Experience of Mental Health Professionals Collaborating with Peer Supporters in a Community Mental Health Service Team

Introduction

Amid social change, people are becoming more accepting of those with mental disorders; still, prejudice against mentally ill people persists [1]. Diagnostic and therapeutic approaches to mental disorders have diversified according to changes in perception, but social rehabilitation remains limited. In 2019, 34.9% of people with disabilities in Korea were employed. Among them, the employment rate of people with mental disabilities was 11.6%, significantly lower than that of people with facial disorders (59%) and intellectual disabilities (44.3%) [2]. These high unemployment rates may be due to the lack of understanding of mental disorders and their low priority as service targets [3].

Peer support for people with mental disorders can be considered a process of mutual aid between persons experiencing the same mental disorders [4]. Peer supporters with mental disorders play a dual role as patients or experts in the recovery process to engender hope in people with mental disorders [5,6]. Peer supporters can play various roles by connecting resources, sharing their experiences, and building communities to help patients, collect information, and communicate with team members as indirect partners [7]. These roles allow them to positively affect others to create a virtuous cycle of self-improvement. To that end, hiring and nurturing peer supporters is important [8].

In Korea, peer support programs for people with mental conditions have been discussed since the 2000s [6]. Peer support programs began to be implemented nationwide in 2020 as a standard service led by the Ministry of Health and Welfare [9]. A standardized peer support training curriculum and teaching materials were established in 2020, and peer supporters are currently being trained [8]. In addition, peer supporters for people with mental disorders are employed in the outpatient clinics of the National Mental Health Center, where peer counseling rooms are set up [4]. Some hospitals also commission mental health care centers to hire peer supporters and place them in local mental health care centers or rehabilitation centers [10]. At present, however, peer support is not institutionalized as a mandatory service, as in the United States, and is only offered as a pilot project [11].

The concept of peer support for people with mental disorders has only recently been applied in Korea [5]. Although the number of people certificated through the peer supporter program has increased in 2020, job availability remains low [12]. Although established as a system, peer supporters struggle without additional forms of employment [4]. Previous research findings indicate that peer supporters experienced a sense of alienation due to a lack of understanding about their roles while employed at mental health service institutes [13–15].

In addition to expanding the number of mental health peer support workers, understanding the adaptation of colleagues working together in an unfamiliar environment is also important in peer support work [16]. Studies about peer support in Korea have primarily focused on the establishment of a foundation to develop the job theme and provision of service, including studies on the foundation for the development of the job theme [13], the recovery of peer supporters through their peer support activities [5,17], and peer support services [18,19]. Foreign studies on peer supporter activities have expanded to include studies on the future of mental health care centering on peer support and social media [20] and the peer support protocols in treating addiction and other mental health issues [21]. Only one study has been conducted on the employment of mentally disabled people and peer supporters with mental disorders in Korea [10,22]. It focused on employers who hired mentally disabled people but did not work with them directly. A series of studies on collaboration with peer supporters were recently carried out in Korea. However, studies focusing on mental health professionals working with peer supporters are rarely conducted. In Canada and Germany, studies on the employment of peer supporters focused on their significance and how they were integrated with mental health professionals [10,22,23].

In South Korea, a certain number of peer supporters have become certified each year since 2020, and they are employed through a pilot project in some mental rehabilitation institutions [6]. In Korea, peer supporters with mental disorders mostly work at mental health rehabilitation centers, and mental health professionals are their stakeholders [24]. Psychiatric rehabilitation institutions are staffed by practitioners who have a basic understanding of people with mental disabilities [15]. This arrangement is beneficial because peer supporters with mental disabilities are more likely to perform their duties and retain their jobs when working with practitioners who have a basic understanding of mental disabilities [12,13]. Therefore, employment is an integral part of the welfare of people with mental illness, and the process of adapting as a colleague of practitioners in psychiatric institutions, which is currently being piloted, must be understood for the development of the mental health sector in Korea and the institutionalization of peer support [4]. Thus, in order to explore these processes, a qualitative research approach was selected to understand the experiences of professionals working with peers with mental disabilities and the meaning of such experiences. Through this, we aim to provide basic data necessary for the activation and settlement of Korean-style peer support workers in mental rehabilitation institutions.

Method

Research design and participants

This study applies the qualitative research approach to explore the experience of mental health professionals collaborating with peer supporters in a community mental health service team, as stated above. As in this study, a qualitative research method that allows in-depth and detailed access to the experiences can be more effective than the existing quantitative research method for accessing the experience of working with fellow applicants. The participants in this study were selected among mental health professionals working at mental health rehabilitation centers with peer supporters hired through the peer supporter nurturing program based on the recovery model after receiving their consent.

Specifically, the study participants are mental health professionals who 1) work at mental health rehabilitation centers with peer supporters who have worked there for more than 6 months and 2) have experience collaborating with peer supporters. Purposive sampling was applied to collect the study participants after contacting two centers that agreed to have an interview because few institutes had paid peer supporters, as the peer supporter program was still in its early stage of adoption. However, the participants were selected among those who volunteered to participate in the study. A total of six mental health professionals—one male and five female-participated in the study. Their average age was 36.20 and ranged from 26 to 50. Meanwhile, they served for 6.5 years on average, and the years of service varied: 3–5 years (3 persons), 6–9 years (2 persons), and over 10 years (1 person) (Table 1).

Data collection

The research was carried out from January 19 to February 23, 2021, and data were collected through individual or focus group interviews, spanning approximately 60 to 90 min for each session. Each interview was carried out in the training room of the institutes that participated. The interviewees were divided into two groups based on their years of service: those who worked for three years or longer at the mental health rehabilitation center and those who joined the center less than three years ago. Each person was interviewed once or twice separately, and two group interviews were performed. The purpose of the individual interviews was to collect in-depth data and materials from each participant about the main themes of the study. Both interviewer and interviewee were checked for fever and respiratory symptoms for concerns over the spread of COVID-19, and the interview was carried out in compliance with the COVID-19 regulations and guidelines while wearing masks. The individual and focus group interviews on the training room started with semi-structured and open questions (Table 2). The interviews ended when they were considered to have reached the point of theoretical saturation with overlapping comments and content without the generation of new categories for data collection and analysis.

Data analysis

This study adopted the six simple steps developed by Braun et al. [25] to thematically analyze the content of the in-depth interviews. An evaluation team with two coders, including one of the researchers and one editor, analyzed the data. The editor had extensive clinical experience in psychiatric nursing and conducted qualitative research projects as a nursing professor. In the first step, the two coders highlighted the words or sentences containing core statements, metaphorical expressions, etc. The coefficient of agreement was derived and verified to measure the consistency in coding between the two coders. The coefficient of agreement was approximately 93.1%, indicating high consistency and reliability [26]. In addition, with the agreed coding units, a third coder analyzed the same coding units using the same coding book to ensure the stability of reliability. In other words, the results of one researcher’s analysis can produce the same results over time, confirming theoretical saturation.

They also conducted a line-by-line analysis independently to develop a coding book with words, sentences, and paragraphs as a draft. In the second step, researchers extracted 149 codes from the content. Step 3 was to search for themes. By combining each code with similar concepts, the first and second corresponding authors received IRB approval while attending Gyeongsang National University. Written consent was acquired from the participants. The participants were informed of their right to confidentiality, recording of the interview for data analysis, confidentiality and use of the interview results, potential discontinuation of the study, withdrawal, etc. The collected data were assigned an ID for storage and codified to avoid disclosure of personal information. The researcher guaranteed participants’ anonymity and confidentiality and explained that their interview would be used for research only. The questionnaire will be retained for three years after the completion of the study and then discarded. Gift certificates were given to the participants after the interview as compensation. Researchers compared them to ensure they corresponded to the themes and defined how each theme was conceptualized and connected to others. They continued to review themes until they reached saturation of meaning. To ensure the reliability of the research, two coders from step 1, developed and validated a coefficient of agreement to measure the consistency of coding. During the process, 26 subcategories were drawn, and the interview content was confirmed by the participants to find the point of saturation. Reviewing themes was the fourth step. After extracting 149 meaningful statements, researchers developed four main themes and eight categories from 26 subcategories based on commonalities. In the fifth step, to define and name themes, researchers continued to compare the themes to identify ones that were clearly distinguished from others. Next, they provided clear definitions and named the themes based on participants’ opinions. To that end, researchers shared the analysis results with two participants to clarify poorly understood or misinterpreted items. The final step was to produce a report, which involved citing the statements that conveyed the meaning of each theme the most concisely.

Ensuring the validity of the research

The four-dimension criteria of Guba et al. [27] were applied to assess the rigor of the research. First, the researcher and a coresearcher repeatedly read notes and records of the interview to analyze the data to understand the perceptions and experiences of the participants to guarantee the credibility of the research. Second, the participants were selected among those who could express their experience working with peer supporters as colleagues. Third, the researcher ensured that the collection and analysis could be carried out in parallel during the research. Fourth, the researcher took notes during the data collection and analysis and reviewed them later to exclude subjectivity and prejudice.

Ethical considerations

This study received approval from the Institutional Review Board of Gyeongsang National University (IRB No. 079-01). Written consent was acquired from the participants.

Results

As a result of the study, 149 meaningful statements were gathered and then developed into 24 subcategories, 8 categories, and 4 themes (Table 3).

Theme 1: Perceptions of and challenges in working with peer supporters with mental disabilities

The participants were concerned about working with peer supporters with mental disorders in the early stage because they had no such experience. For instance, they did not know how peer supporters with mental disorders were perceived by mental health professionals. However, they looked forward to working with peer supporters because they wanted to know how well the peer supporters could fulfill their roles and hoped that they could carry out their duties proactively.

Burdens of collaborating with peer supporters as colleagues

The participants responded that they were unsure how to treat peer supporters because they considered them members under case management at the mental health rehabilitation center. The participants also pointed out a lack of criteria and vague responsibilities of peer supporters because the mental health center hired them in accordance with a government job-creation policy. They were concerned about the potential burden of supporting the activities of peer supporters. Their biggest concern came from the uncertainty about the capability of peer supporters.

“At first, I could not say that I was glad to have them as my colleagues. It took time to understand each other. We had to know how much we could expect them to do as our colleagues and what roles they could play. It appeared that they were confused about their roles in working as peer supporters as well. Thus, I had no room to figure out the benefits of collaborating with peer supporters.” (Participant 2).

Expectations of job competency as mental health professionals to peer supporters

The participants expected peer supporters to understand their roles and carry out activities proactively as their colleagues. For instance, they thought peer supporters could help them form healthy relationships with others recovering from mental disorders.

“I initially expected that peer supporters could play a role in crisis intervention or accompany the members during their ambulatory care by adjusting hours or days of work. Also, I hoped that they could use their flexible work schedule to spend time together with the members.” (Participant 3).

Theme 2: Conflict and confusion about working with peer supporters as colleagues

The participants said that peer supporters initially had difficulties adapting to the work. The peer supporters wanted to do office work such as project planning, handling of the budget, etc. However, the participants responded that they hoped peer supporters could work as mediators to link them with the members. Therefore, a conflict arose between the roles that peer supporters wanted and the ones that the institute expected, which confused peer supporters.

The discrepancy between the expectations of professionals and the competencies of peer supporters

The participants said they initially experienced an increased workload because they had to help the peer supporters. Although they expected that the peer supporters could play the role of experts, the participants answered that thoughtful considerations were needed to work with peer supporters as colleagues as conflicts arose due to vague responsibilities, lack of mutual understanding, etc. The participants added that patience and communication are required until the peer supporters fulfill their roles as experts.

“Peer supporters were serving as external lecturers for other institutes, and they carried out activities that required many responsibilities. The members of this institute largely participated in its programs only, and that was where a difference was made with peer supporters. Unlike the members of the institute, peer supporters had a mindset to accomplish a task given to them no matter how difficult it was, and they considered that “They had to overcome the challenge no matter what it took.” That is the basic difference between the members and peer supporters. As for the peer supporters who joined the institute as employees, they needed to serve as mediators to help the members under case management deal with difficulties more professionally. However, they were lacking in that respect.” (Participant 1).

Difficulties in having a vague relationship with colleagues

The participants answered that building relationships with peer supporters was confusing because they were unsure whether to treat them as colleagues or members. Although they knew that they had to recognize peer supporters as colleagues, accomplishing this required approximately six months. They said that the position and role of peer supporters according to the form of employment resulted in issues of equity with existing employees working at the mental health rehabilitation center. The participants also said that they worried about peer supporters who might experience the aggravation or recurrence of symptoms due to the stress incurred while carrying out their duties.

“It was very difficult to establish a relationship with peer supporters who joined the institute. They took the stance of questioning why we treated them as members instead of employees. Later, it turned out that they thought that it was not fair to ask them to do the work like this, even though they were still suffering from mental disorders.” (Participant 4).

Theme 3: Forming partnerships with peer supporters who are experts through experience

The participants found that peer supporters gradually began to understand their job roles and carry out their work as colleagues. By watching the peer supporters approach the members excluded from others and talk to them as colleagues, the participants found that they searched for work they could do and responded to the circumstances proactively as time passed. During the process, the participants said that they formed partnerships with peer supporters while accepting their job competency.

Changing perceptions from patients under case management to colleagues as experts by experience

Initially

Peer supporters could not fulfill their duties due to not understanding their roles. As time passed and they became aware of what they had to do, the peer supporters began to find the boundaries and scope of their responsibilities, such as operating programs and caring for the members under case management. Moreover, participants felt great witnessing the peer supporters serving their roles as colleagues and experts by experience, and working together brought a positive change in jobs.

“Those who completed the peer support program were aware of their mental disorders in most cases, and it seemed that they felt the responsibility to the extent that they could ‘do something for their colleagues with mental disabilities based on their experience’ while working at the center.” (Participant 5).

A glimpse into the possibility of cooperation to serve as a bridge between patients and professionals

The participants said that peer supporters slowly began to understand what they could do better as the persons directly involved and what they should do as peer supporters. For instance, the members shared stories with peer supporters, who served as a bridge for communication to convey the difficulties and needs of the members. The participants found that the peer supporters considered how the members would think in their position and what they should do as mental health professionals. The participants also said they felt peer supporters could now mingle with them naturally as coworkers.

“When the members registered as those with mental disabilities were operating social skills programs for employees with mental disorders, they often faced difficulties. In such cases, I often find it difficult to continue the program as well. That is when help from peer supporters is needed. As they participated in the program and took initiative, the members were more encouraged to be engaged in the program following their lead. Thus, I believe that it is good for peer supporters to provide aid to run group programs for people with mental disabilities.” (Participant 2).

Theme 4: Policy recommendations for the job security of peer supporters

The participants stressed that the system should be reinforced to hire peer supporters and promote the program. Most of all, the participants considered that building peer supporters’ capacities was required for them to play their roles accordingly, in addition to economic aspects, such as budget support from the government, etc. They said that there was a need to build infrastructure allowing peer supporters to build their capacities, such as intensive training programs or ones to reinforce their competencies as experts.

Establishment of systematic training programs to better understand their roles with each other

The participants believed that the current peer support program was focused on the nurturing of peer supporters only. Thus, they considered that both quantitative and qualitative growth was required for peer supporters to help them increase their expertise as mental health professionals. Specifically, the participants emphasized that specified intensive programs and supervision were required for peer supporters who would volunteer and willingly participate in such programs to strengthen their capabilities. In addition, the participants said that the peer supporters should be understood by their colleagues as members of an organization after completing programs as experts.

“Although many members want to work as peer supporters, there are not enough resources to supervise and help them move on to take a new leap forward. Teachers were exhausted as well.” (Participant 3).

“I think that it would be great for peer supporters and experts to receive training to work together in practice to prepare for collaboration in reality.” (Participant 2).

Building the infrastructure to enhance the capability of mental health professionals.

The participants considered that there was a need to build a network for peer support to communicate and share opinions to promote their activities. As mentioned above, each community mental health institute in Korea has its strengths and operates different systems to assign roles to peer supporters. To help peer supporters fulfill their roles, therefore, the participants believed that peer supporters should be involved in the process of developing manuals on the standardization of operations corresponding to the circumstances in Korea, away from the concept of temporarily providing jobs.

“I hope that the government can help peer supporters continue their work stably so that they can grow while working. Stabilization of their wage, working hours, etc., as a concept of investing in human resources can be an example of such efforts. Peer supporters left the mental health rehabilitation institutes to find better jobs for themselves. Otherwise, they could be paid as public employees and play their part in the community. It would be great if they were able to focus on their work at community mental health rehabilitation centers.” (Participant 6).

Discussions

This study explored the experiences of mental health professionals collaborating with peer supporters with mental disabilities based on their interviews as stakeholders. After exploring the experience of the participants, their experience was primarily divided into four categories: “perceptions of and challenges in working with peer supporters with mental disabilities,” “conflict and confusion about working with peer supporters as colleagues,” “forming partnerships with peer supporters who are experts by experience,” and “policy recommendations for the job security of peer supporters.”

First, the participants felt the burden of collaborating with peer supporters and expected them to have job competency as their colleagues. For instance, the participants expected that peer supporters would provide relevant expertise. Simultaneously, they were concerned about the potential poor performance of peer supporters in fulfilling duties because they had no experience working with them. The results suggest that such concerns were caused by a low level of understanding of peer supporters’ role, leading participants to view the peer supporters as patients or those under case management. Similarly, Jacobson et al.’s [7] interviews with peer supporters revealed that the peer supporters felt that mental health professionals viewed them as “patients who were vulnerable and required particular attention” rather than “colleagues with expertise.” Therefore, precisely defining the scope of responsibilities of peer supporters can significantly improve job satisfaction [28,29]. Unlike other workplaces, these participants have a basic understanding of the nature of mental disorders, and the peer support organization is a source of advice and support from supervisors and managers that they can talk to if they are struggling with symptoms at work. Therefore, training is essential for peer support to become established and widespread in Korea, but it must be accompanied by a professional understanding of peer supporters by the professionals with whom they work.

Second, the conflict and confusion about working with peer supporters as colleagues were related to their poor performance based on a low level of understanding of their duties and vague relationships with colleagues. As in the study of Ha [4], it seems that the failure of peer supporters to volunteer and assume an active role was due to difficulties in shifting their position from patients to employees because they had long been accustomed to being members and patients. Peer supporters experienced various types of stress, which led to the recurrence of symptoms and hospitalization. According to McLean et al. [30], peer supporters’ relationships with employees and colleagues were critical elements that significantly impacted the rehospitalization of peer supporters. Studies by Asad et al. [23] and Burr et al. [30] reported that peer supporters worried about whether the mental health professionals collaborating with them still considered them as vulnerable patients and whether expressing their difficulties might be interpreted as indicating symptom recurrence. These studies [22,30] pointed out that working as peer supporters involves changing from “patients” in need of help to “peer supporters as colleagues and experts by experience” and practicing how to manage stress from work and personal relationships. Participants in the present study reported feeling uneasy because of the blurring boundaries of work when peer supporters who were under their case management became their colleagues and the recurrence of peer supporters’ symptoms due to stress. For mental health professionals, forming relationships with peer supporters are like collaborating with experts from an unfamiliar field. For peer supporters, it involves conducting activities proactively with significant responsibility [31]. Thus, it is an important process for both parties. In Korea, peer support training programs are fairly new, so even mental health professionals may lack a sufficient understanding of peer support. This lack of understanding may impede peer supports from conducting their own work, even if they are employed by community mental rehabilitation organizations, limiting them to playing a supporting role in the organization [32,33]. Therefore, training for peer support workers must be accompanied by training for professionals to improve their understanding of peer support workers.

Third, forming partnerships with peer supporters as colleagues required recognizing them as experts by experience rather than individuals under case management and embracing the possibility for collaboration between experts and members to serve as a bridge. Mental health professionals could recognize support workers as colleagues while increasing their roles according to the level and speed of adapting to their work instead of assigning them fixed roles. Peer supporters can understand the difficulties patients face because they have faced similar difficulties. Thus, they are uniquely positioned to help to patients or persons under case management [4]. In this regard, the participants were relatively slow to engage in the activities in the early stage. However, they could eventually set the boundaries and scope of their work by identifying their roles. Peer supporters appeared to develop their new identity as experts by experience as time passed and explored their roles proactively. As peer supporters or experts by experience, they can also play the role of mediator to help mental health professionals and patients better understand each other amid a conflict or communication process. Peer supporters also desired to overcome the stigma and trauma associated with being under case management to serve as role models for others in the recovery process [28]. Due to the stigma associated with mental disorder, employers are reluctant to employ people with mental disabilities, resulting in limited job opportunities [34]. However, the employment of peer support workers, who can use their experiences with mental disabilities as strengths, is expected to spread through the cooperation system of mental health organizations, job development tailored to the characteristics of people with mental disabilities, and increased awareness of social stigma [4,35]. In particular, if the activities of peer supporters in mental health organizations prove to be beneficial to the recovery of other people with mental disabilities, the number of jobs will continue to increase, and the employment model for peer supporters with mental disabilities will spread.

As for policy recommendations to ensure job security for peer supporters, it is necessary to provide intensive training programs and build infrastructure to enhance their capability as mental health professionals [10,13]. Experts in mental health rehabilitation organizations recognize the effectiveness of peer support and see it as a necessary service within the mental health care field [16]. However, they remain concerned about the wages and working system for peer support workers; thus, policy changes are needed to provide them with a stable social network.

Although there were job analysis guidelines [1,17] and training programs provided by the Ministry of Health and Welfare [36] for peer supporters, the participants suggested that more detailed and precise courses should be provided. Meanwhile, they believed that building infrastructure for cooperation with related agencies and organizations was necessary to help peer supporters develop their expertise and proactively carry out activities. Because peer supporters’ know-how is based on their experience, it can only be shared between people with similar experiences. Having experience is required for peer supporters in the United States, Canada, and Australia [37]. Community mental health institutes differ by region. Thus, they have different service content to offer. To minimize the impact of their limitations on service provision, peer supporters must be matched with patients or persons under case management based on their demand through the workforce pool and cooperation with local communities. To that end, efforts are needed to provide intensive training programs to increase expertise and nurture peer supporters who can operate training programs or build workforce pools in local communities.

Moreover, legitimate, conveniently located facilities and relevant regulations based on understanding the characteristics of mental disorders vulnerable to stress should be provided [13–15]. To secure peer supporters’ expertise, community mental health professionals should precisely understand the peer supporters they collaborate with [4]. Thus, training programs for peer supporters and mental health professionals in the institutes where peer supporters mostly work will be needed for their equal relations as they work as a team.

Limitations

The subjects of this study were mental health professionals. Although they were colleagues of peer supporters, they previously served as their case managers. Moreover, all participants worked at the same institute, so their responses may not be generalizable because the types of employment and duties assigned to peer supporters may vary by the institute. Moreover, although the training of peer supporters has been institutionalized in Korea, their employment types differ, which could limit the findings’ generalizability. Some provide services as more of a form of self-help than employment, while others are part-time, with an activity fee for visiting services and the cost of the activity billed later. Therefore, the findings are limited because the data were collected from professionals in the same mental health organizations. The experiences of practitioners from different organizations are heterogeneous, which is why a qualitative approach was taken to studying practitioners in the same organization. This study is an attempt to explore the perceptions of professionals in mental health rehabilitation organizations who work with peer supporters and their experiences in this process. Therefore, it may not be possible to compare the collaboration between peer supporters and mental health professionals and the dynamic changes in their interactions.

However, Korea has only recently adopted the concept of peer supporters. It is expected that with the emergence of new occupations, employing peer supporters may become a model for vocational rehabilitation as the new era of mental health unfolds. Diversity in data collection should be secured by conducting a joint interview with peer supporters and mental health professionals and providing means for raising issues as minority opinions, such as sharing information between members and clarifying boundaries, although this was not investigated in this study.

Conclusion

This study explored the experiences and future directions of professionals working with paid peer supporters with mental disorders in a community mental health organization. Early in the study, participants identified vague anxiety about working with peer supporters and the trial-and-error process of adjusting to the role as challenging. Over time, however, participants found that peer supporters worked to form relationships with professionals as coworkers and establish meaningful roles. Participants see peer support workers as a necessary service within the mental health field. However, they remain concerned about the wages and management system for peer support workers and believe that policies should provide them with a stable social network. Employing peer support workers who can use their experiences with mental disorders as a strength requires establishing a cooperative system of specialized organizations for people with mental disabilities and infrastructure for job development and capacity-building tailored to the characteristics of people with mental disabilities. Furthermore, public and private organizations must recognize the need for peer supporters, hire them, and establish an institutional foothold to support their work performance. Thus, professionals in mental health rehabilitation institutions play a significant role in the adoption of peer support workers. Thus, professionals in mental health rehabilitation institutions play a significant role in the adoption of peer support workers. In creating a nationalized employment environment, policymakers should not only emphasize the effectiveness of employing peer supporters in mental rehabilitation institutions but also invest in training and education to stabilize their role in these institutions.

Acknowledgement: The authors would like to acknowledge all the anonymous participants in the research.

Funding Statement: This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Education (2019R1F1A1A0057735).

Author Contributions: The authors confirm their contribution to the paper as follows: study conception and design: B.K.; data collection: B.K., S.L.; analysis and interpretation of results: S.L., B.K., C.K.P.; draft manuscript preparation: S.L., B.K., C.K.P. All authors reviewed the results and approved the final version of the manuscript.

Availability of Data and Materials: The data is available on request from the corresponding author.

Ethics Approval: This study received approval from the Institutional Review Board of Gyeongsang National University (IRB No. 079-01). Written consent was acquired from the participants.

Conflicts of Interest: The authors declare that they have no conflicts of interest to report regarding the present study.

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