Increasing Self-Efficacy Among Future Health Educators: An Exploratory Study Using Service Learning

Abstract

Background. Service learning is a pedagogical tool that involves students delivering a service, linked to course learning outcomes, to the community and measured through acquisition of knowledge, attitudes, and skills along with overall satisfaction of the experience. Undergraduate students enrolled in a peer health education course, collaborated with campus health promotion staff, in a semester-long service learning project to plan, implement, and evaluate a campus-wide health fair. Purpose. The purpose of the study was to examine how participation in a service learning project affected students’ self-efficacy aligned with the seven Areas of Responsibilities (AoR) of Certified Health Education Specialists. Method. The multimethod design used pre- and posttest results and reflective writing samples to evaluate changes in students’ (n = 58) self-efficacy related to the seven AoR of Certified Health Education Specialists. Students completed semistructured reflective journals responding to overall satisfaction, barriers to implementation, and significance of the learning experience and health fair on their professional development. Results. Results indicated students’ self-efficacy increased across all AoR, with the largest improvements reported in Areas III, V, and VI. Students described feeling competent responding to questions and directing attendees to available on- and off-campus resources. Results emphasized overall satisfaction with the service learning health fair project, uniquely the importance of applying information from the classroom setting to the real world. Conclusions. Service learning opportunities in classroom settings and professional preparation programs aid in preparing future leaders within the field of health education to exemplify the seven AoR with competency and confidence.

Keywords

CHES professional competency service learning seven Areas of Responsibility

Conducting health fairs on college campuses is a common approach for providing students, faculty, and staff with health information and resources (Fennell, 1993a); however, using peer health educators to implement health fairs as a means to improve self-efficacy in performing tasks related to the profession of health education is a relatively new concept. In fact, investigating the potential increase in peer health educators’ self-efficacy in performing the Certified Health Education Specialists’ (CHES) Areas of Responsibility (AoR) as a means of professional preservice development is an area of research lacking in the professional literature. Two previous studies evaluated community-based health fair projects in nursing programs, which resulted in increased communication and collaboration skills; however, those involved were nursing students rather than peer health educators (Maltby, 2006; Montgomery & Johnson, 2015). A study conducted by Fennell (1993a) used undergraduate students to sponsor a campus health fair, but self-efficacy, related to the AoR, was not examined. Given this gap, this study seeks to inform peer health education program directors and practitioners with strategies for increasing preservice professionals’ self-efficacy by using a service learning health fair project within a peer health education course.

Peer Education

Peer educators have been used on college campuses for decades (Fennell, 1993b). As a common intervention framework, peer education allows peers (i.e., individuals who are similar to those they are teaching) to provide education and instruction to one another across various topics (Gould & Lomax, 1993). Peter Finn (1981) noted peer education “takes place constantly among youngsters and adults, regardless of instructional efforts, to promote the use of more reliable sources of information and advice” (p. 13). While residential living programs often support peer education, the vast majority are operated through student health services or health education undergraduate programs, providing information and services to the larger student population (Hong, Robertson, Catanzarite, & McCall, 2011).

Peer health educators can be effective at influencing their peers’ behaviors in many ways, including serving as credible role models, reinforcing both positive and negative socially learned behaviors, and empowering others with effective communication and social skills (Bandura, 1977; Turner & Shepherd, 1999). Especially true for adolescents and young adults who are often unable to relate to or fully trust adults, people are more likely to change behaviors and attitudes if they believe the message is relevant to their own lifestyle (Valdiserri, 1989). Activities provided by peer health educators vary, including one-on-one consultations, group presentations and events, role-plays, mass media campaigns, and campus-wide awareness efforts (Hong et al., 2011). Although evaluation efforts are taking place, very few peer health education programs have been successfully evaluated to determine whether behavior change has occurred (Fennell, 1993b). One approach for evaluating peer health education is to collaborate with academic departments to develop practical evaluation methodologies, which should also assess changes in peer health educators and their satisfaction in the overall experience (Fennell, 1993b). For this study, a service learning health fair project was implemented, within a peer health education course titled Concepts in Peer Health Education, to determine the impact on preservice professionals’ self-efficacy in conducting the seven AoR,

Health Fairs

On college campuses, health fairs serve as an opportunity for health promotion professionals to assist students, faculty, and staff by providing information and resources to enhance health (Fennell, 1993a). Typically, health education at fair interventions is one step on a continuum of individual- and population-level strategies to enhance health through awareness, knowledge, and policy change (Fournier, Harea, Ardalan, & Sobin, 1999). Health fairs are interactive events in which attendees (e.g., students, employees, or community members) engage in educational outreach efforts aimed at providing basic health information (M. J. Clark, 1985; Unite for Sight, 2015). Health fairs support booths, exhibitors, and vendors that cover various health topics intended for large groups of people, at relatively low financial costs (M. J. Clark, 1985). Traditional health fair topics and services include early detection and disease management, consultations with health care providers (Burron & Chapman, 2011), aspects of wellness, fitness and lifestyle improvements, appointment procedures, hearing and vision conservation, and blood pressure and cholesterol screenings (M. J. Clark, 1985; Werch, Schroeder, & Matthews, 1986).

Health fairs are popular training mechanisms used to increase preservice professionals’ self-efficacy and skills related to sharing health content, understanding target populations, and promoting patient-centered practice (Fournier et al., 1999; Landy, Gorin, Egusquiza, Weiss, & O’Connell, 2012). Instructors of peer education programs and health education degree plans can leverage health fair interventions to improve professional development among preservice professionals.

Service Learning

Implementing the health fair provided an opportunity to incorporate a service learning project into an undergraduate peer health education course. The Corporation for National and Community Service (1990) defines service learning as “a method under which students learn and develop through active participation in thoughtfully organized service activities” (p. 64). Service learning integrates service with instruction and reflection to enrich the learning experience, promote professionalism, and expand community relationships (Buckner, Ndjakani, Banks, & Blumenthal, 2014; Cress, Kerrigan, & Reitenauer, 2005). Effective service learning projects should (1) meet the needs of a community, (2) integrate educational institutions (e.g., primary, secondary, and higher education) and community settings, (3) foster civic responsibility and philanthropy, (4) enhance academic curriculum, and (5) provide structured time for reflection (Cress et al., 2005; Flannery & Ward, 1999).

Potential outcomes of service learning are well documented and include increased student engagement and improved problem solving, critical thinking, and decision-making skills (Housman, Meaney, Wilcox, & Cavazos, 2012; Meaney, Kopf, Bohler, Hernandez, & Scott, 2008). Service learning improves attitudes toward service and philanthropy, increases respect for diversity and cultural competence, and enhances civic responsibility (Carson & Domangue, 2013; Housman et al., 2012). Incorporating service learning, in the form of a health fair within health education degree programs, provides a unique opportunity for students to experience the defined AoR outlined by the National Commission for Health Education Credentialing, Inc. (NCHEC; 2015b).

Professional Areas of Responsibility

The service learning health fair project allowed peer health educators to practice the seven AoR with efforts geared toward improving their competency and skill levels. Health education specialists, both preservice and practicing professionals, have a responsibility to provide information and services that improve individual- and population-level health. The Health Education Specialist Practice Analysis 2015 identified the contemporary practices of entry- and advanced-level health education specialists and reported major changes in job analysis and performance over the past 5 years (NCHEC, 2015a). The profession is guided by competencie, and subcompetencies packaged into areas of professional responsibility during practice (Jim, 2012). The seven AoR for entry-level CHES (Allegrante, Moon, Auld, & Gebbie, 2001) include the following:

I. Assessing needs, assets, and capacity for health education,

II. Planning effective health education programs,

III. Implementing health education,

IV. Conducting evaluation and research related to health education,

V. Administering and managing health education,

VI. Serving as a health education resource person, and

VII. Communicating and advocating for health and health education

The knowledge and skills underlying these seven areas help guide, evaluate, and enhance the preparation and professional development of CHES. As such, more than 90% of undergraduate health education professional preparation programs use entry-level CHES competencies as a basis for their degree plans (Schwartz, O’Rourke, Eddy, Auld, & Smith, 1999).

Purpose

The purpose of this study was to determine if participating in a service learning health fair project influenced peer health educators’ self-efficacy related to the seven AoR for CHES.

Method

Peer health educators, enrolled in an undergraduate course during the fall (2015) and spring (2016) semesters, were tasked with investigating and synthesizing health-related educational materials (e.g., content and activities) designed to meet the unique needs of college students. The course was loosely based on the Certified Peer Educator Training currently implemented as a Bacchus Initiative of NASPA–Student Affairs Administrators in Higher Education (formerly the National Association of Student Personnel Administrators; NASPA, 2016) and was taught at a large institution in the Southwestern United States. Using skills and knowledge gained from lectures and activities throughout the course, Concepts in Peer Health Education, peer health educators implemented the service learning health fair project in collaboration with campus health promotion staff. A multimethod design using survey methodologies and semistructured reflective journals was employed to evaluate changes in students’ self-efficacy related to the seven AoR for CHES.

Data Collection Strategies

Data were collected in two phases: Phase 1 used a pre- and posttest design while Phase 2 consisted of reflective journaling by students answering a group of questions (see Figure 1) focusing on their individual experience of developing, implementing, and evaluating the project. For Phase 1, students completed a pretest questionnaire designed to measure baseline self-efficacy related to the seven AoR for CHES. After the pretest, an intervention targeting knowledge and skill development occurred throughout the semester via lectures, in-class activities, and course assignments centered on a service learning health fair project. At the end of the semester, the service learning health fair project was implemented on campus. Following the event, students completed an identical posttest questionnaire to measure levels of self-efficacy related to the seven AoR for CHES.

Figure 1.

Reflective journal prompts.

Data in Phase 2 were collected following the service learning health fair project via semistructured reflective journals by students answering semistructured questions regarding their preparation for the event, skills learned, and barriers to effective planning. Journal prompts also included feelings on the overall experience, challenges to implementing the health fair, professional skill development and application, and lessons learned (see Figure 1).

Instrument Development

A pretest (see Appendix) was developed by researchers and included seven questions, one for each AoR. Students were asked to rate their self-efficacy via a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree) using the paper-and-pencil questionnaire. The instrument had good internal consistency, with Cronbach’s alpha coefficients of .786 (pretest) and .803 (posttest).

Recruitment Strategy

After receiving institutional review board approval, research assistants provided a recruitment speech and collected consent documentation. Although the actual service learning health fair project and reflection journals were mandatory for all students, participation in the research study was not a course requirement. Students who chose not to participate in the study were still required, as per course requirements, to participate in the health fair event and complete the reflective writing assignment. To be eligible for the study, students must have been (1) at least 18 years old, (2) full-time undergraduate students, and (3) enrolled in the university course within the study.

Sample

The course was offered one time during the fall (2015) and spring (2015) semesters and had 41 and 23, respectively, students enrolled. A total of 58 students completed both pre- and posttests and reflective journals associated with this study. The final sample consisted of 49 females (84.5%) and 9 males (15.5%). Students were classified according to their university standing (i.e., U1 [freshman]: n = 4; 6.9%; U2 [sophomore]: n = 8; 13.8%; U3 [junior]: n = 35; 60.3%; or U4 [senior]: n = 11; 19.0%).

Data Analysis

Quantitative data were entered using Excel®, deidentified to protect students’ identity, and coded to align pre- and posttest results. Data were analyzed using SPSS 22.0 to obtain descriptive statistics, conduct paired t tests, and determine partial eta squared effect size. Statistical significance was set at p < .0001.

Qualitative data analysis involved open axis coding and triangulation to reach agreement on codes and representations among the data. On completion of triangulation, codes were advanced to themes if the following criteria applied: (1) each researcher identified the code independently, (2) all researchers grouped codes into similar categories, and (3) the categories were acknowledged by at least 80% of the content (Patton, 2002).

Results

Quantitative Findings

A paired-samples t test was conducted to evaluate the impact of the service learning health fair project on students’ levels of self-efficacy related to the seven AoR. There was a statistically significant increase in scores across all AoR from pretest (M = 21.83, SD = 4.16) to posttest (M = 32.29, SD= 2.38), t(58) = −17.49, p < .0001 (two-tailed). The mean increase in self-efficacy scores was 10.47 with a 95% confidence interval with upper and lower bounds ranging from −11.66 to −9.27. The η² statistic (0.84) indicated a large effect size. Composite t test results can be found in Table 1.

Table 1.

Composite Results of t Test for Pre- and Posttest on Self-Efficacy.

Outcome	Pretest		Posttest		n	95% CI for mean difference	t	df	p
Outcome	M	SD	M	SD	n	95% CI for mean difference	t	df	p
Self-efficacy	21.83	4.16	32.29	2.38	58	[−11.66, −9.27]	−17.49*	57	.000*

Note. CI = confidence interval; df = degrees of freedom.

p < .0001.

The three AoR representing the largest differences included Areas III (i.e., implementing health education), V (i.e., administering and managing health education), and VI (i.e., serving as a health education resource person. t test results for all of the AoR are provided in Table 2.

Table 2.

t Test Results for Areas of Responsibility.

Outcome	Pretest		Posttest		n	95% CI for mean difference	t	df	p
Outcome	M	SD	M	SD	n	95% CI for mean difference	t	df	p
Area 1: Assess	3.29	0.86	4.47	0.50	58	[−1.43, −0.92]	−9.15*	57	.000*
Area 2: Plan	3.21	0.99	4.71	0.46	58	[−1.78, −1.23]	−10.91*	57	.000*
Area 3: Implement	2.93	0.95	4.66	0.52	58	[−1.98, −1.47]	−13.30*	57	.000*
Area 4: Evaluate	2.90	1.04	4.36	0.58	58	[−1.76, −1.17]	−10.04*	57	.000*
Area 5: Administer	2.93	0.84	4.60	0.53	58	[−1.93, −1.42]	−13.24*	57	.000*
Area 6: Resource	3.14	0.83	4.72	0.49	58	[−1.85, −1.33]	−12.18*	57	.000*
Area 7: Promote	3.43	0.75	4.78	0.42	58	[−1.57, −1.12]	−11.78*	57	.000*

Note. Boldface indicates largest changes from pre- to posttest. CI = confidence interval; df = degrees of freedom.

p < .0001.

Qualitative Themes

Results from the reflective journals indicated that involvement in the service learning health fair project enhanced the self-efficacy of the peer health educators related to the seven AoR for CHES. Without exception, the service learning experience challenged peer health educators to skillfully design and implement health intervention messages intended for a diverse campus audience. Three themes emerged from the reflective journal content analysis: (1) barriers to implementation, (2) skills acquired throughout dissemination, and (3) lessons learned. Quotations from students illustrate emerging themes from this investigation.

Theme 1: Barriers to Implementation

All students experienced barriers during the planning and implementation stages of the service learning health fair project. Barriers such as limited self-confidence and lack of peer interest and engagement presented unique challenges for peer health educators collaborating together on the project. Students discussed a sense of “nervousness” and “unease” leading up to the health fair event, which was heightened by “low levels of self-confidence” to deliver health information to peers. One student reported, “One of the barriers I faced on a personal level was the lack of confidence in myself and my abilities to comfortably talk to individuals my own age.” Another student stated, “I got really nervous and didn’t really know what to do. I mean, it’s a little different in seeing it planned out on paper and actually having to do it in person.”

Leading up to the health fair event, students reflected on their fears and hesitations about engaging and interacting with peers. Interestingly, students reported that attendees “were excited to interact with our posters” during the event and “embarrassment wasn’t an issue.”

Students did note many students walking by the fair were “distracted or preoccupied with media devices” (e.g., cell phones, iPods, iPads), hindering their ability to reach out and engage more people during the event.

An additional barrier faced by students was interacting with attendees who had differing levels of motivation. For example, some attendees received additional course credit for attending the health fair, resulting in increased levels of motivation to interact with the peer health educators and health fair content. One student commented, “I noticed that people tended to not come to our table and avoided eye contact with us if they weren’t there to get extra credit.” Challenged by varying levels of motivation, students were tasked with using creative strategies (e.g., trifold tabletop displays, interactive games and activities, and educational materials) for recruiting, engaging, and interacting with attendees at each table. Examples of creative strategies included trifold table top displays, games and activities, and educational materials.

Theme 2: Skills Acquired Throughout Dissemination

A key goal of the service learning health fair project was to provide an experience for peer health educators to strengthen necessary skills and confidence for successful careers in health education and promotion. Skills-based learning, such as working on a team, applying the AoR, and planning programs, enhanced students’ self-efficacy by providing authentic practice needed for professional development.

The service learning health fair project was designed to incorporate elements from each of the seven AoR by challenging students to apply competencies and subcompetencies to the health education intervention. Students described the experience as being a “great opportunity for us, as students, to practice as future health educators,” with one student commenting, “As a result of the health fair, I learned firsthand how to be a health educator and advocate for the profession.” Students reflected on the various AoR and how their skills improved throughout the experience, with one student asserting,

Before, the AoR had just been a foreign concept that seemed to only stay in the textbook. I feel like I understand how to actually implement them in a real life setting now because I can now actually apply the steps.

To prepare for the service learning health fair project, extensive in-class and out-of-class planning was required. Overall, students discussed improvements in understanding and applying program-planning skills with one stating, “The project as a whole helped reinforce how many steps go into planning and executing an event.” Another student reported,

Throughout the planning process, I learned how to create goals and SMART objectives and learned the difference between them. I also learned how valuable it is to have objectives to provide clearly defined checkpoints so the end result runs smoothly.

Improved confidence contributed to intrapersonal skill development and learning transfer from the classroom setting into authentic practice for all students. One student commented on applying classroom content:

. . . However, once I used the tools that we learned in the classroom setting, and applied them to the health fair, I gained an outward confidence and began to be more comfortable speaking to the diversity of students who were interested in learning more about our heath topic.

Others commented, “I feel more confident in myself as a health educator to educate youth on subjects” and “I now know how to engage and encourage positive behavior change.” Moreover, students experienced further improvements in self-efficacy with one stating, “This will help my future career as a nurse when I try to explain basic health-related information to my patients in a way they can understand.”

Theme 3: Lessons Learned

Students were tasked with reflecting on the experience and asked what things could be changed or improved for future health fair events. The majority of students appreciated the mock health fair event but suggested adding peer evaluations as well as increasing the amount of advertising and marketing throughout campus. Prior to the implementation of the service learning health fair event, students conducted a “mock” or “practice” health fair during the previous class period. One student noted, “I especially liked that we did a run through in the class before the event. We were able to then work out the quirks of how our booth would function.” Another student commented on the mock health fair by stating,

My overall preparedness for the health fair was not very high. We did have everything planned out but we had not practiced how things were going to be run at our table . . . So I would suggest for future events like this to be fully prepared on their routine, detail the order activities should be in, and to not be afraid to talk to strangers.

Students recognized peer evaluations as a potential strategy for holding each other more accountable throughout the project. One student suggested, “In the future, a peer evaluation could be part of each group member’s grade. It may be more of an incentive to participate if your grade depended on your participation.” Moreover, another student commented, “It is easier to let others do the work if you know there is no consequence for your inaction.”

Last, advertising and promoting the health fair was identified as a critical step for increasing attendance at the event. A student suggested “utilizing the department’s Facebook page for marketing could make an impact on future event participation and awareness,” while another recommended “including more advertisements before and during the event because many students mentioned they were unaware of the health fair.”

Discussion

According to NCHEC’s 2010 Health Education Job Analysis Report, undergraduate programs in health education should prepare “graduates to perform all seven of the health education responsibilities, 34 competencies, and 162 sub-competencies identified as entry-level in the 2010 hierarchical model” (American Association for Health Education, NCHEC, & Society for Public Health Education, 2010). According to these governing bodies, it is important for preprofessionals to develop their self-efficacy through performance-based exercises (McKenzie, Neiger, & Thackaray, 2013). In the current study, students reported increased self-efficacy across all seven AoR by using tools learned in the classroom setting and applying them to the health fair event, which further emphasized the importance of learning “by doing” through application and direct experience. Students described feeling prepared for the health fair event and appreciated practicing all seven AoR versus hearing about them via traditional lecture and/or textbook format.

As indicated by the results, the largest increases in self-efficacy appeared in AoR III (i.e., implementing health education), V (i.e., administering and managing health education), and VI (i.e., serving as a health education resource person). To simulate the real world, students were tasked with thinking creatively, using existing resources, and prioritizing needs. To adequately prepare students for the event, the course instructor also delivered information on each AoR and provided authentic skills practice on group facilitation, problem-solving and communication skills, and strategies for changing health behaviors in college students.

In relation to the qualitative themes, students experienced the AoR firsthand by working alongside team members to implement the service learning health fair project. Together, they developed a budget and creatively managed what little finances they had to improve attendance rates and the overall quality of the event. Last, students appreciated acting as a resource person, because they could see the value and relevancy of providing information and connected this experience to their future professional responsibilities in various health care settings.

The peer health education course used a team-based model (Parmelee & Michalesen, 2010; Prince, 2004) to engage students in the planning, implementation, and evaluation processes involved in hosting a campus health fair. Team-based learning, developed by Larry Michaelsen in 1979, requires students to work together toward a common goal while shifting the focus from knowledge transfer to knowledge acquisition (M. C. Clark, Nguyen, Bray, & Levine, 2008; Della Ratta, 2015). Using this model, students were challenged to synthesize information and provide resources on- and off-campus in an effort to increase the health literacy and well-being of their peers.

Team-building skills were strengthened among all students throughout the service learning health fair project. The health fair involved multiple components, requiring teams to be detail-oriented and timely with planning and submission efforts. Students commented on developing “problem-solving skills,” “an open appreciation for new ideas,” and learning how to “negotiate tasks and team member responsibilities.” One student described the teamwork experience:

I was able to work in a group setting in which we brainstormed ideas and collaborated to achieve the same end goal. In my future career, I will be surrounded by other individuals, working alongside one another to solve a common problem.

The opportunity for students to collaborate with a team during the project improved the individual and collective confidence needed to be effective health educators and future practicing professionals (Society for Public Health Education, n.d.).

Implications for Professional Preparatory Programs

Professional preparation programs have a unique responsibility to provide preservice professionals with the knowledge and skills needed to address the complex health issues of today and tomorrow (Cottrell et al., 2012). In pursuit of such responsibility, preparatory programs must adopt a competency-based framework for which courses, training, and experiences are aligned to the current job analysis outlook of the profession. By incorporating the professional AoR, preservice professionals would be adequately equipped to serve individuals and communities.

Findings from this study suggested that the integration of the AoR, through a service learning health fair project, was an effective mechanism to increase self-efficacy among peer health educators. These increases in knowledge and skills lay the foundation for preservice professionals to build on as they prepare for the workforce. Health education is essential to public health service and intervention, and as such, the workforce must be guided by job responsibilities and competencies acquired during preservice training (Allegrante et al., 2001). Professional preparation programs could address shortcomings in competencies or skills among preservice professionals by implementing strategic health education and promotion (i.e., health fairs or health-focused service learning projects) on their campuses. By allowing peer health educators to conduct the health fair, students were able to collaborate with another campus entity (e.g., Health Promotion), furthering collaboration and allowed for academic integration into student life services.

Strategies such as health fairs, curriculum development, employment shadowing/interning, or service learning projects are high-impact teaching practices, which could increase self-efficacy and provide insight into the job responsibilities performed by CHES (Bajracharya, 2006). Fostering opportunities for practice and skill development among preservice professionals permits students to experience the roles, functions, and standards of practice for health educators (Allegrante et al., 2001). Other health education preparatory programs are encouraged to integrate service learning opportunities into coursework to complement traditional methods (e.g., direct lectures and textbook readings) to prepare future CHES.

Limitations

Despite the importance of these findings for future health education professionals, there are limitations to the study that must be recognized. First, data collected were self-reported and thus presented possibilities for students to inject bias and inaccuracies in their responses. Second, lack of familiarity and experience with the AoR may have inflated pretest self-efficacy scores among some students. A third limitation is the imbalance of males to females in the sample, with a large portion (84.5%) represented by females. Given the self-reported and reflective nature of the data, the results from the study are not generalizable to a broader audience or context. Last, this research study was conducted in a contained, classroom setting and did not have a control group for comparison. This setting and lack of control group may have introduced bias from not only students but also the instructor who served as the principal investigator. The students, therefore, may have felt inclined to answer in a particular manner on the questionnaire or reflection journals.

Conclusion

Findings indicated increased self-efficacy among all AoR with the greatest differences in AoR III, V, and VI for CHES. Results also emphasized overall satisfaction with the service learning health fair project, uniquely the importance of applying information from the classroom setting to the real world. These findings highlight the importance of incorporating service learning opportunities in professional preparation programs to aid preprofessionals in exemplifying the AoR with competency and confidence, which can lead to increased levels of effectiveness, mastery, and productivity in the field.

Footnotes

Appendix

Authors’ Note

The protocol for this study was reviewed and approved by the institutional review board of the university at which the study was conducted (Approval: IRB2015-0409D).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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