Investigating The Mediating Role of Ethical Issues and Healthcare Between The Metaverse and Mental Health in Pakistan, China, and Saudi Arabia

ARTICLE
https://doi.org/10.1057/s41599-024-02643-z OPEN
Investigating the mediating role of ethical issues

and healthcare between the metaverse and mental
health in Pakistan, China, and Saudi Arabia
Yineng Xiao 1,2 ✉, Sayed Fayaz Ahmad 3 ✉, Muhammad Irshad4, Han Guo2, Haitham A. Mahmoud5,
Emad Mahrous Awwad6 & Yasser Khan7
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This article examines the mediating role of ethical issues and healthcare on the relationship
between the Metaverse and mental health. It also investigates the impact of the Metaverse
on ethical issues and healthcare. It is based on quantitative methodology. Using a purposive
sampling technique, a close-ended questionnaire was used to collect data from 392 nurses
and doctors across Pakistan, China, and Saudi Arabia. The Partial Least Squares Structural
Equation Modelling technique was used for the analysis. The findings show a significant
mediating role of ethical issues between the Metaverse and mental health. The results do not
support the mediating role of healthcare between the Metaverse and mental health. In
addition, the findings also show a positive relationship between the Metaverse and ethical
issues and between ethical issues and mental health. Similarly, the findings also support the
relationship between the Metaverse and healthcare. The results do not support the rela-
tionship between healthcare and mental health. The study has many implications for tech-
nology developers, scientists, policymakers, and healthcare providers.
1 The Global Intellectual Property Institute, Nanjing University, Suzhou, China. 2 Advanced Institute of Information Technology, Peking University,
Hangzhou, China. 3 Head of Research/Assistant Professor, Institute of Business Management, Karachi, Pakistan. 4 Department of Management Sciences,
University of Gwadar, Gwadar, Pakistan. 5 Department of Industrial Engineering, College of Engineering, Kind Saud Univerity, Riyadh, Saudi Arabia.
6 Department of Electrical Engineering, College of Engineering, Kind Saud Univerity, Riyadh, Saudi Arabia. 7 Post Doc Research Fellow, Multimedia University,
Cyberjaya, Malaysia. ✉email: [email protected]; [email protected]
HUMANITIES AND SOCIAL SCIENCES COMMUNICATIONS | (2024)11:441 | https://doi.org/10.1057/s41599-024-02643-z 1

ARTICLE HUMANITIES AND SOCIAL SCIENCES COMMUNICATIONS | https://doi.org/10.1057/s41599-024-02643-z
I
Introduction
n the past two decades, digital technology has advanced sig- 2. To find out the role of the Metaverse in creating ethical
nificantly and transformed our lives (Cowie and O’Connor, issues in healthcare
2022). It has allowed us to create, process, store, and access 3. To find out the impact of the Metaverse on healthcare
large amounts of data. With the help of digital technologies and
the internet, we can interact on various platforms and engage in
activities over long distances. There are approximately five billion Research questions. The research addresses the following ques-
internet users worldwide, with 93% using social media as of April tions, which provide a base for examining the complex links
2022 (Bardus et al. 2022). On average, people spend 147 min daily among the Metaverse participation, ethical issues, healthcare, and
on social media (Liu et al. 2023) and 6 h and 58 min online MH.
(Evenson et al. 2023). This highlights the need to examine the 1. How does the Metaverse affect human MH?
impact of the internet and social media on its users’ mental 2. How does the Metaverse affect ethical issues?
health (MH). 3. Do the ethical issues and healthcare mediate the relation-
Undoubtedly, digital technology is becoming an integral part of ship between the Metaverse and MH?
our lives, and its impact reshapes society and our behavior. 4. Is there any role of the Metaverse in providing access to
Similarly, we cannot run from societal transformation due to healthcare?
these technological changes and advancements. It is so powerful
that digital technology has become an important part of many
societal functions (Hodson, 2018). As a result, no one can escape Research significance. The study has many significant aspects. It
from using digital technology, and its adoption is becoming highlights a new and important issue in the current digital era.
obligatory without any other choice. Understanding the possible effects of the Metaverse on MH is
Technological transformation always comes with its issues and essential as it grows increasingly and integrates into everyday life
challenges. And so the use of digital technology has also given (Benrimoh et al. 2022). This study also highlights the potential
rise to many MH problems and issues (Pandya and Lodha, advantages, the considerable ethical issues, and the requirements
2021). For example, depression, anxiety, and suicide attempts for healthcare within this setting. The study also ties technological
increased among teens after the availability of smartphones. advances and well-being together, making it further important. It
Most parents, children, friends, etc., interact with their devices, attempts to offer empirical evidence regarding whether the virtual
not with each other, even if they are physically together world impacts MH, clarifying whether it worsens or reduces MH
(Mindrescu and Enoiu, 2022). This leads to weakened human problems. It provides a comprehensive view of the intricate
and societal relationships along with a sense of empathy, crea- relationships between technology, ethics, and health essential to
tivity, introspection, etc. The final target will be the social lawmakers, healthcare providers, and technologists by examining
bonding and fabric that holds society and communities together the intermediary role of ethical concerns and healthcare. The
(Sherry, 2015). Due to these issues, many researchers have research has implications for individuals, firms, and managers
stressed minimizing the use of digital technologies (Cal, 2019). associated with Metaverse development and MH. It provides
Such concerns were increased when efforts were carried out to insights regarding ethical guidelines, policies, and regulations to
immediately stop the speed of COVID-19, and willingly or ensure responsible development and use of Metaverse and users’
unwillingly, every aspect of society’s business, including educa- MH. Similarly, by exploring the mediating role of ethical issues
tional, professional, personal, cultural, etc., was shifted online and healthcare involvement, the study assists in making informed
(Marandi, 2023). This craving for virtual togetherness was made decisions, designing Metaverse technology responsibly, and sup-
possible by the digital technological revolution, which developed porting customized MH in the Metaverse digital world.
dramatically during the epidemic under the phrase “social dis-
tancing.” Meanwhile, the adoption and acceptability of DT Hypotheses development and conceptual framework
expanded with time (Sayibu et al. 2022). Additionally, many Theories. The framework of the study is based on the integration
scientists and researchers were attracted to enhance the tech- of the Human-Computer Interaction Principles (HCI), Social
nology further to meet an immediate need or create the Meta- Cognitive Theory (SCT), Technological Determinism Theory
verse of the future (Zhang et al. 2022). Moreover, technological (TDT), and Digital Well-being frameworks (DW). These theories
giants like facebook, etc., also started to invest in the Metaverse establish a foundation for an empirical investigation to examine
(Chen and Zhang, 2022). the complex interactions among the Metaverse, ethical issues,
access to healthcare, and MH. They were used to determine the
Problem statement. “The issues related to MH due to the Metaverse’s effect on MH while considering healthcare and
excessive use of DT and the internet became a significant chal- ethical issues as mediators.
lenge in the Metaverse.” Its emergence has raised concerns
regarding the possible effects of immersive digital platforms on Social cognitive theory. Albert Bandura presented the SCT. It
human MH (Usmani et al. 2022). Although there is early opti- explores how people learn from their society and environments
mism, it is necessary to look at the complex relationships con- (Bandura, 1986). It highlights the essential function that cognitive
necting the Metaverse, ethical issues, healthcare availability, and processes, self-efficacy beliefs, and observational learning influ-
its combined effect on MH (Benrimoh et al. 2022). Moreover, ence a person’s behavior. It argues that people learn through
investigating these complex relationships is necessary for making experiences and by observing and copying others and highlights
policies, technological support systems, healthcare facilities, and the dynamic interaction between an individual’s character, sur-
service planning to increase the Metaverse’s benefits and ensure roundings, and behavior. In sum, SCT offers a thorough frame-
MH. This study aims to determine how the Metaverse affects work for comprehending how people learn and use knowledge
MH, emphasizing the mediating roles of healthcare and ethical and behavior in everyday life, which makes it significant across
concerns. numerous scientific fields (Bandura, 2002). In the context of this
The objectives of the study are: study, it can be used to investigate how ethical concerns and
medical therapies mediate the effects of the Metaverse
1. To find out the impact of the Metaverse on MH experiences on MH.
2 HUMANITIES AND SOCIAL SCIENCES COMMUNICATIONS | (2024)11:441 | https://doi.org/10.1057/s41599-024-02643-z

HUMANITIES AND SOCIAL SCIENCES COMMUNICATIONS | https://doi.org/10.1057/s41599-024-02643-z ARTICLE
Technological determinism theory. This idea explores how tech- In addition, it is a complicated subject to discuss how the
nology affects both society and people. It asserts that technology Metaverse impacts MH. Here, we apply the TDT to investigate
fundamentally and inevitably influences the development of how the technological entity that is the Metaverse may impact
human culture, history, and society. This idea also argues that ethical issues and MH. TDT enables us to see if the technical
social development and changes in how individuals think, orga- characteristics of the Metaverse intrinsically influence
nize, and interact are driven by technological advances (Héder, ethics and, consequently, MH. For example, we examine if
2021). Moreover, it says that technology has a transformative people act differently due to the immersive aspect of the
strength that shapes the structures of society and individuals’ Metaverse and if these actions affect their mental wellness.
behavior in predictable manners (Jan et al. 2020). This opinion Similarly, the research uses DW to explore how the Metaverse
frequently minimizes the importance of social and cultural facilitates healthcare access. DW frameworks provide a
influences, accusing technological advancements and their systematic approach to examining how well-being is affected
inherent characteristics for the changes. Some scholars have by technological advancements. Using such frameworks, we
disagreed on the usefulness of TDT as an approach to under- investigate whether the Metaverse could be used as a platform
standing how technology affects society, while some believe it is for providing and supporting healthcare. For instance, con-
(Bibri, 2022). Others believe it oversimplifies the complicated sidering the possible ethical issues raised by this special
relationship between technology and society (Bojic, 2022). In the healthcare option, we examine if virtual healthcare provided
context of this study, it provides useful insights to examine the via the Metaverse improves access to healthcare and patient
role of the Metaverse in shaping healthcare and MH. MH. With the help of these theories, the study seeks to present a
thorough understanding of the interplay of the Metaverse,
Human-computer interaction principles. It provides a compre- healthcare, ethics, and MH in the currently evolving virtual
hensive framework for developing and evaluating technology landscape.
systems and interfaces (Alkatheiri, 2022). HCI is primarily user-
centered, highlighting accessibility and usability through a user-
The Metaverse. The Metaverse is a digital world, an inter-
centered design. It fosters simplicity, learnability, and consistency
connected and interactive virtual reality where users may
while offering clear feedback with error management (Hustak and
interact and navigate in real-time. With many distinctive fea-
Krejcar, 2016). The importance of ethics in HCI has grown, with
tures, including user content, a distinct digital economy, and
a focus on security and privacy due to the wider societal effects of
smooth multi-platform accessibility, it differs from conventional
technology (Nie et al. 2023). Further, technology needs to be
online environments (Wang et al. 2023). Leading companies like
tested and evaluated regularly to fulfill its purpose, improve user
Google and Meta have made significant investments in its
satisfaction and interaction, and express the collaborative link
development and consider it the next frontier for the web, where
between technological advancement and human interaction
people can work, socialize, and play (Mosco, 2023). It also
(Saltarella et al. 2023). In the context of this research, the
brings complex challenges, such as digital ownership rights,
Metaverse technology can be used to investigate the usability and
monopolistic control, accessibility, security, and privacy (Ooi
design of the Metaverse platforms and how they affect MH.
et al. 2023). Overcoming these problems is essential as the
Metaverse reshapes our lives and how we engage with the
Digital well-being frameworks. The DW frameworks evaluate how
virtual world.
digital technology affects well-being and function as roadmaps to
The development of the Metaverse accompanies a wide range
assist people in navigating the complicated realm of digital
of implications. Undoubtedly, it provides opportunities for
technology, focusing on balanced, healthy, and vigilant connec-
improved social connectedness, new commercial opportunities,
tions (Gennari et al. 2023). The basic concepts of these models
healthcare, and advanced learning possibilities. Nevertheless, it
cover anything from encouraging self-awareness and healthy time
also prompts issues related to privacy, access (Letafati and
management to teaching consumers about online security, priv-
Otoum, 2023), equal benefits, and the possibility of monopolistic
acy, and digital literacy (Tinmaz et al. 2023). These frameworks
domination of a few companies. Areas that need extra attention
promote practices prioritizing MH while using technology (Smith
include intellectual property problems, challenges concerning
et al. 2023). People can establish a more harmonic connection
content control, and the effect on in-person relationships (Wylde
with digital tools and platforms. They can improve the quality of
et al. 2023). These implications must be managed in the light of
their life in today’s digital world by incorporating these frame-
equality, ethics, and regulation while encouraging creativity and
works into their individual and institutional strategies (Hamdoun
connectivity across the changing digital environment to fully
et al. 2023; Li, 2023). In the context of this study, these frame-
utilize its potential for the common good (Arief et al. 2023).
works can be used to measure the relationship between the
The Metaverse will change our lives, working styles, and
Metaverse and MH.
interactions by offering a virtual environment, enabling deep
The research applies HCI to examine the layout and usefulness
social connections, creative business options, and novel health
of simulated environments of the Metaverse to find out the
and educational opportunities (Banaeian et al. 2023; Reibstein
Metaverse’s influence on MH. HCI guides investigating the
and Iyengar, 2023). It might revolutionize all walks of life and
influence of human interactions and experiences in the virtual
provide people with an environment for innovation, entrepre-
world on MH. For instance, user interfaces and immersion in the
neurship, and cooperation (Calandra et al. 2023; Schiller et al.
Metaverse will either positively or negatively affect MH.
2023). This makes it both beneficial and challenging. Its
Furthermore, it is not easy to comprehend the relationship
usefulness depends on managing major concerns like privacy,
between the Metaverse, ethics, and MH. The study uses SCT to
security, and accessibility and on the investing firms to develop
comprehend more about the ethics and behaviors in virtual
and maintain the Metaverse that is accessible, ethical, and useful
spaces and how they may impact the MH of people. This theory
for society.
facilitates us to comprehend the perception of people regarding
ethical conduct and its impact on MH in the Metaverse. For
example, we examine whether experiencing or taking part in The Metaverse and mental health. MH is a person’s ability to
immoral activities leads to anxiety, guilt, etc., in the Metaverse perceive, think, and behave in ways that enhance their living
or not. quality while respecting their personal, cultural, and social

boundaries (Manwell et al. 2015). Emotional, social, and psy- Metaverse in healthcare. The Metaverse consists of two words:
chological well-being are the parts of MH that influence human meta, which means “beyond,” and the universe (Hollensen et al.
perception, behavior, and cognition. A person’s MH determines 2023). It connects social media, AR, and VR technologies via
how to handle stress, relationships, and the process of decision- high-speed internet (Ullah et al. 2018). It is a digital universe
making (Galluccio, 2019). Sleep disturbance, fatigue, and merging virtual and physical reality (Bibri, 2022). Advanced
thoughts of harming oneself or others are early indicators of MH technologies like AR, VR, artificial intelligence, blockchain, cloud
issues (Pappa et al. 2021). Mental disorders influence and change computing, and 5 G and 6 G internet are its building blocks
a person’s cognitive functioning, behavior, and emotional reac- (Wang and Zhao, 2022). The Metaverse refers to a collaborative,
tions linked with distress or other impaired functioning (Gold- interactive, and immersive digital environment where people
man and Grob, 2006). It has a relationship with diet, stress, interact as online crowds (Dwivedi et al. 2022) to support work,
exercise, abuse, drugs, social interactions, and connections play, and socialize (Askr et al. 2023; Wolf et al. 2013). It is a fact
(Manger, 2019). Professionals like therapists, psychologists, psy- that our lives are becoming a mix of virtual and physical worlds
chiatrists, family physicians, etc., assist in MH treatment in var- (Meta, 2022). Some scientists believe the present social media and
ious forms like counseling, therapy, etc. (Sass et al. 2022). digital communication technologies are its primary form, while
Depression, anxiety, phobias, eating disorders, schizophrenia, some say it is yet to come (Salar et al. 2023). In the Metaverse,
obsessive-compulsive disorder, and personality disorders are people will enter through AR glasses or VR headsets, symbolizing
major MH conditions that can cause psychosis, self-harm, panic avatars to interact with others and participate in various activities
attacks, suicidal thoughts, etc. (Solmi et al. 2022). A complex (Njoku et al. 2023). People in the Metaverse will experience a
interaction of different factors causes any MH issue, and it is very strange sense of presence and feel themselves in an environment
difficult to identify as they may differ from person to person. without any technological perception that generates it (Oh et al.
Some of the common factors are abuse, lack of sleep, loneliness or 2023). People will feel they perform tasks like they do in a real
social isolation, discrimination, social disadvantage, stress, drugs, environment. The simulative progressions presented by VR, AR,
violence, bullying, trauma, etc. Physical and environmental fac- and MR offer a potential basis for recognizing the Metaverse
tors also affect behavior, such as injuries and neurological con- experience as a real-world experience (Smith et al. 2019). It is
ditions (Limone and Toto, 2022). important to note that VR, AR, or MR embodied simulations will
It is unclear that technology always creates MH issues, and share human brain functions. The brain produces its body
researchers are divided on this. For example, if technology leads simulation to predict and represent actions and emotions. (Par-
to problems associated with behavior, attention, and self- sons et al. 2020). In the same way, humans will experience the
regulation, it also minimizes depression and anxiety (Weinstein sensory consequences of various scenarios in virtual spaces as in
et al. 2021). Users with low socio-economic status are at higher the real world (Riva and Wiederhold, 2022).
risk of MH issues than those with high socio-economic status. This shows that the Metaverse and human brains are working
Another reason for MH issues is the duration of using technology side by side, and their existence is made possible by the normal
(Strutt et al. 2022). Those who spend more time using digital functions of the human brain (Islam Mozumder et al. 2023). The
technology are more likely to suffer from fighting, lying, and perceptions and feelings a human brain experiences in the real
other behavioral problems. It also leads to issues like “paying world are similar to those of a virtual one (De Borst and de
attention and exhibiting attention deficit-hyperactivity disorder Gelder, 2015). It can also have a significant psychological and
symptoms.” Similarly, self-regulation problems are also evident in behavioral impact on human beings (Ningning and Wenguang,
frequent users (Liston et al. 2011). Digital technology also 2023). Similarly, the brain’s functions are strongly associated with
decreases the bonding between family members and society MH and well-being. There are many risks associated with human
(Newman et al. 2019). People who spend more time using digital behavior, psychological experience, and well-being from the
devices have less time for social activities, sports, or time with Metaverse. Conversely, it has profound applications in rehabilita-
family members or relatives. This increases the chances of mental tion, telemedicine operations, psychotherapy, etc. (Mozumder
disorders in the form of behavior, psychosis, self-harm, panic et al. 2023). It can further assist the healthcare system in
attacks, and suicidal thoughts (Fegert et al. 2020). Perhaps the enhancing personalized care at a lower cost, regardless of the
most severe challenge of using digital technology is that people patient’s location. Telepresence, blockchain, and digital twining
can easily access and see the lifestyles of others, the different kinds could also provide amazing possibilities and opportunities for
of thoughts, and face bullying and harassment, etc., that often MH care in the Metaverse (Shetty et al. 2022). Some MH
leads to feelings of discrimination or abuse (Ali and Shahbuddin, applications are Mood Fit, Better Help, Mood Mission, Sanvello,
2022). These are some of the problems digital technology brings Calm, Happify, Depression CBT Self-Help Guide, Shine, e-
to our lives, causing MH issues. On the other hand, many MH Moods, Bearable, Todoist, PTSD Coach, etc. Many hospital
problems can be solved using digital technology (Areàn et al. chains and fitness centers are adopting technologies beyond
2016). For example, it minimizes the issues of isolation, digital ones for the MH (Bansal et al. 2022). It is evident from the
depression, and anxiety and offers advanced treatment for statistics that the global Metaverse market for healthcare was
various mental disorders. $5.06 billion in 2021 and is expected to reach $71.97 billion
The Metaverse brings both opportunity and risk for MH by 2030.
(Usmani et al. 2022). It provides avenues for social interaction, The Metaverse will significantly change healthcare access by
medical care, and artistic endeavors, enhancing MH (Cerasa et al. eliminating geographical constraints and providing new
2022). Virtual environments can minimize feelings of loneliness, approaches for distant healthcare (Ifdil et al. 2023; Chengoden
offer support for those experiencing MH issues, and provide new et al. 2023). It will facilitate telemedicine sessions (Wiederhold,
methods of treatment (Ifdil et al. 2023). Despite this, it also brings 2022), allowing patients to interact with health professionals from
worries regarding the possibility of addiction, separation from the their homes, and will be especially useful for people living in
real world, and the blurring of real and digital borders, which will underserved or distant locations. Furthermore, virtual medical
increase MH issues (Situmorang, 2023). Achieving the right training can help healthcare workers improve their expertise and
balance between utilizing the Metaverse’s potential for treatment abilities (Tan et al. 2022). Besides its benefits, issues like data
and minimizing its challenges is essential for an individual’s MH security and privacy will emerge, and personal health data will be
(Curtis and Brolan, 2023). at risk of cyber assaults (Benjamins et al. 2023). Therefore,

reducing the potential risks associated with adopting the management of stress and anxiety, and quality relationships.
Metaverse in healthcare is necessary. A proper balance between Cultural and social factors, including societal norms, cultural
using the Metaverse’s potential to enhance healthcare access and values, and financial status, also help or hurt MH (Manger, 2019).
securing medical information is necessary (Solaiman, 2023). Events in life can also have a significant effect on MH. MH is also
influenced by deoxyribonucleic acid and other biological factors,
such as brain chemistry and inheritance (Patalay and Demkowicz,
Ethical issue(s) of the Metaverse in healthcare. Adopting the
2023).
Metaverse brings many ethical challenges that must be taken
Promoting MH is essential for avoiding mental illnesses and
seriously (Kaddoura and Al Husseiny, 2023). The primary con-
improving quality of life (van den et al. 2023). There are various
cern is digital privacy, which arises when people get involved in
initiatives people take to improve their MH. Maintaining
these virtual worlds, leaving a lot of private data behind (Smith
excellent MH requires keeping a healthy weight, eating a balanced
et al. 2023). Secondly, the risk of being overly involved in digital
diet, getting adequate sleep, and reducing (Arslan, 2023; LaBelle,
environments (Chen, 2022). It also includes the legitimacy of
2019). Seeking medical care is necessary for successful MH
virtual encounters, the risk of fraud, and the dissolving of fiction
treatment. Enhancing awareness and lowering the stigma
and reality (De Felice et al. 2023). There are also concerns about
associated with MH problems foster a more welcoming and
digital spying, surveillance capitalism, and the absolute power of a
encouraging community. It significantly impacts one’s life,
few technological giants in controlling the Metaverse (Qamar
especially on a person’s ability to work, establish and maintain
et al. 2023). Resolving these ethical issues is critical to ensure that
relationships, and make decisions. It also leads to physical health
the Metaverse is an environment that serves humanity rather
issues like chronic illnesses, reduced immune systems, and
than endangers our values and MH (Kshetri, 2022).
cardiovascular disease. On the good side, it contributes to
Undoubtedly, the Metaverse will benefit healthcare and provide
resilience and productivity and promotes happy relationships and
tremendous solutions to various problems. Yet, it will also invite
successful living (Foster et al. 2023).
the issue of medical ethics (Leroy et al. 2022). Most ethical issues
like safety, privacy, social, accessibility, identity control, and
freedom of expression are also some of its concerns. Also, new
Theoretical mechanism. A theoretical framework integrating
technology brings new concerns (Quach et al. 2022). For example,
concepts from SCT, TDT, HCI Principles, and DW Frameworks
deep fakes and manipulations might also be serious ethical
can potentially be used to understand the influence of the
concerns (Zhao et al. 2022). Data security is one of the most
Metaverse on MH, with moral issues and healthcare as mediators.
serious concerns in any healthcare system. It is very unethical if
According to SCT, social interactions are the sources of behavior
data regarding patients, etc., is shared or leaked with any
adoption, and interactions in virtual settings influence how
unauthorized party. This could be its potential ethical threat to
people learn and modify their behaviors and attitudes. Users
healthcare (Zeng et al. 2022). Harassment, bullying, and other
engage and observe various content and avatars while immersed
impolite behavior are other serious concerns in the Metaverse
in the Metaverse, influencing their MH. Similarly, TDT highlights
(Wiederhold, 2022). Many people will disregard others and will
the impact of technology on human beings and society. It implies
also violate their freedom (Wang and Zhao, 2022). Mental and
that the Metaverse inevitably influences users’ interactions with
biological privacy will also be threatening when someone reads
digital environments and one another. It impacts individuals’
our minds, models our identity, and controls our behavior. Safety
encounters with ethical issues and their ability to access health-
is another potential threat, as technology and devices can be
care resources in the Metaverse.
attacked by hackers (Wiederhold, 2022). Another serious ethical
Moreover, the study considers HCI principles when navigating
concern is its unequal access. Many poor and developing nations
the Metaverse’s organization and interface, as it strongly
cannot afford the technology, and the digital divide will increase
emphasizes the importance of usability and user-centered design.
(Kaur, 2022).
Implementing HCI concepts in the Metaverse can help users
Perhaps the most important ethical issue in the Metaverse is
access ethical norms and healthcare data. User’s friendly design of
the manipulation of reality. Pictures, videos, etc., can be used as
the Metaverse technology and easy access to healthcare can
deep fake videos. In other words, old videos can be deceived using
improve users’ engagement with healthcare facilities. Finally, DW
the latest digital Metaverse technology in a forged reality. The
Frameworks provides an organized approach for evaluating how
question is, how will such videos impact the MH of the one
digital technology impacts people’s well-being. They can be used
associated with it? In addition, the Metaverse will also change the
in the Metaverse to assess how ethical concerns and healthcare
living habits of humans. Their social life will be highly impacted
procedures fit with standards for fostering mental health. These
as they live in a joint real-virtual world. Their relationships will
frameworks provide a window to evaluate ethical issues and
also be disturbed, and a negative change is expected in their
healthcare facilities in enhancing users’ MH by considering
behavior (Dwivedi et al. 2022). In short, it is a fact that the
elements like autonomy, relatedness, competence, and user
Metaverse in healthcare will bridge the real and virtual worlds
satisfaction.
and provide solutions to many of today’s healthcare problems,
SCT focuses on the process during which people interact
but it also brings some ethical issues like information security,
within the Metaverse, influencing the behaviors associated with
privacy, harassment, bullying, manipulation, unequal access, etc.
their MH. TDT highlights the Metaverse’s inherent influence on
(Kaur, 2022).
ethics and healthcare access. HCI principles ensure that the
Metaverse is designed to make it easier for users to interact with
Mental health. MH encompasses an individual’s social, psycho- moral and medically relevant material. The DW framework
logical, and emotional state (WHO, 2023). It involves mental evaluates how the Metaverse affects’ users’ MH. These theories
disorders, managing stress, upholding healthy relationships, collectively provide a thorough knowledge regarding the influence
dealing with challenges in life, and staying happy and contented of the Metaverse on MH through the mediating roles of ethical
(Hattie et al. 2004). From infancy to maturity, good MH is concerns and healthcare, as shown in Fig. 1. The Metaverse offers
essential since it affects a person’s ability to function well and live a new horizon for healthcare and MH. It can provide an
a satisfied life (van den et al. 2023). Factors contributing to MH appealing, interesting interface for users and healthcare profes-
are emotional well-being, psychological resilience, effective sionals because of its user-centric design. The metaverse will be a

Fig. 1 Proposed theoritical framework of investigating the mediating role of ethical issues and healthcare between the metaverse and mental health.
lively environment for experiential learning, encouraging positive number of the population is known and every individual in the
behaviors, and nurturing social networks that support one population is accessible, the probability sampling technique is
another and positively impact psychological well-being. Likewise, recommended; otherwise, it is suggested to adopt a nonprob-
it will advance innovation in healthcare supply, expanding ability sampling technique (Rahi, 2017). As in this study, the
connectivity, professional collaboration, and healthcare access. researchers adopt a non-probability sampling technique. Among
However, ethical considerations and healthcare mediate the the several types of nonprobability sampling techniques, a pur-
relationships between the Metaverse and MH. Establishing an posive sampling technique was used to select useful respondents
equilibrium between ethical use and the Metaverse is essential to for the research. Data was gathered from the 392 respondents
minimize problems like digital addiction, data breaches, etc. across the research population.
Furthermore, as the Metaverse can be accessed by a wide range of
demographic groups, enhancing the healthcare system’s current Research instrument and statistical technique. The measures
efficiency, healthcare also becomes an important mediator used in the study were adopted from the prior validated studies to
between the Metaverse and MH. ensure reliability and validity. A five-point Likert scale was used
The study uses these theories to comprehend the relationships for the measurement where 1 denotes the lowest level of agree-
as given in the hypotheses. ment, and 5 denotes the highest level of agreement. The partial
least square technique by the SmartPLS software was used to
Hypotheses. The above theoretical mechanism provides the analyze the gathered data. The list of the scales for all constructs
foundation for the following hypotheses. with their items and sources is mentioned in Table 1.
H1: The perceived Metaverse has a significant impact on the
healthcare
H2: The perceived Metaverse has a significant impact on the Result and findings
ethical issues of the Metaverse Demographic profile of the respondent. Table 2 shows the
H3: Ethical issues of the Metaverse have a significant impact on demographic statistics of the respondents. The table’s first section
the MH indicates the gender-wise distribution of the respondents. This
H4: Healthcare has a significant impact on the MH section shows that among 392 respondents, 178 are males and
H5: Ethical issues of the Metaverse mediate the relationship 214 are females. The second section shows the country of the
between the Metaverse and MH respondents. This section indicates that 119 respondents are from
H6: Healthcare mediates the relationship between the Metaverse China, 149 are from Pakistan, and 124 are from Saudi Arabia.
and MH The last section shows the professional level of the medical
respondents. This section shows that among the 392 respondents,
223 are nurses, and 169 are medical doctors.
Methodology
Research philosophy. The philosophical foundation of social
sciences research is often based on interpretivism and positivism Common method bias. Common method bias is a significant
(Babones, 2016). A positivism paradigm is recommended when- problem of primary survey data research. The main reason is the
ever a study is based on prior theories in a specific context to response tendency, in which the respondents intentionally rate all
enhance its generalizability, and the researcher believes in a pre- questions equally. It can be measured through the Variance
determined reality. On the other hand, when the researcher wants Inflation Factor (VIF). The VIF values of any model are not
to explore a new dimension that has not been discovered and is limited to multicollinearity diagnostics, but they also denote the
not properly supported by a prior theory, then an interpretivism common method bias (Kock, 2015). If the VIF value of any
paradigm is recommended (Moon and Blackman, 2014). This construct is equal to or less than 3.3, then the model is believed to
study is based on previously established ideas that the researcher be free from the common method bias. Table 3 shows that all the
will test in specific contexts, so it follows the positivism paradigm. values are less than 3.3, which shows that the collected data is free
The Positivist paradigm is a scientific paradigm based on objec- from the issues of common bias.
tive beliefs about social phenomena in research. The study is
quantitative and was conducted with the help of a close-ended Reliability and convergent validity. Table 4 shows the statistics
questionnaire adopted from prior studies. of reliability, construct reliability, and the convergent validity of
the scales. The measure used for the item’s reliability is outer
Research population and sampling. The population of this study loading values (Griffiths et al. 2022). The threshold value for the
includes medical doctors and nurses in the health sector of outer loading value is 0.7, but even a value of 0.6 or close to 0.6 is
Pakistan, China, and Saudi Arabia. There are two primary also acceptable if the convergent validity of the construct is
options for the researcher to adopt: probability sampling and established (Bagis, 2022). Table 4 shows that all the items have
non-probability sampling (Baker et al. 2013). When the exact outer loading values greater than the threshold value, which

Table 1 Research instrument.
Metaverse MV1 I enjoy my experience with Metaverse.

MV2 I am keen to integrate technology into my healthcare tasks in the future.
MV3 My preferred mode of the healthcare facility is face-to-face.
MV4 I am confident in using future technology.
Mental health MH1 Have you recently Been able to concentrate on whatever you are doing
MH2 Have you recently Lost much sleep over worry
MH3 Have you recently Felt that you are playing a useful part in things
MH4 Have you recently felt capable of deciding things
MH5 Have you recently Felt constantly under strain
MH6 Have you recently Been able to enjoy your normal day-to-day activities
Ethical issues of Metaverse EI1 There is honesty in the online healthcare services
EI2 Online healthcare services are not considering the quality of patient life
EI3 Online healthcare is not respecting patient confidentiality/privacy
EI4 The online healthcare system is ignoring patient/family autonomy
Healthcare HC1 Would you suggest an online healthcare facility for the treatment
HC2 How would you rate the quality of treatment by online healthcare sources
HC3 Patients are being treated with dignity and respect via online healthcare
Table 2 Respondent demography.
Gender Numbers Percentage

Male 178 45%
Female 214 55%
Total 392 100%
Country in Serving Numbers Percentage

China 119 30%
Pakistan 149 38%
Saudi Arabia 124 32%
Total 392 100%
Profession Numbers Percentage

Nurses 223 57%
Doctors 169 43%
Total 392 100%
measure for the discriminant validity of a structural equation

Table 3 Variance inflation factor (VIF). model. The threshold value for the HTMT values is 0.85 or less.
Table 5 shows that all the constructs have HTMT values smaller
Ethical Issues of Healthcare Mental than the threshold value, which indicates that all the constructs
MV health are discriminately valid.
Ethical issues of 1.218
MV Structural model. Figure 2 shows the relationship among the
Healthcare 1.218 variables.
Metaverse 1.000 1.000
Regression analysis. Table 6 shows the regression analysis of the

indicates that all the items are reliable. The measure used for the hypotheses. The statistics show that five of the six hypotheses are
construct reliability is Cronbach alpha and composite reliability. significant. The following are the details.
Both have a threshold value of 0.7 or greater. Table 4 shows that H1: The results give evidence in support of H1 that there is a
all the constructs have Cronbach’s alpha and composite reliability positive and significant relationship between the Metaverse and
values more than the threshold value, indicating that all the healthcare with a significant coefficient, a Beta value of 0.320, a
study’s constructs are reliable for further analysis. The measure T-statistic 7.277, and a p-value of 0.000. The statistics show a
used for the convergent validity is the Average Variance Extracted statistically significant relationship between the Metaverse and
(AVE). The threshold value for the AVE is 0.5 or greater healthcare, showing that the Metaverse will facilitate healthcare in
(Melkamu Asaye et al. 2022). Table 4 shows that all the constructs general.
have AVE values greater than the threshold value, indicating that H2: The results give evidence in support of H2 that there is a
all the constructs are convergently valid. positive and significant relationship between the Metaverse and
its ethical issues with a significant coefficient, a Beta value of
Discriminant validity. In primary data analysis, three major 0.484, a T-statistic 9.60, and a p value of 0.000. The statistics show
measures are used for discriminant validity: cross-loading, HTMT that a statistically significant relationship between the Metaverse
values, and Fornell Larcker criteria (Alwi et al. 2022). However, and its ethical issues and the increase of the Metaverse adoption
most researchers suggest HTMT values as the most suitable will lead to more ethical issues.

Table 4 Reliability and convergent validity. H3: The results give evidence in support of H3 that there is a
positive and significant relationship between the ethical issues of
the Metaverse and MH with a significant coefficient, a Beta value
Construct Items Loading CA CR AVE
of 0.383, a T-statistic of 8.82, and a p value of 0.000. The statistics
Ethical issues of MV EI1 0.825 0.876 0.915 0.730 show a statistically significant relationship between the ethical
EI2 0.856 issues of the Metaverse and MH, and with the increase of ethical
EI3 0.88
issues, mental health problems will increase.
EI4 0.855
Healthcare HC1 0.767 0.814 0.875 0.637
H4: The results do not support H4 that there is a positive and
HC2 0.715 significant relationship between healthcare and MH. The statistics
HC3 0.877 show a Beta value of −0.053, a T-statistic of 0.99, and a p value of
HC4 0.825 0.319 for the hypothesis.
Mental health MH1 0.594 0.805 0.855 0.500
MH2 0.689
MH3 0.736 Mediation analysis. Table 6 also shows the mediation relation-
MH4 0.779 ship of the model. It indicates that there are two mediation
MH5 0.765 relationships. These relationships show the mediation of the
MH6 0.741 ethical issues between the Metaverse and MH and the healthcare
Metaverse MV1 0.795 0.830 0.886 0.661
mediation between the Metaverse and MH. Using a mediator
MV2 0.814
variable, a mediation analysis using PLS-SEM examines the
MV3 0.851
MV4 0.791
indirect effect of an independent variable on a dependent vari-
able. Using this method, the researcher develops mediating
hypotheses between independent and dependent variables. After
finding the validity and reliability and other necessary tests as
discussed in other sections of the study, the mediating analysis is
assessed by finding the significance and interpreted accordingly.
Table 5 HTMT values.
A p value, beta, and T-statistics are the common measures used in
the interpretation. The P-value must be less or equal to 0.005 for a
Ethical Issues of MV Healthcare Mental health significant relationship, otherwise, there will be no relationship.
Healthcare 0.494 The following are the details.
Mental health 0.39 0.137 H5: The results show evidence in support of H5 that there is a
Metaverse 0.565 0.359 0.346 mediating influence of ethical issues between the Metaverse and
MH with a significant coefficient, a Beta value of 0.185, a
Fig. 2 Tested theoritical framework of investigating the mediating role of ethical issues and healthcare between the metaverse and mental health.

Table 6 Hypothesis Testing.
Beta T state P values Remarks

H1: Metaverse -> Healthcare 0.320 7.277 0.000 Supported
H2: Metaverse -> Ethical Issues of MV 0.484 9.609 0.000 Supported
H3: Ethical issues of MV -> Mental health 0.383 8.828 0.000 Supported
H4: Healthcare -> Mental health −0.053 0.997 0.319 Not Supported
Metaverse -> Ethical Issues of MV -> Mental Health 0.185 5.618 0.000 Supported
Metaverse -> Healthcare -> Mental Health −0.017 0.990 0.322 Not Supported
model has 5.8% prediction power if the same model is applied in

Table 7 Model Fitness. a different context.
Saturated Model Estimated Model IPMA analysis. Table 9 shows each variable’s importance and
SRMR 0.070 0.095 performance for the model’s target variable. According to the
d_ULS 0.827 1.545 statistics, ethical issues of the Metaverse have an importance value
d_G 0.245 0.276 of 53.6%, the most important variable of the model for MH. At
Chi-Square 575.139 625.064 the same time, healthcare, which has a performance value of
NFI 0.813 0.797 77.8%, has the highest but least important value. Based on this
model, it is recommended that ethical issues of the Metaverse
T-statistic 5.61, and a p-value of 0.000. This means that the must be addressed properly to improve the users’ MH.
relationship between the Metaverse and MH will be mediated by
the ethical issues of the Metaverse. The threshold value for the Multigroup analysis. Table 10 shows the categorical comparison
significance of a relationship based on the mediation relationship of the model based on gender and profession. Gender includes
is the p-value, which must be 0.05 or less and the t-value is 1.96 or male and female, including 178 males and 214 females, while
above. These values show a significant mediation between the profession also includes two categories, including 169 doctors and
Metaverse and MH by the ethical issues. The beta value shows the 223 nurses. The p value of the Table 10 shows the significance of
strength of the relationship and how much the Metaverse impacts the relationships. The threshold value for this is 0.05 or less. Table
mental health. 10 shows no statistically significant difference in responses
H6: The results show against evidence in support of H5 that between the gender (either males or females) and profession
there is no mediating influence of healthcare between the (either doctors or nurses).
Metaverse and MH with a Beta value of −0.017, a T-statistic
0.99, and a p-value of 0.322. The threshold value for the Discussion
significance of a relationship based on the mediation relationship The study investigates the impact of the Metaverse technology on
is the p value, which must be 0.05 or less and the t-value is 1.96 or the MH, considering the ethical issues and healthcare as med-
above. These values show an insignificant mediation between the iating factors in the healthcare industry of Pakistan, China, and
Metaverse and MH by the ethical issues. Saudi Arabia. The first hypothetical argument claims that the
Metaverse significantly impacts healthcare. The findings of this
study support this argument (β = 0.320, p < 0.05). If we look at
Model fitness. Once the reliability and validity of the measure-
the prior research, we also see the same pattern where the
ment model are confirmed, the structural model fitness must be
researchers have tested the same argument in a different context
measured. For the model fitness, several measures are available in
(Sun et al. 2022) (Bhugaonkar et al. 2022). The second hypo-
the SmartPLS, like SRMR, Chi-square, NFI, etc., but most of the
thetical argument claims that the Metaverse in the healthcare
researcher recommends the SRMR for the model fitness in the
industry will lead to different ethical issues. The results of this
PLS-SEM. When applying PLS-SEM, a value less than 0.08 is
study also support this argument (β = 0.484, p < 0.05). If we look
generally considered a good fit (Hu and Bentler, 1998). Table 7
at the prior research, the same pattern of findings exists. Even
shows that the SRMR value is 0.06, less than the threshold value
ethics means different in different cultures. Still, it prevails as a
of 0.08, indicating the model’s fitness.
significant cause for people to avoid healthcare facilities based on
the Metaverse technology (Grote and Berens, 2020). The third
R square. Table 8 shows the value of the coefficient of the hypothetical argument claims that ethical issues will lead to MH
determination of the model of study, which describes the per- problems. The findings of this study support the argument that
centage of the variation in the dependent variable due to inde- ethical concerns will lead to MH issues (β = 0.383, p < 0.05).
pendent variables. For the primary data analysis, even an R According to several researchers, ethics always remains a problem
square value equal to 0.1 or greater is considered a good coeffi- in healthcare. It is not only limited to digital healthcare but also a
cient of determination. Table 8 shows that MH has an R square challenge faced by the physical healthcare system (Bucci et al.
value of 0.132, which shows that 13.2% of the variation in MH is 2019). The fourth hypothetical argument claims that healthcare
due to the model’s independent variables. access significantly impacts people’s MH. The findings of this
study in the context of Pakistan, China, and Saudi Arabia do not
support this argument (β = −0.053, p > 0.05). Still, according to
Predictive relevance of the model. Table 8 also shows the pre- many other researchers, this remains a problem for people’s MH.
dictive power of the model of the study. A model is considered This may be due to culture or the acceptance of the new tech-
good for predicting social sciences based on primary data if its nology because people resist new technologies and their appli-
predictive relevance value is greater than zero. Table 8 shows the cations (Marx, 1998) even if the new technology is more reliable
MH having a predictive power of 0.058, which shows that the and economical (Ratten, 2020).

Table 8 R Square and Q Square.
R Square R Square Adjusted SSO SSE Q² (=1-SSE/SSO)

Ethical issues of MV 0.234 0.232 1568 1310.053 0.165
Healthcare 0.102 0.1 1568 1478.693 0.057
Mental health 0.132 0.128 2352 2215.52 0.058
Table 9 IPMA Matrix.

increasing the timeliness of treatment (Vismara et al. 2012). In
short, the Metaverse will take mental healthcare to the next level
through high-speed internet, applications, AR, VR, MR, etc. It
Importance Performances
should be welcomed by addressing ethical concerns, digital
Ethical issues of MV 0.536 72.438 divide, interconnectivity, availability, and convergence.
Healthcare −0.086 77.808
Metaverse 0.237 67.496
Theoretical implications. The results provide credence to the
framework that tested the relationships among the Metaverse,
The study’s model proposes mediation relationships. First, with ethics, healthcare, and MH. It advances the understanding by
the introduction of the Metaverse in the healthcare sector, various stressing the influence of the Metaverse on moral, ethical, and
ethical issues will arise, ultimately impacting healthcare profes- healthcare concerns and their influence on MH in the
sionals’ mental health (MH). The study’s findings also support virtual world.
this (β = 0.185 and a p value = 0.000). Previous research supports
this hypothesis, revealing consistent findings in the empirical Managerial implications.
analyses of researchers like Dwivedi et al. (2023). Second, the
study explores the idea that healthcare itself could mediate the 1. The study suggests that using the Metaverse in mental
impact of the Metaverse on people’s MH. Surprisingly, the results healthcare is crucial. Healthcare organizations should use
do not support this hypothesis (β = −0.017, a p value = 0.322). the Metaverse’s technologies, such as virtual reality therapy,
Past research, represented by studies such as Michie and West remote healthcare delivery, etc., for improved healthcare.
(2004), has shown mixed findings, with some aligning with our 2. Strong ethical rules must be developed and implemented
results and others presenting opposite conclusions. This is sur- due to the Metaverse’s enormous impact on ethical
prising and noteworthy because it goes against the consensus of concerns.
the present understanding regarding how healthcare affects 3. Organizations should prioritize the Metaverse’s MH
mental health problems in an era of modern technologies. It support systems (peer assistance, online counseling services,
indicates that conventional healthcare services do not mediate the and MH resources) because of the relationship between
Metaverse’s impacts on mental health; rather, virtual and ethical concerns and MH.
immersive digital experiences directly impact it. It provides new
directions for future studies to explore the relationships between
advance technologies, healthcare, and MH. Practical implication.
Whether we accept it or not, technology has intensely changed 1. It is necessary to educate and train the users of the
healthcare (Shrestha and Kim, 2019). Some of the contributions Metaverse regarding its impact on MH to ensure its
include introducing new medicines, new ways of treating patients, responsible use, awareness about risks, and support. It is
new operating instruments and theatres, lower costs, addressing important to support the promotion of digital well-being
the problem of distance, and so on (Matricardi et al. 2020). and a healthy balance between virtual and real-life activities.
Fortunately, technology is also assisting in the treatment of MH 2. Ethical concerns should be given priority during the design
problems. Its outcomes will increase further with the adoption of and development of the Metaverse by platform providers
this new technology. Companies like “Brain lab AG, Novarad and developers. Virtual environments will become safer and
Corporation, GE Healthcare, Siemens Healthiness, Meta Plat- more inclusive when privacy features, content control tools,
forms Inc., Nvidia, Microsoft, Roblox, Game Change, VR, AR,” and inclusive features are implemented.
etc., are continuously driving this shift for improvement (Pillai 3. Collaboration among technological professionals and
and Mathew, 2019). healthcare practitioners is essential. To develop and
A significant section of the public is unable to receive treatment incorporate virtual reality-based therapies into healthcare
for mental disorders due to financial constraints, long wait times, practices, healthcare professionals and technology experts
lack of professionals and healthcare facilities, burden on doctors, should work together. This partnership will result in
and other factors. The Metaverse could treat and minimize these ground-breaking innovations for improving MH assistance
concerns (Corrigan et al. 2014). Telehealth, VR, AR, MR, etc., will in online settings.
provide an environment that could assist MH patients. Lone-
liness, anxiety, depression, etc., could be lessened with the help of
the Metaverse (Dwivedi et al. 2023). Specialists of various kinds Conclusion
could be approached remotely, and mental disorders could be The study investigated the complex relationship of the Metaverse,
treated effectively (Mohr et al. 2013). More options could be healthcare, ethical issues, and MH. The study found positive
available for patients to get a doctor of their choice and avail relationships between the Metaverse and healthcare, the Meta-
themselves of more personalized therapy and treatment. Patients verse, and ethical issues. This highlights the importance and need
and the general public should also be monitored and directed 24/ for incorporating ethics into the Metaverse healthcare services.
7 by digital healthcare assistants in the Metaverse (Ghazal et al. However, the assumed relationship between healthcare and MH
2021). Their data and readings could be recorded through various was not supported, underlining the importance of a compre-
applications and shared at the right time with their therapist, hensive approach to MH treatments beyond digital technology.

Table 10 MGA Analysis.
Beta (Male-Female) p value Beta (Nurses-Doctor) p value

Ethical issues of MV -> Mental health 0.037 0.671 −0.038 0.677
HC/MH/EI -> Mental health −0.043 0.682 0.077 0.452
Healthcare -> Mental health −0.062 0.594 0.026 0.813
Metaverse -> Ethical issues of MV 0.065 0.499 −0.089 0.360
Metaverse -> Healthcare 0.104 0.241 −0.033 0.721
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Wang Y, Zhao J (2022) Mobile Edge Computing, Metaverse, 6G Wireless Com- Competing interests
munications, Artificial Intelligence, and Blockchain: Survey and Their Con- The authors declare no competing interests.
vergence. 2022 IEEE 8th World Forum on Internet of Things (WF-IoT), 1–8.
https://doi.org/10.1109/WF-IoT54382.2022.10152245
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Ethical approval
The research ethics committee examined, approved and endorsed the evaluation survey
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Investigating the mediating role of ethical issues

Cyberjaya, Malaysia. ✉email: [email protected]; [email protected]

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Table 1 Research instrument.

Metaverse MV1 I enjoy my experience with Metaverse.

Table 2 Respondent demography.

Gender Numbers Percentage

Country in Serving Numbers Percentage

Profession Numbers Percentage

measure for the discriminant validity of a structural equation

Regression analysis. Table 6 shows the regression analysis of the

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Table 6 Hypothesis Testing.

Beta T state P values Remarks

model has 5.8% prediction power if the same model is applied in

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Table 8 R Square and Q Square.

R Square R Square Adjusted SSO SSE Q² (=1-SSE/SSO)

Table 9 IPMA Matrix.

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Table 10 MGA Analysis.

Beta (Male-Female) p value Beta (Nurses-Doctor) p value

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