sensors

Article
Using Extended Technology Acceptance Model to Assess
the Adopt Intention of a Proposed IoT-Based Health
Management Tool
Dewen Liu 1 , Qi Li 2, * and Shenghao Han 3

1 School of Management, Nanjing University of Posts and Telecommunications, Nanjing 210003, China
2 School of Economic Management, Tongji University, Shanghai 200092, China
3 College of Business, Shanghai University of Finance and Economics, Shanghai 200433, China
* Correspondence: 1810285@tongji.edu.cn

Abstract: Advancements in IoT technology contribute to the digital progress of health science. This
paper proposes a cloud-centric IoT-based health management framework and develops a system
prototype that integrates sensors and digital technology. The IoT-based health management tool can
collect real-time health data and transmit it to the cloud, thus transforming the signals of various
sensors into shared content that users can understand. This study explores whether individuals in
need tend to use the proposed IoT-based technology for health management, which may lead to
the new development of digital healthcare in the direction of sensors. The novelty of this research
lies in extending the research perspective of sensors from the technical level to the user level and
explores how individuals understand and adopt sensors based on innovatively applying the IoT
to health management systems. By organically combining TAM with MOA theory, we propose a
comprehensive model to explain why individuals develop perceptions of usefulness, ease of use, and
risk regarding systems based on factors related to motivation, opportunity, and ability. Structural
equation modeling was used to analyze the online survey data collected from respondents. The
Citation: Liu, D.; Li, Q.; Han, S. results showed that perceived usefulness and ease of use positively impacted adoption intention,
Using Extended Technology Perceived ease of use positively affected perceived usefulness. Perceived risk had a negative impact
Acceptance Model to Assess the on adoption intention. Readiness was only positively related to perceived usefulness, while external
Adopt Intention of a Proposed benefits were positively related to perceived ease of use and negatively related to perceived risk.
IoT-Based Health Management Tool. Facilitative conditions were positively correlated with perceived ease of use and negatively correlated
Sensors 2022, 22, 6092. https:// with perceived risk. Technical efficacy was positively related to perceived ease of use and perceived
doi.org/10.3390/s22166092 usefulness. Overall, the research model revealed the cognitive mechanism that affects the intention of
Academic Editor: Eiichi Tamiya individuals to use the system combining sensors and the IoT and guides the digital transformation of
health science.
Received: 19 July 2022
Accepted: 12 August 2022
Keywords: Internet of Things; digital health; optical sensor; technology acceptance model; MOA theory
Published: 15 August 2022

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in
published maps and institutional affil- 1. Introduction
iations.
In sensing technology, rapid advancements have been observed in detecting and
improving individuals’ health status [1]. For example, pulse oximetry is a painless, non-
invasive method of measuring oxygen saturation in a person’s blood, providing essential
Copyright: © 2022 by the authors.
health data for users to monitor their degree of blood oxygen saturation. When people
Licensee MDPI, Basel, Switzerland. were “blocked” at home during the COVID-19 epidemic, in-house light sensors helped
This article is an open access article monitor individuals’ behavioral patterns and remotely judged their vital signs.
distributed under the terms and In the past years, there have been tremendous advancements in different specializa-
conditions of the Creative Commons tions of health science, such as remote diagnosis and treatment, medical care, and health
Attribution (CC BY) license (https:// monitoring which has led to humans finding newer and better ways to tackle health prob-
creativecommons.org/licenses/by/ lems and prevent emerging situations. Multiple reports from IDTechEx [2,3], for example,
4.0/). show that the global market for electronic skin patches in wearable medical devices will

Sensors 2022, 22, 6092. https://doi.org/10.3390/s22166092 https://www.mdpi.com/journal/sensors

Sensors 2022, 22, 6092 2 of 19

exceed $10 billion in revenue in 2021 and is expected to exceed $30 billion by 2031, The
market for medical piezoelectric sensing systems is expected to reach $1.04 billion by 2029.
In addition, the global market for artificial intelligence image-based medical diagnostics
will exceed $3 billion by 2030, and the market for flexible medical electronics will exceed
$8.3 billion in the same period. However, although sensing technology can significantly
improve people’s health, many people are skeptical of its application [4]. Especially regard-
ing optical biosensors, which many discommenders argue would expose people’s personal
privacy [5,6].
More commercially available sensing devices combined with the Internet of Things
(IoT) help people share physiological and biochemical information to get more benefits
through transmitting and analyzing these data. With the rapid adoption of IoT technology
for various industries, it is predicted that by 2026, the IoT market will be valued at USD
1102.6 billion [7]. IoT-based applications have attracted voluminous academic attention [8],
and researchers have been exploring the possibility of using IoT for every possible scenario,
including health management.
With the combination of IoT and sensing technology, it is possible and inexpensive to
implement a regulatory health management system and provide sound warnings to the
users’ family members at an early stage of any emergency or provide practical suggestions
for users to improve their health status. This combination of health management and
application has recently gained the attention of many technology giants. For example,
Apple has added blood oxygen sensors to the Apple Watch to monitor the user’s blood
oxygen levels and to suggest adaptive adjustments that should be made.
In the information system (IS) research field, scholars also recently discovered the
trend of combining health management and digital technologies. For example, Ref. [9]
designed an approach to diagnose the on-time and future panic health state of people at
fog layer, indicating a good predictive effect. Ref [10] developed a telemonitoring program
via cardiac implantable electronic devices (CIEDs) in conducting Cardiac rehabilitation and
secondary prevention. One study further argued that this kind of health management tool
consists of new technical issues (e.g., privacy, literacy, accessibility) [11] and the willingness
of individuals to accept such technological products determine the success or failure of the
products [12].
In this study, we propose a cloud-centric IoT-based health management framework
prototype, as shown in Figure 1. This framework allows for the automatic reporting of
health emergency to hospitals and users’ contacts (e.g., family members) without human
intervention within a few seconds when related sensors detect the abnormal data. The
users’ data is regularly uploaded to the cloud, and health experts analyze the data to
make health recommendations for the users. Users can also check their health data and
health status in real-time on their mobile devices. The framework also has provisions for
continuous reporting of detailed information, thereby allowing health experts to effectively
plan future diets or exercise dynamically according to the variation trend of physical signs.
The foundation of this management system is optical sensors, which are responsible for
monitoring basic indicators through forming images. Users can check real-time data in the
interface of the mobile devices and control all functions. A diabetic patient, for example, is
a user of this system. The user’s data is captured by sensors and transmitted to the sensing
unit. The user can view various health data, including blood glucose, blood oxygen and
pressure status, on the mobile interface of Applications. The optical sensors in the house
also capture the user’s activity and remind him or her to exercise or take medication on
time. The user can also turn these sensors on or off on the phone. At the same time, the
user’s data is also transmitted to the cloud, and sent to the appropriate health experts.
They analyze the user’s health data to find out the changes in the user’s physical status,
such as decreasing blood sugar level. This leads to recommendations for appropriate
health interventions, such as reducing the intake of bran foods. The user can also choose to
turn off these health information pushes. However, since such IoT-based systems are not
reportedly deployed, most individuals and health experts are unaware of the benefits of
 appropriate health experts. They analyze the user’s health data to find out the changes in
the user’s physical status, such as decreasing blood sugar level. This leads to
Sensors 2022, 22, 6092 recommendations for appropriate health interventions, such as reducing the intake3of of 19
bran foods. The user can also choose to turn off these health information pushes.
However, since such IoT-based systems are not reportedly deployed, most individuals
and health experts are unaware of the benefits of systems based on such frameworks.
systems based on such frameworks. Therefore, it is imperative that individuals become
Therefore, it is imperative that individuals become acquainted with this innovative
acquainted with this innovative technology to enable their adoption. This paper developed
technology
a prototypeto enable their adoption.
of the system to informThis paper developed
the individuals a prototype
who may of thethe
need it about system to
proposed
inform the individuals who may need it about the proposed system. The prototype
system. The prototype comprises the optical biosensors used by individuals in daily life
comprises
and otherthe optical
related biosensors
processing used These
sensors. by individuals
details are in daily life fetched
dynamically and otherfromrelated
a cloud
processing
database. sensors. These details are dynamically fetched from a cloud database.

In house
Optical
SH 1 Healthy
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Optical Service
SH 2
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Other
SH n
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On body Data
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SB 1
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SB 2 Interface
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Alert
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Family
Hospital Members

Figure
Figure 1. Proposed
1. Proposed IoT-based
IoT-based framework
framework forfor health
health management.
management.

Various sensors, such as blood oxygen, motion tracking, image, and position sensors,
Various sensors, such as blood oxygen, motion tracking, image, and position sensors,
are embedded in the framework. Some of the sensors are placed in the user’s living
are embedded in the framework. Some of the sensors are placed in the user’s living house
house (e.g., motion tracking sensors). Other sensors are wearable ones. For example, Ma
(e.g., motion tracking sensors). Other sensors are wearable ones. For example, Ma et al.
et al. (2022) found that the correlation between strain and optical signals generated by
(2022) found that the correlation between strain and optical signals generated by surface
surface wrinkle establishment demonstrates a novel design strategy for wearable optical
wrinkle establishment demonstrates a novel design strategy for wearable optical sensors
sensors based on the superb strain sensitivity of the double-layer wrinkle system to surface
based on the superb strain sensitivity of the double-layer wrinkle system to surface
wrinkles [13]. These sensors collect and provide real-time data to a data aggregator that
wrinkles [13]. These sensors collect and provide real-time data to a data aggregator that
amalgamates them into a data package with a panel form. The package is transmitted
amalgamates
to the cloudthem intosensing
and the a data package with a panel form.
unit simultaneously. In theThe package
cloud, is transmitted
the data to
are in an online
the“storage”,
cloud and the sensing unit simultaneously. In the cloud, the data
containing other users’ information. This process is conducted for each set ofare in an online
“storage”, containing
sensor values, other
and the users’
cloud couldinformation.
depict theThis
normal process is conducted
numerical values offoreach
eachindicator
set of
sensor values, and the cloud could depict the normal numerical values
through constant deep learning and comparing. All data packages are stored in the right of each indicator
through
places constant
under thedeep learningof
supervision and comparing.
regulations andAll data packages are stored in the right
laws.
places under the supervision
The healthy sensing unit of isregulations
also embeddedand laws.
as a customized service on the cloud, which
turns the raw data into apprehensible content. as
The healthy sensing unit is also embedded a customized
The service on
unit uses extensive datathe cloud, to
analysis
which turns the raw data into apprehensible content. The unit uses extensive
determine if the user is in a normal state of health. Suppose the unit detects that the user is data analysis
to in
determine
an unhealthyif thestate
user(e.g.,
is in aa body
normal state
index of is
that health. Suppose
far from the unit
standard), detects
the unit wouldthatlike
the to
user is in an unhealthy state (e.g., a body index that is far from standard),
initiate an alert module and send the user’s health information to relevant parties, such as the unit would
like tocontacts
the initiate an alert
(e.g., module
family and send
members) thehospitals
and user’s health information
that the user has setto relevant parties,
up. All associated
such as the
parties contacts
that receive (e.g., family members)
the message can initiateand hospitals that
an emergency the user
solution in thehas setinstance
first up. All to
associated
help the parties
user getthatbackreceive the message
to a healthy state. can initiate an emergency solution in the first
instance to help the user get back to a healthy state.
2. Literature Review
2.1. IoT-Based Management
The Internet of Things (IoT) describes physical objects with sensors that connect and
exchange data with other devices over the Internet or other communications networks.
The emergence of IoT has changed the traditional approaches to managing various sensors
and opened new perspectives for digital health that delivers useful and real-time infor-
Sensors 2022, 22, 6092 4 of 19

mation [14]. Many studies have examined sensors and IoT together and concluded that
IoT-based sensor collaboration systems could often be more effective. For example, based
on the need for physiological parameter monitoring during the rehabilitation training
process, the system constructed with IoT can closely monitor changes in vital signs of target
users while providing real-time monitoring and feedback [15]. In addition, IoT technology
can help detect minimal environmental changes [16], leading related parties to react to
these changes swiftly.
Especially in health management, IoT is a promising solution for providing continuous
and holistic detections and supporting clinical decision-making [17]. For the smart home, a
networking system would be able to detect possible chronic disease of family members [18].
The combined system with smartphone and wearable sensors could also be used to prevent
individuals’ anxiety, obesity, and disorders [19]. In our proposed framework, IoT connects
various house and body sensors. By collecting real-time information for improving and
tracking the images of users and objects, processing and analyzing the data, and providing
specific suggestions, IoT can stimulate and magnify the usefulness of sensors. Users can
obtain real-time information on the condition of their comprehensive health indicators on
their devices (e.g., smartphones, personal computers, and laptops) to improve their health
status and improve their quality of life. Other parties could also observe the images of the
focal user.

2.2. Technology Acceptance in IS Field

The acceptance of technology related products is the core in information system re-
search. Studies found that older adults resist adoption of such technological products,
leading to the emergence of an age-based digital divide [20,21]. Ref. [21] proposed an
integrated framework that combined protection motivation theory and social cognitive
theory and this model was used to explore the mobile health adoption intention among US
and Ireland citizens. The authors found that seniors’ perceived inability to adopt stemming
stemmed from mistrust, high risk perceptions, and a strong desire for privacy. Ref. [22]
conducted a meta-analysis to develop a synthetic framework regarding the adoption of
mobile health services and found that perceived usefulness, perceived ease of use, per-
ceived vulnerability and perceived severity significantly influenced individual attitude.
Similar results could be observed in Ref. [23], which found that usefulness, convenience and
monetary value of mobile health positively influenced adoption intention. Ref. [24] used
a UTAUT2-based model to evaluate individuals’ adoption through Partial least squares
structural equation modeling (PLS-SEM) and the fuzzy-set qualitative comparative anal-
ysis (fsQCA) approach and proved the possible combined conditions (e.g., performance
expectancy, habit) in cultivating individuals’ willingness to adopt the health system. Based
on trust and anxiety perspectives, Ref. [25] confirmed that affective and cognitive trust en-
hanced elderly users’ continuance intention and health anxiety moderated the relationship
between trust and intention. The main barriers affecting individual adoption of mobile
health come from technology, individual and system, including security/privacy concerns,
knowledge and economic factors [26].
Scholars in the IS field have used different theories and different models to study the
willingness of different groups of people to adopt or accept mobile health. The core variables
(e.g., perceived usefulness, perceived ease of use) included in these studies are still derived
from the TAM model. As Ref. [27] suggested, the model with PU and PEU accounted for
61% and 72% of the variance in predicting individuals’ adoption of technology products in
the limited and expanded use groups, respectively. Compared to other contest models, the
TAM model showed considerable power in explaining individuals’ intentions towards the
proposed technical system [20].

2.3. TAM Model

Technology Acceptance Model (TAM) was put forward by Ref. [28], based on the The-
ory of Reasoned Action, which explains and predicts individuals’ adoption or acceptance of
Sensors 2022, 22, 6092 5 of 19

computer information systems or information technologies. This model puts forward two
main determinants: perceived usefulness and perceived ease of use. Perceived usefulness
refers to the degree to which users think using a specific system can improve their work
efficiency or performance, and perceived ease of use refers to the degree to which users
think the system is easy to use [28]. Meanwhile, perceived ease of use strengthens perceived
usefulness in specific situations [20]. Due to the simplicity, ease of operation, and strong
pertinence of the model, TAM theory has been applied in many technical fields, and with a
change of research objects, different extended versions of TAM have been extended [29,30].
The perceived risk theory is often integrated with TAM to study consumer behavior. The
concept of perceived risk was first extended from psychology by Ref. [31] and advocated
by many studies [32]. Uncertainty about the outcome implicit in an individual’s decision
was defined as risk.
Recent pieces of evidence show that information and communication technology
(ICT) and the Internet of Things (IoT) have brought significant changes to the traditional
environment of healthcare services [33,34]. However, it is a helpful health management
tool only when people start to use it. Therefore, the overall attitude of end-users towards
accepting digital health management tools plays an important role. In current studies, it
was found that although TAM has been widely used in various fields, there are few studies
on users’ adoption behavior in the digital healthcare environment, and most of them are
from the single factor level [35]. Therefore, this study uses TAM as the main theoretical
framework to develop a research model to evaluate the adoption intention of IoT-based
health management tools. Individuals are in the stage of understanding and exploring IoT-
based health management tools and are unfamiliar with its related operating mechanisms
and systems. The information in the system is scattered, and the amount of information
is extensive, leading to risk perception. Therefore, this study considers the impact of
perceived risk, perceived usefulness, and perceived ease of use, and comprehensively
explores the main facilitators and barriers to users’ adoption intentions of IoT-based health
management tools.

2.4. MOA Theory

As a theoretical underpinning, motivation-opportunity-ability (MOA) theory under-
scores the motivation, opportunity, and ability to co-determine individuals’ desire to
become involved in a particular behavior [36]. If all three factors are satisfied simulta-
neously, the odds of an individual performing a behavior are maximized. In the MOA
framework, motivation pertains to the readiness, interest, and other related incentives to
conduct information processing toward a particular behavior. The concept of opportunity is
the degree to which a situation is conducive to achieving the desired outcome, representing
the environmental stimulus that enables action. Ability refers to individuals’ skills or
competency in “turning” an action into a natural action [37]. The MOA framework is based
on theoretical discussions among behavioral scientists who believe behavior results from
combining these three factors [38].
The MOA model has been used in varied research into acceptance of technological
products, such as media use [39] and sustainable purchase [40]. Some studies have also
combined this theory with other theoretical frameworks to get a deeper insight into in-
dividuals’ behaviors. For example, Ref. [41] used MOA factors as essential moderators
in the relationship between charismatic leaders and service-sales ambidexterity. Ref. [42]
integrated planned behavior theory (PBT) with MOA theory in entrepreneurial behav-
ior research and found the performance and predictive power of the synthetical model
compared to the individual models. Similar results were also observed in energy-saving
behaviors [43] and label use [44], by the combination of MOA theory with other behavioral
theories or models (e.g., norm activation model).
In this study, we argue that the TAM model alone does not explain the behavioral
intentions of individuals toward the proposed system as antecedent factors of individuals’
perceptions were underappreciated in the original TAM model. In our proposed IoT-based
Sensors 2022, 22, 6092 6 of 19

framework, combining motivation (readiness and external benefits), opportunity (facili-

tating conditions) and ability (technical efficacy) with the TAM model can explain why
individuals develop perceptions of usefulness, ease of use, and risk toward the system,
which then influences their adopt intention. In this paper, readiness, as an intrinsic moti-
vation, is defined as the degree to which users are ready to adopt and use the proposed
system to achieve specific goals [45], which can positively influence users’ perception of
new technologies and systems [46]. External benefits, as an external motivation, refer
to the motivation and benefits beyond the system–user interaction itself [47], which is
the concentrated embodiment of the extensive benefits and functional upgrading of the
IoT-based health management framework. Facilitating conditions, as environmental op-
portunities, are defined as the objective factors in the environment recognized by users
that make the adoption and use of the proposed system easy to complete [48], such as a
user guide and concise and efficient interactive interface, which can improve the degree
to which individuals believe that the infrastructure exists to support the system [48,49];
Technical efficacy refers to the confidence and necessary skills that users have to achieve
specific goals by using the proposed system [50], which can significantly affect users’ un-
derstanding and adoption of new health management tools. To sum up, this paper holds
that users’ perceptions of usefulness, ease of use, and risk toward the proposed IoT-based
framework for health management are influenced by users’ willingness to prepare for the
new technology framework (motivation), their own efficacy (abilities) and environmental
factors (opportunities).

3. Hypotheses Development
3.1. Perceived Usefulness
Perceived usefulness refers to the degree to which users believe adopting a technology
(platform/software) can increase their performance [51]. In the research of online ser-
vices [52], mobile services [53,54], and the functions of new technologies/systems [55,56],
perceived usefulness is mostly demonstrated and measured by the function and service
upgrade degree and relative advantages of new technologies/systems, and there is a per-
fect measurement scale for reference. Specific to digital health management, perceived
usefulness refers to the convenience brought by patient users who adopt and use the
IoT-based health management tools to improve their quality of life. Compared with the
traditional offline medical examination and other health management modes, the IoT-based
health management tools can improve the transmission speed of medical information and
provide timely health care suggestions for users. Users do not need to go through the
long offline medical treatment process, such as queuing, registration, and seeing a doctor,
and can, thereby, improve the efficiency and convenience of their lives. At the same time,
detailed and continuous health reports and data visualization services can help patient
users to see the general situation of health information and the relationship between data
more intuitively. Therefore, when patients perceive the value in adopting IoT-based health
management tools, the easier it is for them to adopt and use them. In addition, several
studies have also confirmed the positive influence of perceived usefulness on adoption
intention [57,58]. Therefore, we assume the following:

Hypothesis 1 (H1). PU positively affects AI.

3.2. Perceived Ease of Use

Perceived ease of use is the perception of the ease of using new technologies [28]. In
the previous literature, perceived ease of use is mostly reflected by newbie friendliness and
operation convenience of new technologies/systems, and there is a perfect measurement scale for
reference [59,60]. In digital health management, perceived ease of use is defined as the ease with
which patient users adopt and use the IoT-based health management tools [51,61]. For example,
can patient users quickly realize a series of operations, such as real-time uploading and
checking of their health data and health status, online diagnosis and treatment consultation,
Sensors 2022, 22, 6092 7 of 19

or disease information inquiry on the IoT-based health management tools, or is it easy for
patient users to learn and master these operations? TAM asserts that the perception of
ease of use broadly explains people’s perception of usefulness and their attitude towards
using a specific system [62]. If all other factors remain the same, an easier-to-use system
will improve the user’s productivity or performance [63,64]. When users do not have the
necessary skills and confidence or do not know a specific system, giving full play to the
system’s advantages is not easy.
On the contrary, when users can easily understand and use the system, the system’s
functions will be effectively coordinated to serve users and respond to users’ needs in a
targeted manner. Most users will now change their views on its usefulness [34]. Therefore,
perceived usefulness should be increased by adding current functions that are easier to use
in the system [65].
Meanwhile, if it is not easy to use the IoT-based health management tools, and users
have to spend more time and energy on this particular system to learn how to use it,
they may not like to use it or may give up using it. Therefore, the more concise and
understandable the IoT-based health management tools are, the higher the fluency of
operation, the better the user’s experience of the new system, and the stronger the intention
to adopt and use it. In addition, several studies have confirmed the positive influence of
perceived ease of use on adopt intention [66,67]. Therefore, we assume the following:

Hypothesis 2 (H2). PEU positively affects PU.

Hypothesis 3 (H3). PEU positively affects AI.

3.3. Perceived Risk

Perceived risk refers to the psychological danger that people feel because of the
uncertain outcome of their own choices, including fear, hesitation and even some negative
emotions [68]. This concept now has been widely used in research on the adoption of
various new technologies [69,70], with a perfect measurement scale for reference. In the
research of this paper, perceived risk refers to the user’s estimation of the severity of adverse
consequences of digital health management system and the uncertainty and unfamiliarity
of its safe and stable operation. Although the emergence and application of digital health
management has brought much convenience to the majority of patients, it is, however,
precisely because this process is carried out through the cloud online that there is perceived
risk. In the process of adopting and using the IoT-based health management tools, there
may be the possibility that private information will be leaked or illegally stolen, tampered
with and used. This perceived risk reduces the user’s evaluation of the system, the degree
to which the system improves the user’s quality of life, and the perception of the usefulness
of the new system.
Furthermore, if users think that their information is not safely protected in digital
health management, the adoption of new technical solutions is reduced [34,70]. At the
same time, when it comes to health care, people aremore cautious, lack a sense of adventure
and innovation, have poor cognition and acceptance of new things, and are more inclined
to choose traditional methods to avoid risks when the results are uncertain. In addition,
many studies have analyzed that perceived risk leads to the expectation of destructive
consequences, which hurts the adopt intention [71,72]. Therefore, we assume the following:

Hypothesis 4 (H4). PR negatively affects PU.

Hypothesis 5 (H5). PR negatively affects AI.

3.4. Motivation
Motivation refers to related incentives that urge someone to conduct a behavior,
consisting of intrinsic and external motivation [73]. Intrinsic motivation is defined as
Sensors 2022, 22, 6092 8 of 19

conducting a behavior for its inherent satisfactions rather than for some separable conse-
quences, and external motivation means that the reasons for conducting a behavior come
from a source outside oneself [74]. In our framework, we argue that readiness and external
benefits can reflect intrinsic and external motivation towards the proposed system.
Readiness (RS) is the state of readiness before a user performs a certain behavior [52].
Research has shown that when an individual has a solid internal tension to perform a
behavior, the more relevant experience the individual has and the better the understanding
of the process and role of the behavior, the more prepared the individual is to perform
the behavior. That is, the more relevant experience he or she has, and the better he or she
understands the process and role of performing the behavior so the more muscular the
individual’s internal tension to perform a behavior is [75]. For a sensor- and IoT-based
system, readiness allows users to have a better understanding of the “script” and the role
they should play, to know when and how to participate in the process, and, therefore, to
have a higher level of perceived usefulness and perceived ease of use to the system, and a
lower level of perceived risk.
External benefits (EB) represent an individual’s benefits that have nothing to do
with intrinsic or core benefits [47,76]. An individual extrinsically motivated to attain the
focal object aims at utilitarian rewards, seeking assistance, or maintaining a sense of it
being worthwhile [77,78]. The premise of an individual’s use of a technology system also
depends on how much external utility (e.g., external benefits) they expect to derive from
that technology system. Individuals also tend to develop positive perceptions of technology
systems when they provide more external utility. Thus, the following hypotheses are put
forward:

Hypothesis 6-1/2/3 (H6-1/2/3). RS significantly affects PU/PEU/PR.

Hypothesis 7-1/2/3 (H7-1/2/3). EB significantly affects PU/PEU/PR.

3.5. Opportunity
The proposed system is intended to be mainly used by individuals who need it (e.g.,
patients) and can relate the usefulness of the proposed system in executing their daily
health monitoring activities. In our framework, the opportunity provides a “window”
for users to approach the technological system. We use facilitating conditions to measure
the individuals’ opportunity factors. Previous studies have confirmed the significant
relationship between facilitating conditions and usage behavior [79].
Based on literature perspectives, we assume that facilitating conditions (FCs) are
important variables that influence individuals’ perceptions [80]. In the context of the
technological system, facility conditions include guidance on how to use it, the necessary
knowledge, and the complexity of the expressed processing steps [81], helping the indi-
viduals to access the system with low effort. Thus, a positive correlation exists between
facilitating conditions and perceptions of the proposed system, so the facilitating conditions
are assumed to be a vital variable that affects both perceived usefulness, perceived ease of
use, and perceived risk. The following hypotheses were accordingly derived.

Hypothesis 8-1/2/3 (H8-1/2/3). FC significantly affects PU/PEU/PR.

3.6. Ability
We use technical efficacy (TE) to measure individual ability to approach or use the
proposed system. As new technologies are introduced in any domain, users often lack
confidence. Accordingly, current studies have confirmed the positive effect of technological
efficacy on innovative product usage as an important factor [82]. Since the proposed system
in this study is a health management tool for obtaining essential data to enable effective
detection in case of emergencies, we also considered technical efficacy in the proposed
system because it could have a direct effect on individuals’ perceptions of the system,
 We use technical efficacy (TE) to measure individual ability to approach or use the
proposed system. As new technologies are introduced in any domain, users often lack
confidence. Accordingly, current studies have confirmed the positive effect of
technological efficacy on innovative product usage as an important factor [82]. Since the
Sensors 2022, 22, 6092 proposed system in this study is a health management tool for obtaining essential data 9 of to
19
enable effective detection in case of emergencies, we also considered technical efficacy in
the proposed system because it could have a direct effect on individuals’ perceptions of
the system,
including including
perceived perceived
usefulness usefulnessease
and perceived and perceived
of use ease of use by
[83,84]. Unconstrained [83,84].
time
Unconstrained by time and space,
and space, the popularization the popularization
and commercialization and commercialization
of optical of optical
sensors and IoT technology
sensors and IoT
have boosted the technology have boosted
use of the proposed system.the Hence,
use of technological
the proposedefficacy
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Hence,
technological efficacy involves
individual perceptions individual
of the system perceptionscan
[85]. Individuals of the system [85].
accomplish Individuals
health management can
accomplish
through this health
systemmanagement through
and attain their this system
goals. Therefore, andwith
users attain their
high goals. Therefore,
technological efficacy
can perceive
users more
with high usefulness,efficacy
technological ease ofcan
use, and less
perceive risk.usefulness,
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easewe propose
of use, the
and less
following
risk. hypothesis:
Accordingly, we propose the following hypothesis:

Hypothesis 9-1/2/3 (H9-1/2/3). TE significantly affects PU/PEU/PR.

Figure 2 depicts the research model based on the hypotheses mentioned

mentioned above.
above.

Motivation
Readiness Perceived
Ease of Use
External Benefit

Opportunity
Perceived Adopt
Facilitating Usefulness Intention
conditions

Ability
Perceived
Technical
Risk
Efficacy
.
Figure 2. Research model.
Figure 2. Research model.
4. Methodology
4. Methodology
4.1. Survey Design
4.1. Survey Design used an online semi-structured questionnaire to collect raw data as this
This research
Thiscan
method research
be doneused an online
quickly semi-structured
and easily. questionnaire to collect
That is, a smartphone/tablet with araw data as was
hyperlink this
used to collect
method can berawdonedata. The corresponding
quickly and easily. Thatrelations between latent variables
is, a smartphone/tablet are shown
with a hyperlink
in Figure
was used2to based on the
collect rawextended
data. The TAM framework,relations
corresponding and mature scales latent
between were adopted
variablesfrom
are
previous mature studies, ensuring the measures’ effectiveness. This
shown in Figure 2 based on the extended TAM framework, and mature scales were study also modified
the question
adopted fromitems based
previous on the
mature initial ensuring
studies, understanding of the research
the measures’ context
effectiveness. to study
This make
them more relevant to the IoT-based framework for health management. The
also modified the question items based on the initial understanding of the research context scales for
perceived usefulness and perceived ease of use were adapted from
to make them more relevant to the IoT-based framework for health management. TheRef. [28]. The items
for adopt
scales intention usefulness
for perceived were from and
Ref. perceived
[86]. The items
ease offor perceived
use risk were
were adapted fromfrom Ref. [32].
Ref. [28]. The
The readiness and external benefits items were from Ref. [87]. The items for perceived risk
were from Ref. [76]. The scales for facilitating conditions were from Ref. [81]. The scales for
technical efficacy were from Ref. [85].
It is important to note that since the scale in this research is originally in English, our
study was conducted in China. Therefore, a translation and back-translation step were
performed in this research to ensure that the entries corresponded to the original meaning.
In order to determine the formal measurement entries, the questionnaire was presented
to senior managers in the field to determine whether they thought the corresponding
entries would respond to the corresponding latent variables. Based on their comments, the
questionnaire was modified, and two entries were removed. All items were designed using
a seven-point Likert scale, with one being “strongly disagree” and seven being “strongly
agree”.
To further ensure that the subjects could understand the content of the questionnaire,
20 subjects were invited to conduct a pretest. In other words, they were asked to fill out the
questionnaire and correct any awkward points in the questionnaire. The study continued
Sensors 2022, 22, 6092 10 of 19

to revise the questionnaire based on these subjects’ comments. Finally, the questionnaire
(English version) used in this study is shown in Table 1. The responses recorded during
the pilot study were subjected to Cronbach’s alpha using Stata 17.0 to measure internal
reliability. All Cronbach’s alpha coefficients above 0.75 indicated that all initial scales
employed were reliable measures.

Table 1. Measure items.

Latent Variables Items

Adopting the proposed system for my personal health management is a good idea.
Adopt Intention
I will voluntarily use the proposed system in near future.
(AI)
I would make full use of the proposed system if I obtained it.
Perceived This proposed system would be used in a simple way.
Ease of Use I think I can easily handle this proposed system with various sensors.
(PEU) The data provided by this proposed system can be understood with little effort.
This proposed system can improve my health status.
Perceived
This proposed system can enhance the effectiveness of detecting potential problems.
Usefulness
This proposed system is needed if I face some health problems.
(PU)
This proposed system will be useful in reminding me to keep healthy.
This proposed system may run the risk of losing my losing benefits (e.g., personal information).
Perceived
This proposed system may expose my privacy.
Risk (PR)
This proposed system may cost me time or money.
I prefer to use the most advanced technology available.
Readiness Technology gives me more freedom of personal management.
(RS) Technology makes me more efficient in my life.
I keep up with the latest technological developments in my areas of interest.
This proposed system represents an important value to the community.
External Benefits (EB) This proposed system attracts similar individuals like me to get benefits.
This proposed system considerably improves the well-being of citziens.
Facilitating I was given adequate guidance to use this proposed system.
Condition I acquired the necessary knowledge to use this proposed system.
(FC) This proposed system is compatible with health management.
I am able to figure out how to use this proposed system on my own.
Technical
I am able to figure out how to use the interface of this proposed system on my own.
Efficacy (TE)
I am able to figure out how to use the different functions provided by the proposed system on my own.

4.2. Data Collection

The pre-prepared online questionnaire link was distributed to two different groups of
respondents by invitation messages [88]. The first group comprised the elderly who do not
live with their children in two cities in Anhui province of China: Wuhu and Ma’anshan.
These respondents are the targets of biopharmaceutical companies as they receive regular
medical checkups and are equipped with many devices with sensors to “monitor” their
activities. Under the help of area managers, we distributed the questionnaire link to their
clients. Before the questionnaire was filled out, an ethics statement was included, informing
participants that this research was intended to be market research for a prototype product
and that all questions would be used only for an academic study. If the respondent did not
agree at the outset, or during or after the completion process, he or she could terminate at
any time. The second group was the group of patients with chronic diseases. These respon-
dents were contacted through agents of a health insurance company in Anhui province. We
likewise included an ethics statement for this segment of participants. These subjects were
also afflicted with diseases and needed to keep themselves informed about their health
status. All respondents volunteered to participate in our study, and we also distributed
small gifts to each participant who filled out the completed questionnaire. It should be
noted that overlapping data between the first and second categories of respondents were
removed from this study. In addition, it should be further noted that the research in this
paper did not involve the use of an actual sensor or system, but rather a pre-test for a
prototype product. Therefore, the research in this paper did not, to a certain extent, involve
Sensors 2022, 22, 6092 11 of 19

an invasion of individual privacy. The respondents were informed of the purpose and pro-
cedure of the study and were given feedback on the results before the study was conducted.
In sum, our study was conducted as permitted by legal and ethical norms.
In order for all respondents to better understand the proposed health management
system based on the combination of IoT and sensors, there was a textual description before
the start of the formal questionnaire. This textual description informed the respondents
that the system was a new health monitoring system based on optical sensors and other
sensors and that the user’s behavioral data would be transmitted to the cloud for analysis.
This research distributed 322 questionnaires in total and received 276 valid responses.
Then, a data processing program was performed to delete duplicate responses based on IP
address. This research also removed questionnaires that showed a clear pattern of answers,
too many of the same options, and those that took too little time to complete. Finally, only
243 questionnaires were treated as valid. Among them, 118 questionnaires were filled out
by senior citizens (Group 1), and the second group of respondents filled 125 responses.
Three questionnaires belonged to both the first and second groups, so the first questionnaire
completed by these respondents was selected as a valid questionnaire for this research.
As shown in Table 2, the valid response rate was 70.4%. Among these respondents,
59.67% were males, and 40.33% were females. For monthly income, 38.6% were 2000 RMB
or less, 25.10 were 2001–3000 RMB, and only 9.47% were above 5000 RMB. Among their
ages, 15.23% were 40 years old or younger, 28.81% were 41–50 years, 7.00% were 51–60 years
and 48.97% were over 60 years old. Most of the respondents were illiterate (no education,
43.62%), 19.75% had primary education, 6.17% had secondary education and 30.45% had
high school education or above. Table 2 demonstrates the characteristics of the respondents.

Table 2. Descriptive statistics.

Variable Mean SD Min Median Max

RS 4.355 1.364 1 4.333 7
EB 4.159 1.331 1.667 4 7
FC 3.683 1.248 1 3.667 7
TE 3.827 1.229 1 3.667 6.333
PEU 4.040 1.320 1 4.333 7
PU 4.486 1.249 1 4.5 7
PR 3.461 1.311 1 3 6.333
AI 4.514 1.266 1.333 4.667 7
Income 2.058 1.316 1 2 5
Education 2.235 1.291 1 2 4
Age 2.897 1.176 1 3 4
Gender 0.403 0.492 0 0 1

5. Results
5.1. Descriptive Statistics
The following table depicts the data distribution characteristics of the data, including
the mean, median, and standard deviation, which are shown in Table 3. The means
and medians of all latent variables were between 3 and 4, and the standard deviations
were within acceptable limits. This indicated that the data largely conformed to a normal
distribution. In addition, the mean value of perceived risk (PR) was small (3.461), indicating
that respondents perceived risk for these products at a low level.
Sensors 2022, 22, 6092 12 of 19

Table 3. Sample description.

Category Value Numbers Percentage (%)

Male 145 59.67
Gender
Female 98 40.33
≤2000 RMB 116 47.74
2001–3000 RMB 61 25.10
Income
3001–4000 RMB 25 10.29
(Monthly)
4001–5000 RMB 18 7.41
≥5001 RMB 23 9.47
≤40 37 15.23
41–50 70 28.81
Age
51–60 17 7.00
≥61 119 48.97
Illiteracy 106 43.62
Primary school or sishu 48 19.75
Education Middle school 15 6.17
High school or above 74 30.45
Note: N = 243, the same as below.

5.2. Confirmatory Factor Analysis

Confirmatory factor analysis (CFA) was conducted to verify whether the relationship
between a latent construct and its corresponding measure conformed to the theoretical
relationship designed by the researcher [89,90]. It is a multivariate statistical technique
to test the reliability and validity of many survey-based studies. In CFA, factor loading
measures this matching. If a specific standardized item’s factor loading is greater than
0.70, then it represents this item attached to the latent variable well. The standardized
factor loadings of eight latent variables with their respective items in this study are shown
in Table 3. It can be seen that all standardized factor loadings were greater than 0.7. In
addition, the goodness-of-fit (GOF) of the measurement of this study indicated that the
fitness of the measurement model and data was acceptable [χ2 /df = 1.579, CFI = 0.956,
TLI = 0.947, SRMR = 0.051, RMSEA = 0.049], which indicated that the proposed model fit
our data in an acceptable standard.

5.3. Reliability and Validity Test

As shown in Table 4, all of the composite reliability (CR) and Cronbach’s alpha
coefficients were computed and found to be more than 0.80 (the recommended cut-off is
0.70). Each average variance extracted (AVE) was above 0.57 (the recommended critical
value is 0.50), indicating that the measurements were reliable and passed the convergent
validity test. These results indicated that the convergent validity and reliability tests had
been passed.
As for discriminant validity, it reflects the distinctions between different constructs
and is often assessed by the comparisons of the correlation coefficients and the square root
of AVE. Discriminant validity is considered to pass if the square root of the AVE of a latent
variable is greater than the correlation coefficient between the focal variable and any other
variable. Taken Tables 4 and 5 together, it can be observed that the corresponding square
roots of all AVE were higher than the inter-construct correlations, confirming the accredited
discriminant validity.
Sensors 2022, 22, 6092 13 of 19

Table 4. Results of CFA and reliability/validity test.

Factor Standard Cronbach’s

Construct Item CR AVE Sqrt (AVE)
Loading Error Alpha
RS1 0.759 0.035
RS RS2 0.820 0.030 0.835 0.836 0.630 0.794
RS3 0.801 0.031
EB1 0.833 0.025
EB EB2 0.835 0.025 0.888 0.889 0.728 0.853
EB3 0.890 0.020
FC1 0.860 0.028
FC FC2 0.833 0.029 0.853 0.854 0.663 0.814
FC3 0.744 0.035
TE1 0.737 0.047
TE TE2 0.848 0.047 0.806 0.811 0.589 0.767
TE3 0.711 0.049
PEU1 0.796 0.034
PEU PEU2 0.695 0.041 0.806 0.808 0.585 0.765
PEU3 0.799 0.034
PU1 0.681 0.040
PU2 0.758 0.034
PU 0.841 0.841 0.571 0.756
PU3 0.779 0.032
PU4 0.798 0.030
PR1 0.838 0.025
PR PR2 0.863 0.023 0.866 0.868 0.687 0.829
PR3 0.784 0.030
AI1 0.747 0.036
AI AI2 0.765 0.035 0.812 0.811 0.589 0.767
AI3 0.790 0.033

Table 5. Correlation table.

RS EB FC TE PEU PU PR AI
RS 1
EB 0.580 *** 1
FC 0.200 ** 0.147 * 1
TE 0.061 0.110 0.010 1
PEU 0.349 *** 0.314 *** −0.0470 0.184 ** 1
PU 0.446 *** 0.346 *** 0.134 * 0.277 *** 0.401 *** 1
PR −0.489 *** −0.422 *** −0.093 −0.033 −0.525 *** −0.334 *** 1
AI 0.398 *** 0.321 *** 0.140 * 0.160 * 0.342 *** 0.646 *** −0.293 *** 1
Note: *** p < 0.001, ** p < 0.01, * p < 0.05, the same as below.

5.4. Hypothesis Testing

The structural equation model (SEM) helped explain the relationship among the men-
tioned latent variables defined in the model. SEM allows for the existence of interactions
between variables and assumes that these effects occur simultaneously, estimating a num-
ber of equations jointly. Therefore, SEM was more suitable for this study. The fit indices
[χ2 /df = 1.540, CFI = 0.945, TLI = 0.934, SRMR = 0.054, RMSEA = 0.047] indicated that that
the model was set correctly. The results are shown in Table 6.
Sensors 2022, 22, 6092 14 of 19

Table 6. Hypotheses testing results.

Hypothesis Relationship Estimate S.E. Z p 95% CI Result

H1 PU→AI 0.571 0.062 9.160 0.000 0.449 0.693 Supported
H2 PEU→PU 0.193 0.088 2.200 0.028 0.021 0.365 Supported
H3 PEU→AI 0.239 0.079 3.040 0.002 0.085 0.394 Supported
H4 PR→PU 0.011 0.104 0.110 0.914 −0.193 0.216 Not Supported
H5 PR→AI −0.199 0.070 −2.840 0.004 −0.336 −0.062 Supported
H6-1 RS→PU 0.401 0.092 4.380 0.000 0.222 0.580 Supported
H6-2 RS→PEU 0.159 0.101 1.580 0.113 −0.038 0.357 Not Supported
H6-3 RS→PR −0.159 0.086 −1.850 0.064 −0.327 0.009 Not Supported
H7-1 EB→PU −0.029 0.105 −0.270 0.784 −0.234 0.177 Not Supported
H7-2 EB→PEU 0.224 0.095 2.350 0.019 0.037 0.411 Supported
H7-3 EB→PR −0.504 0.078 −6.430 0.000 −0.657 −0.350 Supported
H8-1 FC→PU 0.111 0.077 1.430 0.152 −0.041 0.262 Not Supported
H8-2 FC→PEU 0.291 0.074 3.920 0.000 0.145 0.436 Supported
H8-3 FC→PR −0.225 0.064 −3.500 0.000 −0.352 −0.099 Supported
H9-1 TE→PU 0.303 0.069 4.420 0.000 0.169 0.438 Supported
H9-2 TE→PEU 0.182 0.068 2.660 0.008 0.048 0.316 Supported
H9-3 TE→PR 0.053 0.059 0.900 0.370 −0.062 0.168 Not Supported

As also reported in other TAM-based research, this study found a significant impact
of perceived ease of use on perceived usefulness (β = 0.193; Z = 2.200; p < 0.05). Therefore,
hypothesis H2 was supported. The perceived ease of use was also found to impact adopt
intention (β = 0.239; Z = 3.040; p < 0.010), thereby confirming hypothesis H3.
Perceived usefulness had a significant impact on adopt intention (β = 0.571; Z = 9.160;
p < 0.001), supporting hypothesis H1. Perceived risk negatively influenced adopt intention
(β = −0.199; Z = −2.840; p < 0.010), supporting hypothesis H5. However, the perceived risk
did not exert a significant impact on perceived usefulness, indicating that an individual’s
perception of the system’s risk did not affect the perception of its usefulness; the two were
independent of each other.
Readiness was observed to be related to perceived usefulness (β = 0.401; Z = 4.380;
p < 0.001), supporting hypothesis H6-1. The ability factor (technique efficacy) was the
only one to be related to perceived usefulness (β = 0.303; Z = 4.420; p < 0.001), supporting
hypothesis H9-1.
Hypothesis 6-2/7-2/8-2/9-2 tests what factors influence perceived ease of use. Among
them, it was found external benefits (β = 0.224; Z = 2.350; p < 0.050), facilitating conditions
(β = 0.291; Z = 3.920; p < 0.001), and technique efficacy (β = 0.182; Z = 2.660; p < 0.010)
positively related to perceived ease of use, supporting hypothesis H7-2, H8-2 and H9-2
respectively.
In addition, external benefits (β = −0.504; Z = −6.430; p < 0.001) and facilitating
conditions (β = −0.225; Z = −3.500; p < 0.001) negatively influenced perceived risk; thus
supporting hypothesis H7-3 and H8-3.
Thus, this study provided support for most hypotheses H1–H8, except hypotheses H4,
H6-2, H6-3, H7-1, H8-1 and H9-3.

6. Discussion and Contributions

6.1. Discussion
This study aimed to discover if individuals in need of healthcare management were
inclined to use the proposed IoT-based technology for health management. Combined with
the TAM model and MOA theory, this study designed a comprehensive model to test the
intent to adopt the technology of individuals. To be specific, readiness and external benefits
reflected the individual’s inner and external motivations; facilitating conditions were the
opportunity factors that facilitate use; technological efficacy stands for the ability of an
individual to handle technological systems. Thus, the motivation, opportunity, and ability
factors might alter individuals’ perceptions toward the proposed system.
Sensors 2022, 22, 6092 15 of 19

This study further developed a prototype of the proposed system, integrating the
sensors and digital technology. It provided first-hand pieces of evidence of the final system.
The prototype deployed on the cloud was used to understand and translate the signals of
various sensors, shared with people who were able to use it on their smartphones, so as
to know their health status. Since the proposed health management system is intended to
be used by average citizens, it was essential that they perceive the system as helpful, easy,
and less risky as these factors are directly linked to adopt intention. This study found a
positive effect of readiness and technical efficacy on perceived usefulness, indicating that
such Internet-based systems are perceived to be more useful if individuals have sufficient
intrinsic motivation and high levels of belief about the use of the system. However,
providing external situational benefits using the IoT system can enable individuals to
experience the system’s convenience, thereby improving the adopt intention in the event of
an emergency, such as abnormal physical movements captured by in-house optical sensors.
The opportunity and ability factors were also found to be correlated to perceived ease of
use, providing pieces of evidence in offering chances to approach the proposed system.
External benefits and facilitating conditions alleviated the risk perception, which indicated
the importance of creating more benefits for individuals to use this system.

6.2. Theoretical Contributions

This study has the following theoretical contributions. First, this paper proposes an
IoT-based health management system that extends the framework of sensor research. In
previous sensor studies, scholars have favored the technical aspects. However, how various
sensors are interpreted by individuals and adopted by those who need them has recently
started to enter the research domain. The system proposed in this paper combines data
signals from sensors through the cloud and big data, effectively extending the research in
related fields.
Second, this study also contributes to the research literature in the field of inform
systems. User acceptance of technological products has been the focus of IS research. A
large number of studies have conducted in-depth research on user research on mobile
health systems, i.e., the antecedents of users’ adoption of a particular mobile health appli-
cation. This study proposes an integrated sensor- and mobile health-based system from
a broader perspective that goes beyond user mobile health adoption studies based on a
single application perspective.
Third, this paper also effectively extends the theoretical frontier of the TAM model. By
organically combining the TAM model and MOA theory, this study not only reveals the
impact of the TAM model on the proposed system acceptance but also further explains why
individuals develop perceptions of usefulness, ease of use, and risk to the system based on
their motivation, opportunity, and ability related factors.

6.3. Practical Implications

With the commercialization of various sensors, this study also sheds light on the psy-
chological mechanisms that influence individuals’ intentions to use systems that combine
sensors and the Internet of Things by establishing several vital variables. The system of this
study can be further improved and enhanced in future practice with natural configurations
of different sensors to improve individual acceptance. Furthermore, given the positive
evaluation of the system by the intended users, this system could shortly be integrated
and manufactured at the commercial level, with additional optical sensors to increase the
capture of optical images in detecting, managing, and preventing health problems. In addi-
tion, healthcare commercial companies can benefit from this paper and design marketable
systems based on IoT and medical diagnostics that are acceptable for users and benefit
both users and companies.
Sensors 2022, 22, 6092 16 of 19

7. Limitations and Further Directions

The present study also has several research limitations as well. First, the research
subjects of this study were concentrated in the riverine region of eastern China, which
has a higher degree of economic development, and people are more willing to accept
new technologies. Future scholars could adopt a universal sample when studying related
issues. Second, this study combined MOA theory and the TAM model, which extended
the framework of TAM theory. Future research can investigate the problem of individuals’
technological system acceptance from other perspectives. Third, the core of the proposed
IoT-based health management system lie in transforming the data from optical sensors into
signals that could be understood and read. That is, the individual saw only the system,
not the sensors at work. There may be cognitive differences in individuals’ attitudes
towards combinations of sensors and towards individual sensors, and future research
could continue to explore this in-depth.

Author Contributions: Conceptualization, D.L. and Q.L.; methodology, D.L., S.H. and Q.L.; investi-
gation, D.L.; writing of the original draft, D.L. and S.H.; review, D.L., S.H. and Q.L.; validation, D.L.
and S.H.; formal analysis, D.L., S.H. and Q.L. All authors have read and agreed to the published
version of the manuscript.
Funding: This research was funded by General Project of Philosophy and Social Science Research in
Jiangsu Universities (2022SJYB0103), Talent Introduction Project of Nanjing University of Posts and
Telecommunications (NYY222011), and Fundamental Research Funds for the Central Universities
(CXJJ-2021-406), China.
Ethics Statement: Ethical review and approval was not required for the study on human participants
in accordance with the local legislation and institutional requirements. Written informed consent
from the patients/participants was not required to participate in this study in accordance with the
national legislation and the institutional requirements.
Institutional Review Board Statement: Not Applicable.
Informed Consent Statement: Not Applicable.
Data Availability Statement: Not Applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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