age to engage in moderate-to-vigorous physical
activity (MVPA) for about 60 min per day [13]. Higher recreational screen time is associated
with unfavorable body composition, higher cardiovascular risk, lower physical fitness,
and lower self-esteem in adolescents [14]. In Germany, 60.4% to 72.3% of boys and 55.6%
to 57.8% of girls spent two hours per day watching TV and using electronic devices [15].
In Seoul, 22.4% of their 570 junior high school students were addicted to smartphones
or screen devices [16]. In Korea, there has been a rapid increase in smartphone addicted
adolescents, from 11.4% in 2011, to 18.4% in 2012, 25.5% in 2013, and 29.2% in 2014 [17].
Every provincial office of education, including the Seoul Metropolitan Office of Ed-
ucation, endeavors to improve the health of students with PAPS scores between the 4
and 5 ranges. A number of studies have demonstrated the effectiveness of health-related
physical fitness classes, in both addressing the problem once it arises, and preventing
the problem from emerging [18–24]. Kim (2002) demonstrated that students with poor
HrPF scores voluntarily and actively participated in the sports they were interested in, and
showed a desire to continue to participate in the exercise programs [25]. This suggests that
positive health outcomes are more likely to be achieved if students with poor health are
provided with exercises tailored to their individual characteristics and interests.
Various aspects of PAPS have been thoroughly studied, but until now, there has
been no assessment of the effectiveness of the school based HrPF program currently
recommended by the Korean Ministry of Education for students with PAPS scores of 4
and 5. In the present study, we evaluated whether this program was effective for high-
risk youths. Specifically, the purpose of the present study was to evaluate if a 16-week
school-based HrPF program would improve PAPS scores of middle school students.

2. Method
2.1. Study Design and Participants
The present study was a quasi-experiment design (One-Group Pretest–Posttest De-
sign). The present study was performed in a middle school located in Seoul. School
teachers or administrators encouraged all students to participate in a schoolbased HrPF
program. A total of 129 students started the program. Among those 129, 42 students were
classified at level 4 or 5 (for details on levels, see Section 2.2. PAPS measures) in the regular
April 2019 PAPS evaluation. Among all the participants, only 36 students’ scores were
analyzed for the present study; six students out of the 42 withdrew from the study because
they wanted to discontinue.
The purpose and requirements of the study were sufficiently explained to all partici-
pants, and their parents or family correspondence. They were all provided with written
informed consent before the study began. The Health-related Physical Fitness (HrPF) pro-
gram was operated with the consent of the students and their legal guardians. The study
was approved by the IRB (JNUE-IRB-2020-012), confirming the extraction of demographical
and clinical data for analysis and written or verbal consent from the study participants.
Appropriate total sample size was calculated using G*power 3.1.9.7.; test family = t tests,
statistical test = means: difference between two dependent means (matched pairs), type
of power analysis = a priori: compute required sample size given α, power, and effect
size, input parameters (one, effect size (0.5, medium), α err prob (0.05), power (0.8)). The
calculated total sample size (n) equals 27, with an actual power of 0.81.

2.2. PAPS Measures

In the present study, only “Required” components of PAPS were measured, and “Elec-
tive” metrics were excluded from measurement (Figure 1); to evaluate the “Elective”, the
Healthcare 2021, 9, 358 4 of 11

school must own expensive equipment, but most schools do not have this equipment.
An essential PAPS assessment measures cardiopulmonary endurance, muscular strength,
and endurance, quickness, flexibility, and body composition. Typically, the cardiovascular
endurance evaluation consists of a Progressive Aerobic Cardiovascular Endurance Run
(PACER), distance run, and step test. The muscular strength and endurance evaluation nor-
mally consist of sit-ups and maximum grip strength tests, as well as push-ups. Quickness
is generally measured with a 50 m-running test and a standing long-jump test. Flexibility
is normally evaluated with comprehensive flexibility tests and trunk flexion tests. Body
composition is commonly assessed using the body fat percent and body mass index (BMI).
In the present study, with consideration of the facilities and convenience of the school,
only one test measuring each of the essential PAPS components was employed: PACER for
cardiovascular endurance, trunk flexion test for flexibility, sit-up test for muscular strength
and endurance, 50 m-run for quickness, and BMI for body composition. Each PAPS evalua-
tion was taken twice, once before and once after the HrPF program was implemented.
In the PACER test, one lap is a 15 m distance. The recorded score is the total number of
laps completed by a student. The student ran as many laps as possible. In the trunk flexion
test, sit-and-reach was evaluated using a sit-and-reach testing equipment (K-115, KL Sports
Industry Co., An Yang, Korea, http://www.klsports.co.kr/ (accessed on 22 March 2021)).
In the sit-up test, the student performed the test with bent knees, feet flat about 45 cm
from the buttocks using a testing equipment (K-111, Sports Industry Co., An Yang, Korea).
The student touched their elbow to the sensor with each sit-up. The students performed as
many sit-ups in 1 min as possible.
In the 50 m-run test, the student stood at a starting line and waited for a start signal.
Once the student started running, the student ran as fast as possible for 50 m straight.
For the BMI test, each student’s body weight and height were measured.

2.3. Health Related Physical Fitness(HrPF) Program

The 36 participants were enrolled in the HrPF recommended (as of 2019) by the Seoul
Metropolitan Office of Education for 16 weeks, during which they met for three 50-min
sessions per week.
Each 50-min class was comprised of a warm-up exercise (5 min), exercises related to
four physical fitness elements (10 min each), and a cool-down exercise (5 min) (Table 1).
Because students with poor physical fitness were enrolled, exercise intensity was initially
low and proceeded according to their personal fitness level but was gradually increased
over the course of the 16-week program. In addition, efforts were made to maintain a
positive and energetic class atmosphere to sustain the participants’ interest in the exercise
program. The exercise levels were determined by the rating of perceived exertion (RPE)
using a scale from 0 to 10, where sitting is 0 and the highest level of effort is 10. The exercise
intensity level was gradually increased on an RPE scale of 3~4 (Light) to an RPE scale of
5~6 (Moderate) [3].

Table 1. Contents of HrPF Program.

Steps Exercise Elements Durations

Warm-up Stretching Exercises, Walking and Jumping 5 min
Fitness exercises
Cardiovascular endurance Jump Rope, Cycling, Interval Training
20 min
Flexibility Trunk, Hip, and Leg Flexions and Extensions
MusStrEnd Push-ups, Sit-up, Squat, Burpee
20 min
30 m run, Sergeant Jump, Consecutive
Quickness
Obstacles Jump
Cool-down Walking, Stretching Exercises 5 min
MusStrEnd: Muscular Strength and Endurance.

2.4. Statistical Analysis

Demographic characteristics of the study subjects were listed in Table 2. In order to
analyze the effect of the HrPF program on PAPS measures, a paired sample t-test was used
Healthcare 2021, 9, 358 5 of 11

(SPSS 22.0). The statistical significance level was set to α = 0.05. Descriptive statistics, effect
size, and confidence interval (CI) for the difference between means were computed for
additional analysis (Table 3).

Table 2. Demographic of the study sample (n = 36).

Variables Participants (n = 36) Percentage (%)

Sex
Male 18 50.0
Female 18 50.0
Grades
7th 11 30.6
8th 11 30.6
9th 14 38.8
PAPS level
4 28 77.7
5 8 22.3

Table 3. Descriptive Statistics for Five PAPS Measures (n = 36).

Measures Time Mean SD Cohen’s D p-Value

PACER Before 13.36 4.98
(repetitions) 0.93 <0.001
After 18.64 6.31
Sit-up Before 18.06 7.22
(repetitions) 0.93 <0.001
After 24.89 7.52
50 m-Run Before 10.74 1.30
−0.04 0.063
(seconds)
After 10.69 1.25
Trunk Before 2.64 3.49
Flexion 1.06 <0.001
After 5.98 2.78
(centimeters)
Before 24.84 3.97
BMI (kg/m2 ) −0.02 0.458
After 24.76 3.61
SD: standard deviation, PACER: Progressive Aerobic Cardiovascular Endurance Run, BMI: Body Mass Index.

3. Results
Demographic characteristics of the study subjects are shown in Table 2.
Descriptive statistics (mean and standard deviation) and overall scores of the variables
used in this study were analyzed, and the results are shown in Table 3.

3.1. Cardiovascular Evaluation

There was a significant increase in PACER in the post-test (95% CI; 16.579, 20.701)
compared to the pre-test (95% CI; 11.736, 14.984), t(35) = −9.88, p < 0.001 (Table 3). The 95%
confidence interval for the difference between the means was statistically significant (95%
CI; 2.608, 7.952).

3.2. Muscular Strength and Endurance Evaluation

There was a significant increase in the number of sit-ups in the post-test (95% CI;
22.434, 27.346) compared to the pre-test (95% CI; 15.702, 20.418), t(35) = −14.26, p < 0.001
(Table 3). The 95% confidence interval for the difference between the means was statistically
significant (95% CI; 3.365, 10.295).

3.3. Quickness Evaluation

The results indicated that there was not a statistical difference between the pre-HrPF
50 m-Run (95% CI; 10.315, 11.165) and post-HrPF 50 m-Run (95% CI; 10.282, 11.098) results,
Healthcare 2021, 9, 358 6 of 11

although a small improvement was apparent in program participants (Table 3). The 95%
confidence interval for the difference between the means was statistically insignificant (95%
CI; −0.549, 0.649).

3.4. Flexibility Evaluation

The results indicated that there was a statistical difference between the pre-HrPF
Trunk Flexion (95% CI; 1.500, 3.780) and post-HrPF Trunk Flexion results (95% CI; 5.072,
6.888), t(35) = −14.00, p < 0.001 (Table 3). The 95% confidence interval for the difference
between the means was statistically significant (95% CI; 1.857, 4.823).

3.5. BMI Evaluation

The results indicated that there was not a statistical difference between the pre-HrPF
BMI (95% CI; 23.543, 26.137) and post-HrPF BMI (95% CI; 23.581, 25.939) (Table 3). The
95% confidence interval for the difference between the means was statistically insignificant
(95% CI; −1.704, 1.864).

4. Discussion
As a general matter, physical fitness has a skill-related and a health-related compo-
nent. In recent years, the health-related component has received more attention [15–17,26].
Cardiovascular endurance, muscle strength and endurance, quickness, body composi-
tion, and flexibility are all elements of health-related physical fitness that are deeply
tied to daily exercise habits [27–29]. Particularly in adolescents, physical fitness should
emphasize health-related concerns, because these aspects of fitness can be seriously de-
graded by a lack of exercise, significantly increasing the risk of health-related disorders or
diseases [27,30–32]. In South Korea, adolescents perform less and less physical activity as a
result of their educational environment, which is focused on examinations, and increasing
time spent on smart devices, despite the fact that the middle school years are among the
most critical for physical development and growth [12,33].
In agreement with previous studies [34–36], the study participants in the present
study improved their cardiorespiratory endurance. Previous studies suggested that var-
ious types of aerobic exercises improved the cardiovascular endurance of adolescents
and as cardiorespiratory endurance decreased in adolescents, the incidence of obesity
increased [37]. To improve their cardiorespiratory endurance, individual students would
have to maintain regular exercise habits. To achieve this, schools would have to introduce
programs specifically geared towards improved cardiorespiratory endurance.
Similar to previous studies [38–41], study participants improved their muscular
strength and endurance. In addition, Smith et al. [42] reported that adolescents who
exercised less, watched more television, and had a higher body mass index had poorer
muscular strength and endurance [42].
In a deviation from previous studies [43–45], participants in our study did not improve
their quickness after the 16-week program. This may be because previous studies mostly
tested professional athletes, and not students with poor PAPS scores. Quickness as a
characteristic is difficult to significantly improve through training, as it is, to a large degree,
influenced by genetic factors and not simply physical strength. As the HrPF program of this
study was undertaken with the goal of improving overall physical strength in participants,
it may not be reasonable to expect rapid improvement in quickness over a mere 16 weeks.
In agreement with previous research [46–50], the participants’ flexibility improved.
Prior studies found that adolescents who regularly exercised demonstrated good flex-
ibility. Alaguraja and Yoga [46] suggested that good flexibility allowed participants to
achieve efficient motor function, stabilize and smoothen their movements, improve exercise
performance, and reduce the risk of future injuries [46,47,49].
The participants in the present study did not improve their BMI. Similar results were
found in the previous studies [51–53] that reported no changes in weight, body fat mass,
and lean mass after participation in various exercise programs. Of course, the goal of
Healthcare 2021, 9, 358 7 of 11

the fitness program in our study was not to achieve weight loss, but rather to improve
overall physical fitness. Participating students received no coaching regarding their diet
for the purpose of weight loss. In fact, we did not measure body fat mass, but rather
body mass index; had we measured body fat mass (%fat), the results may have shown
an improvement.
PAPS evaluates body composition through the % body fat or BMI. One study [54]
that investigated the relationship between BMI and physical ability, noted that adolescent
obesity inversely correlated with overall motor development, while an active lifestyle was
associated with an improvement in motor development [55–57]. These results were not
confirmed in the present study. This may be a sign that BMI should be used to measure
weight status in population or to screen potential weight problems in individuals.
Adolescents should participate in at least 60 min of physical activity daily to decrease the
risk for numerous adverse health outcomes [3], and activity programs provided by schools
should be a key strategy to increase physical activity levels and address health issues for
adolescents [58]. In spite of these recommendations and suggestions [3,37–41,46–50,54–58],
middle school students’ regular physical education classes are only 2~4 credit hours per
week in Korea, England, Japan, Finland, Canada, New Zealand, France, among other
countries [59,60]. These hours for physical education classes for middle school students
are very short to meet physical activity needs to maintain good health outcomes [57–60].
School-based interventions by teachers or staff can help provide students with consistent
messaging and opportunities related to physical activity; as a result, they are very effective
in helping to foster positive attitudes toward physical activity [57–61]. A study [62] reported
multiple systematic reviews of school-based programs on the outcomes of physical activity
levels and BMI or obesity prevention. The study [62] suggests that school-based physical
activity interventions are associated with some positive effects and should be focused
on fostering positive attitudes toward physical activity and geared toward promoting
physical activity within school-based interventions. Few information about the effects
of school-based HrPF programs in Korea on health outcomes of adolescent and physical
activity measures is available internationally, although data from Belgium, Canada, Czech
Republic, Cyprus, Estonia, Germany, Hungary, Italy, Spain, Sweden, and the U.S.A are
available [60–64]. The results from the present study suggest that one hour of HrPF class in
addition to regular physical education classes in a day in a school setting should improve
HrPF levels or PAPS measures of middle school students in Korea.
The present study included all the PAPS evaluation items during a 1-h physical fitness
program, whereas most of the school-based physical activities from the previous studies
were an extension of already existing regular weekly physical education classes, including
several short activity breaks (2–5 min each), physical activities during recess, or flyers and
posters to promote active commuting to school [65,66]. However, in the results, both the
present study and previous studies suggest that the interventions are effective in improving
HrPF of adolescent.
There were limitations to our present study that could be addressed in future research.
Due to classroom or educational situations, the factor of interest was not manipulated and
no control group was assigned for the present study. In other words, the present study
was a quasi-experiment. Therefore, the major limitation of the present study is that it lacks
a demonstration of cause due to there being no control group. Simply put, the present
study is prone to threats to internal validity such as testing effects and regression toward
the mean. First, study results were probably influenced by the home environment, dietary
choices, and personal lifestyles of the students, factors that were beyond our ability as
researchers to control. However, any factors related to PAPS measures were attempted
to be controlled as much as possible in the present study. For example, participants were
told not to change eating habits or/and daily schedule. The results from the present
study suggest that there were no effects in physiological growth and development over
the 16 weeks; participants’ growth in terms of mass and height were not significantly
changed after 16 weeks. Second, the results were derived by subjecting all participants
Healthcare 2021, 9, 358 8 of 11

to the HrPF, and assessing their progress with pre- and post-HrPF tests. However, future
studies would benefit from dividing the participants into experimental and control groups.
Third, we did not attempt to restrict participants’ access to other physical activities; thus,
in addition to the HrPF program, the observed changes in the PAPS factors may have
been driven by participation in physical education classes or other school-offered physical
activities. Nevertheless, there was very little chance that subjects in the present study
would participate in any other after school exercise program besides the program offered
by the present study, since class was over at 4:30 p.m. and the program lasted until almost
6:00 p.m.

5. Conclusions
Individual health care plans should focus on identifying and managing basic health-
related lifestyle habits, including disease prevention, eating, exercise, rest, and sleep.
Ideally, of course, middle school students would be self-aware of their health choices,
but schools have a significant role to play, and should encourage students to regularly
participate in health-related classes and physical activities. In particular, participation in
a moderate level exercise should be effective in improving overall fitness, promoting the
development of physical and motor skills, and enhancing the body’s ability to cope with
diseases and risks. Because of the emphasis placed on academic achievement and the
frequent use of smart devices among Korean middle school students, this group maintains
a low level of physical activity. To maintain and promote good health among these students,
they should be engaging in physical activities that increase their heart rate for at least
30 min a day, three days a week. If this proves to be insufficient, middle school students
should explore and practice alternative means of increasing their health-related physical
activity throughout the school year. Specifically, pursuant to current recommendations by
the Office of Education, a systematic plan for health and fitness classes geared towards
students with poor physical fitness should be established and then implemented at the
school site.

Supplementary Materials: The following are available online at https://www.mdpi.com/2227-903

2/9/3/358/s1, File S1.
Author Contributions: Study design: H.H.S. and S.K. Study conduct: H.H.S. and J.H.S. Data
collection: H.H.S. and J.H.S. Data analysis: J.S and S.K. Data interpretation: H.H.S., J.H.S. and
S.K. Drafting manuscript: H.S, J.H.S. and S.K. Revising the manuscript content: J.H.S. and S.K. All
authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Institutional Review Board of Jeonju National University
of Education (JNUE-IRB-2020-012).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Restrictions apply to the availability of these data. Data was obtained
from Seoul Metropolitan Office of Education and are available from the authors with the permission
of Seoul Metropolitan Office of Education.
Conflicts of Interest: The authors declare no conflict of interest.

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