Medical students’ knowledge and attitudes towards integrative care with traditional Chinese medicine in Taiwan during the COVID-19 pandemic

Abstract

In 2020, a novel botanical preparation of traditional Chinese medicine was developed and officially recommended for treating mild COVID-19 cases in Taiwan. This study examined the perceptions of integrative care combining Western and Chinese medicine in Taiwanese medical students. A cross-sectional questionnaire survey was conducted in April and May 2020 among first- to fourth-year medical undergraduates to evaluate their knowledge, attitudes, and behaviors regarding the use of Chinese medicine in integrative health care. In total, 396 out of 668 medical students (59.3%) responded to the survey, including 255 students who had participated in at least 1 elective Chinese medicine course, with the most common courses being “Introduction to Chinese Medicine” (86.3%) and “Chinese Medical Physiology” (47.1%). These 255 students scored higher on the knowledge scale (P < .001) and positive attitude scale (P = .002) in terms of Chinese medicine utilization compared with 141 undergraduates who did not participate in any Chinese medicine courses. Most students reported that they would collect their patients’ Chinese medicine history (63.4%) and the concurrent use of Western and Chinese medications (72.5%). Among Taiwanese medical students, those who completed an elective Chinese medicine course demonstrated high levels basic knowledge, positive attitudes towards Chinese medicine utilization, and proactive engagement in integrative care involving both Western and Chinese medicine.

1. Introduction

From January 2020 to December 2022, Taiwan reported a total of 15,253 COVID-19-related deaths among 88,72,955 confirmed cases.^[1] In response to the pandemic, many infection control measures were implemented, and various Western medicine interventions and medications were administered. In April 2020, the National Research Institute of Chinese Medicine (NRICM) and the Tri-Service General Hospital developed a traditional Chinese medicine (TCM) preparation known as NRICM101 for the treatment of COVID-19.^[2] They also established the Traditional Chinese Medicine Clinical Guideline for COVID-19, which was approved by the Ministry of Health and Welfare of Taiwan in June 2020.^[3] Following these guidelines, Chinese Medicine physicians prescribed 2 concentrated powder preparations, namely NRICM101 for mild-to-moderate cases and NRICM102 for severe or critical respiratory illnesses, during the mid-2021 outbreak.^[4] These treatments, combined with standard Western medicine care, covered by Taiwan’s National Health Insurance system, were associated with reduced risks of intubation, intensive care unit admissions, and mortality among patients with mild-to-severe COVID-19.^[5-7]

Since 2015, hospitals in Taiwan with Chinese medicine departments have been given Hospital and Teaching Hospital Accreditation^[8] by the end of 2019, 4 Chinese medicine hospitals, 3944 Chinese medicine clinics, and 122 Western medicine hospitals with Chinese medicine departments had been included.^[8] Since 2018, the National Health Insurance system of Taiwan has covered 10 distinct versions of combined Western medicine and TCM care models for outpatient and inpatient services, addressing conditions such as vertigo, pain, and bowel obstruction. Currently, 5 departments of Chinese medicine operate within 4 Western medical schools in Taiwan, providing professional education in TCM. These departments offer 2 undergraduate and 3 postbaccalaureate programs, collectively admitting 365 Chinese medical students every year.^[8] Elective courses on TCM are also offered to a limited extent at the remaining 9 Western medical schools.

In 2001, the Tri-Service General Hospital established its department of Chinese medicine. To foster a deeper understanding of TCM and Western medicine, elective TCM courses such as “Introduction to Chinese Medicine” and “Introduction to Acupuncture” were offered at the affiliated Western medicine school, National Defense Medical Center, in 2004. By September 2016, the elective TCM curriculum expanded to include 10 subjects, each comprising 32 hours per semester, covering both fundamental theory and advanced clinical practices (Supplement 1, Supplemental Digital Content 2).

In a previous Taiwanese questionnaire survey,^[9] half of the participants, who were surgical patients, reported using Chinese medicine and dietary supplements before their surgeries. One-third of the patients acknowledged concurrent use of TCM with Western medications prescribed for their underlying diseases. Given the increasing incorporation of Chinese medicine into Taiwan’s healthcare system, this study aimed to investigate medical students’ perspectives on the integration of Chinese and Western medicine. A questionnaire survey was conducted during the first wave of the COVID-19 pandemic (April–May 2020) to assess participants’ basic TCM knowledge, attitudes toward integrative care involving Western medicine and TCM, and perceptions of potential drug-herb interactions.

2. Materials and methods

2.1. Western medical students with or without an elective TCM course

This cross-sectional study was approved by the Institutional Review Board of Tri-Service General Hospital (TSGHIRB-1-108-05-040). Given the nature of the survey, the requirement for written informed consent was waived for all participants. Registration prior to patient enrollment was not applicable because participants were not assigned to treatment groups in this study. Prior to participant recruitment, we conducted an a priori sample size estimation using G*Power 3.1 software (Heinrich Heine University Düsseldorf, Düsseldorf, Germany). Assuming a small to moderate effect size (Cohen’s d = 0.3), a 2-tailed independent samples t test, a significance level (α) of 0.05, and a statistical power of 0.80, the estimated required sample size was approximately 176 participants per group, for a total of 352 participants. In April 2020, a list of all medical students who had participated in at least 1 elective TCM course was obtained from the Office of Student Affairs in the present medical school. Questionnaires were distributed on all first- to fourth-year students by a trained research assistant. The participants completed the questionnaires either independently or with verbal assistance from the research assistant until the end of May 2020. Students who were on academic leave or submitted incomplete questionnaires were excluded from the analysis.

2.2. Questionnaire development: review committee and test-retest reliability

This novel Chinese language questionnaire (Supplement 2, Supplemental Digital Content 1), derived in part from similar previous surveys,^[10-12] was primarily developed in 2019 by the board-certified Chinese Medicine clinicians.^[13] All questions underwent refinement for content validity by a review committee, which comprised 8 senior specialists, including 3 Chinese Medicine physicians, 1 Western medicine surgeon, 1 anesthesiologist, 2 medical education professors, and 1 epidemiologist. To evaluate the questionnaire’s test-retest reliability (i.e., stability over time), 20 third-year medical students were asked to complete a follow-up questionnaire 2 to 3 weeks after completing the initial questionnaire. Test-retest reliability was evaluated by an intraclass correlation coefficient for each item on 2 scales, with an acceptable threshold set at ≥0.55. The internal consistencies of these 2 scales were indicated by Cronbach’s α ≥ 0.70.^[13]

2.3. Study instrument: questionnaire for medical students

In the final questionnaire, the first section was on basic characteristics, including details on the topics covered and the hours spent on previous TCM courses. The second section was designed to evaluate medical students’ grasp of TCM terminology, concepts on the meridians, and the applications of acupuncture (scale on knowledge of basic TCM theory); their attitudes towards the benefits and potential drawbacks of TCM (scale on attitude); and their willingness to engage in behaviors promoting integrative care involving Western medicine and TCM in clinical practice.

2.4. Statistical analysis

Data on the basic characteristics are presented as their frequency (%) or their mean ± standard deviation. Questionnaire responses were analyzed using IBM SPSS Statistics version 22 (IBM, Armonk). Categorical responses of 1, 2, 3, 4, and 5 corresponded to strongly agree, agree, unsure, disagree, and strongly disagree, respectively, with incorrect statements of knowledge or negative statements of attitude. Scores of correct knowledge and positive statements of attitude were adjusted to 5 for strongly agree and 1 for strongly disagree. Personal behaviors and willingness to deliver integrative care are presented as numbers (%) and were compared using chi-squared test and Student t test, with responses of always, frequently, sometimes, seldom, and never. The total responses for all items, presented as mean ± SD, were compared using a paired t test. In all tests, a P value <.05 was considered statistically significant.

3. Results

Among a total of 668 first- to fourth-year medical students, 396 (59.3%) responded to the questionnaires, including 255 (51.2%) out of 498 students who had participated in at least 1 TCM course and 141 (82.9%) out of 170 students who had not (Table 1). Voluntary enrollment in both the course and the study led to an inherent imbalance in group sizes (255 vs 141). The courses taken were primarily “Introduction to Chinese Medicine” and “Chinese Medical Physiology,” in which 220 (86.3%) and 120 (47.1%) out of 255 students, respectively, participated.

Table 1.

Characteristics of medical students.

	Chinese medicine course (n = 255)	No Chinese medicine course (n = 141)	P value*
Gender, n (%)
Male	169 (66.3)	100 (70.9)	.343
Female	86 (33.7)	41 (29.1)
Do you have relatives or friends who work as TCM physicians or operate TCM pharmacies?
Yes	52 (20.4)	24 (17.0)	.415
No	203 (79.6)	117 (83.0)
Have you ever participated in TCM courses before joining this medical school?
Yes	44 (17.3)	10 (7.1)	.005
No	211 (82.7)	131 (92.9)
Previous elective TCM courses in this medical school
1. Introduction to Chinese medicine, 32 h	220 (86.3)
2. Chinese medical physiology, 32 h	120 (47.1)
3. Chinese medical pathology, 32 h	9 (3.5)
4. Chinese medical life cultivation, 32 h	6 (2.4)
5. Chinese medical formulas and pharmacology, 32 h	7 (2.7)
6. Chinese medical diagnostics, 32 h	2 (0.8)
7. Chinese medical pattern differentiation and treatment, 32 h	0 (0.0)
8. Chinese internal medicine (obstetrics and gynecology and pediatrics), 32 h	0 (0.0)
9. Chinese external medicine (orthopedics and traumatology), 32 h	0 (0.0)
10. Introduction to acupuncture and moxibustion, 32 h	3 (1.2)
Total hours, n = 255 (100.0%)	46.1 ± 21.5

Data are presented as n (%) or as mean ± SD.

SD = standard deviation.

^*P values based on the chi-squared test.

Table 2 presents the scores for basic TCM knowledge. Students who participated in 1 TCM course exhibited a higher mean score on the knowledge scale compared with those who had not (3.96 ± 0.58 vs 3.74 ± 0.55, P < .001; Fig. 1). Compared with students who did not participate in a TCM course, a larger number of those who participated responded to the following statement: “Epidemic-scale diseases in TCM are somewhat equivalent to large-scale infectious diseases in Western medicine” (3.98 ± 0.74 vs 3.80 ± 0.66, P = .015).

Table 2.

Knowledge scores of medical students who had taken or had not taken TCM courses.

Correct statement	With Chinese medicine course (n = 255)	Without Chinese medicine course (n = 141)	P value*
1. The World Health Organization announced 64 indications for acupuncture in 1996	3.80 ± 0.75	3.69 ± 0.72	.164
2. Epidemic-scale diseases in TCM are somewhat equivalent to large-scale infectious diseases in Western medicine	3.98 ± 0.74	3.80 ± 0.66	.015
3. Wei-defensive qi in TCM theory is somewhat equivalent to immune function in Western medicine	3.93 ± 0.75	3.72 ± 0.66	.004
4. Ying-nutrient qi in TCM theory is somewhat equivalent to proteins, carbohydrates, and lipids in Western medicine	3.90 ± 0.82	3.71 ± 0.67	.017
5. Spleen Zang-Xiang (i.e., visceral manifestations) in TCM is somewhat equivalent to the function of the digestive system in Western medicine	3.81 ± 0.83	3.63 ± 0.79	.040
6. Bodily fluid in TCM theory is somewhat equivalent to sweat, saliva, joint cavity fluid, and cerebrospinal fluid in Western medicine	3.96 ± 0.78	3.68 ± 0.73	.001
7. TCM theory divides the body of spiritual operation into ethereal soul (Hun), spirit, sense, corporeal soul (Po), and will	4.13 ± 0.73	3.83 ± 0.75	<.001
8. TCM theory believes that shape, essence, qi, and spirit constitute and determine the physical characteristics of each individual	4.17 ± 0.67	3.88 ± 0.68	<.001
9. The meridian system includes 12 meridians and 8 extraordinary meridians	4.09 ± 0.74	3.83 ± 0.72	.001
10. The Governor and Ren vessels belong to the 8 extraordinary meridians	3.84 ± 0.86	3.67 ± 0.83	.060
Total mean score	3.96 ± 0.58	3.74 ± 0.55	<.001

Data are presented as mean ± SD.

The scores of correct statements were adjusted to 5 for strongly agree, 4 for agree, 3 for unsure, 2 for disagree, and 1 for strongly disagree.

SD = standard deviation, TCM = traditional Chinese medicine.

^*P values based on Student t test.

Figure 1.

Comparison between Western medical students with or without an elective Chinese medicine course.

As shown in Table 3, the overall attitude scores towards TCM use were more positive among students who had participated in a TCM course (3.82 ± 0.41 vs 3.68 ± 0.41, P = .002) than among those who had not. Those who had participated in a TCM course agreed with the following statements: “Having TCM knowledge will benefit Western medicine physicians during patient care” (P = .032) and “Government policies should support the development of TCM” (P = .001).

Table 3.

Attitude scores of medical students with or without TCM courses.

Attitude statement	With Chinese medicine course (n = 255)	Without Chinese medicine course (n = 141)	P value*
1. TCM is beneficial to individuals’ daily health care	4.35 ± 0.63	4.20 ± 0.67	.026
2. TCM emphasizes holistic considerations and whole person health to a greater extent than Western medicine does	4.13 ± 0.78	3.91 ± 0.73	.007†
3. TCM treatment is gentler and has fewer side effects than Western medicine	4.02 ± 0.79	3.85 ± 0.78	.037
4. Patients should consult a Western medicine physician before receiving concomitant TCM and Western medicine	4.05 ± 0.78	4.04 ± 0.74	.809
5. Western medicine physicians should be able to recognize commonly used TCM remedies for their patients	3.91 ± 0.72	3.76 ± 0.72	.047
6. Most TCM doctors in Taiwan have undergone structured educational courses and examinations during the development process	4.07 ± 0.72	3.93 ± 0.80	.080
7. Having TCM knowledge will benefit Western medicine physicians during patient care	4.23 ± 0.68	4.10 ± 0.64	.032†
8. Governmental policies should support the development of TCM	4.10 ± 0.74	3.84 ± 0.78	.001
9. TCM practice is unreliable because it lacks large-scale randomized controlled trials for evidence-based medicine (negative)	2.37 ± 0.91	2.40 ± 0.88	.737
10. Taking Chinese herbal medications is associated with a higher risk of liver and kidney toxicity compared with Western medicine (negative)	2.96 ± 0.90	2.79 ± 0.84	.078
Total mean score	3.82 ± 0.41	3.68 ± 0.41	.002

Data are presented as mean ± SD.

Scores of negative statements were presented as 1 (strongly agree) to 5 (strongly disagree), whereas scores of positive statements were adjusted as 5 (strongly agree) to 1 (strongly disagree).

SD = standard deviation, TCM = traditional Chinese medicine.

^*P values based on Student t test.

^†P values based on the Mann–Whitney U test.

As indicated by Table 4, medical students who had participated in a TCM course reported more positive responses regarding behaviors towards TCM (50.9% ± 29.6% vs 43.3% ± 30.3%, P = .016) compared with those who had not. Although only a low proportion of respondents stated a strong willingness (always or frequently) to seek TCM treatment for personal (29.3%) or family (27.5%) illnesses, a significantly greater number of students indicated they would prioritize TCM therapy for their patients as an alternative when Western medicine treatment is not effective (P = .003). Most students tended to proactively inquire about their patients’ TCM medical history (66.3% vs 58.2%, P = .108) and the concurrent use of Chinese and Western medications (74.9% vs 68.1%, P = .146), although these differences were not statistically significant.

Table 4.

Positive behavior responses of medical students with or without TCM courses.

n (%)	With Chinese medicine course (n = 255)	Without Chinese medicine course (n = 141)	P value*
1. I would proactively learn TCM knowledge
Always or frequently	65 (25.5)	27 (19.1)	.257
Sometimes	127 (49.8)	71 (50.4)
Seldom or never	63 (24.7)	43 (30.5)
2. I would pay attention to TCM news
Always or frequently	83 (32.5)	32 (22.7)	.117
Sometimes	126 (49.4)	79 (56.0)
Seldom or never	46 (18.0)	30 (21.3)
3. If I am not feeling well, I would seek TCM treatment
Always or frequently	72 (28.2)	44 (31.2)	.627
Sometimes	114 (44.7)	56 (39.7)
Seldom or never	69 (27.1)	41 (29.1)
4. If my relatives or friends are not feeling well, I would advise them to seek TCM treatment
Always or frequently	68 (26.7)	41 (29.1)	.736
Sometimes	128 (50.2)	65 (46.1)
Seldom or never	59 (23.1)	35 (24.8)
5. I would include TCM therapy history as a necessary item in medical records
Always or frequently	169 (66.3)	82 (58.2)	.206
Sometimes	72 (28.2)	52 (36.9)
Seldom or never	14 (5.5)	7 (5.0)
6. I would proactively inquire about my patients’ use of TCM and Western medications
Always or frequently	191 (74.9)	96 (68.1)	.216
Sometimes	51 (20.0)	39 (27.7)
Seldom or never	13 (5.1)	6 (4.3)
7. I would agree for my patients to take TCM prescribed by a qualified Chinese Medicine physician
Always or frequently	176 (69.0)	80 (56.7)	.050
Sometimes	70 (27.5)	54 (38.3)
Seldom or never	9 (3.5)	7 (5.0)
8. I would prioritize TCM therapy as an alternative when Western medicine treatment is not effective for my patients
Always or frequently	149 (58.4)	60 (42.6)	.003
Sometimes	78 (30.6)	67 (47.5)
Seldom or never	28 (11.0)	14 (9.9)
9. If necessary, I would consult with a Chinese Medicine physician to discuss the appropriate treatment for my patients
Always or frequently	171 (67.1)	83 (58.9)	.266
Sometimes	71 (27.8)	49 (34.8)
Seldom or never	13 (5.1)	9 (6.4)
10. I would engage in academic exchanges with Chinese Medicine physicians
Always or frequently	153 (60.0)	65 (46.1)	.020
Sometimes	81 (31.8)	64 (45.4)
Seldom or never	21 (8.2)	12 (8.5)
Total positive responses (i.e., always or frequently), %	50.9 ± 29.6	43.3 ± 30.3	.016†

Data are presented as n (%) or as mean ± SD.

SD = standard deviation, TCM = traditional Chinese medicine.

^*P values based on the chi-squared test.

^†P values based on Student t test.

4. Discussion

This comparative questionnaire survey demonstrated that Western medical students who had participated in at least a 32-hour elective TCM course exhibited a stronger grasp of basic TCM concepts and more positive attitudes towards integrative care involving Chinese medicine compared with those who had not. Although fewer than 30% of students expressed strong willingness to use TCM for illness personally or for family care, a greater proportion tended to accept TCM as an alternative for their patients when Western medicine treatment is not effective Following the course, most medical students would actively inquire about their patients’ TCM medical history and concurrent use of Chinese and Western medications.

In the present study, most medical students participated in the basic TCM courses “Introduction to Chinese Medicine” and “Chinese Medical Physiology,” 2 of the ten topics in this elective curriculum (Supplement 1, Supplemental Digital Content 2). This survey evaluated the effectiveness of these elective TCM courses during the COVID-19 outbreak. The lecturers, all licensed Chinese Medicine physicians, emphasized the disease-based clinical applications of TCM,^[14-16] and introduced the promptly formulated Chinese herbal prescriptions for managing COVID-19 in early 2020, guided by TCM theories on etiology, pathogenesis, characteristics, and clinical therapeutic efficacy.^[5-7] The observed improvement in acceptance of integrative care among students may be attributed to their increased foundational TCM knowledge and the inclusion of disease-oriented instruction in TCM diagnosis and pattern differentiation.

Comparable findings have been reported in prior studies. A pre- and post-course survey in Taiwan demonstrated significant gains in TCM knowledge and attitudes among medical students following a structured course.^[12] Similarly, an educational reform survey of TCM learning in China indicated that modern medical students held a more positive attitude toward scientific nature of TCM and necessity to learn TCM.^[17] However, the students favored clinical training to theoretical teaching, while the TCM teachers emphasized the importance of lecture-based education.^[17] In other East-Asian regions, exposure to traditional medicine tends to remain largely theoretical and less systematically incorporated into medical curricula,^[18-20] which may account for lower self-rated knowledge and weaker behavioral intentions toward integrative care compared with Taiwan. In contrast, Taiwan’s well-established integrative healthcare system reinforces relevant competencies through consistent clinical exposure. Short-term yet well-structured TCM education aligns with real patient care needs and interprofessional practice, thereby enhancing students’ readiness for clinical application.

In the current study, students who had taken a TCM course demonstrated more positive attitudes towards TCM use, particularly regarding its holistic and whole-person health concepts. Previous studies have also shown that TCM’s theoretical frameworks and clinical approaches can complement Western medicine by addressing systemic imbalances, promoting functional recovery, and improving overall patient well-being.^[14-16] According to the 2021 Taipei Consensus on Integrative Traditional Chinese and Western Medicine, Western medicine excels in the diagnosis and treatment of diseases or disorders, whereas TCM focuses on patient-centered wellness.^[19] Although TCM may not be sufficient for acute, critical, and life-threatening conditions, it serves as a complementary and alternative approach to Western medicine.^[19] This perspective is embodied in the integration of “Whole Person Health” into healthcare practices.^[21] According to data from the Taiwan National Insurance reimbursement database, approximately 28.4% of the Taiwanese population (23 million) have received prescriptions from Chinese Medicine physicians,^[22] and 14.1% have concurrently used Chinese herbal products and Western medications.^[23] Overall, Western medical students and caregivers in Taiwan should be aware of the potential for drug-herb interactions in clinical settings.

In the present study, students who had participated in a TCM course exhibited greater behavioral willingness to engage with TCM practices. Nevertheless, the proportion of students expressing strong willingness (“always” or “frequently”) to seek TCM treatment for personal or family illnesses remained relatively low (<30%). This finding is understandable, as young and healthy medical students trained in a conventional Western medical school may be more inclined to use Western medicine for first-line or emergency care, while considering TCM as a complementary option. This attitude aligns with our finding that a higher proportion of students indicated that they would prioritize TCM therapy as an alternative when Western medical treatments proved ineffective for their patients. During the COVID-19 pandemic, exposure to real-world examples of integrative strategies likely enhanced students’ understanding not only of how TCM can be incorporated into biomedical care but also of why interdisciplinary collaboration can lead to meaningful clinical benefits. Looking forward, the emergence of generative artificial intelligence offers new opportunities to support culturally grounded medical decision-making and to reduce access barriers within TCM care systems.^[24] Practically, these technologies may enable future physicians to participate more effectively in shared decision-making with TCM practitioners and to manage herb-drug interaction safety concerns with greater confidence in clinical practice.

This study has several limitations. First, approximately 40% of students did not respond to the survey, likely reflecting reduced on-campus activity during COVID-19 restrictions. Western medical students who chose to participate in an elective TCM course may have been interested in Chinese medicine, potentially resulting in selection bias. Second, as the majority of students had undertaken only foundational courses, their TCM knowledge retention may diminish without subsequent practical reinforcement. Third, the voluntary nature of both course selection and study participation resulted in an inherent imbalance in group sizes (255 vs 141) within this non-randomized observational design. Fourth, clinical behaviors were not assessed, which limits evaluation of whether increased knowledge and positive attitudes translate into practice-related outcomes. Fifth, the cross-sectional design precludes causal inference. Future studies should employ longitudinal or interventional designs to monitor behavioral changes throughout clinical training and into early professional practice.

5. Conclusions

Western medical students who had completed at least a 32-hour elective Chinese medicine course gained a deep understanding of basic TCM knowledge and developed positive attitudes towards the integration of Western medicine and TCM. Most students would proactively inquire about the concurrent use of Chinese and Western medications. Despite the low willingness to seek TCM treatment for personal or family illness among Western medical students, most respondents expressed acceptance of TCM as an alternative when Western medical treatment proved ineffective for their patients. Future longitudinal and outcome-based studies are warranted to quantify changes in clinical behavior, interdisciplinary communication, and patient safety improvement over time.

Acknowledgments

The authors would like to thank Huei-Han Liou for her contributions to the statistical analysis.

Author contributions

Conceptualization: Sunny Jui-Shan Lin, Shung-Tai Ho, Yi-Chang Su, Chien-Jung Lin, Tso-Chou Lin.

Data curation: Sunny Jui-Shan Lin, Chien-Jung Lin, Tso-Chou Lin.

Formal analysis: Sunny Jui-Shan Lin, Chien-Jung Lin, Tso-Chou Lin.

Funding acquisition: Shu-Meng Cheng.

Investigation: Sunny Jui-Shan Lin, Chien-Jung Lin.

Methodology: Sunny Jui-Shan Lin, Shung-Tai Ho, Yi-Chang Su, Chien-Jung Lin, Tso-Chou Lin.

Project administration: Chien-Sung Tsai, Shu-Meng Cheng, Cheng-Yi Cheng.

Resources: Chien-Sung Tsai, Shu-Meng Cheng, Cheng-Yi Cheng.

Supervision: Chien-Sung Tsai.

Validation: Sunny Jui-Shan Lin, Shung-Tai Ho, Yi-Chang Su, Chien-Sung Tsai, Shu-Meng Cheng, Cheng-Yi Cheng, Chien-Jung Lin, Tso-Chou Lin.

Visualization: Tso-Chou Lin.

Writing – original draft: Sunny Jui-Shan Lin.

Writing – review & editing: Shung-Tai Ho, Yi-Chang Su, Chien-Sung Tsai, Shu-Meng Cheng, Cheng-Yi Cheng, Chien-Jung Lin, Tso-Chou Lin.