Introduction
Schizophrenia is regarded as being one of the most serious of all psychiatric illnesses [
1], and affects about 1% of the general population around the world [
2]. According to the Global Burden of Disease Study, as of 2019, there were approximately 5.5 million individuals with schizophrenia in China, ranking first in the world [
3]. As early as 2011, The National Severe Mental Disorder Information Surveillance System was put into operation in our country. The official system proposes relevant policy by aggregating and analyzing the data reported by provinces and municipalities, and not provide for individuals with the health care services [
4]. Almost patients with schizophrenia experience numerous relapses and ongoing impairment [
5]. Obviously, patients with schizophrenia need lifelong health care services, such as reminders to take medication, sleep and diet guidance, knowledge of illness, management of psychiatric symptoms, and rehabilitation training [
6]. Hence, continuous health care services are of the highest importance.
To ensure that health care services are not interrupted or hindered by external factors, the telemedicine provide more opportunities for health care services [
7] and has enabled new and various ways of delivering health care services via mobile health (mHealth) systems [
8], such as WeChat, QQ, Email, Facebook, What’s app, YouTube, text messaging, telephone, virtual reality (VR) systems [
9‐
12]. Telemedicine can provide many advantages compared to the standard ways (community health center and home visit), includes accessibility, portability, as well as unconstrained by time, distance, and place [
13]. Surprisingly enough, documents revealed that caregivers of patients with schizophrenia still showed a higher endorsement rate for hospital-based family intervention than WeChat-based family intervention [
10]. Meanwhile, a study showed that over half of the patients with schizophrenia were not willing to participate in WeChat-based mHealth programs [
14].
This has generated considerable interest in how to choose the preferred health care services for patients with schizophrenia. Neither according to the tendency of the popular or only based on the available resources of the implementation of the health care services, nor taking the perspectives of merely clinicians and caregivers of patients, which seems to be unfeasible. Patients with schizophrenia, presented with a variety of typical symptoms, including delusions, hallucinations, social withdrawal, affective blunting, and cognitive impairment [
1,
15], choosing the preferred delivery way for patients with schizophrenia is the first prerequisite for long-term health care services. Some researchers have pointed out that the current health care of patients with schizophrenia, mainly from the preferences of the clinicians or the caregivers, is considerably lack of personalization and often stereotyped, not evidence-based and not targeted to the specific preference of the patients with schizophrenia [
16]. So, the investigation of patients’ preferences is the first and key step for the development of mental health care systems, as well as the basis of planning mental health interventions, and is a fundamental input to form the care services [
17].
However, the vast majority of studies are according to the suggestions of previous studies to implement a randomized controlled intervention trials without a survey process. It remains unclear the preferences of patients with schizophrenia regarding the telemedicine and standard health care services in china. Consequently, the main aim of our study is investigated the preferences of patients with schizophrenia with respect to the telemedicine and standard health care services, when they living in home. According to the cross-sectional data, comparing the advantages and disadvantages of the telemedicine and standard health care services and analyzing the correlate impact factors.
Discussion
To the best of our knowledge, it is the first study to investigate the preferences of patients with schizophrenia regarding the telemedicine (WeChat, telephone, and Email) and the standard health care services (community health center and home visit), compare the advantages and disadvantages among those, and finally analyze the associated impact factors. A relatively high proportion of patients with schizophrenia would be interested in WeChat, while only the fewest chose Email obtaining the health care services. Telephone was acceptable, there are still many participants preferred it. For the standard ways, in terms of the community health center and home visit, very small number of patients with schizophrenia chose them. There are so many associated factors affected the patients with schizophrenia to choose their favorite delivery way of health care services, of which the age, gender, employment, residence, and duration of illness were the independent impact factors.
One major finding is that a higher percentage of individuals endorsed the WeChat-based health care services than telephone-based health care services, especially for younger, with employed, living in urban, and with the shorter course of illness. WeChat is widely used in China, with 1.13 billion monthly global active users [
25]. WeChat can be used as an indispensable, typical, mature and super app of the telemedicine, including but not limited to the online consultation, patient group management and live patient education [
26]. The potential benefit of it is the scalability for delivering services to more patients in China, coping the shortages in professional mental health staff [
27]. The WeChat could be committed to deliver high-quality health care services, decrease loss of follow-up, improve the medication adherence, reduce disease symptoms, improve quality of life, meanwhile, relieve the financial burden (e.g. hypertension, diabetes, coronary heart disease, schizophrenia, cancer, and depression) [
27‐
31].
However, there are also limitations and barriers to the wider usage of WeChat. The young people are usually good at the electronic device in the internet than the older; in general, it’s difficult to adapt and master how to use the internet for the latter [
32]. The unemployed may be less access to pay for a smartphone with a poor economic capability. Nevertheless, broadband is an important infrastructure construction project in China in recent years, because of scattered residences and relatively low household consumption ability, by the end of 2021, 57.6% of people in rural areas were using the internet, compared to 81.3% of people in urban areas [
27,
33]. That will result in the unsuitability of the WeChat-based health care services in remote village. The complex function of WeChat requires the patients with schizophrenia own a better recognitive ability, as well as a short course of illness. With development of the telemedicine, the privacy and security issues has become one of the significant concerns. The WeChat obtain so much personal information data of patients with schizophrenia, such as picture, video and text. That need be management safely and prevented a malicious disclosure of personal information [
34].
That is no doubt that the rapid development of contemporary electronic device, the patients with schizophrenia have more choice for their favorite ways of health care services, The WeChat is only the one of hundreds of apps [
35]. Based on the preferences of patients with schizophrenia to choose the most suitable one. Naturally, our study found that the latest is not necessarily the best for everyone.
Even though WeChat-based health care services are the most popular, telephone-based health care services still come in second place and cannot be ignored, which has a long history of implementation with rich experiences and successful cases being reported and shared by numerous previous studies [
36‐
38]. The telephone-based health care serves are delivered by phone call and text message. The advantage compared to the WeChat is the participants do not necessarily both with smartphones and a wireless network. Thus, it is friendly to people who live in rural and remote communities. However, the disadvantages are also obvious, the communication content is conservative. So, the telephone is recommended more suitable to be combined with community health center and home visits to integrate a variety of health care services for patients with schizophrenia.
The current study observed that the individuals showed a less preferences to use Email-based health care services or home-visit-based health care services. When we conducted the investigation, many patients with schizophrenia were not familiar with Email or had not even heard of it, which may possibly attribute to the reason that Email is mainly used for formal affairs such as work and study, as well as among the users with a relatively higher education and income [
39]. Alongside the widely used of WeChat in work environments, the rate of usage has a decrease tendency [
40]. Although, the usage of email is wide and general in US, Hong Kong and Singapore owing to highly privacy and security [
41,
42], and have demonstrated that email can increase the quality and efficiency of the health care services [
43]. The Email remained underutilized in china, with an underlying value to be developed. Therefore, more research is needed to explore its development approach in the Chinese context.
Concerning the home visit, the survey concluded that only the older accepted the home visit- health care services, and few younger showed a preference for it. There are overriding reason here, the stigma of schizophrenia from the patient’s perspective, which severely affects their socialization, such as making friends, learning, and job hunting. On account of a psychiatrist comes to the patients with schizophrenia home for a follow-up visit, it means telling everyone surround that he is a maniac. The increasing evidence demonstrated that patients with schizophrenia are at high risk of suffering and internalizing stigma, which leads to self-discrimination, self-imposed isolation, and strengthening social withdrawal [
44‐
47]. Therefore, an essential issue is to reduce the prejudice of the public towards them, that needs to educate the public widely about the concept of schizophrenia. Simultaneously, from the perspective of the psychiatric medical staff, it is difficult to carry out home-visit services, limited the severe lack of mental health care resources [
48]. Apparently, the advantages of the home-visit, the patients with schizophrenia and caregivers can meet face-to-face, which facilitates accurate assessment of rehabilitation outcomes. The caregivers can get a realistic picture of the patient’s living environment and provide a practical basis for the development of rehabilitation program [
49]. Thus, action is needed by official organizations such as the Centers for Disease Control and Prevention (CDC), to implement strategies that can guarantee the sufficient medical supplies and personnel, which can minimize the effect of those factors to provide the continuous health care services for patients with schizophrenia smoothly [
50].
The study presented a significant difference in the attitude towards the community health center-based health care services between the patients with schizophrenia living in rural and urban areas. That may be related to there is no health care service for the remote rural population. The United Nations International Labour Organization reported that “while 56% of the global rural population lacks health coverage, only 22% of the urban population is not covered,” further compounded by rural health work-force shortages resulting in a lack of access to urgently needed care for half the global rural population [
51]. The most advantages of the community health center are alleviating the financial burden, some regular medicines are free of charge [
4]. However, the national severe mental disorder information surveillance system revealed that the patients with severe mental disorders did not receive professional therapy or were not treated very well in the community health center [
52]. The main reasons are summarized as follows: (a) The inherent complexity and intractability of schizophrenia, as well as the characteristic psychotic symptoms, are extremely different from usual chronic disease such as hypertension and diabetes; (b) In addition to conventional antipsychotic medication, professional psychosocial, cognitive, and behavioral interventions or therapy, as well as social-vocational training are in demand. Those call for numerous personnel, material, and financial resources; (c) Stigma and discrimination coming from the public and even health professionals prevent patients when the patients with schizophrenia seek professional medical assistant [
53]. Although, health professionals are medically trained, they are prone to hold negative attitudes and label patients with schizophrenia [
54]. Analyzed the current state of the community health center has turned our perceptions upside down. Despite the long development and abundant experience of it, there are still many dilemmas and unsatisfactory results. Although, with so many difficulties, we still should be committed to all patients with schizophrenia access to the health care services. So, when we revealed the strengths and weaknesses of each way, followed the preferences of the patients with schizophrenia. We can combine a variety of ways to deliver the health care services and alleviate the gap among these.
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