Barriers to Implementing behavioral sleep interventions for infants: a path analysis of parental cognition and sleeping arrangement

Barriers to Implementing behavioral sleep interventions for infants: a path analysis of parental cognition and sleeping arrangement | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 18 June 2025 V1 Latest version Share on Barriers to Implementing behavioral sleep interventions for infants: a path analysis of parental cognition and sleeping arrangement Authors : Seoha Kyung and Sooyeon Suh 0000-0003-0644-8634 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175027695.56719327/v1 Published Behavioral Sleep Medicine Version of record Peer review timeline 256 views 118 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction: Behavioral sleep interventions (BSIs) improve infant sleep but are less implemented in Asian countries, where co-sleeping is common. This study explored environmental (sleep arrangements) and personal (parental cognition) barriers to BSI implementation among South Korea parents. Methods: A total of 507 parents with children aged 6 to 36 months. Participants completed the Parental Understanding and Misperceptions about Baby’s sleep- Questionnaire (PUMBA-Q) and Brief Infant Sleep Questionnaire-Revised (BISQ-R). Information about sleep arrangements and BSIs experience were collected. Path analysis tested a model predicting BSIs implementation and infant sleep. Results: Only 21.9% of parents reported implementing at least one BSIs. Children receiving BSIs had significantly longer total sleep. Path analysis showed parental cognition and bed-sharing directly affected BSIs and indirectly affected child sleep through BSIs implementation. Discussion & Conclusion: This study identifies sleep arrangement and parental cognition as barriers to implementing BSIs, which may inform tailored BSI strategies. Barriers to Implementing behavioral sleep interventions for infants: a path analysis of parental cognition and sleeping arrangement Introduction: Behavioral sleep interventions (BSIs) improve infant sleep but are less implemented in Asian countries, where co-sleeping is common. This study explored environmental (sleep arrangements) and personal (parental cognition) barriers to BSI implementation among South Korea parents. Methods: A total of 507 parents with children aged 6 to 36 months. Participants completed the Parental Understanding and Misperceptions about Baby’s sleep- Questionnaire (PUMBA-Q) and Brief Infant Sleep Questionnaire-Revised (BISQ-R). Information about sleep arrangements and BSIs experience were collected. Path analysis tested a model predicting BSIs implementation and infant sleep. Results: Only 21.9% of parents reported implementing at least one BSIs. Children receiving BSIs had significantly longer total sleep. Path analysis showed parental cognition and bed-sharing directly affected BSIs and indirectly affected child sleep through BSIs implementation. Discussion & Conclusion: This study identifies sleep arrangement and parental cognition as barriers to implementing BSIs, which may inform tailored BSI strategies. Keywords : pediatric sleep, behavioral sleep intervention, parental cognition, co-sleeping Abbreviations: BSIs, Behavioral Sleep Interventions; BISQ-R, Brief Infant Sleep Questionnaire-Revised; CFI, Comparative fit index; LL, Lower limit confidence interval; NWAK, Number of aWAKenings; PUMBA-Q, Parental Understanding and Misperceptions about Baby’s sleep- Questionnaire; RMSEA, Root mean square error of approximation; SOL, Sleep onset latency; SRMR, Standardized root mean square residuals; TLI, Tucker-Lewis index; TST, Total sleep time; UL, Upper limit confidence interval; WASO, Wake time after sleep onset Introductions Infants, whose circadian rhythms are not yet established after birth, undergo dynamic sleep changes and gradually differentiate between night and day over the first year, eventually developing a stable sleep pattern (Mirmiran, Baldwin, & Ariagno, 2003; Sadeh, Mindell, Luedtke, & Wiegand, 2009). The average total nighttime sleep duration for infants aged 3 to 24 months remains stable between 9.1 and 10.2 hours(Paavonen et al., 2020). However, approximately 20-30% of infants and children are reported to have sleep problems, including night awakenings, difficulty falling asleep without parental intervention, and difficulty sleeping alone(Williamson, Mindell, Hiscock, & Quach, 2019). Behavioral sleep interventions (BSIs), which are based on learning principles such as extinction, have been proven effective in improving sleep problems and stabilizing sleep in infants and young children(Meltzer & Mindell, 2014). To date, there are three types of BSIs that have been proven to be effective: unmodified extinction, graduated extinction, and extinction with parental presence(Mindell et al., 2006). Small to moderate effect sizes were found for BSIs interventions in 12 studies examining the efficacy of BSIs in young children, which indicated Sleep Onset Latency (SOL), Number of aWAKenings (NWAK), and Wake time After Sleep Onset (WASO) improved following intervention(Meltzer & Mindell, 2014). In addition, increases in nocturnal total sleep time and advances in bedtime in intervention groups compared to control groups have also been reported(Rouzafzoon, Farnam, & Khakbazan, 2021). Previous studies emphasize the importance of providing early intervention for pediatric sleep problems because they have the potential to negatively affect behaviors. Meta-analysis studies have suggested that pediatric sleep problems may have a negative effect on behavioral problems(Liu et al., 2024). However, although BSIs have been shown to be effective, the rate of implementation of BSIs varies widely and certain populations have lower implementation rates. For example, implementation rates of BSIs have been reported to range from 8.8 to 64.0% depending on geographical location and ethnic background (Honaker, Mindell, Slaven, & Schwichtenberg, 2021; Kahn, Barnett, & Gradisar, 2023; Kyung et al., 2022). These low implementation rates suggest that there may be significant barriers to implementing BSIs(Etherton, Blunden, & Hauck, 2016). Parental cognition and sleep arrangements are proposed as barriers to implementing BSIs(Whittall, Kahn, Pillion, & Gradisar, 2021). Parental cognition about their child’s sleep involves perceptions, attitudes and beliefs about their child’s sleep in addition to concerns, worries, and fears about the child’s sleep(Knappe, Pfarr, Petzoldt, Härtling, & Martini, 2020). Previous studies have emphasized the relationship between parental cognition and infant’s sleep problems. Morrel and colleagues found that maternal cognitions related to difficulty with limit setting, increased doubts about parenting competence and increased anger at infant’s demands were significantly associated with infant sleep problems(Morrell, 1999; Sadeh, Flint-Ofir, Tirosh, & Tikotzky, 2007). Parental cognition about infant sleep has also been associated with the implementation of BSIs. Parents who believed that parents needed to help their child sleep alone were significantly less likely to implement BSIs(Honaker et al., 2021). Additionally, many studies suggested that parents who interpret their child’s crying as pain and have difficulty in limiting setting find it difficult to ignore their child’s crying(Etherton et al., 2016; Sadeh, Tikotzky, & Scher, 2010). Another identified barrier to implementation in BSIs is sleeping arrangements: solitary sleeping, room sharing without bed sharing, and bed sharing (parent and child sharing the same bed)(Mindell, Sadeh, Kohyama, & How, 2010; Volkovich, Ben-Zion, Karny, Meiri, & Tikotzky, 2015). Infants in cultures where it is the norm to sleep in the same bed as their parents get less sleep than those who don’t(Mindell et al., 2010). Tolerating a child’s crying is difficult for many parents, and co-sleeping may make it easier for parents to respond to their child’s crying, making parental cry tolerance a significant barrier in implementing BSIs(Whittall et al., 2021). However, few empirical studies have examined the role of parental cognition, particularly in relation to infant sleep concerns, and parent-child sleep arrangements on BSIs implementation. Considering the low implementation rates of BSIs in cultures that encourage co-sleeping despite strong evidence of improving pediatric sleep problems, identifying and addressing modifiable factors that act as barriers to BSIs should be investigated. In this current study, we investigated the indirect effect of parental cognition and bed-sharing on implementing BSIs in infant sleep. The specific hypotheses are as follows: (1) High levels of negative parental cognitions about the child’s sleep will be associated with lower implementation of BSIs and shorter total sleep duration of the infant; (2) bed sharing will be associated with lower implementation of BSIs and shorter total sleep time for the infant. Methods Participants This study was conducted among parents with children aged 6 to 36 months (N=507) in South Korea. Inclusion criteria consisted of the following: (1) parent’s age ≥ 19 years; (2) child’s age between 6 to 36 months; (3) and the child’s gestational age born after 37 weeks. Participants were excluded if they had been diagnosed with bipolar disorder, schizophrenia spectrum disorders, or psychotic disorders, or if the child’s gestational age was before 37 weeks or after 42 weeks. Procedure Participants completed an online self-report survey through a research company, Macromill Embrain (www.embrain.com). This company specializes in collecting data from online questionnaires and has the largest research panel in Korea. Participants were randomly selected using a stratified sample. All participants completed an informed consent form prior to participating. The survey was conducted anonymously. This study received ethical approval from the Department of Institutional Bioethics Committee of Sungshin Women’s University (SSWUIRB-2022-050). Measures Socio-demographic information. Participant’s socio-demographic information was collected for the study, including sex, age, education level, and monthly household income level. Additionally, the child’s sex, birth order and age in months were also collected. Parental Understanding and Misperceptions about Baby’s sleep- Questionnaire (PUMBA-Q)(Jang et al., 2023). The PUMBA-Q measures parental thoughts and beliefs about their child’s sleep. PUMBA-Q consisted of 23 items and four subscales: (a) misperceptions about parental intervention; (b) misperceptions about feeding; (c) misperceptions about child’s sleep; (d) general anxiety of parents. This scale does not assume that solitary sleeping of the child is the norm and was developed to be a culturally inclusive questionnaire. The PUMBA-Q was validated in a large sample and also validated with subjective sleep measures and child sleep indices measured by auto-videosomnography(Jang et al., 2023). PUMBA-Q is a 4-point Likert scale, with high scores reflecting higher levels of dysfunctional beliefs about the child’s sleep. Internal consistency (Cronbach’s alpha) was 0.868 in this sample. Information on infants’ sleep and sleeping arrangement. Participants responded about their child’s sleep, including their child’s sleep problems (e.g., which of the following sleep problems does your child have?). In the study, sleep questions were presented as difficulty with sleep onset, difficulty with limit-setting, difficulty with sleep onset after awakening, and other (open-ended). Sleeping arrangement was assessed with one question. Participants responded about the child’s sleeping arrangement through the question ”How do you sleep with your child?”. Each sleeping arrangement was presented alongside an illustrated image to aid in understanding. It was coded as bed sharing if the child and caregiver were sleeping in the same bed. Implementation of Behavioral Sleep Intervention for infants. Participants responded to three questions about whether they had implemented each of the three BSIs (e.g., Which sleep interventions have you tried before or are you currently using? You can choose multiple methods). The BSIs included in the questions were standard extinction, graduated extinction, and extinction with parent presence. In the study, additional information about each BSIs was provided to help participants’ understanding. The three methods are presented with an explanation of how is implemented, respectively: standard extinction (a method where you put the child down to bed when he/she is drowsy, leave the room, and do not attend to the child crying), graduated extinction (also called ferber method, a method where you gradually extend the time you check in with your child after putting him/her down to sleep, extinction with parent presence (called camping out, a method where you put the child down to bed when he/she is still awake, and stay in the room until the child goes to sleep, and this method is often accompanied by distancing yourself physically in a gradual manner every day from the child). Participants implementing any of the three methods were considered to be implementing BSIs. Brief Infant Sleep Questionnaire-Revised (BISQ-R)(Mindell, Gould, Tikotzy, Leichman, & Walters, 2019). BISQ-R is a revised questionnaire that measures infant sleep patterns, sleep-related behaviors, and infant sleep environment by parent report(Sadeh, 2004). The questionnaire was translated and back-translated into Korean by a sleep specialist fluent in English and Korean, and a master’s level student. Answers to multiple-choice questions about where the baby usually sleeps (e.g., Bumper Bed) and the parents’ education level were added or modified to fit the Korean cultural context. For this study, we used a question that asked about the child’s total sleep time (TST): ”How many hours and minutes does your child sleep during the night?”. We converted sleep time into minutes for analysis. Statistical Analysis In this study, descriptive statistics were analyzed using SPSS 27.0, and the research model was analyzed using Mplus 6.12(Muthén & Muthén, 2011). Categorical variables were described using frequencies and proportions. Continuous variables were described using means and standard deviations. Multiple linear regression was used to examine the relationship between child sleep, implementation of BSIs, parental cognition, and bed-sharing. In addition, a t-test was conducted to examine the difference in the child’s sleep between parents who implementing BSIs compared to those who did not. We conducted path analysis to test the hypothesized model of parental cognition and sleeping arrangements as predictors of implementation of BSIs and infant sleep. Path analysis is an extension of multiple regression and is useful for estimating the magnitude and strength of effects within a hypothesized causal model, especially in social science research that deals with the complexity of variables (Lleras, 2005). The model fit was assessed using five fit indices: (1) chi-square ( χ 2 ) verification; (2) the Comparative Fit Index (CFI)>.90; (3) Tucker-Lewis Index (TLI)>.990; (4) Root Mean Square Error of Approximation (RMSEA)<.08; and (5) Standardized Root Mean square Residuals (SRMR)<.08(Hu, 1995). Results Descriptive statistics Among the sample (n=507), there was a slightly higher proportion of mothers (318 mothers, 62.7%). The mean age of parents was 35.94 ( SD =4.61) years. Over half (88.0%) of the participants reported having completed a university education or higher. Approximately half of the sample were boys (268 boys, 52.9%). The mean age of children was 22.73 ( SD =8.49) months. Most people (455 participants, 89.7%) reported that their child had at least one sleep problem. A total of 135 (26.9%) participants reported difficulty with sleep onset, 173 (34.5%) with limit-setting, and 181 (36.1%) with sleep onset after awakening. Approximately 63% (n=322) of the children slept in the same bed with their parents, and 21.9% (n=111) reported implementing at least one BSIs. Among the sample, 43 (8.5%) participants reported implementing standard extinction, 40 (7.9%) reported implementing graduated extinction and 55 (10.9%) reported implementing extinction with parent presence. Descriptive characteristics of the participants are shown in Table 1. *** Put Table 1 here *** TST differences based on BSIs implementation The results of the t -test showed a significant difference [ t (505)=-3.422, p <.001] in TST between child who had received BSIs compared to those who had not (575.2 vs. 552.9 min, respectively). Path coefficients that affect implementation of BSIs and child’s sleep The study model examined the effect of parental cognitions about their child’s sleep and bed-sharing on the child’s sleep through implementation of BSIs. The model of parental cognition and co-sleeping affecting BSIs and child’s sleep is shown in Figure 1. Results indicated adequate model reliability ( χ 2 =169.655, df = 61, p <.000; TLI=.934; CFI = 0.916; RMSEA = .075, 90% confidence interval= .062~.089; SRMR= .046). Goodness of fit indices indicated that the model fit was adequate. *** Put Figure 1 here *** There was a significant direct effect of parental cognitions about child’s sleep on implementation of BSIs. Higher scores on the PUMBA-Q ( β =-.133, p <.01) and bed sharing ( β =-.124, p <.01) were associated with lower implementation rates of BSIs. Only the direct effect of the PUMBA score on the child’s TST was significant ( β =-.141, p <.01), and not the effect of bed-sharing on child TST (Table 2). The model found an indirect effect of PUMBA scores and bed-sharing on child’s TST through implementation of BSIs ( β =-.016, p <.05; β =-.018, p <.05). *** Put Table 2 here *** Discussion This study investigated the effects of sleep arrangement and parental cognition on the implementation of behavioral sleep interventions (BSIs) and infant sleep among Korean parents with children aged 6–36 months. The findings demonstrated that bed-sharing and higher levels of dysfunctional parental cognitions regarding child sleep were associated with lower rates of BSI implementation. Furthermore, sleep arrangements and parental cognitions were directly and indirectly associated with infant sleep through BSIs. Implementation rate differences and barriers of behavioral sleep interventions In this study, only 21.9% of parents reported implementing at least one type of BSI, which is lower than the rates reported in Germany and Switzerland (32.6%) and among White American families(Honaker et al., 2021; Kahn et al., 2023; Loutzenhiser, Hoffman, & Beatch, 2014; Maute & Perren, 2018). These findings indicate that Korean parents are comparatively less likely to implement BSIs, pointing to potential cultural or contextual barriers. Cultural differences in sleep arrangements may affect BSIs implementation. For instance, more Asian families (30%) share their beds than white families (12.1%) (Tomalski et al., 2016), and 63.5% of parents in this study reported bed-sharing. Honaker and colleague suggest that these differences may be linked to variations in BSIs practice rates(Honaker et al., 2021). Barriers to implementation can include sociocultural, parental, and infant-related factors(Whittall et al., 2021). Our findings suggest that both sleep arrangements and parental cognitions act as barriers. Recently, BSIs have been proposed using the informed choice model (ICMoC) based on parental needs (Blunden, Honaker, Hyland, Born, & Metse, 2025). Thus, culturally approach considering environmental factor is essential when promoting BSIs in co-sleeping populations. Infant sleep in relation to sleep arrangement and parental cognitions This study identified both a direct association between sleep arrangements and BSIs implementation and an indirect association between sleep arrangements and infant sleep through BSIs implementation. Bed-sharing was associated with shorter nighttime sleep, likely due to increased parental presence(Mindell et al., 2010). While some studies have reported differences in infant sleep based on sleep arrangement(Mao, Burnham, Goodlin-Jones, Gaylor, & Anders, 2004), others have found no such effect (Volkovich et al., 2015). This inconsistency may stem form not accounting for BSIs that could decrease parental presence, highlighting the importance of considering BSIs when evaluating the impact of sleep arrangements on infant sleep. Parental cognitions were also directly and indirectly related to infant sleep through BSIs. Honaker and colleagues found that parents who held the belief related to infant sleep were more likely to Implement BSIs(Honaker et al., 2021). One study has shown that parents who respond sensitively to nighttime crying may reinforce frequent night wakings(Tikotzky & Sadeh, 2009), and misperceptions about infant sleep can reduce total sleep time and increase nighttime visits(Jang et al., 2023). This study emphasizes the importance of exploring parental barriers to BSI implementation. Limitations Limitations of this study and suggestions for future research include the following. First, it was a cross-sectional study without longitudinal follow-up or experimental design, which limits the ability to describe a clear causal relationship between variables. Additional longitudinal or experimental design research is required to clarify the relationship. In addition, there was a significant relationship between parental age and implementation of BSIs in the study. Parental age has been suggested to be influenced by external factors, such as parenting experience(Millikovsky‐Ayalon, Atzaba‐Poria, & Meiri, 2015). According to the transactional model, infant sleep interacts to various factors (Sadeh & Anders, 1993). There is a need to consider the factors (e.g. parenting style, shift or night work, birth order) that may influence infant sleep and BSIs. Furthermore, despite random sampling, the sample was not representative of the general Korean population. Approximately 88% of participants had a university-level education or higher, which may bias the findings. Some studies suggest that parental education level affects adherence to safe sleep practices and recommendations, which can influence the infant’s sleep environment(Aggelou, Metallinou, Dagla, Vivilaki, & Sarantaki, 2024; Zundo, Richards, Ahmed, & Codington, 2017). Further studies should include more diverse and clinical samples to enhance generalizability. Finally, the assessment of infant sleep in this study was based on subjective reports which can be a useful and valid tool for exploring sleep problems in children(Bauer & Blunden, 2008). However, parental perceptions may be influenced high levels of stress and anxiety, potentially leading to over- or under-reporting compared to the child’s actual sleep(Gossé, Wiesemann, Elwell, & Jones, 2022). Future research should consider examining objective measures(Kahn et al., 2023; Tikotzky & Sadeh, 2009). 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A., Mindell, J. A., Hiscock, H., & Quach, J. (2019). Child sleep behaviors and sleep problems from infancy to school-age. Sleep Medicine, 63 , 5-8. Zundo, K., Richards, E. A., Ahmed, A. H., & Codington, J. A. (2017). Factors associated with parental compliance with supine infant sleep: an integrative review. Pediatric nursing, 43 (2), 83. Table_1. Demographic information and socio-demographic status. Implementation of BSIs(n=111) No implementation of BSIs(n=396) Sex (parent) Male 189 (37.3) 45 (9.3) 142 (28.0) 1.559 Female 318 (62.7) 64 (12.6) 254 (50.1) Sex (child) Boy 268 (52.9) 59 (11.6) 209 (41.2) 0.005 Girl 239 (47.1) 52 (10.3) 187 (36.9) Age Parent (years) 36.0 (4.6) 34.8 (4.6) 36.3 (4.6) 2.919** Child (months) 22.7 (8.5) 21.6 (9.1) 23.0 (8.3) 1.536 Birth order First 269 (53.1) 63 (12.4) 206 (40.6) 2.263 Second 182 (35.9) 40 (7.9) 142 (28.0) Third and above 56 (11.0) 8 (1.6) 48 (9.5) Education level High school/secondary or less 56 (11.0) 16 (3.2) 40 (7.9) 7.791 Colleage/University 374 (73.8) 73 (14.4) 301 (59.4) Graduate 72 (14.2) 19 (3.7) 53 (10.5) Prefer not to answer 5 (1.0) 3 (0.6) 2 (0.4) Monthly income (KRW ₩1,000,000 = USD 840) Less than KRW 1,000,000 6 (1.2) 1 (0.2) 5 (1.0) 10.272 KRW 1,000,000 - KRW 2,000,000 9 (1.8) 3 (0.6) 6 (1.2) KRW 2,000,000 - KRW 3,000,000 79 (15.6) 14 (2.8) 65 (12.8) KRW 3,000,000 - KRW 4,000,000 126 (24.9) 35 (6.9) 91 (17.9) KRW 4,000,000 - KRW 5,000,000 108 (21.3) 14 (2.8) 94 (18.5) KRW 5,000,000 - KRW 6,000,000 74 (14.6) 17 (3.4) 57 (11.2) KRW 6,000,000 - KRW 7,000,000 42 (8.3) 10 (2.0) 32 (6.3) KRW 7,000,000 or more 63 (12.4) 17 (3.4) 46 (9.1) Child’s sleep TST (minute) 557.8 (61.4) 575.2 (55.0) 552.9 (62.3) -3.423** Sleep position Bed-sharing 322 (63.5) 57 (11.2) 265 (52.3) 9.0678** Room-sharing or solitary sleeping 185 (36.5) 54 (10.7) 131 (25.8) Self-report scale PUMBA-Q 35.8 (12.7) 21.6 (9.1) 34.1 (11.9) 3.036** Note . BSI=behavioral sleep intervention, TST=Total Sleep Time, PUMBA-Q=Parental Understanding and Misperceptions about Baby’s sleep-Questionnaire, **p <.001, Continuous variables are presented as mean ± standard deviation, and categorical variables as frequencies and percentages. Table_2. Indirect effects of parental cognition to BSIs and child’s sleep LL UL Bed sharing → Implementation of BSIs → Child’s TST -0.016 * -4.078 -0.605 Parental cognition about child’s sleep → Implementation of BSIs → Child’s TST -0.018 * -0.513 -0.079 Note . BSI=behavioral sleep intervention, Implementation of BSIs=implementation of at least one Behavioral Sleep Interventions, TST=Total Sleep Time, * p <.05 Figure_1. Path model of parental cognition and bed-sharing affecting BSIs and child’s sleep Note. Parental Understanding and Misperceptions about Baby’s sleep-Questionnaire, Implementation of BSI=implementation of at least one Behavioral Sleep Intervention, TST=Total Sleep Time, * p <0.1 Supplementary Material File (figure.docx) Download 134.01 KB File (tables.docx) Download 17.80 KB Information & Authors Information Version history V1 Version 1 18 June 2025 Peer review timeline Published Behavioral Sleep Medicine Version of Record 23 Feb 2026 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords behavioral sleep intervention co-sleeping parental cognition pediatric sleep Authors Affiliations Seoha Kyung Sungshin Women's University View all articles by this author Sooyeon Suh 0000-0003-0644-8634 [email protected] Sungshin Women's University View all articles by this author Metrics & Citations Metrics Article Usage 256 views 118 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Seoha Kyung, Sooyeon Suh. 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