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Article The Impact of the Community Built Environment on the Walking Times of Residents in a Community in the Downtown Area of Fuzhou

Lizhen Zhao 1,2, Zhenjiang Shen 1,*, Yanji Zhang 2 and Yan Ma 2 1 School of Geoscience and , Kanazawa University, Kanazawa 920-1192, Japan; [email protected] 2 School of , Fuzhou University, Fuzhou 350116, China; [email protected] (Y.Z.); [email protected] (Y.M.) * Correspondence: [email protected]

 Received: 23 December 2018; Accepted: 21 January 2019; Published: 28 January 2019 

Abstract: By means of on-site and network investigation, we collected data relevant to residents of communities, point of interest (POI) data, and land-use data of Fuzhou. We set traffic walking time and leisure walking time as an independent variable, built environment as dependent variable, and gender, age, education level and income level as control variables. Six linear regression models were established using Statistical Product and Service Solutions (SPSS). The results showed that in the 5D (i.e., Density, Diversity, Design, Destination and Distance) elements of the built environment, the density was negatively correlated with the traffic walking time, whereas other elements were positively correlated with the walking time, but the degree of influence was different.

Keywords: walking time; density; diversity; design; destination; distance

1. Introduction On the basis of case-related data, this study quantitatively analyzed the correlation between the resident walking times and the community built environment and identified the urban built environment factors that significantly affected resident walking. This study was conducted to provide a theoretical basis and a practical direction for creating a healthy urban space. We aimed to clarify the relationship between and urban . Modern originates from problems [1]. After more than 100 years of urban development, rapid has introduced new health problems to human beings [2]. Urban health has once again attracted the attention of scholars in various fields [3,4]. The current path of urban planning to promote health has manifested in two ways. The first is through a reduction in the impact of on the human body, which means adopting certain protective measures and planning methods to prevent pollutants from spreading to places where people gather and to reduce the human body’s absorption of particulate matter. The second way is through the promotion of physical activity to promote healthy lifestyles by improving community-built environments [1]. In 2003, the ‘American Journal of Public Health’ published an article on the theme of the “Built Environment and Health”. In the same year, the ‘American Journal of Health Promotion’ also published a special issue entitled “Health Promotion and Community Design”. These articles showed the importance of a environment in relation to health [5]. A complex relationship exists between a healthy life and a community built environment, but increasing evidence shows that the occurrence of chronic diseases is related to a lack of physical activity in the modern lifestyle [6,7]. Effective physical activity is important to reduce the incidence of chronic diseases, such as , and to enhance the health of the population [7]. In studies of

Sustainability 2019, 11, 691; doi:10.3390/su11030691 www.mdpi.com/journal/sustainability Sustainability 2019, 11, 691 2 of 11 building , scholars often favor physical activity as a mediating factor between built environments and health. This research mainly has focused on traffic physical activity and leisure physical activity [5,8]. To research physical activity and a community built environment, we also need to define a built environment and physical activity. The definition of a built environment includes all and places that are constructed and transformed artificially. In particular, this definition refers to those built environments that can be changed by policies and human behavior. These include the locations and designs of residential buildings, commercial buildings, offices, schools, and other types of buildings as well as the locations and designs of pedestrian paths, bicycle paths, green ways, and roads [9]. Cerveor et al. concluded that the built environment affecting physical activity has 3D elements, including density, diversity, and design [10]. Based on this definition, Ewing and Cervero added destination accessibility and distance to transit, and proposed the 5D elements of built environmental measurement, including density, diversity, design, destination, and distance [11]. Physical activity is defined as any bodily movement caused by the contraction of the skeletal muscles [12]. General physical activity is divided into occupational, traffic, housework, and leisure activities [13]. Existing studies on physical activities show that built environment planning and design can significantly influence the spatial and temporal behavior of residents, as well as guiding traffic behavior and physical activities [14]. Using data from the U.S. Health and Nutrition Survey, Kelly et al. found that areas with high-density accessibility and road connectivity tended to have higher health levels under the control of individual characteristics because they established hierarchical models [15]. Jiawen Yang and French found that long periods of car use significantly increased the proportion of obesity, whereas non-motorized transportation helped reduce body mass index and obesity [7]. Vojnovic’s study found that short distances and highly connected neighborhood characteristics encouraged residents to increase physical activities, such as walking and cycling [16]. Handy pointed out that density is an important measurement for judging interference with physical activity [17]. The influence of density on physical activity is mainly reflected in traffic walking [18–20]. The relationship between density and leisure physical activity is not clear [8]. Frank pointed out that there are not enough existing studies to show which case is more appropriate for using the density index. Thus, many studies regard density as a potential influencing factor [21,22]. Learnihan pointed out that when mixed reached a certain level, it had the greatest impact on traffic walking [23]. McCormack pointed out that the accessibility of public space not only increased walking physical activity but also promoted leisure physical activity [24]. Frank et al. thought that street connectivity was positively correlated with physical activity [25–27]. Handy et al. found that street connectivity was negatively correlated with physical activity or had no relationship [28–30]. In 2010, the New York government provided a strong design basis for designers to build healthier buildings, streets, and public spaces to combat obesity, entitled “Active Design Guidelines: Promoting Physical Activity and Health in Design.” The aim was to encourage citizens to choose healthier travel, integrate physical activity into a healthy lifestyle for daily life, and finally to achieve the goals of friendliness and livability. The design elements of a public space, such as street scale, street pavement, greening condition, and street furniture, play an active role in walking activities [31,32]. Rhodes believed that the aesthetic perception of a built environment played a positive role in leisure physical activities [33]. Safety perception is positively correlated with physical activity [34], but some studies have found that safety perception had a more significant impact on women [35]. Susan and Berke took walking as a research object when they studied the relationship between built environments and physical activity [36,37]. Thus, from the perspective of healthy urban planning, a large number of documents have clarified the impact of building environment on sports activities. Thus, we can establish that walking time is an important factor in measuring community sports activities. Health is an essential requirement for promoting the all-round development of human beings. In October 2016, China promulgated the “Plan Outline of the Healthy China 2030.” Building healthy has become an important strategy for China. To prevent urban problems in the process of rapid Sustainability 2019, 11, 691 3 of 11 urbanization in China, it is necessary to attach importance to the study of the relationship between the built environment of Chinese cities and the promotion of walking, which will play an active guiding role in promoting urban health. Taking the community in the downtown area of Fuzhou as an example, this study integrated a social survey, a point of interest (POI), and road traffic network and land use data and explored the impact of the built environment characteristics on walking times at the community scale. This study primarily analyzed the factors of a community built environment that have a clear impact on the community.

2. Research Method and Variable Selection

2.1. Data Sources and Research Methods From June to August in 2017, we conducted a social survey in the central city of Fuzhou with the theme of “Building Environment and Walking Activities.” This survey covered the basic information of the social population, the community built environment, walking times, and subjective perception evaluations. In total, 2000 questionnaires were sent out and 1712 surveys were collected. After removing the questionnaires lacking major information, such as family address, physical activity, and environmental assessment, we obtained 1424 valid samples. After manual inquiry and coordinate correction, we obtained the spatial location of the respondent’s residence (Figure1). At the same time, the research also used the Fuzhou POI captured on a map website in a 2017 Fuzhou land-use status map, as well as other information.

Figure 1. Sample residence distribution map.

According to the availability of the data and the complex causal relationship between the built environment and walking activities, this study constructed a structural equation to test the existence of multiple impact paths. That is to say, we tested the relationship between the built environment and the traffic walking time, as well as the relationship between the built environment and the leisure walking time, to explain the environmental impact factors that promoted walking times. In this study, we used a field survey, POI data collection, an objective evaluation of the Geographic Information System (GIS) data, and a subjective evaluation of the respondents to measure the relevant variables. Sustainability 2019, 11, 691 4 of 11

2.2. Variable Factor Analysis

2.2.1. Explained Variables We identified two explanatory variables (Table1). The first variable was the traffic walking time and the second variable was the leisure walking time. The traffic walking time refers to the walking time during purposeful work or shopping activities every day. We believed that the traffic walking time could essentially reflect the characteristics of general traffic physical activity. Therefore, it could be used as an interpreted variable to reflect the relationship between traffic physical activity and an urban built environment. The leisure walking time refers to the walking time of aimless leisure activities every day, which we used as an explanatory variable to reflect the relationship between leisure physical activities and the urban built environment. To avoid the uncertainty of the geographical background, the analysis scope of the physical activity and the built environment needed to be unified [38,39]. Because the space range within the 500-m search radius around the residences was similar to the 15-min life circle of the community [40], this study took the 500-m area around the residences of the respondents as the research scope (in the community). The walking time took the form of hours needed to collect data. According to the survey, 34.16% of the respondents did not walk for more than half an hour on work days, and 63.43% of the respondents did not walk for more than one hour on work days. 27.71% of the respondents did not walk more than half an hour on rest days, and 50.62% of the respondents did not walk more than one hour on rest days. Of those who walked for less than half an hour, 90% owned a car and used it by themselves. These data indicate that a lack of physical activity among citizens in Fuzhou is common.

2.2.2. Explanatory Variables The explanatory variables of this study included the built environment characteristics (Table1). This study took the sample residences as the center of a circle and 500 m as the search radius to measure the built environment characteristics in this area. In this study, the characteristics mainly included the density of built environment, the diversity of the built environment facilities, the design of the built environment space, the destination accessibility, and the distance to transit of the built environment. Additionally, we wanted to increase the safety factors of the built environment. Considering foreign research and Chinese characteristics, we selected the factors of street and POI density for building environmental density. We determined street population density using data from China’s sixth population census in 2010. The POI density was based on the data of relevant interest points in Fuzhou City in 2017 obtained from a map application programming interface (API). We conducted a connection analysis using GIS software to evaluate the compactness of the social and economic activities in the communities. The higher the numerical value was, the more compact the community activities were. We determined the diversity of the built environment using a land-use mixing factor. We explained the function mixing degree of the land use with a data information entropy model. The higher the numerical value was, the higher the land mixing degree was. We selected the accessibility of the , living service facilities, catering facilities, commercial facilities, sports facilities, and park green space facilities as the explanatory variables for the accessibility of the built environmental facilities. Using the POI data captured by a map website, we expressed the accessibility of the facilities by the proportion of the POI number of various facilities in the range of 500 m to the POI number of all facilities. The higher the numerical value, the better the accessibility was and the higher the convenience. We selected the quantity of park green space, the satisfaction in the community walking environment, the feelings related to the community green coverage, and the condition of the public space facilities as the explanatory variables for the spatial quality of the built environment. We selected community security and traffic safety as the explanatory variables for the security of the built environment. We defined park green space as the ratio of the number of park green spaces to Sustainability 2019, 11, 691 5 of 11 the total land use within 500 m. Other explanatory variables were defined according to subjective evaluation data. For the explanatory variables, we added the traffic modes and the degree of love for sports. We divided the traffic modes into non-individual motor traffic and individual motor traffic. We classified public transportation, nonmotorized vehicles, and walking trips as non-individual motorized trips with a value of 1. We classified cars, taxis, and electric vehicles as individual motorized trips, with a value of 0. The percentage of non-individual motorized trips in the sample was 46.8%, and the percentage of individual motorized trips was 53.2%. We generally believed that the physical activity of nonindividual motorized travel was higher than that of individual motorized travel. The degree of love for sports had an impact on the walking time.

2.2.3. Control Variable Sample individual characteristics, such as age, gender, education level, marital status, psychological status, and income status, also affected physical activity (Table1). This study controlled related variables together. The average age of the participants in the social survey was 31 years old, which we considered to be relatively young. Of these participants, 41% had higher education, 37.7% were women, and 62.8% were men.

Table 1. Measurement and descriptive statistics of variables.

Mean Standard Variable Measurement Method Data Sources Value Deviation Explained Variable Traffic Walking Time Unit: hour Social Survey 0.95 1.30 Leisure Walking Time Unit: hour Social Survey 0.36 0.96 Explanatory Variable Density of Resident Population in the The Sixth Subdistricts and Townships Where the Population Census Population Density 1.27 1.33 Community is Located in Fuzhou City in Unit: 10,000 people/km2 2010 Number of POI within a Radius of 500 m from Point of Interest (POI) a Residence A Map Website 0.03 0.04 Density Unit: 10,000 Information Entropy Formula Land Use Mixedness A Map Website 0.29 0.28 H(x) = − Σ p(x) log2p(x) Proportion of POI in Catering within a 500 m Proportion of POI in Radius of a Residence to the total POI in A Map Website 15.00% 16.07% Catering Facilities this area Proportion of POI in Shops within a 500 m Proportion of POI in Radius of a Residence to the total POI in this A Map Website 21.61% 22.57% Commercial Facilities area Proportion of POI in Living Service Facilities Proportion of POI in Living within a 500 m radius of a Residence to the A Map Website 10.19% 10.79% Service Facilities total POI in this area Proportion of POI in Sports Facilities within a Proportion of POI in Sports 500 m Radius of a Residence to the total POI in A Map Website 0.02% 0.02% Facilities this area Proportion of POI in a Park Green Space within Proportion of POI in Park a 500 m Radius of a Residence to the total POI A Map Website 0.01% 0.02% Green Space in this area Number of Bus Stops within a 500 m Radius of Number of Bus Stops A Map Website 2.31 2.83 a Residence Non Individual Motorization = 1 Traffic Trip Mode Social Survey 0.47 0.50 Individual Motorization = 0 Proportion of Park Green Area within a 500 m Land-Use Map of Park Green Area Ratio 7.71% 11.83% Radius of a Residence to Total Area Fuzhou City Perception of Green Good Sunshade Effect = 4~Poor Sunshade Social Survey 2.60 0.79 Coverage Ratio Effect = 1 Walking Environmental Very Satisfied = 4~Very Dissatisfied = 1 Social Survey 2.73 0.72 Satisfaction Facilities Conditions very Plentiful = 4~Very Scarce = 1 Social Survey 2.90 0.85 Degree of Love For Sports Very Like = 4~Very Dislike = 1 Social Survey 2.80 0.73 Community Security Not Very Worried = 4~Very Worried = 1 Social Survey 2.58 0.82 Community Traffic Security Not Very Worried = 4~Very Worried = 1 Social Survey 2.58 0.83 Sustainability 2019, 11, 691 6 of 11

Table 1. Cont.

Mean Standard Variable Measurement Method Data Sources Value Deviation Control Variable Gender Female = 1, Male = 0 Social Survey 0.38 0.48 Age Unit: year Social Survey 31.05 9.34 Whether or not Enrolled in Yes = 1, No = 0 Social Survey 0.41 0.49 Higher Education Marital Status Married = 1, Unmarried = 0 Social Survey 0.63 0.48 Psychological Status Never Depressed = 4~Depressed = 1 Social Survey 2.98 0.58 Income Status Lower Level = 1~Upper Level = 5 Social Survey 2.48 0.92

3. Result Analysis

3.1. The Impact of an Urban Built Environment on Traffic Walking Time Viewed from the influence of built environment density (Model 1, Table2), we did not identify a significant correlation between the traffic walking time and the density of the street population. We also did not find a significant correlation between the length of the traffic walking time and the density of the POI, or the mixing degree of function in the community where the residents lived. At the 0.01 level in particular, the degree of functional mixing had a higher correlation with the length of traffic walking time, which verified that the density pointed out by Handy was an important measure for intervening physical activity [9]. The results, however, showed that the density was negatively correlated with the traffic walking time, which was contrary to the empirical conclusions of foreign countries. This contradiction likely is due to the fact that is more serious in North America. Urban development that relies too much on automobiles has a significant negative impact on physical activity, and increasing density has a significant impact on promoting walking time. Fuzhou, however, is a dense city in southeastern China, and it has a compact urban center. When the compactness is higher than a certain degree, the high-density agglomeration and the functional mixing will reduce the walking distance necessary for work and life to a very close range. Therefore, more intensive areas will account for less physical activity time. The accessibilities of the built environmental facilities, catering facilities, commercial shopping facilities, financial outlets, living service facilities, and green park facilities were significantly related to traffic walking times. This relationship showed that convenient commercial service facilities had a positive significance for the promotion of the length of the traffic walking times of residents. The more accessible the built environment facilities were, the more beneficial it was to the promotion of the length of the traffic walking times of residents. Individual travel patterns were correlated with the length of traffic walking times at a level of 0.1. We generally believed that the residents who used walking, bicycles, and public transportation traveled for a long time, whereas the residents who used private cars and taxis and other forms of motor transportation traveled for a short time. To explore the impact of the environmental quality and safety factors on the traffic walking times and conduct a regression analysis, model 2 (Table2) increased the proportion of park green space areas, reflecting the quality of the built environment space, the residents’ perception of the green coverage, and the satisfaction of the walking environment. Among these changes, the green area and walking environment satisfaction had no significant correlation, which was mostly a necessary behavior for traffic walking times, and there was essentially no requirement for environmental beauty. The perception of green coverage, however, was negatively correlated with walking time on weekdays, which was contrary to general thinking on the subject. The reason for this correlation was that most of the communities with a better greening effect were also those of higher quality. The residents of these communities primarily used motorized vehicles, and the traffic walking time was lower. Model 3 (Table2) added community security and community traffic safety into the regression analysis, both of Sustainability 2019, 11, 691 7 of 11 which were correlated with the length of traffic walking time. The better the community security was, the more conducive it was to promoting the walking times of residents. On the basis of the regression results, gender, age, degree of higher education, marital status, psychological status, and income level had no significant correlation with the traffic walking time.

3.2. The Impact of the Urban Built Environment on Leisure Walking Time Of the people surveyed, 58.4% said they would take part in recreational activities, including physical exercise, within 500 m of the community. On the basis of the built environment density (model 4, Table2), POI density had a significant positive correlation with leisure walking time, which was contrary to POI density and traffic walking time. We analyzed the fact that the high POI density decreased the necessary walking time for transportation. For leisure activities, an increase in the POI density was conducive to promoting leisure walking activities. We did not find a significant correlation, however, between the street population density and the functional mix and walking times on rest days. On the basis of the accessibility of the built environmental facilities, and according to the characteristics of leisure walking times, the POI proportion of the sports facilities and the degree of love for sports were increased. The results showed that leisure walking time had no significant correlation with catering, business, finance, life services, and other facilities, but it had a significant correlation with the POI proportion of sports facilities. The degree of love for sports had a positive impact on leisure walking time. Compared with traffic walking, leisure walking was more spontaneous, and people who loved sports had intended to walk for greater distances. On the basis of quality of the built environment (model 5, Table2), the conditions of public space facilities had a significant positive correlation with leisure walking activities, and the perception of green coverage was still negatively correlated. The reasons for this conclusion were the same as those for the impact on traffic walking behavior mentioned earlier. The impact of satisfaction with the walking environment, however, was not significant. In model 6 (Table2), we added community security variables. The results showed that community security was positively correlated with leisure walking activities, but not with traffic safety. The reason for this result was that the study used the subjective evaluation of traffic safety by community residents as the analysis data. Because the residents subjectively considered that the community was generally relatively safe, the analysis results showed no significant correlation. In this study, the control variables of gender, age, marital status, psychological status, and income level had no significant impact, but the degree of higher education had a significant negative correlation. Residents without higher education were more willing to engage in leisure walking activities, whereas residents with higher education had less time to engage in community leisure walking activities. We determined that the residents with higher education had more choices for other leisure activities, so they had less time for leisure walking in the community.

Table 2. Results of the regression analysis (ordinary least squares).

Traffic Walking Time Leisure Walking Time Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Population Density −0.010 −0.012 −0.016 −0.018 −0.017 −0.012 POI Density −0.085 * −0.082 * −0.088 * 0.083 * 0.084 * 0.091 * Land Use Mixedness −0.509 *** −0.502 *** −0.508 *** −0.178 −0.153 −0.145 Number of Bus Stops 0.044 0.035 0.047 0.002 −0.004 −0.010 Proportion of POI in 0.262 *** 0.264 *** 0.264 *** 0.036 0.028 0.029 Catering Facilities Proportion of POI in 0.140 ** 0.142 ** 0.146 ** 0.032 0.026 −0.019 Commercial Facilities Proportion of POI in 0.090 ** 0.087 ** 0.086 ** 0.016 0.013 −0.013 Financial facilities Proportion of POI in Living 0.132 * 0.129 * 0.133 * −0.038 −0.041 −0.045 Service Facilities Proportion of POI in Park 0.224 *** 0.225 *** 0.228 *** −0.032 −0.036 −0.041 Green Space Sustainability 2019, 11, 691 8 of 11

Table 2. Cont.

Traffic Walking Time Leisure Walking Time Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Traffic Trip Mode −0.037 * −0.037 * −0.038 * 0.048 0.048 0.049 Park Green Area Ratio −0.044 −0.053 0.491 0.525 Perception of Green −0.076 ** −0.075 ** −0.069 ** −0.070 ** Coverage Ratio Walking Environmental 0.042 0.053 −0.033 −0.048 Satisfaction Proportion of POI in Sports 0.182 ** 0.079 ** 0.078 ** Facilities Degree of Love For Sports 0.130 *** 0.135 *** 0.136 *** Facilities Conditions 0.069 ** 0.067 ** Community Security 0.059 * 0.101 *** Community Traffic Security 0.054 * 0.025 Whether or not Enrolled in −0.052 −0.048 −0.049 −0.134 *** −0.132 *** −0.130 *** Higher Education Gender 0.003 −0.003 −0.004 −0.014 −0.013 −0.013 Age −0.012 −0.018 −0.009 0.005 0.007 −0.005 Marital Status −0.006 −0.005 −0.008 0.156 0.051 0.156 Psychological Status −0.045 −0.040 −0.036 −0.016 −0.002 −0.007 Income Status 0.040 0.048 0.046 −0.008 −0.005 −0.003 B 363.376 447.711 343.037 49.229 51.034 31.598 R2 0.057 0.053 0.048 0.051 0.054 0.061 Sig 0.000 0.000 0.000 0.000 0.000 0.000 Notes: ***, **, * were significant at 0.01, 0.05 and 0.1 levels, respectively.

4. Conclusions and Recommendations In this paper, we discussed the relationship between a built environment and walking times using a structural equation based on data from central Fuzhou. The empirical results showed that the factors of the length of walking time promoted by the built environment were essentially consistent with those of Western industrial countries. However, we identified some differences in the impact mechanism of built environment factors, which were related to the characteristics of urban development in China. The conclusions of this study are as follows:

1. The factors related to the walking times included the density (population density, POI density), function mixing degree, built environment design (greening rate, facility conditions, people’s use feelings), accessibility of purpose (richness of various facilities), and convenience of bus stops. These factors were generally consistent with the 5D elements of the built environment studied abroad. 2. Because of the high population densities and construction densities in the urban centers of China, the conclusions show that the density was negatively correlated with the time of traffic walking. Excessive density brought all kinds of transportation travel more close together, but it reduced the amount of physical activity, which was different from the low-density spread in cities in North America, but was consistent with the research of some domestic scholars in China [26]. However, the increase of POI density was conducive to promoting leisure activities. 3. The individual traffic trip mode had a positive correlation with the length time of traffic walking. The use of non-individual motorized travel (walking, bicycles, and public transport) was conducive to promoting physical activities and health. 4. Greening environment, accessibility of sports facilities, and facilities conditions played a positive role in promoting leisure walking time.

In the field of urban planning, paying attention to the built environment of cities will be conducive to promoting health. Urban functions should be moderately mixed. Urban density should be moderately compact. Facilities should have good accessibility. Good walking and non-motor-vehicle travel facilities should be constructed. Urban public transport should be developed. As many green environments as possible should be built to improve the quality of the space. More sports activities and sports facilities that can be used fairly should be set up. A good community atmosphere should be Sustainability 2019, 11, 691 9 of 11 created. All of these conditions will promote the physical activities of residents and help to enhance the health of the population. Influenced by data and space, this research has the following shortcomings: (1) The time data for the walking time used in this paper adopted the subjective report value of the respondents, which introduced the problem of credibility. (2) The traffic walking time and leisure walking time had some intersections, and it was difficult to distinguish them clearly. (3) The factors of various elements of the built environment should be further studied and determined. (4) The study should further track the impact of improvements to the community built environment on walking time. This paper discusses an empirical study on the built environment and physical activity in China. Future research will be conducted. It is expected that to promote and to pay more attention to healthy built environments, relevant guidelines will be formed to guide the design of these built environments.

Author Contributions: Conceptualization, L.Z. and Y.M.; Methodology, Y.Z.; Software, L.Z.; Validation, Y.Z.; Formal Analysis, L.Z.; Investigation, L.Z., Y.Z. and Y.M.; Data Curation, L.Z.; Writing-Review & Editing, Z.S.; Supervision, Z.S. Funding: This research was sponsored by Natural Science Foundation of Fujian Province, No. 2018J01747. Conflicts of Interest: The authors declare no conflict of interest.

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