Article information

J Korean Acad Soc Nurs Educ. 2025;31(1):84-95

Publication date (electronic) : 2025 February 28

doi : https://doi.org/10.5977/jkasne.2025.31.1.84

Myoung-Lyun Heo¹⁾, Seung-Ha Kim²⁾, Chang-Sik Noh²⁾, Yang-Min Jang^3),

허명륜¹⁾, 김승하²⁾, 노창식²⁾, 장양민^3),

¹⁾ Assistant Professor, Department of Nursing, Jeonju University

¹⁾ 전주대학교 간호학과, 조교수

²⁾ Undergraduate Student, Department of Nursing, Jeonju University

²⁾ 전주대학교 간호학과, 학부생

³⁾ Assistant Professor, Department of Nursing, Cheongju University

³⁾ 청주대학교 간호학과, 조교수

Address reprint requests to: Jang, Yang-Min Department of Nursing, Cheongju University, 298, Daeseong-ro, Cheongwon-gu, Cheongju-si, Chungcheongbuk-do, 28503, Republic of Korea Tel: +82-43-229-7835, Fax: +82-43-229-8969, E-mail: sellry100402@naver.com

*본 연구는 2023년 7월 한국성인간호학회 하계학술대회에서 포스터 발표되었음.*This manuscript was partially presented as a poster at the Korean Society of Adult Nursing in July 2023.

Received 2024 October 25; Revised 2024 December 31; Accepted 2025 January 7.

Abstract

Introduction

The coronavirus disease 2019 (COVID-19) pandemic that struck the world in December 2019 ushered in an online era, significantly expanding the use of digital devices. Especially in education, the shift to online learning was abrupt, but educators and students adapted quickly [1]. While this change has been observed across generations, members of Generation Z—often called digital natives—have displayed more openness to change and have rapidly adapted to new lifestyles amidst evolving circumstances [2].

A previous study on the lifestyle changes of Generation Z college students during the pandemic reported that they adapted to a new lifestyle transcending space and time, using mobile devices to work, study, eat, exercise, and even rest [3]. While this lifestyle offers convenience not bound by spatial or temporal constraints, it has led to reduced physical activity [4] and decreased face-to-face interactions, consequently causing emotional health problems [3]. Despite these challenges, digital devices have become indispensable tools in Generation Z’s daily lives, facilitating essential activities and interactions in ways that are often unavoidable. However, this reliance on digital tools has also contributed to increased physical inactivity and emotional health problems, highlighting the need for strategies that address these issues while acknowledging the importance of these tools in modern life.

In the past, individuals in their twenties have been perceived as healthy and thus have not received significant societal attention in terms of health management. However, lifestyle changes have led to an increased prevalence of major chronic diseases such as hypertension and diabetes mellitus in this age group [3]. In addition, digital dependency has created a unique set of challenges for young adults, including an increased prevalence of depression and emotional distress, further emphasizing the need for targeted health strategies. According to a 2021 analysis of data regarding depression treatment in South Korea by age, individuals in their twenties accounted for 19.0% of all patients, a 22.8% average annual increase compared to five years prior [5]. This indicates a pressing need to address the physical and mental health issues of young adults.

Health promotion interventions are effective for disease prevention and overall health improvement. In South Korea, a variety of health promotion projects are implemented primarily through public health centers; these projects are mainly carried out in face-to-face formats and are therefore subject to disparities in the use of programs due to accessibility issues [6]. In anticipation of future pandemics, more no-contact programs with enhanced accessibility are needed such that more clients can make use of these programs conveniently. Hence, this study aimed to develop and evaluate a no-contact health promotion behavior (HPB) program tailored to the generational characteristics and cultures of young adults (i.e., members of Generation Z).

Nursing students are prospective facilitators of HPB, and their personal lifestyle and health behaviors affect their recognition of their roles [7]. However, nursing students tend to display poor health management as they undergo an intensive educational curriculum, including clinical practicums, and they may be more vulnerable to mental health issues (such as depression and stress) due to several reasons such as the gap between theory and practice as well as stress from preparing for their national board exam [8]. Against this backdrop, we developed a program for nursing students—who are prospective health managers—aimed at enhancing their HPB and health self-efficacy as well as alleviating depression and stress and investigated its effectiveness. We established the applicability of the program, aiming to present foundational data in order to advance no-contact HPB programs for the digital generation.

Methods

Development of the program

● Theoretical framework: The health promotion model

We designed the program based on Pender’s health promotion model (HPM) [9]. According to the HPM, predictors of “behavioral outcomes” include “individual characteristics and experiences” and “behavior-specific cognitions and affect.” Chief motivators for HPB include “perceived benefits of action, perceived barriers to action, perceived self-efficacy, and activity-related affect.” Recognizing the importance of self-awareness and perception in motivating HPB, we designed the program to enhance participants’ awareness of their health behaviors and lifestyle patterns.

Interpersonal and situational influences can be included as additional concepts that impact behavioral outcomes. Interpersonal influences refer to norms and support from family, peers, and healthcare providers; we structured the program to encompass management by, and feedback from, health management providers. Since situational influences involve choice-related needs, we structured the program to allow participants to choose their actions.

Immediate conflicting preferences (low control and high control) are further concepts that affect behavioral outcomes. Generation Z’s reliance on digital immediacy and autonomy aligns with the concept of immediate conflicting preferences, as it reflects their tendency to prioritize rapid results over long-term planning. To address this, the program incorporated activities that balance immediate rewards with strategies encouraging sustainable health behaviors. As members of Generation Z are known for their immediacy and strong sense of autonomy, we decided to set the generational characteristic as immediate conflicting preferences.

● The ADDIE model

Based on Pender’s HPM [9], we developed our program in accordance with the ADDIE instructional systems model [10]. The acronym ADDIE stands for Analyze, Design, Develop, Implement, and Evaluate. The sections below describe in detail how each phase of the ADDIE model was followed to develop our program.

. Analysis

The analysis phase encompasses defining the content to be taught through needs, learner, environmental, and task analyses as well as identifying educational needs, objectives, and constraints [10]. We performed literature reviews to determine the program’s needs, educational content, and constraints. We searched the international literature using keywords such as “health promotion,” “young adult health,” “Generation Z,” “health promotion behavior program,” and “health promotion model” on CINHAL, Google Scholar, DBpia, KISS, and RISS.

. Design

Based on the characteristics of young adults and the HPM identified in the analysis phase, we designed the program’s purpose, content, and operational method as follows. The program’s purpose was “to develop and evaluate the effectiveness of a fully no-contact program aimed at improving HPB among nursing students accustomed to a mobile lifestyle.” The specific content is as follows:

• - Participants will receive personalized reports analyzing their lifestyle patterns to enhance self-awareness, which serves as a key motivator for HPB.

• - Health management providers will provide regular feedback and oversee the program to ensure active engagement and sustained progress in HPB.

• - Situational influences for HPB will be strengthened by allowing participants to choose their missions.

• - Immediate conflicting demands and preferences will be addressed by balancing short-term motivators with strategies that promote sustainable health behaviors.

• - Young adults will be offered autonomy through a program that is not bound by spatial or temporal constraints.

• - Health behavior information will be delivered in concise, visually engaging formats, such as infographics, to enhance accessibility and comprehension.

• - Self-control will be promoted by encouraging participants to complete structured challenges, reinforcing consistent health behaviors. (Figure 1 illustrates the conceptual framework of the revised program composition, highlighting the integration of HPM with generational characteristics and program design elements.)

. Development

We developed the program based on the matters determined in the design phase (Table 1). The program comprises three sessions; the details of each session and the media used for each session are outlined below.

Table 1

Program Procedure and Composition

Session 1: The orientation. Held in a metaverse (ifland; SKTelecom) space, participants joined with their avatars using nicknames to maintain anonymity during the orientation and subsequent activities. The session is designed to pique interest in the program, explain how the program is run, and educate students on HPB. Participation is encouraged by using avatars that do not expose their identity, running the program without being bound by spatial constraints, and supporting engaging, smooth program implementation through dual-track management by educational experts and metaverse facilitators.

Session 2: Card news and surprise missions. Health information and related missions are transmitted via Instagram (Meta Platforms), with participants submitting proof of completion through direct messages. Content about psychosocial health, personal hygiene, dietary habits, health management, using mobile devices, and physical activity is randomly chosen and provided once every three days. The emphasis is on using a social media platform that is familiar to college students (i.e., Instagram) in order to impart concise, impactful health information through card news and to encourage them to submit proof of completing their missions.

Session 3: Proof of completion of personal missions. Participants identify their weakest areas of HPB (psychosocial health, personal hygiene, dietary habits, health management, using mobile devices, physical activity) via a baseline survey. Participants choose one mission each day and post proof of having completed it. The program’s design allows participants to select their missions, and the researchers reveal information to them about their weakest areas in order to facilitate self-awareness. Further, proof of mission completion is used to promote self-management.

To inspire the students to complete each session, they were given points based on the number of posts showing completed missions. Individual score rankings (the number of points) were published weekly, and rewards were offered after the program’s conclusion based on the scores.

The program design was reviewed by a doctor of nursing, a doctor of education, and a psychological counselor to ensure the validity of the program’s duration, content, and procedures. Specifically, the card news and surprise missions were shown on a social media platform familiar to college students in order to facilitate high accessibility. Card news offers visually concise and intuitive content, thereby deepening participants’ understanding of their missions. Since there is a widespread culture of posting confirmation on social media and in small group meetings, we predicted that it would help keep participants motivated and encourage their active involvement. Furthermore, each session had clear objectives and specific guidelines, which enabled smooth implementation. Table 1 summarizes the program composition and operation method.

. Implementation

We ran the program for four weeks from February 4 to March 7, 2023. The phases of the program included participant recruitment, a pretest, program implementation, and a posttest. We recruited participants by posting an ad on an online bulletin board and social media. We screened volunteers for eligibility and enrolled them. We collected data on HPB, health self-efficacy, depression, stress, and general characteristics using Google Forms. Subsequently, the participants received an orientation followed by four weeks of surprise missions and individual missions on the metaverse platform, and their individual score rankings were published weekly. During the program, we collected data on the participants’ mission completion rates and participation frequency, which were used to evaluate their level of engagement with the program. These data are presented in Table 2.

Table 2

Participation in Personal and Surprise Missions Over Four Weeks (N=14)

After the four-week program ended, we administered the posttest (which consisted of the same items as the pretest) via Google Forms.

. Evaluation

To evaluate the program’s effects, we administered a questionnaire containing items about post-pandemic HPB, health self-efficacy, depression, and perceived stress before and after the program.

Results

Participants’ characteristics

Table 3 outlines the participants’ general characteristics. There were five males (38.5%) and eight females (61.5%). There were three freshman (23.1%), seven sophomore (53.8%), and three junior (23.1%) students. Monthly income was <200,000 KRW (n=2, 15.4%), 200,000 to 399,999 KRW (n=2, 15.4%), 400,000 to 599,999 KRW (n=6, 46.2%), or ≥600,000 KRW (n=3, 23.1%). Each participant considered themself to be an introvert (n=5, 38.5%) or an extrovert (n=8, 61.5%). Eight students (61.5%) lived off-campus or in a dorm, and five (38.5%) lived with their parents. Six (46.2%) lived alone, and seven (53.8%) lived with family members or friends. Their mean age was 21.92±2.72 years, with a range of 19 to 28 years.

Table 3

Participants’ General Characteristics (N=13)

Effects of the HPB program on study variables

The analysis of the study’s main variables is presented in Table 4. The mean HPB score was 3.51±0.72, with the lowest practices observed in dietary habits 3.03±0.95 and physical activity 3.03±1.21. The mean health self-efficacy score was 2.95±0.67, while depression and stress scores were 2.62±3.07 and 11.62±7.02, respectively.

Table 4

Effects of the HPB Program on HPB, Health Self-Efficacy, Depression, and Stress (N=13)

The no-contact HPB program significantly improved HPB (Z=-2.90, p=.004), with notable effects on psychosocial health (Z=-2.36, p=.018), personal hygiene (Z=-2.73, p=.006), using mobile devices (Z=-2.87, p=.004), and physical activity (Z=-2.38, p=.017). Health self-efficacy also improved significantly (Z=-2.24, p=.025), particularly in the nutrition management domain (Z=-2.07, p=.038). Depression levels significantly decreased (Z=-2.13, p=.033), while no significant changes were observed in stress levels (Z=-0.88, p=.380).

Discussion

We developed a no-contact program to promote HPB based on Pender’s HPM and tailored it to the unique generational characteristics of the members of Generation Z, who were raised in a digital environment and have adapted to the changes brought about by the COVID-19 pandemic. The program was entirely virtual and designed for use on personal computers or mobile devices. The apps used for the program were the metaverse program ifland, the social media platform Instagram, and the app Challengers (Whitecube Inc.) (for confirming that missions had been completed). Our participants, who were familiar with mobile devices, were able to engage in all activities without significant difficulty, but there were some points of discussion during the activities.

For the orientation and health education components, we chose the metaverse platform for its anonymity and its ability to facilitate simultaneous connections among users without physical or temporal constraints. Individuals in their twenties stated that their reasons for using the metaverse were the ability to customize characters and their interest in diverse virtual maps [18]. Thus, we used ifland, which ensures the anonymity of online communities [19] and features diverse, engaging options for character customization. However, we noticed that many participants were new to the metaverse, so we brought in a metaverse expert to guide them and employed interactive methods (such as games and quizzes) to keep the sessions engaging and recreational in order to boost their motivation.

Despite these efforts, we encountered technical challenges, such as varying degrees of device performance and battery draining, which have been reported in similar contexts [20], thus highlighting the need for technical refinement when implementing metaverse-based educational programs. Furthermore, a study on age-related differences in metaverse engagement suggests that while teenagers are fully immersed and are consistently active in virtual worlds, people in their twenties may initially display interest but eventually disengage due to technical issues or waning interest [18]. Hence, although the metaverse is a popular platform, it is crucial to ensure technical reliability and to implement programs in a time-efficient, engaging, and motivating way when applying the metaverse to individuals in their twenties.

Instagram is a widely used social media platform among young adults; one distinctive feature of this platform is that it is image-centric in contrast to other text-based social media platforms. Pittman and Reich [21] suggested that image-based platforms could enhance intimacy and reduce loneliness compared to text-based platforms. As Instagram is widely used by educators to share educational content and communicate [22], we deemed it an appropriate medium to relay card news on health information or announcements.

Finally, we used the Challengers app, which allows individuals to set health-related missions and post proof of completion. Jo and Cho [23] identified sharing one’s own experiences and information through social media as a distinctive feature of the digital generation. Uploading proof (e.g., via photos) serves as a visual representation of interactions with others and aids in identity affirmation. While using the app was straightforward, challenges arose regarding the need to contact the app’s developers each time technical issues occurred.

Although various apps were used according to the characteristics of each session, using too many platforms caused some confusion among the participants. Thus, developing a dedicated app based on the specific design and suggestions of this program could be beneficial. Although numerous health management apps already exist, sustainable health management relies heavily on personal motivation [24], and meaningless push notifications from the app do not effectively motivate users. As such, social interactions between users and mediators are important; this impacts changes in health behaviors [25]. In this study, we (the researchers who designed the program) served as administrators to communicate with the participants. Even with app-based programs, actual administrators should be available to ensure communication and create a sense of reality. Additionally, creating images for card news, individual reports, and content for rankings is time-consuming; therefore, employing generative artificial intelligence algorithms should be considered in the future.

Participants selected various missions aligned with specific domains of HPB, including “protecting eyesight and hearing” (using mobile devicesh), “walking challenges” (physical activity), and “cleaning tasks” (personal hygiene). These missions were intentionally designed to engage participants in areas linked to key HPM constructs, such as perceived self-efficacy, behavior -specific cognition, and interpersonal influences. For example, participants who chose self-directed missions related to mobile device usage or personal management appeared to experience an increase in self-efficacy as they independently completed tasks and monitored their progress. This alignment between mission types and HPM domains likely contributed to the observed improvements in HPB and health self-efficacy.

Applying this program to nursing students significantly increased their HPB and health self-efficacy. We believe that incorporating certain features—such as having participants choose their own missions (depending on their PP-HPB scores) to address their areas of weakness—helped boost their HPB and health self-efficacy. Previous studies have identified self-efficacy as a strong predictor of HPB [26]. Moreover, despite the brief duration of four weeks, the program has significant implications in the sense that both cognitive (self-efficacy) and behavioral (HPB) aspects were improved. However, we did not observe any significant effect in the diet domain of HPB. Since the nutrition management domain of health self-efficacy improved significantly, extending the program’s duration may help to foster behavioral changes.

The use of Instagram and social media addiction strongly predict depression [27], and the tendency toward social media addiction is reported to lower HPB [3]. In our study, we actively utilized mobile devices and social media, but the program was specifically structured with activities that enhance a mobile device-related lifestyle and physical activity. Further, the participants were able to take part without disclosing their identities and they could access the program from anywhere while being motivated by an actual human administrator (as opposed to artificial intelligence). These factors appear to have helped alleviate the participants’ depressive mood.

Finally, our program was not effective at reducing stress. Han [28] reported that HPB lowers college students’ stress, but our results were contradictory despite attempts made to improve HPB. Participants in our program may have experienced stressors due to suppressing enjoyment for activities such as exercise, cleaning, and diet management or while completing their missions to engage in HPB; this highlights the need for further research in this area.

Nursing students play a key role in health promotion and thus require direct experience and understanding of their said role [29]; our findings can help foster experiences among these prospective nursing professionals. In this regard, this study is significant in confirming that the developed program helped improve the health of nursing students, who primarily comprise young adults who face challenges in managing their health due to their studies and clinical rotations. According to Kim [30], there was no difference in HPB between non-nursing and nursing students, and in terms of the school year, HPB was significantly higher only among fourth-year students. As we did not include fourth-year students, our results can be utilized for preliminary applications targeting young adults in the general population. Further replication studies should be conducted with more diverse populations, including general college students, job seekers, and employed individuals in order to strengthen the program.

Since we only included some nursing students in South Korea in this study, the findings have limited generalizability, which indicates the need for further research with a more diverse population. Moreover, we considered monthly income as a potential factor influencing HPBs, recognizing that financial support from part-time jobs could affect students’ engagement in health-promoting activities. Additionally, the incentive structure of this program, which provided rewards based on participation and performance, might have had varying motivational impacts depending on the students’ financial situations. Addressing these variables in future research could help design tailored interventions. Also, this study was an early-stage investigation that used several mobile apps. Future research should develop a dedicated mobile app specifically for the program in order to control external factors pertinent to the complexity of program management. On another note, while we successfully developed and evaluated a fully no-contact program in anticipation of another infectious disease pandemic, the increasing reliance on mobile devices and reduced opportunities for social contact may lead to emotional problems. Therefore, we recommend that future programs provide opportunities to build social relationships in a post-COVID context where contact among participants is permitted.

Conclusion

We attempted to develop a fully no-contact program to enhance HPB in young adults who have experienced the COVID-19 pandemic as well as to implement and evaluate the program’s effects on nursing students. The results showed improvements in HPB and health self-efficacy and a reduction in depression. This is significant in validating the potential of no-contact programs for the health management of young adults as well as in fostering experiences and promoting personal health among nursing students who are prospective health managers. Hence, we hope that future scholars will strengthen the program based on our findings and repeatedly evaluate its effectiveness in larger populations to establish it as an extracurricular program in educational institutions or as a health management initiative in health management organizations.

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