Introduction
Globally, to this point (10 September 2021), there have been 223,022,538 confirmed circumstances of COVID-19, together with 4,602,882 deaths, reported to the World Well being Group (WHO).1 The fast unfold of COVID-19 poses a grave well being risk and has critical socioeconomic implications for all.2 In response to this international outbreak, many nations have adopted quite a lot of measures, corresponding to social distancing, self-isolation and journey restrictions, and even pressured lockdown. The COVID-19 disaster has nearly actually positioned a major pressure on well being methods throughout the globe and has uncovered well being care employees to an unprecedented risk.3,4 Not surprisingly, well being care employees aren’t solely positioned on the core of the pandemic however are in a very weak place.4 They’re predisposed to plenty of dangers: heavy workloads, unpredictable work patterns, and a better danger of an infection, which could have penalties on their well being and well-being.5,6 Furthermore, compared to the overall inhabitants, well being care employees are dealing with elevated skilled and private tasks in the course of the pandemic, which can result in an extra psychological burden.7
A number of work stressors enhance the chance of hostile psychological well being outcomes, together with however not restricted to psychological misery (worry, stress, anxiousness, melancholy, exhaustion, post-traumatic stress dysfunction (PTSD)) and sleep dysfunction (poor sleep high quality, sleep debt, insomnia). Certainly, throughout a disaster corresponding to the present COVID-19 pandemic, the standard of sleep of well being care employees turns into important.4 Nonetheless, there is no such thing as a single completely dependable criterion for outlining sleep and even sleep high quality as a result of it’s typically outlined as a fancy state.8 Ample sleep, a balanced eating regimen, and bodily exercise are three elementary wants.9 Ample sleep is summarized by at the very least three points: enough sleep amount (amount), good sleep high quality (high quality), and common sleep patterns (circadian rhythm).10 Good sleep is significant to good well being.11 Subjective sleep high quality complaints could also be a consequence of illness.12 Sleep high quality is a vital sign and signal of the transition between well being and illness. Poor sleep high quality, sleep debt, acute/continual stress, and different psychological well being issues might impair cognitive functioning and weaken decision-making skill, thereby decreasing medical work effectivity and growing the chance of medical errors, which can hinder the struggle towards COVID-19 and will end in a long-lasting impact on general well-being.13–18 Therefore, the toll of the disaster has been heavy on well being care employees.
Well being care providers are widely known as a difficult occupation; well being care employees, who obtain rigorous coaching to arrange themselves for this occupation, report a better degree of sleep disturbance in the course of the COVID-19 pandemic. As an example, a 2021 meta-analysis reported that worldwide, the prevalence of sleep disturbance has been estimated to be between 18.4 and 84.7% in well being care employees and 17.65–81% within the common inhabitants.19 Publicity to the COVID-19 pandemic within the office might act as a precipitating issue of a hyperarousal state, which might result in a better incidence of sleep disturbance and different sleep problems in comparison with the overall inhabitants.3 Sleep dysfunction is usually accompanied by psychological misery signs amongst well being care employees in the course of the COVID-19 pandemic.20–22 Research have proven that work stressors from COVID-19 can induce gentle to extreme ranges of tension, melancholy, exhaustion, PTSD and sleep dysfunction.15,23–26 Alternatively, one other argument for there may be nonetheless little proof of a rise in sleep disturbances in well being care employees in the course of the outbreak;27 well being care employees had poor sleep standing, even earlier than COVID-19. Work stressors can have on sleep, however lack or poor high quality of sleep has on resilience and stress, which is cyclical relationship.28 In the long run, we’re addressing the pressing wants of defending the sleep well being, psychological well being and well-being of well being care employees.29,30 Nonetheless, proof is restricted relating to the influence of the present pandemic on sleep dysfunction in well being care employees derived from coronavirus stress, notably the underlying mechanism of each variables.
Regardless of the robust relationship between psychological well being and sleep, little is understood concerning the mechanism of the connection between COVID-19 stress, anxiousness and melancholy, and sleep high quality. Based mostly on the present literature, a priori hypotheses are that prime stress in well being care employees will scale back sleep high quality, primarily not directly by means of anxiousness and melancholy in the course of the COVID-19 epidemic. Contemplating the out there proof that anxiousness and melancholy might act as a danger issue to accentuate the unfavorable penalties of perceived stress on well being care employees, the intention of this research was to discover the mediating position of tension and melancholy within the relationship between perceived stress and sleep high quality. In the meantime, the present research revealed influencing elements on the psychological well being of well being care employees in the course of the COVID-19 disaster. The findings will assist to higher perceive elements related to perceived stress, anxiousness and melancholy, and sleep high quality, particularly the influencing mechanism of tension and melancholy on each variables of well being care employees. These findings may need important implications for efficient interventions designed to enhance sleep high quality and well-being of well being care employees.
Strategies
Contributors and Process
From February 25 to March 3, 2020, for about per week, we recruited well being care employees from throughout Zhejiang and Hubei provinces to finish the net survey. Initially of the COVID-19 outbreak, a snowball sampling methodology was used to recruit individuals anonymously.31 The self-selection survey was distributed by means of a dozen division heads, and the respondents selected to take part by clicking on a hyperlink or scanning a fast response (QR) code. Every respondent and her or his division head knew one another. Inclusion standards: (1) well being care employees, (2) agreed to take part within the survey, and (3) might learn a Chinese language questionnaire. Exclusion standards: (1) wouldn’t be allowed to submit survey responses utilizing the identical IP handle, (2) who weren’t in place on the time of the survey resulting from any depart of absence and (3) invalid response corresponding to brief response time and longstring. Contributors included medical docs, registered nurses, medical technicians (eg, pharmacists, therapists, laboratory technicians) and directors (eg, division administrators, nursing supervisors). Previous to information analyses, we excluded 2 (0.3%) of the preliminary respondents as a result of they had been recognized as invalid responses. Our last pattern contained 588 submitted surveys with no lacking information.
Measures
Sociodemographic Traits and COVID-19-Associated Traits Questionnaire
The sociodemographic traits included gender (female and male), province (Zhejiang, Hubei, and others), marital standing (single, married, divorced, widowed), occupational classes (medical physician, registered nurse, medical technician, administrator), skilled title (unknown, junior, intermediate, vice-senior or senior), and academic degree (technical secondary faculty or beneath, faculty diploma, bachelor’s diploma, grasp’s diploma or above).
The COVID-19-related traits embrace departmental perform (designated hospitals, neighborhood well being centre, different medical establishments), if work affairs had been the identical as earlier than (an identical, principally constant, inconsistent), job class (direct contact with confirmed sufferers and/or physique fluid, doable contact with confirmed sufferers and/or physique fluid, direct contact with suspected sufferers and/or physique fluid, doable contact with suspected sufferers and/or physique fluid, don’t have any contact with any confirmed and suspected sufferers and/or physique fluid), enough safety (No or Sure), quarantined standing at the moment (No or Sure), the burden of household care (No and Sure), and work expertise in response to outbreaks (No or Sure).
Sleep High quality Questionnaire (SQQ)
The Sleep High quality Questionnaire (SQQ) was used to evaluate sleep high quality.32 Contributors responded to 10 objects about their subjective expertise of sleep up to now month. They rated the extent of settlement with every 5-point Likert scale merchandise, starting from 0 (strongly disagree) to 4 (strongly agree). Particular person scores on the SQQ can vary from 0 to 40, with larger composite scores indicating poorer sleep high quality. The Chinese language model of the SQQ (SQQ-C) was tailored and validated for the primary time by a doctoral program of the corresponding creator and exhibited passable psychometric properties utilizing a big pattern survey amongst college college students, medical employees, and common sufferers.33,34 Cronbach’s α coefficient for the SQQ-C was 0.901 (95% CI [0.889, 0.913]), suggesting optimum inner consistency.
Perceived Stress Scale (PSS-10)
The Perceived Stress Scale (PSS) is a quick scale of stress perceptions and measures the diploma to which one perceives three points: uncontrollable, unpredictable, and overloading.35 There have been three kinds: fourteen objects (PSS-14), ten objects (PSS-10) and 4 objects (PSS-4).36 Respondents had been required to answer every merchandise on a 5-point Likert scale, starting from 0 (by no means) to 4 (fairly often), with larger composite scores indicative of larger ranges of perceived stress inside the previous month. The present research used the PSS-10, and thus, particular person scores on the PSS can vary from 0 to 40. The Chinese language model of the PSS-10 (PSS-10-C) established enough reliability and validity statistics when utilized in a pattern of Chinese language policewomen.37 Cronbach’s α coefficient for the PSS-10-C was 0.815 (95% CI [0.792, 0.837]), suggesting passable inner consistency.
Affected person Well being Questionnaire (PHQ-4)
A self-report model of the Main Care Analysis of Psychological Problems (PRIME-MD) referred to as the Affected person Well being Questionnaire (PHQ) was developed and validated in two giant research.38 The Generalized Anxiousness Dysfunction scale (GAD) is derived from the unique PHQ. The GAD-2 and PHQ-2 altogether encompass the PHQ-4 for detecting possible generalized anxiousness dysfunction and main depressive dysfunction, respectively. Every scale charges the severity of every merchandise over the previous 2 weeks on a four-point Likert scale (0–3; 0 = under no circumstances, 3 = almost day-after-day).39 A rating of every scale ranges from 0 to six. When screening for anxiousness problems or depressive problems, a advisable cut-off level for additional analysis is a rating of three or larger. The Chinese language model of the PHQ-4 (PHQ-4-C) and its instruction guide are actually publicly out there from the Affected person Well being Questionnaire (PHQ) Screeners (Retrieved from: https://www.phqscreeners.com). Cronbach’s α coefficient for the PHQ-4-C was 0.870 (95% CI [0.852, 0.886]), suggesting passable inner consistency.
Information Analyses
The authors managed the information with EXCEL (model 2010; Microsoft Company, Redmond, WA, USA) software program. SPSS plus Amos (model 18.0; SPSS Inc., Chicago, IL, USA) and JASP (model 0.12.2; JASP Staff, College of Amsterdam, Amsterdam, The Netherlands) had been adopted to analyse the information. Frequencies had been used to explain the sociodemographic traits and COVID-19-related traits. The imply (95% confidence interval, 95% CI) represented the imply worth; evaluation of variances or chi-square check was used to check values amongst teams. We estimated the energy of the pathways between perceived stress, anxiousness and melancholy, and sleep high quality utilizing structural equation modelling (SEM) with most probability estimation (MLE). A suitable goodness-of-fit (GOF) mannequin was indicated by the basis imply sq. error of approximation (RMSEA, 90% CI) < 0.08, standardized root imply residual (SRMR) < 0.08, goodness of match index (GFI) > 0.90, normed chi-square (NC) < 2.0–3.0, Tucker–Lewis index (TLI) > 0.90, comparative match index (CFI) > 0.90, parsimony goodness-of-fit index (PGFI) > 0.50, and parsimony normed match index (PNFI) > 0.50.40–42
Ethics Assertion
Participation within the research was voluntary and nameless, and individuals might decide out at any time whereas responding to those survey questions to make sure full respect and safety of particular person privateness all through this course of. Don’t enable the information to be related to a selected individual. Knowledgeable consent was obtained from all individuals enrolled within the research. This research meets the related necessities of the Declaration of Helsinki and its revised model.43 The Ethics Committee of Ningbo School of Well being Sciences reviewed and permitted the protocol.
Outcomes
Sociodemographic Traits and COVID-19-Associated Traits
Sociodemographic traits and COVID-19-related traits are described in Table 1. Concerning sociodemographic traits, 75.68% of respondents had been feminine. Of the respondents, 60.37% labored in Zhejiang Province, 32.31% labored in Hubei Province, and seven.31% labored in different provinces. A complete of 17.69% of individuals surveyed had been single, 80.95% had been married, and 1.36% had been divorced. Amongst all individuals, 40.65% had been medical docs, 45.24% had been registered nurses, 10.71% had been medical technicians, and three.40% had been directors. A complete of three.57% had unknown titles, 31.29% had junior titles, 48.30% had intermediate titles, and 16.84% had vice-senior or senior titles. Contributors reported their training degree, together with technical secondary faculty (1.19%), faculty diploma (10.03%), bachelor’s diploma (77.72%), and grasp’s diploma or above (11.05%).
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Desk 1 Sociodemographic Traits and COVID-19-Associated Traits (N = 588) |
Concerning COVID-19-related traits, 45.24% of respondents labored within the designated hospitals, 24.49% labored locally well being centre, and 30.27% labored in different medical establishments. Of the respondents, for 22.79% the work affairs had been an identical to the work affairs earlier than the pandemic, for 50.51% the work affairs had been principally in step with the earlier work affairs, and for 26.70% the work affairs had been inconsistent with the earlier work affairs. A complete of 12.76% of the individuals had direct contact with confirmed sufferers and/or physique fluid, 14.29% had doable contact with confirmed sufferers and/or physique fluid, 6.12% had direct contact with suspected sufferers and/or physique fluid, 40.48% had doable contact with suspected sufferers and/or physique fluid, and 26.36% had no contact with any confirmed and suspected sufferers and/or physique fluid. Amongst all individuals, 82.65% had enough safety with normal precautions, and 17.35% had insufficient safety with normal precautions. A complete of 9.35% of individuals at the moment reported a state of quarantined standing, 50.51% had a burden to care for the household, and 16.50% had work expertise in response to outbreaks.
Final result Traits – SQQ, PSS-10 and PHQ-4
The entire imply of the SQQ rating was 16.01 (95% CI [15.40, 16.57]). The SQQ scores had been considerably completely different by departmental perform (F = 3.73, P = 0.024), job class (F = 4.02, P = 0.003), and burden of household care (F = 13.86, P < 0.001). No important distinction was discovered by gender, province, marital standing, occupational classes, skilled title, academic degree, whether or not work affairs had been the identical as earlier than, enough safety, quarantined standing, and work expertise in response to outbreaks (all P > 0.05) (Table 2).
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Desk 2 Variations Between Teams on Sleep High quality and Perceived Stress |
The entire imply PSS rating was 15.46 (95% CI [15.05, 15.87]). The PSS scores had been considerably completely different by province (F = 7.05, P = 0.001), occupational classes (F = 3.14, P = 0.025), if work affairs had been the identical as earlier than (F = 4.31, P = 0.014), job class (F = 3.51, P = 0.008), enough safety (F = 14.26, P < 0.001), and burden of household care (F = 10.36, P = 0.001). No important distinction was discovered by gender, marital standing, skilled title, academic degree, quarantined standing, or work expertise in response to outbreaks (all P > 0.05) (Table 2).
The PHQ-4 (GAD-2 and PHQ-2) scores are described individually in Table 3. Within the GAD-2, the portions of scores from 0 to six had been 132, 123, 275, 22, 22, 6, and eight, accounting for 22.45%, 20.92%, 46.77%, 3.74%, 3.74%, 1.02%, and 1.36%, respectively. The constructive price of the anxiousness signs check was 9.86% (58/588). Within the PHQ-2, the portions of scores from 0 to six had been 154, 108, 265, 32, 16, 6, and seven, accounting for 26.19%, 18.37%, 45.07%, 5.44%, 2.72%, 1.02%, and 1.19%, respectively. The constructive price of melancholy signs check was 10.37% (61/588).
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Desk 3 Frequency of Every Rating on the GAD-2 and the PHQ-2 (N = 588) |
The anxiousness and non-anxiety symptom people had been considerably completely different by province (χ2 = 11.640, P = 0.003), if work affairs had been the identical as earlier than (χ2 = 8.818, P = 0.012), job class (χ2 = 15.300, P = 0.004), and enough safety (χ2 = 8.408, P = 0.004). The melancholy and non-depression symptom people had been considerably completely different by province (χ2 = 17.807, P < 0.001), skilled title (χ2 = 9.904, P = 0.019), if work affairs had been the identical as earlier than (χ2 = 10.486, P = 0.005), job class (χ2 = 11.477, P = 0.022), and enough safety (χ2 = 16.633, P < 0.001) (Table 4).
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Desk 4 Comparisons Between Anxiousness and Non-Anxiousness Symptom as Nicely as Despair and Non-Despair Symptom People |
Correlational Evaluation and Structural Equation Modelling
Correlational evaluation confirmed that there have been important correlations between perceived stress and sleep high quality (r = 0.52, P < 0.001), anxiousness and melancholy and sleep high quality (r = 0.57, P < 0.001), and perceived stress and anxiousness and melancholy (r = –0.64, P < 0.001). Good sleep high quality normally indicated decrease stress and fewer anxiousness and melancholy signs in the course of the COVID-19 pandemic.
Based mostly on a priori hypotheses for constructing a mannequin, perceived stress was related to sleep high quality (beta = 0.25, P = 0.045), perceived stress was related to anxiousness and melancholy (beta = 0.78, P = 0.014), and anxiousness and melancholy had been related to sleep high quality (beta = 0.42, P < 0.001). The outcomes are proven in Figure 1. All path coefficients within the mannequin had P < 0.05. The outcomes of the assessments and the goodness-of-fit of the mannequin are introduced in Table 5.
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Determine 1 Ultimate structural mannequin (N = 588). |
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Desk 5 Analysis of the Goodness-of-Match of the Mannequin (N = 588) |
Dialogue
This development is worrisome, as research counsel that well being care employees suffered from sleep dysfunction and psychological misery in the course of the outbreak of COVID-19, particularly poor sleep high quality in frontline well being care employees.3,15,21,44–48 This research exhibits that sleep high quality was associated to departmental perform, job class, and burden of household care amongst well being care employees. Well being care employees who work in designated hospitals had poorer sleep high quality than these in neighborhood well being centres and different medical establishments. Well being care employees who labored in comparatively secure locations had higher sleep high quality as a result of they won’t have contact with the COVID-19 sufferers or their physique fluid. COVID-19 outbreak-associated occasions, corresponding to publicity to danger elements, correlate with decreased sleep high quality in relationship with a rise in unfavorable temper.23 Well being care employees who had the burden of taking good care of the household had considerably worse sleep high quality. On this research, we didn’t discover the distinction between the outbreak and non-outbreak instances on sleep high quality amongst well being care employees. Nonetheless, one other research from us discovered that the standard of sleep amongst well being care employees in the course of the outbreak was higher than that in non-outbreaks,33 and whether or not this discovering was actual and its trigger wants follow-up proof.
Research point out that well being care employees preventing towards COVID‐19 are typically underneath stress worldwide.24,49–53 Our research exhibits that the perceived stress of well being care employees on this outbreak was associated to province, occupational classes, whether or not work affairs had been the identical as earlier than, job class, enough safety and burden of household care. Well being care employees in Zhejiang had decrease perceived stress ranges than well being care employees in Hubei and others, most likely as a result of Wuhan (the capital of Hubei Province) and Hubei had been within the epicentre in the course of the early stage of the epidemic. Well being care employees in Wuhan had been confronted with varied stressors, corresponding to a scarcity of medical professionals, a scarcity of provides of non-public protecting gear and medical units, and a excessive risk of occupational publicity; thus, their perceived stress was comparatively excessive. Because of the great amount of coordination and administration, the perceived stress of directors was larger than that of registered nurses, medical docs and medical technicians. Many well being care employees left their unique positions and stationed on the frontline in the course of the COVID-19 outbreak, which elevated their perceived stress. Well being care employees who had doable contact with sufferers or physique fluids had the best stress, which can be resulting from uncertainty and insufficient safety, in contrast with well being care employees who straight contacted confirmed sufferers with COVID-19. Well being care employees with out enough safety had considerably larger perceived stress than these with enough safety, and well being care employees with a burden of household care had considerably larger perceived stress.
This research exhibits that 9.86% of well being care employees within the COVID-19 response might have anxiousness signs, and 10.37% of well being care employees might have melancholy signs. Moreover, a multinational and multicentre research on the psychological outcomes amongst well being care employees in the course of the COVID-19 outbreak exhibited 8.7% average to extraordinarily extreme anxiousness, and 5.3% screened constructive for average to very extreme melancholy.54 Preliminary proof in a latest evaluate means that the incidence price of tension and melancholy was 16–28%.55 The constructive price of tension and melancholy signs in our survey was pretty low, which could possibly be as a result of the surveyed respondents consisted of well being care employees working within the confirmed ward and neighborhood well being care employees and different well being care employees who had been comparatively much less affected by the outbreak. The anxiousness and non-anxiety symptom people in addition to melancholy and non-depression symptom people had been considerably completely different by province, if work affairs had been the identical as earlier than, job class, and enough safety. Furthermore, the melancholy and non-depression symptom people had been considerably completely different by skilled title.
Confronting an unexpected international occasion because of the COVID-19 outbreak, most people are uncovered to an unprecedented demanding scenario of unknown length, which could not solely enhance stress, anxiousness and melancholy symptom ranges but additionally lower sleep high quality.56 The ultimate SEM mannequin within the present research offers us with additional proof that mitigating stress and growing coping might assist scale back anxiousness and melancholy signs, thereby bettering the extent of sleep high quality amongst well being care employees. Many well being care employees from a qualitative research talked about that they didn’t want a psychologist however wanted extra relaxation with out interruption and sufficient protecting provides.57 Along with growing focused methods to mitigate key stressors, the pressing want for higher sleep well being administration methods must be emphasised in the course of the COVID-19 disaster. Furthermore, managing sleep issues as greatest as doable in the course of the COVID-19 disaster might restrict perceived stress and probably stop disruptions of social relationships.56 The present wave of COVID-19 outbreaks, which started greater than a yr in the past around the globe, remains to be ongoing. To advertise the psychological well being of well being care employees, we should always first put their precise wants by means of a stress discount program, thereby basically reducing their anxiousness and melancholy signs and bettering sleep high quality degree. There are at the moment three out there interventions for consideration: work interventions, psychosocial interventions, and pharmacotherapies.58 Moreover, our organizations ought to intensify the efforts to enhance humanistic concern in case well being care employees might have turn into overexcited in medical work and refused affordable relaxation to make sure their well being.59 As well as, it’s equally essential for well being care employees to keep up a steadiness between their wants and others’ wants.60 Briefly, we spotlight the position of perceived stress or work stressors and tailor-made interventions to mitigate poor sleep high quality and stop long-term bodily and psychological implications. Nonetheless, be sure you remember the fact that the present scenario in the course of the COVID-19 outbreak is not going to disappear in a single day and the main focus must be on longer-term occupational capability fairly than repeated short-term disaster responses, based mostly on the WHO robust suggestions.61,62 Future research ought to intention to offer high-quality info on the long-term penalties and the effectiveness of utilized interventions dealing with COVID-19.
There are worthwhile strengths and key limitations. First, this research assessed sleep high quality and perceived stress and anxiousness and melancholy signs amongst well being care employees in the course of the COVID-19 disaster and explored related elements and their interactions, which might present clues to assist exact interventions of sleep high quality and different psychological well being issues for well being care employees. Second, the inclusion of multidisciplinary well being care employees allowed for comparability between completely different backgrounds. Nonetheless, some limitations must be famous. First, the snowball sampling on this research typically may imply poor representativeness resulting from constraints on sources and circumstances. Second, the pattern dimension is comparably small to different research on this subject, and no large-scale research was carried out on extreme pandemic conditions on the preliminary stage of outbreaks. This nonrandom sampling methodology with small samples might restrict the generalizability of those findings. Third, a cross-sectional research design based mostly on a fast on-line survey can not make legitimate causal inferences concerning the relationship between the research variables, and no follow-up information from completely different levels of the pandemic levels had been collected, which doesn’t enable us to analyse sleep high quality and perceived stress over a while. Lastly, to maintain the survey time and the response price acceptable, the sampled questions didn’t embrace some mediating and moderating variables (eg, psychological resilience, psychological capital, social assist, self-compassion, self-care, and optimism) and potential confounders15 (eg, work shifts, work schedule, sleeping lodging, caffeine/nicotine consumption, diets, and coexisting sleep problems).
Conclusions
Poor sleep high quality and excessive perceived stress had been frequent in Chinese language well being care employees in the course of the COVID-19 pandemic. Decreasing perceived stress might assist scale back anxiousness and melancholy signs, thereby bettering sleep high quality amongst well being care employees. Furthermore, in an try to advertise psychological sources, we should always maybe take a number of measures, together with private tailor-made intervention and organizational humanistic concern.
Acknowledgments
The authors are indebted to the division heads and the individuals who made the present research doable. Particularly because of each builders and introducers of those three devices. The authors recognize edits on earlier drafts from Dr. Xiaoyu Lan (College of Oslo, Oslo, Norway). Furthermore, they’re notably grateful for the insightful feedback from three nameless reviewers and the educational editor.
Creator Contributions
All authors made a major contribution to the work reported, whether or not that’s within the conception, research design, execution, acquisition of information, evaluation and interpretation, or in all these areas; took half in drafting, revising or critically reviewing the article; gave last approval of the model to be revealed; have agreed on the journal to which the article has been submitted; and comply with be accountable for all points of the work.
Funding
The primary creator was supported by the Ningbo Philosophy and Social Science Planning Undertaking (Grant No. G20-ZX66). Moreover, the final creator was supported by the Analysis Initiation Fund of Hangzhou Regular College (Grant No. RWSK20201003).
Disclosure
The authors declare no conflicts of curiosity.
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