2. Diagnosis of APS

are generated against different epitopes of the participant of the coagulation system (mainly against phospholipid-binding proteins) that result in thrombosis.  Lupus anticoagulant (LA), anti-cardiolipin antibodies (ACA) and anti-β2 glycoprotein 1 (aβ2GPI) are the most important among them [2]. APS may be a secondary disease, as it frequently associates to systemic autoimmune diseases such as SLE and also to malignant lymphoproliferative diseases and chronic hepatic disorders [3]. On the contrary, APS can appear without any underlying disease, and in this case, it is

Neurologic involvement in APS is common and can be manifested by headaches, memory impairment, dizziness, epilepsy and blurred vision, but the most common presentations are transient ischaemic attacks and ischaemic strokes. Some of them are not thrombotic manifestations but are generated by connection of aPL antibodies and an antigen in the nervous system [4]. There is a special form of APS: the obstetric antiphospholipid syndrome (OAPS). It is characterised clinically only by obstetrical morbidity: at least two unexplained miscarriages, three non-consecutive miscarriages, preeclampsia, placental abruption, foetal growth restriction, stillbirth, premature birth, or two or more unexplained in vitro fertilisation failures [5, 6]. Catastrophic antiphospholipid syndrome (CAPS) is rare, but very serious form of APS. The mortality rate is very high. CAPS is characterised by thromboses generating in two or more organs in a few days. That leads to infarction and necrosis of the affected tissues causing multiple

Standard care for thrombotic APS is indefinite anticoagulation with a vitamin K antagonist [8]. There is currently insufficient evidence to recommend the routine use of direct oral anticoag-

The 13th Task Force recommendation for primary thromboprophylaxis in APS supports the use of aspirin [10]. A recent meta-analysis conducted on a total of 1208 asymptomatic patients with persistently positive aPL has shown that low-dose aspirin (LDA) is associated with significant risk reduction in arterial but not in venous thrombosis when compared to placebo [11]. Aspirin with low molecular weight or unfractionated heparin may reduce the incidence of pregnancy loss in obstetric APS [12]. Aspirin alone is advised for treating patients with aPL-

Treatment regimens of APS further include hydroxychloroquine, statins, B-cell inhibitors, complement inhibitors, blocking of aPL/B2 GPI receptors on target cells and tissue factor

A combined therapy of anticoagulation, glucocorticoids, plasma exchange and intravenous immunoglobulin (especially in the presence of infection) can be used in complicated cases of multiorgan failure due to thrombosis as in CAPS. Cyclophosphamide can also be used in CAPS in the presence of secondary autoimmune disease such as SLE [15]. Rituximab can also be used in refractory cases after failure or inability to take the above-mentioned combined

However, the majority of aPL-positive patients do not have thrombosis. That is why the stereotypical treatment for APS patients should be avoided and stratification of the thrombotic

therapies or in the presence of micro-angiopathic haemolytic anaemia [16].

called primary antiphospholipid syndrome.

organ failures [7].

54 Thrombocytopenia

inhibitors [14].

ulants (DOAC) in thrombotic APS [9].

associated stroke or acute myocardial infarction [13].

Diagnosis of APS is based on the Sapporo criteria (proposed in 1999 and updated in 2006 after a conference in Sydney, Australia) [19].

These include at least one clinical and at least one laboratory manifestation of APS. Clinical criteria include objectively confirmed venous, arterial, or small vessel thrombosis, and/or obstetric morbidity including recurrent miscarriage, stillbirth, or intrauterine growth retardation.

The laboratory criteria require demonstration of a persistent presence of lupus anticoagulant (LA), anti-cardiolipin (ACA) or anti-2GPI antibody (IgG or IgM). Antiphospholipid antibody positivity can be stated if at least one of these antibodies could be detected twice, 12 weeks apart. LA is measured by the help of coagulation tests, while ACA and anti-β2glycoprotein 1 (aβ2GPI) are determined by means of ELISA. LA results are expressed as qualitative data and only strong positivity carries clinical significance. In case of ACA and aβ2GPI, antibody medium/high titres of IgM and/or IgG subtype have important clinical value (Table 1).

Clinical symptoms of APS include thrombosis in any blood vessel of any organ. Typically, thrombosis may recur and can present both in arteries and in veins. Anti-phospholipid antibodies represent the strongest thrombophiliac factors, mainly LA.

Although thrombosis due to APS does not differ from thrombosis caused by any other factors, some other symptoms and signs may accompany to the elevated blood clotting: for example, if a patient presents with thrombosis and also has livedo reticularis, it is very likely that thrombosis is a manifestation of APS.

Besides, there are only a few situations when arterious and venous thrombosis present on the same patient. This and the recurrence of the thrombotic event is very likely refers to APS.

There are the so-called "non-criteria" clinical features of APS, such as livedo reticularis, cardiac valve disease, haematological manifestations (thrombocytopenia and haemolytic anaemia), nephropathy and neurological manifestations (migraine, chorea and epilepsy).

Non-criteria manifestations mean that the presence of these characteristic features of the disease is not a requisite of the diagnosis, or with other words, they are not the sine qua non of the diagnosis.

According to another study, patients with cerebrovascular events who are less than 50 years old have shown 17.4% prevalence of positive aPL with five times increase in the risk of

Antiphospholipid Syndrome and Thrombocytopenia http://dx.doi.org/10.5772/intechopen.72509

Thrombocytopenia is the most common non-criteria hematologic manifestation of APS. It has

There is a difference between primary and secondary APS patients in respect of the frequency of thrombocytopenia: in Euro-Phospholipid project, the frequency of thrombocytopenia in

Platelets play a key role in APS-related thrombosis due to the presence of multiple receptors that can interact with anti-β2-GPI antibodies (especially apolipoprotein E receptor 20 (apoER20

and glycoprotein Ibα (GPIbα)) with consequent release of different pro-coagulant mediators such as thromboxane B2, platelet factor 4 (PF4) and platelet factor 4 variant (CXCL4L1) [28]. In case of APS, thrombosis results from a hypercoagulable state caused by activation of endothelial cells, monocytes and platelets. It has been demonstrated that platelets are required for enhanced activation of the endothelium and fibrin generation by the anti-β2GP1 autoantibody/β2GP1 complex. Thus, the first event is the activation of thrombocytes, endothelial cells

Platelet activation, a major contributing factor of arterial thrombosis in APS, might play a role

First, due to the presence of multiple receptors that can interact with antibodies, platelets can

The role of thrombocytes in the pathogenesis of APS is supported by the fact that circulating platelet- and endothelial-derived microparticle level are elevated in patients with primary

Mouse models of APS have shown that platelets are the first target for circulating anti-β2-GPIβ2-GPI complexes, and the enhancement of endothelium activation is also platelet thrombus-

controversial research data. Decreased thrombocyte number might be present because of

/L is considered as normal in some studies. That may be the cause of some

facilitate the dimerisation of β2-GPI enhancing the coagulation response.

Second, platelets provide a surface for coagulation reactions [30].

The normal value of platelet count is between 150 and 300 � 109

)

57

/L. Platelet number between

patients with PAPS was 21%, while it was 41.9% in patients with secondary APS [27].

been reported with prevalence between 30 and 46% among APS patients [26].

ischaemic stroke [25].

4. Role of platelets in APS

are activated indirectly [29].

APS [31].

dependent [29].

100 and 150 � 109

in APS-related thrombosis in at least two ways:

5. About thrombocytopenia in general

Table 1. Revised classification criteria for antiphospholipid syndrome [19].

Thrombocytopenia is the most relevant non-criteria manifestation of APS.

However, despite the pro-thrombotic nature of APS, thrombocytopenia is one of the most common non-criteria findings of the disease. Recently, thrombocytopenia is proposed to be a diagnostic clinical criterion of APS.

In case of OAPS several disease processes may occur in the placentae of women with antiphospholipid syndrome due to the antiphospholipid autoantibodies, not only thrombosis and infarction, but also inflammatory events, mediated by cytokine release, complement activation, angiogenic imbalance and activation of immune cells [20].

### 3. Epidemiology of APS

Presence of aPL Abs per se does not guarantee a patient will develop APS as only 8.1% of patients with aPL antibodies without a history of clinical thrombosis developed thrombosis during a 5-year follow-up period, suggesting that a patient needs an additional insult to develop the clinical disease [21, 22]. The prevalence of the antibodies increases with age [23].

Forty percent of patients with APS have SLE. The prevalence of ACA in SLE is from 12 to 30%, and LA is found in 5–34%. From the patients with SLE and aPL antibodies 50–70% progress to APS.

The incidence of the APS is around five new cases per 100,000 persons per year, and the prevalence is around 40–50 cases per 100,000 persons [24].

The aPLs are positive in approximately 13% of patients with stroke, 11% with myocardial infarction, 9.5% of patients with deep vein thrombosis and 6% of patients with pregnancy morbidity [16]. These data can underline the significance of APS.

According to another study, patients with cerebrovascular events who are less than 50 years old have shown 17.4% prevalence of positive aPL with five times increase in the risk of ischaemic stroke [25].

Thrombocytopenia is the most common non-criteria hematologic manifestation of APS. It has been reported with prevalence between 30 and 46% among APS patients [26].

There is a difference between primary and secondary APS patients in respect of the frequency of thrombocytopenia: in Euro-Phospholipid project, the frequency of thrombocytopenia in patients with PAPS was 21%, while it was 41.9% in patients with secondary APS [27].


**Abstract**

Left ventricular assist device (LVAD) therapy is an essential tool in the armamentarium for managing refractory heart failure. The traditional LVAD placement involves insertion of the inflow cannula (IC) at the left ventricle's true apex and attachment of the outflow graft (OG) to the ascending aorta (AA), which ensures alignment with physiological blood flow and minimizes complications. However, patient-specific anatomical variations and prior medical interventions necessitate considering alternative IC and OG placement techniques. This chapter reviews the standard and alternative IC and OG placement sites and emphasizes the importance of adapting LVAD component placement to individual patient needs, highlighting the potential of alternative techniques in improving outcomes. Despite the predominance of standard sites due to their proven efficacy, the heterogeneity of patient conditions underscores the need for flexible, patient-tailored approaches.

**Keywords:** LVAD, left ventricular assist device, inflow cannula, outflow graft, alternative sites


**6.5 Blood**

*Fads and Facts about Vitamin D*

sitivity reactions) [25]

• Weak immune reactions

**6.2 Muscular system**

muscle) [31]

and protein synthesis [9]

**6.3 Cardiovascular system**

arrhythmias [39]

These changes have been observed:

sympathetic nerve activity [41]

• Loss of arterial pressure gradient [9]

• Redistribution of venous blood volume [40]

described as:

• Increase in virulence of microorganisms [26]

• Hindering of thymopoiesis significantly [27]

authors have not reported significant changes [30].

• More latent viral reactivation [28]

• More allergic symptoms (even sometimes prolonged integumentary hypersen-

• Possibility of increasing opportunistic infections and immunity disorders

There are more reports about immune system alterations [25, 26, 29], but some

The most frequent change is atrophy of skeletal muscles. Alterations are

• Atrophy and loss of function in lower limb muscles (especially the triceps

• Spinal deconditioning (including atrophy of the paraspinal muscle group,

• More damage in plantar flexors than extensors due to a decrease of fiber size

• Significant loss in total body nitrogen and muscle volume in the Mir station [37]

• Alterations in shape and mass of the heart, cardiac function changes, and

• Cephalad fluid shift, not any change in heart rate, a decrease in parasympathetic activity, an increase in output and stroke volume, and no change in

• Decrease in performance of lower extremities muscles [32]

• Reduction of volume and strength in lower limb muscles [36]

• Muscle atrophy greater than 20 days of bed rest [38]

• Atrophy of muscle due to stem cell pool decrease [33]

reduction in curvatures of the spine) [34, 35]

**70**


Pre-Processing

Pre-processing approaches try to enhance the low contrast and improve the image quality. Simple **Contrast Limited Adaptive Histogram Equalisation** (**CLAHE**) [46] or other local histogram equalisation techniques are most prevalent for this purpose. Global contrast equalisation techniques tend to over-amplify bright areas in the image while some other dark areas are not sufficiently enhanced. A localised contrast enhancement technique like CLAHE is a suitable baseline tool to enhance the vein

images as they exhibit unevenly distributed contrast. CLAHE has an integrated contrast limitation (clip limit) which should avoid the amplification of noise.

**High Frequency Emphasis Filtering** (**HFEF**) [47] tries to enhance the vein images in the frequency domain. At first the discrete Fourier transform of the image is computed, followed by the application of a Butterworth high-pass filter in the frequency domain. Afterwards the inverse Furier transform is computed to give prominence to the vein texture. In order to improve the image contrast the authors also apply a global histogram equalisation as a final step. We applied CLAHE instead of the global histogram equalisation.

**Circular Gabor Filter** (**CGF**) as proposed by Zhang and Yang [48] is another finger vein image enhancement technique which is rotation invariant and achieves an optimal joint localisation in both the spatial and the frequency domain. The authors originally suggested using grey level grouping for contrast enhancement and to reduce illumination fluctuations. Afterwards an even symmetric circular Gabor filter is applied to further attenuate the vein ridges in the image. Gabor filters are widely used to enhance images containing a high amount of texture and to analyse image texture information. In contrast to usual Gabor filters, a CGF does not have a direction, thus it amplifies the vein ridges in each direction. The bandwidth and the sigma of the CGF has to be tuned according to the visible vein information in the images (vein width in pixels).

**Figure 9.** Hand vein ROI extraction process, from left to right: Segmented hand including outline and minima/maxima points, appropriate finger valleys and centre of mass selected, rotationally aligned hand image with maximum possible ROI fitted, final extracted ROI.

Furthermore, the images were resized to half of their original size, which not only speeded up the comparison process but also improved the results. For more details on the preprocessing methods the interested reader is referred to the authors' original publications. Each of the above mentioned pre-processing techniques is at least used for one of the feature extraction methods, but not necessarily with the same parameters for each method. The actual methods and parameters used for each feature extraction method are stated in the settings files (cf. Section 2.4).


**4. Fabrication and experiment**

To verify, a transmitarray and two patch antennas were fabricated. **Figure 13** shows that the prototype is verified in the anechoic chamber.

**Figure 13.** *The prototype is verified in the anechoic chamber. Reprinted with permission from Ref. [22]; copyright 2022 IEEE.*

**Figure 14.**

*(a) The simulated and measured patterns of the patch antenna at 25 GHz. (b) The simulated and measured |S11| of the interferometric phase transmitarray excited by the patch antenna. Reprinted with permission from Ref. [22]; copyright 2022 IEEE.*

**Figure 14a** shows the patterns at 25 GHz of the patch antenna, and the simulated and measured curves are similar. **Figure 14b** shows the simulated and measured |S11| of the interferometric phase transmitarray excited by the patch antenna.

**Figure 15** shows the simulated and measured patterns at 25 GHz of the interferometric phase transmitarray excited by the patch antenna. The simulated realized gain is 18.4 dBi, which is 0.9 dBi higher than the measured realized gain. In addition, the simulated and measured sidelobe level is around -15 dB, within a reasonable range. Minor differences between curves are mainly caused by the measurement environment.

### **5. MIMO behavior**

To evaluate the performance of the proposed interferometric phase MIMO system, a same-size unifocal transmitarray antenna with a focus on (18 mm, 0, 30 mm) is introduced for simple comparison. **Figure 16** shows the simulated pattern.

#### **Figure 15.**

*The simulated and measured patterns at 25 GHz of the interferometric phase transmitarray excited by the patch antenna. (a) xoz-plane. (b) yoz-plane. Reprinted with permission from Ref. [22]; copyright 2022 IEEE.*

*Interferometric Phase Transmitarray for Millimeter-Wave MIMO System DOI: http://dx.doi.org/10.5772/intechopen.112468*

**Figure 16.** *The simulated pattern of the unifocal transmitarray antenna at 25 GHz.*

**Figure 17.**

*The simulated 3D pattern of the unifocal transmitarray antenna at 25 GHz.*

**Figure 17** shows the 2 � 2 MIMO system integrated by four unifocal transmitarray. It is assumed that the distance between two unifocal transmitarrays on one side is 100 mm and the transmission distance is 1000 mm, then the angle of the cross weak channels is *θ* = 6°. **Figure 18** shows the simulated xoz-plane pattern of the unifocal transmitarray antenna at 25 GHz. It can be seen from **Figure 18** that when *θ* = 6°, the gain is 15.2 dBi.

The channel capacity can be calculated by Eq. (7) as follows

$$\mathbf{C} = B \log \mathbf{2} (\mathbf{1} + \mathbf{S}/\mathbf{N}) \tag{7}$$

where *B* is bandwidth, and *S*/*N* represents signal noise ratio. In MIMO links, the higher the receiving power, the greater the *S*/*N*, and the larger the channel capacity. The receiving power can be expressed as Eq. (8).

$$P\_r = P\_t \frac{G\_t G\_r \lambda\_0^2}{16\pi^2 d^2} \tag{8}$$

**Figure 18.** *The simulated xoz-plane pattern of the unifocal transmitarray antenna at 25 GHz.*

where *Pr* and *Pt* represent receiving power and transmitting power, *Gr* and *Gt* represent the gain of the receiving antenna and the transmitting antenna, λ0 is the wavelength in free space, and *d* is the distance between transmitter and receiver.

Therefore, the channel capacity is positively correlated with the gain of the receiving antenna and transmitting antenna. To compare the two MIMO systems in **Figures 1** and **2**, it is assumed that all environments are the same, except for antenna gain differences. The gains of the receiving and transmitting antennas in the 2 2 MIMO system integrated by interferometric phase transmitarray are all 18.4 dBi. Normalize the channel capacity of each link to 1, and the channel capacity of the 2 2 MIMO system is 4. By comparison, there are two strong channels and two weak channels in the 2 2 MIMO system in **Figure 17**. The gains of the receiving and transmitting antennas are 19.5 dBi in strong channels and 15.2 dBi in weak channels. In the 2 2 MIMO system in **Figure 17**, the 18.4 dBi of the antenna gain is still used to normalize the channel capacity. After normalization, the channel capacity of the strong channel is 1.056, and the weak channel is 0.823 in **Figure 17**. Therefore, the channel capacity of the 2 2 MIMO system in **Figure 17** is 3.758, which is lower than the 2 2 MIMO system integrated by interferometric phase transmitarray. In addition, the distance between transmitter and receiver *d* will also affect the channel capacity of the MIMO system in **Figure 17**. Since when *d* decreases, the angle of the cross weak channels *θ* increases, resulting in a decrease in antenna gain in weak channels. When d increases, the result is the opposite.

Therefore, through simple comparison, it can be found that the channel capacity of the 2 2 MIMO system integrated by interferometric phase transmitarray is higher than the 2 2 MIMO system integrated by unifocal transmitarray.

### **6. Conclusions**

The proposed interferometric phase transmitarray can adjust two EM waves to the boresight of the transmitarray. When the plane wave illustrates the proposed transmitarray, the transmitted plane wave will be scattered and focused on two

positions. The MIMO system integrated by the interferometric phase transmitarray breaks the limitations of weak channels in conventional lens MIMO. In addition, the proposed method of the MIMO system can be extended to more channels.


**4. Conclusions**

Based on LDM, this study characterizes all three types of polarization voltage of Lithium ion batteries under operating conditions. Three model parameters were used: dimensionless charge exchange current *J*0, ohmic resistance *Rohm*, and diffusion time constant *τ* to characterize activation polarization, ohmic polarization, and concentration polarization, respectively. A joint algorithm consisting of the PSO algorithm and the L-M method was used to identify the model parameters. The deviation of the model output terminal voltage from the actual terminal voltage was used as the accuracy criterion, and the proposed algorithm was compared with the PSO algorithm alone and the L-M method alone. In terms of the intercepted battery testing data, RMSE as the criterion, the voltage error of the joint algorithm was reduced 77.1% compared to the PSO algorithm only, and 72.3% compared to the L-M method only. To further test the effectiveness of the model and the identification algorithm, the identified model parameters were substituted into the second battery test data. It can be concluded that (1) the proposed scheme describes the nonlinear characteristics of the battery cell under the excitation of high dynamic driving conditions, (2) the model reflects the real physical-chemical processes inside the battery to a certain extent. To test the real-time performance of the proposed method, a hardware implementation platform for the real-time quantitative characterization of the polarization voltage of lithium-ion batteries was built, and the model parameters were calibrated and fitted using an offline method. The hardware platform was capable of realizing the basic function of quantitative polarization voltage characterization, and the update frequency of relevant parameters was 1 Hz, with good real-time performance. It has the potential for further development for BMS applications.

**Author Contributions:** B.X. and B.Y. proposed the novel method of polarization voltage characterization for lithium-ion batteries; B.Y. designed the experiment scheme and conducted experiments. B.Y. and J.C. designed and implemented the hardware platform; B.Y. wrote the paper. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by National Natural Science Foundation of China (Grant No. 51877120).

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **Nomenclature**

#### **References**


*Article* **How Has Online Digital Technology Influenced the On-Site Visitation Behavior of Tourists during the COVID-19 Pandemic? A Case Study of Online Digital Art Exhibitions in China**

**Yanqing Xia 1,2**

**Abstract:** The COVID-19 pandemic has had a significant impact on the global tourism industry, leading to a decrease in peoples' willingness to travel and a sense of insecurity regarding tourist destinations. Therefore, restoring people's willingness to travel is the greatest challenge faced by this industry in the post-pandemic era. The tourism industry requires innovative solutions to achieve sustainable recovery. While there is a considerable amount of research on its recovery during the pandemic, there are few studies exploring people's willingness to travel to encourage sustainable and resilient recovery in the post-pandemic era. This study employed a quality model to examine the satisfaction and intention of tourists towards the application of online digital art exhibitions under the influence of COVID-19. The aim was to investigate the promoting role of online digital art exhibitions in the sustainability and resilient recovery of the tourism industry. To achieve these objectives, this study focuses on the online digital art exhibition of Song Dynasty figure paintings launched by China Central Television (CCTV), with post-exhibition surveys conducted and 512 valid questionnaires collected. The research model and hypotheses are tested using structural equation modeling. The results of this study indicate that travelers' intentions to engage in on-site visits through online digital exhibitions are determined by three factors: perceived value, satisfaction, and art therapy. Furthermore, online digital art exhibitions not only represented the most important form of tourism during the pandemic, but they also provided significant psychological healing. They have become a driving force for the transformation of the current culture and tourism industry and the promotion of its sustainable development. This research provides a benchmark for future research on the tourism industry, and it offers new research directions in the field of sustainable tourism.

**Keywords:** sustainable tourism; tourism industry; COVID-19; behavioral intention; online digital exhibition

### **1. Introduction**

The tourism industry provides livelihoods to millions of people and enables billions to appreciate diverse cultures and the natural world. In some countries, tourism accounts for more than 20% of the gross domestic product (GDP), making it the third-largest export sector in the global economy [1]. However, the COVID-19 pandemic has severely impacted the tourism industry, affecting economies, livelihoods, and public services across continents and bringing the industry to a temporary halt [2]. According to forecasts by the World Travel and Tourism Council (WTTC), the COVID-19 pandemic was expected to cause a loss in global tourism to the value of USD 2.1 trillion in 2020 and jeopardize 75 million tourism jobs [3]. Rebuilding market confidence, revitalizing the tourism economy, and achieving high-quality development of the tourism industry have become focal points in academia and industry post-pandemic.

The outbreak of the pandemic has posed unprecedented challenges to the tourism industry, yet it has also presented an opportunity for transformation and change. The

**Citation:** Xia, Y. How Has Online Digital Technology Influenced the On-Site Visitation Behavior of Tourists during the COVID-19 Pandemic? A Case Study of Online Digital Art Exhibitions in China. *Sustainability* **2023**, *15*, 10889. https://doi.org/10.3390/ su151410889

Academic Editors: Zygmunt Kruczek and Bartłomiej Walas

Received: 26 May 2023 Revised: 6 July 2023 Accepted: 9 July 2023 Published: 11 July 2023

**Copyright:** © 2023 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

emergence of online digital technologies has facilitated the digital transformation and innovation of the tourism sector [4]. Digital cultural tourism initiatives have emerged during the pandemic, leveraging new-generation technologies such as virtual reality (VR), augmented reality (AR), and artificial intelligence (AI) to create immersive experiences. These initiatives include virtual reality-based scenic spots, entertainment, and museums, and other new forms of culture and tourism experience, fostering new consumer behavior and reshaping people's travel preferences and tourism concepts [5]. Emphasizing safety in tourism and the ability to explore the world from home, and prioritizing user experience, have become paramount [5]. Under the circumstances of the pandemic, online digital technologies have gained more attention than ever from tourists and destination organizations. Online virtual tours of museums and exhibitions and other forms of "cloud tourism" have become the new norm since the pandemic, stimulating people's interest in tourism. Concurrently, online digital technologies are reshaping the manner in which customers plan their travel and search for destination information. By leveraging digitized environments, these technologies enable customers to experience products, services, or locations prior to their physical visit [6]. The increasing reliance on and desire for such online digital environments reflects a gradual shift in tourism perspectives, with individuals predominantly opting for online virtual tourism. Consequently, online digital technologies have opened up new avenues for the revitalization and recovery of the tourism industry, providing innovative approaches to travel and tourism experiences.

Previous studies have explored the use of on-site digital technologies [7] and VR technology for enhancing tourists' travel experiences [8], as well as the impact of VR technology on intentions to make repeat visits to tourist destinations [9,10]. However, the perspectives explored in these studies have been relatively narrow, focusing solely on the impact of digital technologies on tourism destinations. They predominantly concentrate on the "technology" itself, without delving into the influence of online digital technologies on "people" after the pandemic. In particular, the shift in individuals' tourism perspectives and their heightened concerns for personal well-being and health have significantly dampened their willingness to travel. Yet, the revival of tourist demand is considered a key factor in stimulating the recovery of the tourism industry [11]. Consequently, there is an urgent need to address how to effectively guide tourists in regaining their willingness to travel. In fact, tourists are highly interested in online digital technologies and seek to understand how these platforms can provide humanistic care [12,13]. However, there have been few attempts to evaluate user satisfaction with online digital technology applications and their subsequent impact on travel intentions. How do online digital technologies influence tourists' on-site visitation behavior during the COVID-19 pandemic? What are the underlying factors affecting this behavior? Do they contribute to stimulating tourists' travel intentions and promoting the recovery and sustainable development of the tourism industry in the post-pandemic era?

To address the aforementioned issues, this study introduces a comprehensive research model that incorporates factors derived from perceived quality (content, system, and personalized service) and expectation confirmation. From the perspective of tourists' expectation confirmation, the research model explores the effects of perceived quality of online digital art exhibitions, user expectation confirmation, perceived value, perceived enjoyment, and art therapy on satisfaction with online digital art exhibitions and onsite visitation. By examining how online digital technology influences the physical visit behavior of tourists during the COVID-19 pandemic, this research can assist museum curators and other cultural tourism institutions in leveraging digital technology to increase public engagement with art, promote the digital transformation of the culture and tourism industry, stimulate innovation in this sector, unleash the multiplicative effects of digitization on the industry, and facilitate its sustainable development.

#### **2. Research Theory and Hypothesis**

#### *2.1. COVID-19 and Online Digital Art Exhibitions*

In the spring of 2020, as the novel coronavirus began to spread globally, the true meaning of globalization seemed to resonate with people, as the impact of the virus extended beyond trade disruptions and stagnant tourism to endanger the art world [14]. As a result of the pandemic, planned art fairs and major exhibitions in various countries were hindered, while museums in many countries remained closed, presenting challenges in cross-border artistic collaboration [15]. To cater to audiences who were unable to attend in person, many museums swiftly transitioned their exhibitions to online platforms, offering "virtual exhibitions" for remote viewing. Suddenly, being "online" became the hottest topic of discussion. It is during this distinctive period that the rapid development of digital art took place.

Online digital art exhibitions refer to the integration of online digital technologies with humanistic art, combining rational thinking and artistic sensibility. These exhibitions are founded on the development of online digital technologies and encompass a fusion of artistic expression and human perception [16]. Online exhibitions, as a form of exhibition accessible anytime and from anywhere through the internet on computers and smartphones, represent one of the most effective ways to disseminate digital information in any field [17]. Online digital art exhibitions represent a new artistic language that blends the contemporary era of new media with traditional art. Leveraging technology for human–computer interaction as a medium, these exhibitions enhance visitors' perceptual experiences and create a multidimensional and dynamic interactive environment.

#### *2.2. Perceived Quality*

The concept of perceived system quality was introduced by DeLone and McLean [17], and it is generally defined as "the extent to which users perceive the performance of a system". Subsequently, this model was updated by Delone and McLean [18], who proposed three types of information system quality—system quality, information quality, and service quality, also known as perceived quality. Perceived quality can be defined as customers' judgment of the overall excellence or superiority of a product. These three indicators, evaluated based on individual perceptions, are considered primary predictors of perceived quality [19]. Currently, the Information System Success Model has been successfully applied in the field of e-commerce. This model explains users' adoption of various information systems, for instance, websites, online shopping, mobile applications, online learning, and online travel through VR augmented reality [20–24].

Content quality refers to indicators associated with the content of an e-commerce website, including the relevance, completeness, and comprehensibility of the provided information. Delone and McLean [17] emphasized the importance and relevance of content quality within the Information System Success Model, with various studies further emphasizing its significance. System quality refers to "a system in which the expected characteristics of mobile devices and web browsing services are considered available for user use" [25]. Delone and McLean [17] demonstrated that system quality strongly influences the success of information systems, with indicators relating to system quality and overall system performance measured based on factors such as usability, reliability, functionality, and performance. Service quality is defined as the overall judgment of or attitude towards the quality of a service, and it refers to consumers' overall impression of its advantages and/or disadvantages. Zhao et al. [26] identified service quality as an important determinant of information system effectiveness.

In this study, content quality refers to the organization of information provided in terms of its accuracy, relevance, and personalization within the context of online digital exhibitions on cultural heritage; system quality pertains to the degree of security, speed, reliability, and convenience of the webpages and mobile interfaces; and good service quality is characterized by visually appealing graphics and immersive interactive experiences.

Online digital art exhibitions represent innovative information technology primarily based on new media. Although research on the perceived quality of online digital exhibitions is limited in terms of user expectations confirmation, studies have extensively explored perceived quality and expectation confirmation in various domains, such as online restaurant reviews, online shopping, and online library resources. Joo and Choi [27] confirmed that users' perceptions of the content quality of online library resources positively influence the confirmation of their expectations. Park [28] added that the confirmation of users' expectations is positively influenced by system and service quality in the context of smart wearable devices. Therefore, a similar trend is likely to apply to users of online digital art exhibitions. Based on this premise, we propose the following hypotheses:

**H1a**: There exists a positive correlation between the content quality of online digital art exhibitions and visitor expectation confirmation.

**H1b**: There exists a positive correlation between the service quality of online digital art exhibitions and visitor expectation confirmation.

**H1c**: There exists a positive correlation between the system quality of online digital art exhibitions and visitor expectation confirmation.

#### *2.3. The Expectation Confirmation Model*

The Expectation Confirmation Model (ECM), proposed by the renowned American scholar Bhattacherjee [29], is widely recognized as a prominent theory for explaining the post-adoption behavior of users [30]. Initially, it was developed to elucidate the relationships between factors influencing the repeat purchase behavior of consumers. It posits that there exists an inherent relationship between the "expectations" prior to product purchase, the "perceived performance" after purchase, the "degree of confirmation" between prior expectations and perceived performance, "satisfaction" after purchase, and consumers' "intention to repurchase." These factors were identified to be interconnected. In 2001, Bhattacherjee introduced the Expectation Confirmation Model, which comprises four variables: expectation confirmation, perceived usefulness, satisfaction, and continued usage intention.

Expectation confirmation as a key factor in the ECM that plays a significant role in determining users' perceived satisfaction with information systems and services, which, in turn, influences their system usage. Furthermore, as satisfaction is typically defined as a user's overall evaluation of their experience with a specific information system or service, Mason and Nassivera [31] identify satisfaction as one of the core determinants of behavioral intention. Therefore, this study incorporates expectation confirmation, satisfaction, and behavioral intention from the ECM into its research model.

Additionally, Hsu and Lin [32] demonstrate that perceived value replaces perceived usefulness. Users engage with online digital art exhibitions for various reasons, such as leisure, enjoyment, and learning, rather than to achieve specific goals or enhance performance. Previous research has shown that in the tourism domain, the primary factors influencing behavioral intention are perceived quality, perceived value, and satisfaction [33,34]. Thus, perceived value deserves greater attention.

#### 2.3.1. Confirmation

Bhattacherjee defines expectation confirmation as the degree to which information system users' pre-usage expectations are confirmed after system usage. In the context of this study, expectation confirmation refers to a user's evaluation of the degree to which their overall perception of the online digital art exhibition of cultural heritage aligns with their pre-visit expectations. In the Expectation Confirmation Model, expectation confirmation is a key factor that directly influences user satisfaction with system usage. The higher the confirmation of users' prior expectations, the greater their perceived satisfaction with the usage experience. For instance, Vena-Oya et al. [35] found that the confirmation of high expectations significantly influences people's satisfaction with tourist destinations. Chen et al. [36] demonstrated that expectation confirmation plays a decisive role in determining satisfaction with online shopping. Based on these findings, the following hypothesis is proposed:

**H2**: There is a positive correlation between expectation confirmation and visitors' satisfaction with online digital art exhibitions.

Previous research has shown a strong and important relationship between expectation confirmation and perceived value. Lin et al. [37] revealed that higher expectation confirmation in IPTV leads to greater perceived value. Research found that confirmation of users' expectations of mobile services plays a decisive role in their perception of value and satisfaction [38]. Therefore, the following hypothesis is proposed:

**H3**: There is a positive correlation between expectation confirmation and visitors' perceptions of the value of online digital art exhibitions.

Furthermore, Halilovic and Cicic [39] introduced an extended Expectation Confirmation Model that integrates expectation confirmation with the affective structure of individual users, specifically, the perception of enjoyment. This integration further complements the continuity of perceived information technology quality. Research has shown that expectation confirmation has a positive impact on the perception of enjoyment. Based on this, we propose the following hypothesis:

**H4**: There is a positive correlation between user expectation confirmation and visitors' perceptions of enjoyment in online digital art exhibitions.

#### 2.3.2. Satisfaction

Satisfaction, as defined by Oliver [40], represents the discrepancy between consumers' prior expectations and their perception of the product's performance after consumption. Both the ECM and subsequent studies have confirmed that satisfaction is a primary determinant of users' behavioral intentions. Visitors feel satisfied when their experience meets or exceeds their expectations. Numerous studies have established that user satisfaction is an important indicator of subsequent behavioral intentions [41,42], and that satisfaction with online travel experiences has a positive impact on users' behavioral intentions [42–44]. The more satisfied users are with online travel, the stronger their intention to engage in actual visits. Therefore, the following hypothesis is proposed:

**H5**: There is a positive correlation between satisfaction and visitors' intentions to engage in on-site visitation behavior.

#### 2.3.3. Perceived Value

Perceived value refers to the overall evaluation of the utility of a product or service [45]. Woodruff [46] considers a product's performance, attributes, and usage effects to be customer value factors that influence the attainment of customer goals. Murphy et al. [47] point out that perceived value, in the context of tourism, refers to the comparison made by tourists between the quality of their tourism experiences and the resources (e.g., money, time) invested in their travel. In this study, perceived value refers to users' overall evaluation of the cultural value, aesthetic value, and service value experienced during the expectation confirmation phase of the digital online exhibition of cultural heritage. Perceived value is relative in nature, as it is comparative, personal, and contextual, and is inherently prioritized, affective, and cognitively emotional [48].

Numerous studies have demonstrated a causal relationship between perceived value and satisfaction, effectively explaining tourist satisfaction and destination choice [49]. Gallarza and Gil Saura [50] argue that perceived value is a prerequisite to experiencing satisfaction in a tourism context. Wei et al. [51] identify tourists' perception of value after engaging in cultural heritage tourism as one of the most significant factors influencing their

satisfaction with a destination and their intention to revisit. Chen and Chen [52] find that visitors' perception of value in heritage tourism has a positive impact on their satisfaction. Based on this, we can hypothesize the following:

**H6**: There is a positive correlation between the perceived value of online digital art exhibitions and visitor satisfaction.

A substantial body of empirical research suggests that perceived value may be a stronger predictor of user behavior compared to satisfaction or quality. For example, Cronin et al. [53] examine the relationships between perceived value, satisfaction, and behavioral intentions across six different service industries, and find that perceived value directly influences customer satisfaction and behavioral intentions in all industries except healthcare. Pura [54] analyzes the direct impact of perceived value on behavioral intentions in a service context. The results of their study indicate that there is a significant influence of perceived value on behavioral intentions, with higher perceived value leading to stronger behavioral intentions. Based on this, we can hypothesize the following:

**H7**: The perceived value of online digital art exhibitions has a positive impact on visitors' intentions to engage in on-site visitation behavior.

#### 2.3.4. Perceived Enjoyment

Perceived enjoyment refers to the extent to which users perceive the activity of using a specific information system as enjoyable [55]. Thong et al. [56] were the first to investigate the relationship between perceived enjoyment and the continued intention to use mobile internet services. By extending perceived enjoyment to the Extended Confirmation Model, a better understanding of the continued behavior in mobile internet services can be achieved. Perceived enjoyment represents the level of enjoyment experienced by users during the usage process, independent of the usage outcome. In the context of this research, perceived enjoyment primarily refers to the pleasant emotions experienced by users after engaging in online digital exhibitions on cultural heritage, with greater emphasis on fully immersive experiences through virtual interaction with art exhibitions.

The concept of perceived enjoyment has been widely studied across different domains. In healthcare environments, visual art has been found to alter patients' emotions, evoking a sense of pleasure in hospital rooms and providing patients with a sense of mental wellbeing [57]. Ulrich [58] emphasizes that natural environments elicit pleasant emotions and psychological responses, emphasizing therapeutic perception based on emotions. Day [59] suggests that the full appreciation or enjoyment of artwork can serve as a healing pathway for individuals. In their book, Malchioldi and Lippin [60] state that scientific evidence supports the positive impact of all forms of therapeutic art, because they combine sensibility, emotions, and cognition, allowing individuals to fully enjoy and experience life. Chen [61] discusses how audiences easily find presence after interacting with high-quality interactive art, which provides fundamental sensory enjoyment and awakens emotional resonance in individuals, thus serving as a form of therapy and restoration. Based on these observations, we can propose the following hypothesis:

**H8**: The perceived enjoyment of visitors towards online digital art exhibitions is positively correlated with their perception of art therapy.

#### *2.4. Artistic Healing*

The origin of "art therapy" can be traced back to Hans Prinzhorn, who published "Artistry of the Mentally Ill" in 1922, where he suggests that the configuration impulse in the drawings of psychiatric patients can be traced back to the universal psychological history of humankind. This study also marked the beginning of the intersection between psychology and the field of art [62]. With the dissemination of art and the development of art therapy, in the 1940s, psychiatrist Margaret Naumburg solidified the concept of "art therapy". Simultaneously, artist Adrian Hill and art teacher Edith Kleinman recognized the therapeutic potential of art and the creative process as an intervention for psychological issues. Under the guidance of art therapists, patients enhance their self-awareness, and experience personal growth and therapeutic effects. Over time, art therapy has evolved into a diverse field, encompassing various modalities such as film, music, drama, games, performance, visual arts, and sandplay. Art therapy is no longer solely targeted toward psychiatric patients and has also become a means of healing for individuals seeking to overcome psychological challenges, engage in self-exploration, and express themselves artistically.

In this study, art therapy primarily refers to the "visual arts as therapy" approach, where users primarily view online digital art exhibitions to experience aesthetic pleasure, emotional release, and emotional resonance with the artworks and to attain a state of relaxation, thereby reducing mental anxiety and fostering a sense of social belonging.

Previous research has shown limited discussion on satisfaction and behavioral intentions regarding art therapy and online digital art exhibitions. However, scholars have recognized the positive effects of art therapy in settings such as museums and healthcare [63]. A study by Harris et al. [64] indicated that art therapy in hospital environments is a key indicator of hospital satisfaction. This viewpoint has been supported by subsequent studies [65,66]. Zhang [67] demonstrated the significant impact of decorative art in creating emotionally therapeutic landscapes in public spaces and satisfying individuals' spiritual pursuits. Additionally, Zhang et al. [68] argued that perceived therapeutic effects have a positive influence on the loyalty and behavioral intentions of visitors in urban parks. Kreitler and Kreitler [69] assessed the impact of the art therapy process on individuals' behavioral intentions. Based on these findings, we can propose the following hypotheses:

**H9**: There is a positive correlation between art therapy and visitor satisfaction with online digital exhibitions. *Sustainability* **2023**, *15*, x FOR PEER REVIEW 8 of 21

**H10**: There is a positive correlation between art therapy and visitors' on-site visitation behavior.

#### *2.5. Research Model* their application in this context remains largely unexplored. To address our research inquiries, we propose ten hypotheses (Figure 1).

Figure 1 presents a conceptual model developed based on the proposed hypotheses.

#### **Figure 1.** Research model. **Figure 1.** Research model.

**3. Research Context and Study Methodology**  *3.1. Song Dynasty Figures Online Digital Exhibition* This study focuses on an online digital art exhibition titled "Millennium Tone: Portraits of Song Dynasty Figures", which was launched by CGTN, the China Global Television Network, in January 2023. As noted by the renowned scholar Chen Yinke, "The culture of the Chinese nation has evolved over thousands of years, reaching its pinnacle during the Song Dynasty" [70]. This highlights the significance of Song Dynasty culture in the development of Chinese culture. This special digital exhibition features a curated selection of over 200 precious artworks from more than 10 museums worldwide, showcasing the painted figures of the Song Dynasty to an audience of thousands. The exhibition can be accessed via both computers and mobile devices, and it employs the cuing-edge Unity The conceptual model presented in this study redefines the Stimulus–Organism– Response (S-O-R) theory by incorporating nine variables: system quality, information quality, service quality, expectation confirmation, perceived value, perceived enjoyment, art therapy, visitor satisfaction, and visitor intention to revisit. The S-O-R theory aims to explain users' behavioral responses to external stimuli. In fact, online digital exhibitions inherently operate within the S-O-R framework, as they provide users with visual aesthetics and services, serving as a distinctive form of psychological stimulation. This service (or stimulus) leads to emotional changes and cognitive enhancement in exhibition visitors, which, in turn, influence their final behavioral decisions, specifically regarding their intention to seek offline exhibition experiences (R). Despite the aforementioned logical

engine, developed for the gaming industry, to create interactive 3D scenes of ancient art. This innovative approach brings the thousand-year-old characters and scenes depicted in

egant Demeanor", "Officials", "Performers", "Commoners", and "Immortals" (Figure 2). These halls present the various figures depicted in Song Dynasty paintings, ranging from children and maidservants to scholars, artists, merchants, and Daoist immortals. By offering a close-up experience in which visitors can view the depicted characters, the exhibition provides insights into everyday life in the Song Dynasty, including clothing, cosmetics, and entertainment. Each exhibition area provides vivid interpretations from different perspectives, ensuring a dynamic and interactive experience. Visitors can enjoy and explore 110 high-definition Song Dynasty paintings, whereby the ancient artworks to come alive

and engage the audience in an immersive and enjoyable manner (Figure 3).

relationships, there is a lack of research specifically focused on online digital exhibitions, and their application in this context remains largely unexplored. To address our research inquiries, we propose ten hypotheses (Figure 1).

#### **3. Research Context and Study Methodology**

### *3.1. Song Dynasty Figures Online Digital Exhibition*

This study focuses on an online digital art exhibition titled "Millennium Tone: Portraits of Song Dynasty Figures", which was launched by CGTN, the China Global Television Network, in January 2023. As noted by the renowned scholar Chen Yinke, "The culture of the Chinese nation has evolved over thousands of years, reaching its pinnacle during the Song Dynasty" [70]. This highlights the significance of Song Dynasty culture in the development of Chinese culture. This special digital exhibition features a curated selection of over 200 precious artworks from more than 10 museums worldwide, showcasing the painted figures of the Song Dynasty to an audience of thousands. The exhibition can be accessed via both computers and mobile devices, and it employs the cutting-edge Unity engine, developed for the gaming industry, to create interactive 3D scenes of ancient art. This innovative approach brings the thousand-year-old characters and scenes depicted in Song Dynasty paintings to life, transcending the static nature of traditional artworks. The exhibition website consists of six main thematic digital halls, namely, "Companions", "Elegant Demeanor", "Officials", "Performers", "Commoners", and "Immortals" (Figure 2). These halls present the various figures depicted in Song Dynasty paintings, ranging from children and maidservants to scholars, artists, merchants, and Daoist immortals. By offering a close-up experience in which visitors can view the depicted characters, the exhibition provides insights into everyday life in the Song Dynasty, including clothing, cosmetics, and entertainment. Each exhibition area provides vivid interpretations from different perspectives, ensuring a dynamic and interactive experience. Visitors can enjoy and explore 110 high-definition Song Dynasty paintings, whereby the ancient artworks to come alive and engage the audience in an immersive and enjoyable manner (Figure 3). *Sustainability* **2023**, *15*, x FOR PEER REVIEW 9 of 21 *Sustainability* **2023**, *15*, x FOR PEER REVIEW 9 of 21

**Figure 2.** Six main thematic digital exhibition halls. **Figure 2.** Six main thematic digital exhibition halls. **Figure 2.** Six main thematic digital exhibition halls.

After designing the measurement indicators for each potential variable, this study used existing scales from previous research to create the initial survey questionnaire on

After designing the measurement indicators for each potential variable, this study

[6,19]

[6,19]

der, age, occupation, etc.), and (2) 36 measurement items for 9 potential variables. To ensure the validity of the final survey data, the research team conducted a preliminary investigation of the initial questionnaire before the formal survey, collecting 126 test data for analysis; moreover, the research team optimized the questionnaire by deleting five items with insufficient reliability and low factor loading, and adding two items on whether users are interested in Song Dynasty culture and whether they would like to visit offline museums. The final questionnaire consisted of 31 measurement items, as shown in

questionnaire consisted of two parts: (1) basic information on the survey participants (gender, age, occupation, etc.), and (2) 36 measurement items for 9 potential variables. To ensure the validity of the final survey data, the research team conducted a preliminary investigation of the initial questionnaire before the formal survey, collecting 126 test data for analysis; moreover, the research team optimized the questionnaire by deleting five items with insufficient reliability and low factor loading, and adding two items on whether users are interested in Song Dynasty culture and whether they would like to visit offline museums. The final questionnaire consisted of 31 measurement items, as shown in

*3.2. Questionnaire Design and Measurements*  **Figure 3.** Exhibition content. **Figure 3.** Exhibition content.

*3.2. Questionnaire Design and Measurements*

**Table 1.** Measurement of the variables.

**Table 1.** Measurement of the variables.

painting in Song Dynasty.

painting in Song Dynasty.

beautiful.

beautiful.

Table 1.

Table 1.

Perceived quality

Perceived quality

Content quality

Content quality

Service quality

Service quality

**Constructs Items Explanations Source(s)**

**Constructs Items Explanations Source(s)**

QC2 Online art exhibition content was easy to understand.

QC2 Online art exhibition content was easy to understand.

QS2 Online art exhibition incorporated animation effects. QS3 Online art exhibition screen was high definition.

QS2 Online art exhibition incorporated animation effects. QS3 Online art exhibition screen was high definition.

QC3 Online art exhibition content was very rich.

QC3 Online art exhibition content was very rich.

QC1 Online art exhibition content provided aesthetic information of figure

QC1 Online art exhibition content provided aesthetic information of figure

QS1 In my opinion, the color scheme of this online art exhibition was very

QS1 In my opinion, the color scheme of this online art exhibition was very

#### *3.2. Questionnaire Design and Measurements*

After designing the measurement indicators for each potential variable, this study used existing scales from previous research to create the initial survey questionnaire on factors influencing offline visits by users of the online digital art exhibition. The survey questionnaire consisted of two parts: (1) basic information on the survey participants (gender, age, occupation, etc.), and (2) 36 measurement items for 9 potential variables. To ensure the validity of the final survey data, the research team conducted a preliminary investigation of the initial questionnaire before the formal survey, collecting 126 test data for analysis; moreover, the research team optimized the questionnaire by deleting five items with insufficient reliability and low factor loading, and adding two items on whether users are interested in Song Dynasty culture and whether they would like to visit offline museums. The final questionnaire consisted of 31 measurement items, as shown in Table 1.

**Table 1.** Measurement of the variables.

#### *3.3. Data Collection*

This study was conducted following the launch of the Chinese digital exhibition "Online Guochao Digital Special Exhibition" on CGTN in January 2023. The researchers recruited 542 participants from across China who had not previously visited the exhibition. Participants ranged in age from 18 to 60 years old and were asked to view the entire exhibition before completing the questionnaire. Informed consent was obtained from all participants, and a random sampling technique was used. A seven-point Likert scale (ranging from 1 (strongly disagree) to 7 (strongly agree)) was utilized. The study data were analyzed using SPSS 27.0 and AMOS 27.0, including Confirmatory Factor Analysis (CFA) and Structural Equation Modeling (SEM). A total of 532 responses were collected from the on-site survey and subjected to encoding analysis. Responses with missing or consistently identical answers were excluded, resulting in 512 valid questionnaires with an effective response rate of 96.24%. Table 2 presents the demographic information of the survey respondents.

**Table 2.** Respondents' demographic information.

#### **4. Results**

#### *4.1. Common Method Deviation*

The data for this study were collected from a single source (participants or respondents), and the survey method involved self-perception and self-reporting. This data collection method is susceptible to common method bias, which may arise from the shared measurement environment, contextual factors, and the characteristics of the items themselves. To mitigate the artificial covariance between the predictor and criterion variables caused by the same measurement environment, contextual factors, and item characteristics, the study adopted the approach proposed by Cham et al. [73]. During the data collection phase, the research team intentionally designed the questionnaire items for different variables on separate pages, allowing respondents to have sufficient rest between pages and reducing the common method variance resulting from using the same scale. Additionally, the research team conducted Harman's single-factor test and exploratory factor analysis

(EFA) to examine the presence of common method bias. A total of 31 items were loaded together for the EFA, and the results showed a Kaiser–Meyer–Olkin value of 0.910, with a significance level of *p* < 0.05, indicating the suitability of the questionnaire data for factor analysis. The EFA revealed the presence of nine factors with eigenvalues greater than 1. Although the first unrotated principal component accounted for 34.25% of the variance, which is less than the recommended threshold of 40%, it suggests that common method bias did not have a significant impact on this study.

#### *4.2. Descriptive Analysis*

The descriptive statistics of the constructs employed in the research model are summarized in Table 3.

**Table 3.** Descriptive information of the constructs used in the research model.

#### *4.3. Measurement Model*

To assess the measurement reliability and validity of our sample data, we conducted a confirmatory factor analysis (CFA) on all the item variables in our model. Convergent validity measures whether an item can effectively reflect its corresponding variable, while discriminant validity measures whether two variables have statistically significant differences [74]. Table 4 presents the values of the scale, items, standardized loadings, average variance extracted (AVE), composite reliability (CR), and Cronbach's alpha.

**Table 4.** Descriptive information of the constructs used in the research model.

As shown in Table 4, all the standardized factor loadings exceed 0.7, and the t-values indicate that these factor loadings are significant at the 0.001 level. The composite reliabilities (CR) of all the variables are greater than 0.7, and the average variance extracted (AVE) is greater than 0.5 for all variables. Therefore, all the indicators in this study are higher than the standard values, indicating good convergent validity of the measurement scale [75]. Moreover, the Cronbach's alpha coefficients for each item exceed the value of 0.70 recommended by Hundleby, indicating that the scale also has good reliability [76].

Based on the analysis results presented in Table 5, it is evident that in this study's discriminant validity test, the standardized correlation coefficients between all dimensions are smaller than the square roots of the corresponding AVE values. This observation indicates that there is good discriminant validity among all the dimensions in this study.

**Table 5.** Correlation matrices and discriminant validity.

Note: The items on the diagonal on bold represent the square roots of the AVE.

The analysis results in Table 5 clearly demonstrate that in the context of discriminant validity testing in this study, the standardized correlation coefficients between each pair of dimensions are all smaller than the square root of the average variance extracted (AVE) values corresponding to those dimensions. This finding indicates that there is good discriminant validity among the dimensions in this study.

#### *4.4. Structural Model*

#### 4.4.1. Fit Indices

The fit indices for both the research model and the measurement model were computed. As presented in Table 6, these indices were considered generally acceptable based on the recommendations from previous studies.

#### **Table 6.** Fit indices.

As demonstrated in Table 6, all the fit indices obtained in this study surpass the recommended values, indicating that the research model employed exhibits a satisfactory fit.

#### 4.4.2. Hypothesis Tests

The path coefficients and their significance are summarized in Figure 4 and Table 7. As depicted in the figure, all 10 hypotheses were tested and supported at a significance level of 0.05. The results of this study demonstrate that users' intentions to engage in offline visits are primarily predicted by three variables: art therapy (H10, β = 0.314, *p* < 0.001), perceived value (H7, β = 0.508, *p* < 0.001), and satisfaction with enjoyment (H5, β = 0.141, *p* < 0.001). These variables collectively explain 48% of the variance in users' intentions to engage in offline visits.

*Sustainability* **2023**, *15*, x FOR PEER REVIEW 14 of 21

**Fit Indices chi2/df GFI AGFI CFI TLI RMSEA**

Recommended values <300 >0.900 >0.800 >0.900 >0.900 <0.080 Measurement model 1.330 0.936 0.920 0.988 0.986 0.025 Research model 1.783 0.913 0.896 0.971 0.968 0.039

on the recommendations from previous studies.

The fit indices for both the research model and the measurement model were computed. As presented in Table 6, these indices were considered generally acceptable based

As demonstrated in Table 6, all the fit indices obtained in this study surpass the recommended values, indicating that the research model employed exhibits a satisfactory fit.

The path coefficients and their significance are summarized in Figure 4 and Table 7. As depicted in the figure, all 10 hypotheses were tested and supported at a significance level of 0.05. The results of this study demonstrate that users' intentions to engage in offline visits are primarily predicted by three variables: art therapy (H10, β = 0.314, *p* < 0.001), perceived value (H7, β = 0.508, *p* < 0.001), and satisfaction with enjoyment (H5, β = 0.141, *p* < 0.001). These variables collectively explain 48% of the variance in users' intentions to

*4.4. Structural Model*  4.4.1. Fit Indices

**Table 6.** Fit indices.

4.4.2. Hypothesis Tests

engage in offline visits.

**Figure 4.** The research model. (Note: \*\* *p* < 0.01; \*\*\* *p* < 0.001). **Figure 4.** The research model. (Note: \*\* *p* <0.01; \*\*\* *p* <0.001).

**Table 7.** Fit indices and results of hypotheses test **Table 7.** Fit indices and results of hypotheses test.

(Note: \*\* *p* < 0.01; \*\*\* *p* < 0.001).

In the Emotional Organism, perceived value (H6, β = 0.250, *p* < 0.001), art therapy (H9, β = 0.515, *p* < 0.001), and expectation confirmation (H2, β = 0.271, *p* < 0.001) positively influence satisfaction.

Perceived quality (H1a, β = 0.166, *p* < 0.001), service quality (H1, β = 0.419, *p* < 0.001), and system quality (H1c, β = 0.261, *p* < 0.001) all have positive effects on expectation confirmation.

The results of the mediation analysis are presented in Table 8. In addition to the three variables with direct effects on behavioral intention, user expectation confirmation and satisfaction have two indirect effects on users' intentions to engage in offline visits. (1) Indirect effect 1 (0.072, 95% confidence interval does not include 0): Expectation confirmation → Perceived value → Satisfaction (significant mediation effect). (2) Indirect effect 2 (0.071, 95% confidence interval does not include 0): Expectation confirmation → Perceived value → Art therapy → Satisfaction (significant mediation effect), accounting for 16.6% and 16.5% of the total effect, respectively, and acting as partial mediators.

**Table 8.** Indirect effects on intention to engage in offline visits.

#### **5. Results and Discussion**

The global tourism industry has been severely impacted by the COVID-19 pandemic, which is ongoing and becoming the new norm. As the world gradually recovers, stakeholders in the tourism industry are seeking policies that can facilitate its revival in this new context. Therefore, one of the primary objectives of this study is to assess the impact of online digital art exhibitions on the recovery and revitalization of the tourism industry. This study analyzes the decisive factors in visitors' on-site visitation behavior as influenced by the widespread adoption of online digital technologies during the COVID-19 pandemic. The findings, presented in Table 5, provide support for all ten of our proposed hypotheses.

This study demonstrates that the three dimensions of perceived quality in online digital art exhibitions (content quality, system quality, and service quality) are crucial in confirming visitors' expectations, with service quality having the highest impact coefficient. These findings are consistent with those of previous studies [77–79]. Specifically, the more stimuli visitors experience from online digital art exhibitions on cultural heritage, the more positive their confirmation becomes. The iconic representation of Song Dynasty figure paintings in Chinese aesthetics serves as an attraction for visitors, as the perceived visual aesthetic appeal and diverse interactive experiences stimulate higher levels of expectation confirmation. Therefore, as people's travel demands evolve, future online curators should consider leveraging the increased cognitive recognition of this type of exhibition tourism, focusing on broader sharing, more effective interactions, richer sensory experiences, and convenient information dissemination.

Secondly, the empirical results of this study reveal the existence of two mediating effects between expectation confirmation and satisfaction, which indirectly influence visitors' intentions to visit offline museums. These effects include the mediation of perceived value and enjoyment, as well as enjoyment and art therapy. This implies that perceived value, enjoyment, and art therapy are important pathways through which expectation confirmation influences satisfaction. Expectation confirmation serves as a significant motivating factor for satisfaction, and while previous studies have confirmed the impact of expectation confirmation on satisfaction [80,81], the internal process mechanism underlying the influence of expectation confirmation on satisfaction remains unclear. This study discovers that perceived value, enjoyment, and art therapy can further elucidate the relationship between expectation confirmation and satisfaction. Perceived value plays a partially mediating role in confirmation and satisfaction, which is consistent with previous research demonstrating the important link between perceived value and expectation confirmation and satisfaction [82]. Additionally, for the first time, this study reveals that expectation confirmation influences satisfaction through the mediation of enjoyment and art therapy, with remote mediation effects being significant. In other words, the higher the expectation confirmation of visitors to online cultural heritage art exhibitions, the higher their perceived enjoyment, and the greater their perception of art therapy, leading to physical relaxation and mental comfort; this, in turn, affects visitors' satisfaction with online cultural heritage digital art exhibitions. These findings indicate that the importance of expectation confirmation in ensuring satisfaction can also be understood through the mediating roles of enjoyment and art therapy.

Thirdly, this study reveals that perceived value, satisfaction, and art therapy, as latent variables, exert a positive and significant influence on visitors' offline visitation behavior.

These findings align with those of previous research [83,84], confirming the consistent impact of perceived value and satisfaction on visitors' offline visitation behavior. Moreover, this study provides support for the notion that there is a greater influence of perceived value on behavioral intention compared to satisfaction [85]. Specifically, visitors perceive online digital art exhibitions as possessing high literary and historical value, making them worth visiting. Visitors' behavioral intentions are more strongly driven by perceived value than satisfaction. Additionally, the inclusion of art therapy as a predictor of visitors' on-site visitation behavior represents a novel discovery in this study. Previous research suggests that experiencing a healing sensation from a favorable environmental stimulus strongly affects visitors' attachment to a place and behavioral intentions [86]. This indicates that the confirmation of visitors' emotions arising from the art therapy effect of online cultural heritage digital art exhibitions can effectively predict their intention to engage in on-site visitation and their attachment to the art exhibition. Although COVID-19 is gradually receding, the psychological trauma caused by the pandemic lingers and cannot be easily alleviated. However, through immersive online experiences that allow visitors to immerse themselves in Song and Yuan aesthetics, appreciate the daily culture of the Song Dynasty spanning thousands of years, interact with the exhibits, and learn new information, individuals can effectively address emotions such as anxiety, depression, and anger, thereby promoting psychological healing. Consequently, visitors are more inclined to visit offline museums and personally experience the spiritual healing that art offers.

#### **6. Conclusions and Suggestions**

Firstly, this study establishes a new S-O-R model based on the Expectation Confirmation Model, perceived quality, and art therapy theory. The model explains 48% of the variance in visitors' behavioral intentions to engage in on-site visitation, providing a cognitive framework to analyze the logic underlying the interaction between the perceived quality of online digital art exhibitions and on-site visitation behavior. It delves into the stimuli of perceived quality experienced by visitors through online digital art exhibitions, leading to perceptions of increased value, enjoyment, and art therapy, thereby influencing visitors' decisions to engage in physical visits. Therefore, the model developed in this study serves as empirical evidence of the benefits of using digital technology in tourism experiences and the communication of cultural heritage tourism.

Secondly, we offer an effective method to assess whether online digital art exhibitions meet visitors' expectations regarding enjoyment, value, and art therapy, thereby enhancing their likelihood of engaging in on-site visitation behavior. These research findings will enable cultural heritage tourism managers to understand visitors' motivations, allowing them to design online digital art exhibitions that cater to visitors' psychological needs and encourage them to visit on-site. This is particularly significant in the aftermath of the COVID-19 pandemic. In fact, online digital art exhibitions provide an alternative for individuals who may be interested in art exhibition content but are unable to physically attend. Furthermore, our research results may encourage web designers of online digital art exhibitions to improve the usability and aesthetics of their online interfaces. By effectively utilizing the Internet, multimedia, emotional content, and aesthetic interfaces, online digital art exhibitions can attract a larger audience and generate interest in visiting art exhibitions and environments within the cultural domain. In the digital information age, online cultural heritage art exhibitions bear the social mission of informing the public about historical civilizations and preserving cultural heritage.

Firstly, this study could provide practical insights for tourism managers, as online digital cultural tourism is a key driver in the transformation of the culture and tourism industry. With the accelerated process of digitization, blockchain-based digital art has become a new trend in the wave of digital economic development [87]. The "digital + culture" development model presents infinite possibilities for the revitalization of China's remarkable culture and the development of cultural tourism. Digital transformation has promoted the transformation and upgrading of the tourism industry. Online digital art exhibitions, representing a transition from traditional offline exhibition formats to intelligent online travel experiences, are propelling the tourism industry towards greater efficiency and intelligence.

Secondly, this study provides guidance for tourism managers on the bidirectional integration of online and offline exhibition technologies. Online exhibitions focus on personalized services, offering visitors the opportunity to access and enjoy cultural and artistic activities anytime, while reducing the use of travel resources and associated environmental pressures such as carbon emissions from air travel. It significantly reduces the energy costs associated with maintaining buildings, hosting exhibitions, and travel. This is particularly beneficial for those who have limited mobility or lack economic resources for travel, thereby promoting the sustainability of the tourism industry. On the other hand, offline exhibitions emphasize quality and provide unique tourism value through interactive settings and real-time experiences. Visitor engagement in cultural and artistic activities can stimulate the local community's economic and cultural life. The integration of online and offline experiences mutually reinforces the sustainability of the tourism industry.

Thirdly, this study contributes to the understanding of how online digital technologies can revitalize historical and cultural heritage in the field of culture and tourism management. Online digital exhibitions allow developers to vividly present information on historical and cultural heritage and folk culture, urban stories, and brand concepts to visitors. This not only promotes the vitality of traditional culture and tourism industry values and commercial values, but it also satisfies the public's curiosity and thirst for knowledge through interactive experiences using digital technology. Thus, cultural heritage is effectively protected while being showcased and utilized, providing more inspiration and forms of expression for cultural heritage inheritance and development.

Furthermore, this research contributes to enhancing citizens' well-being. In the context of the post-pandemic era, online digital art exhibitions can serve as healing spaces, alleviating the pressures of temporary living, working, and studying, and nurturing psychological well-being. In this sense, online digital art exhibitions deserve attention from curators and designers. Unrestricted by space and distance, online digital art exhibitions have a large audience and wide dissemination, making them the fastest and most effective platforms for art therapy. Today's online digital art exhibitions extend beyond simply replicating offline museum and art gallery experiences. Through the integration of technology and art, they emphasize individual spiritual pleasure and freedom. Cognitive psychology also demonstrates that high-quality interactive art is more likely to enable viewers to contemplate their own existence, experience basic sensory and behavioral responses, and awaken deep emotional resonance [88]. By guiding audiences from the real world to the virtual world, a dialogue between individuals and artworks is accomplished, incorporating art exhibitions into users' lifestyles and elevating the overall spiritual and cultural development of society.

This study has several limitations that should be acknowledged. Firstly, digital technology tourism is developing rapidly worldwide, but research on this topic in China is still in its early stages. Additionally, the sample used in this study may lack diversity across ethnic and cultural backgrounds, as visitor behavior may be influenced by their ethnic culture. Therefore, the generalizability of our research findings needs to be extended to other countries with well-developed online digital exhibitions and different ethnic cultures. Secondly, due to time constraints, we relied on cross-sectional experiential data to measure customer perceptions and behavior. The internal changes that occurred among visitors remain unknown. Considering the ongoing evolution of online digital exhibition content, features, and services, as well as the advancements in technology, measurement biases resulting from time gaps may be increased. Hence, we recommend that future researchers, given sufficient funding and time, collect longitudinal empirical data to examine the interactions among different temporal variables, thereby obtaining more effective and robust validation results.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Acknowledgments:** The authors would like to express their sincere gratitude to the reviewers and Editor for their valuable suggestions, and the College of Art and Design of Zhejiang Guangsha Vocational and Technical University of construction and Pukyong National University for their strong support of this research.

**Conflicts of Interest:** The authors declare no conflict of interest.

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