Intervening at an early stage of psychosis improves the chances of recovery from first-episode psychosis. However, people who are experiencing distress and early psychotic symptoms generally seem to delay seeking help. Therefore, multifaced information campaigns targeting help-seeking behavior of potential patients and their network are considered important tools within early detection and intervention strategies. In this study, we aimed to explore which discursive meaning content, including roles and actors, such information campaigns build on and construct. Our intention was not to provide objective answers, but to contribute to a discursive debate about potential conflicts in messages conveyed in such campaigns.A broad sample of information material utilized by TIPS Stavanger University Hospital (Norway) was examined. The material consisted of posters, booklets and brochures, newspaper ads, Facebook ads, and TIPS Info’s website, representing various campaigns from 1996 to April 2018. A narrative discursive approach was applied at an epistemological level. At a practical level, a team-based thematic analysis was utilized to identify patterns across data.Diversity and several changes in strategy were recognized throughout the information material. Furthermore, three main themes and four subthemes were found to constitute the meaning content built in the information campaigns: knowledge is key;  an illness among illnesses; and we all have a responsibility .Our findings pointed to common dilemmas in mental health services: How to combine professional expert knowledge with collaborative practices that emphasize shared decision-making and active roles on behalf of patients? How to combine a focus on symptoms and illness and simultaneously express the importance of addressing patients’ recourses? And how can we ask for societal responsibility in help-seeking when professionals are placed in expert positions which may not be optimal for dialogue with potential patients or their network? We discuss whether highlighting practices with more weight on resources and active roles for patients and their surroundings in information campaigns could promote earlier help-seeking.The online version of this article (10.1186/s13033-019-0289-4) contains supplementary material, which is available to authorized users. Psychotic symptoms may include delusions, hallucinations  and disorganized cognition . PsychosResearch has revealed that people may experience longer trajectories of subjective distress than what was emphasized in the focus on DUP . A recenOne explanation for the treatment delay may be that early signs of psychosis, such as social withdrawal, anxiety, sleep difficulties, concentration and memory problems, partly overlap with natural challenges in youth and symptoms of other mental health problems . There iAt the same time, there are clearly challenges related to the implementation of ED and information campaigns. For example, psychosis is not a straightforward concept. In fact, scientists do not yet fully understand the nature of this condition. It is still debated what role different factors such as biological, psychological and social aspects play . As a coTo explore the research questions we examined all the information material utilized by TIPS Stavanger University Hospital (Norway) from 1996 to April 2018. TIPS Stavanger is particularly interesting as their program is one of the most comprehensive interventions internationally, providing a broad and diverse spectrum of material to select from. They have also documented significant reduction in DUP, and explicitly and systematically used information campaigns in this work , 23.The present article is a composite of interrelated methodological and theoretical approaches. On an epistemological level, we used a discursive –29 and nWe chose thematic analysis  as the pTIPS in Stavanger, Rogaland (Norway) started their work in 1996 and was initially designed to test whether early timing of treatment could improve trajectories in first-episode psychosis . The ED http://www.tips-info.com), posters, booklets and brochures  developed and used by TIPS from when they started their work in 1996 up until April 2018. The data was collected by the first author (H.H.) in collaboration with TIPS, Stavanger University Hospital. First, we arranged a meeting between J.O.J. and S.D. from TIPS Stavanger and H.H. to get an overview of the potential data material. TIPS provided both physical ads and posters, in addition to a data file containing relevant information material from their campaigns. Second, H.H. collected digital data through TIPS Info’s Facebook site (available from 2009 to 2018) and website. The complete data material was then checked by three of the authors, H.H., S.H.S., and M.V., for the following inclusion criteria: The data material had to (a) be directed at early detection/intervention in relation to first-episode psychosis (text and/or picture), (b) be marked with TIPS Stavanger’s logo and (c) be TIPS Stavanger’s  material. To avoid considerable incongruity in the material, we excluded longer texts, such as newspaper articles and radio- and video clips from TIPS Stavanger. Links to other Facebook pages , courses, conferences or other institutions’ information posted on TIPS’ Facebook page were also excluded. The included data material was thereafter sent to J.O.J. and S.D. to assess whether it reflected the diversity and nuances in TIPS’ information campaigns. The final data material consisted of a total of 149 pages (collected between January and April 2018) representing various campaigns from 1996 to 2018.The data material consisted of all newspaper and Facebook ads, TIPS Info’s website  were telling about the data. The outcome of our analysis was three main themes and four subthemes which we saw as central meaning patterns in the information material. Yet, in discursive and interpretative approaches, many additional questions can be asked. Analysis is therefore never regarded as exhaustive  face on will most easily put them behind them” (1998). The text in the ad continued: “Rarely will the person who is struggling with mental health problems be able to contact a doctor. Most of the time it is relatives, friends or coworkers who have to do it” and “You can get help in order to help”.Another variation we discovered in the data material was that in the beginning (1996–1997) ads started out with an open invitation to contact the early detection team independent of their degree of concern. In time, the ads communicated a slightly more restrictive service—meaning that people should contact them according to the supposed degree of risk. For example, in several Facebook ads (2017) as well as the website (2018) three levels of danger were utilized: green, yellow and red—representing the severity of signs/symptoms. In addition, the later ads (approximately from 2009 to April 2018) also seemed less authoritative than the early ones, as they often used a more suggestive tone, e.g. “If you’re worried about yourself or someone else you can call TIPS” (2017).mental illness, serious mental illness and psychosis were utilized. In many ads, mental illness was used in the heading followed by a description of psychosis in the text. In some ads, both mental illness and serious mental illness were applied, while in others the term psychosis was used alone.Moreover, we found diversity in the way the concepts Three core categories, or themes, emerged when analyzing this diverse and dynamically changing pool of data for thematic content across ads, across time periods and across target groups. Here, a theme is understood as a basic pattern of communication across contexts. In the following, we present and detail the thematic structure that resulted from the outsiders’ analyses.Throughout the information material, knowledge was presented as key to increasing public awareness and altering help-seeking behavior. It was communicated that the content provided in the information material may assist people in understanding what is going on. For example, one ad said: “Read and become wiser…” (1997). As such, knowledge was presented as something that professionals within the mental health services hold. This is also illustrated through a quotation from one of the ads: “Experienced professionals will tell you what you should do, how you can move forward to figure out the situation and how you can get the right treatment or assessment if that’s necessary” (1999). This knowledge was often depicted as specific and objective. An example from one brochure pointed out: “Good treatment is based on solid knowledge and not just viewpoints and ideological beliefs” (1999). In one of the brochures (1999), the right treatment was described as consisting of mainly three parts: consulting a doctor, psychiatrist or psychologist (psychotherapy), combined with family-oriented therapy and medical treatment. At the same time, it was underlined that one type of treatment does not fit all. Hence, treatment has to be individually tailored.Furthermore, it is not sufficient that the mental health system holds knowledge. One of the main messages in the information material was that people who meet persons at risk of developing psychosis should know what to look for. Through the information provided, people were told to attain a position in which they are able to help others, illustrated by the following quotation from one of the ads: “The more you know about them [mental illnesses] the easier it is to help the one affected” (1997). It was communicated that the reason why people do not act, is that they lack or do not have the right knowledge. In consequence, a core challenge is to get the information out to the public. An ad stated that “TIPS has a goal of increasing knowledge about mental illnesses so that more people contact health care services earlier and get treatment before the patient develops a serious psychosis” (1999).Symptoms or signs of psychosis were presented as information that should be an essential part of common knowledge. Almost every ad in the data material listed signs to be aware of. They were presented as early signs of psychosis, serious mental illness (particularly the early ads) and mental health problems, or simply listed without any label. People were told to be alert if a person withdrew from his or her family, friends and colleagues, or if he or she isolated him- or herself. Other signs to look out for were if he or she slept poorly and ate little, stopped taking care of themselves, spoke or wrote about meaningless stuff or expressed inappropriate emotional reactions (e.g. laughing when hearing about sad news). Furthermore, reasons to be on guard included if the person became expressionless or did not react at all, felt persecuted, controlled by voices from outside or believed they had magical capabilities.Symptoms and diagnoses were also presented on Facebook through a Christmas calendar (2016–2017). Each day, knowledge about one mental health issue was presented, starting with milder symptoms at day one, and gradually increasing the level of severity in the signs presented, e.g. day nine presented hallucinations. An excerpt from the accompanying text stated: “Hallucinations are perceptions which aren’t caused by outer sensations”. The calendar ends with psychosis on day 22—followed by early intervention and prognosis on day 23 and 24. The calendar can be interpreted as a gift to the public, comprising of knowledge as well as hope portrayed through the possibility of improving the prognosis through early intervention.In the early ads 1996–1997), knowledge was also seen as key to breaking down old myths about mental health services. References to (and pictures from) the movie “One Flew Over the Cuckoo’s Nest” were, for example, used to illustrate the stigma and myths surrounding mental health institutions. One of the ads expressed: “A lot has happened in treatment of mental illness the last decades, but old myths still endure” (1996) . Occasionally, ads shed light on diagnostic labels, for example “bipolar disorder” or “schizophrenia” (1996–1997). Furthermore, in one of the ads a metaphor of a particular type of cancer, melanoma, was used. This is a type of cancer which the public knew little about and, consequently, many died from. After applying campaigns that raised public awareness of what to look for, experts were able to save many lives because people now sought treatment at an earlier stage. The same rationale seemed to be applied to psychosis, with the exception that the latter is said to be even more difficult to detect. As such, public awareness needs to be raised so that early intervention can be successful.In the same way as with cancer/melanoma, psychosis was seen as developing in stages. One brochure said, “We see the psychosis as a process, where the psychotic breakthrough or breakdown is a stage of the illness’ development” (1999). As such, psychosis appears to be understood as developing from an early sense of anxiety, with a risk of converting to psychosis if not detected and treated at an early stage. Timely intervention can, however, impede this development. For instance, one ad expressed that: “Psychotic episodes can be prevented” (2015). In addition, psychosis was in part described as a breakdown in rationality and meaning, e.g. one of the signs of psychosis listed in the ads was to “talks and writes about meaningless things” (1998).However, some ads had a slightly different twist. Instead of comparing mental and physical illness, overlap between these was highlighted at just one point—the need for early intervention. For instance, one ad showed a picture of a bandaged thumb pointing upwards, followed by the heading: “At one point, mental illnesses are just like other illnesses—when the help is provided early there is a greater chance of getting healthy” (1997) , and the same ad stated: “Still, they’re hard to talk about” (2000–2001), which seems to point to the stronger stigma related to mental illnesses.In addition, it was communicated that psychosis was seen as something other than physical illness, as there is a fine line between psychosis and problematic, yet normal behavior or feelings, e.g. a quote from one ad said: “That teenagers change is natural. When teenagers change noticeably over a short period of time- parents often worry. If teenagers isolate themselves, are silent or seem depressed, it is natural to be on guard” (2012). As such, natural emotions and behavior were expressed as something worrisome if they lasted over a period of time. Accordingly, signs of illness may also be signs of normality, as mental illness is more complicated to uncover than many physical illnesses.A vital message throughout the information material was the importance of reducing the duration of untreated psychosis. Many of the ads emphasized that treatment is often delayed. This was pointed out in the following quotation from one of the ads: “One of the biggest problems in treatment of serious mental illnesses- psychoses-is that the patients come to treatment too late” (1997). As a consequence, we all have a responsibility to detect people with, or at high risk of developing, psychosis, and help them get in contact with mental health services. By doing so, they can receive the treatment they need to get well. In the material, this task was not communicated as a responsibility only for mental health services. Psychosis, or mental illness, was presented as something that concerns everyone. In one of the brochures it said, “All Norwegians know someone with mental health problems” and “Every 15th Norwegian has a serious mental illness” (1998). This underlined a personal as well as a societal responsibility. Both caring for the people who are affected, as well as saving costs for society were presented as justification for the broad approach and its urgency claims. In this line of communication, mental health is not a private issue, it affects us all—mothers, fathers, friends and health workers. Everyone has to play a role to help prevent and alleviate mental health suffering, albeit with different role instructions. The societal responsibility was demonstrated through the next two quotations from one of the ads: “If the sick get help earlier there is a greater chance of getting healthy and they need less time at the hospital” (1998) and “It saves the society money and the affected will have a better life” (1998).In our analysis, we developed four subthemes to summarize how we have a shared responsibility (a) to respond quickly; (b) to step in; (c) to provide an answer and (d) to tag along.It was held forth as a fundamental problem that those it may concern rarely contact the mental health services themselves, e.g. as expressed in the following quotation from one ad: “The person affected is rarely able to contact a doctor themselves. That’s why it’s often someone close to the person who has to do it. That can feel hard and difficult, but it’s important to act quickly” (1998). A perpetuating message was conveyed saying that one should contact early detection services promptly if symptoms or signs of psychosis are observed. For instance, several ads used the sentence: “Seek help as soon as possible, that’s when you have the greatest chance of getting healthy” (1996–1997). The call for instant action underscored that it is possible to prevent, relieve or delay the onset of serious mental disorders, and that early treatment will be more effective.In some ads, psychosis was presented as something that evolves gradually and almost unnoticeable. In a sense, it creeps up on you. As a consequence, the ads tell people to be on guard, and that there is a need for constant vigilance. What might seem like normal behavior does not have to be. This is articulated in one of the ads: “Serious mental illnesses often begin innocently. The person affected acts a little strange, but that can be temporary. It’s the recurrence which signals danger” (1996–1997).Another way of communicating the need to respond quickly is to stress the negative consequences of delayed action. Such effects were illustrated in several ads using metaphors from children’s songs/plays expressing the poor outcomes of late responses, e.g. “Snip, snap, snout, this tale’s told out” (2000). By using single lines from children’s songs literally, and thus juxtaposing mental images of innocent children playing and severe mental health suffering, the ads employed poignant rhetorical strategies toward immediate action. Another example of possible negative consequences if people do not respond quickly can be found in an ad presenting a picture of domino tiles that have begun falling. Once the domino tiles have started to topple over, one thing leads to another in a downward spiral. Both images stressed the need for early detection and treatment, as well as the need for public awareness and response . A central message in the ads is that people have a moral obligation as citizens to step in. This is illustrated through the following quotation from one of the ads: “If you know somebody who is affected by mental health problems, do as you would with other illnesses, contact a doctor, psychologist or the emergency room (ER) if you need advice” (1996–1997).In many ads, this responsibility is more directly placed on people’s close relatives. For example, one ad stated: “This year many will worry about friends and family developing mental health problems… make sure the worry passes as soon as possible (2000). In this way, the commitment to take action is placed on the reader. As such, the messages conveyed through this strategy seem to suggest that one should go further than one ordinarily would with a young adult. One possible implication of this strategy is that many with mental illnesses are unable to take proper care of themselves, needing others to step in and make good choices for them. The legitimization for this breach of autonomy boundaries seems related to the images presented with regard to the roles of the suffering person and the responsible other.Attention seems to be given to the importance of early intervention and that people around should step in, while the person’s own preferences at this stage are secondary. To lower the limit for contacting the services anonymous calls was presented as an option, e.g. from one of the ads: “You can get help in order to help… call TIPS, feel free to do it anonymously…” (1998) . In the same way as with physical illness, mental health professionals seem to be regarded as experts who can provide knowledge. E.g. from one of the brochures: “We have created a brochure which talks about mental illnesses, what it is and how they are treated” (1999). This expert position was particularly emphasized in the early ads (1996–1999), for example it was said that: “… we will give a true picture of today’s options”, or in one of the brochures: “The patients get help quickly and are offered the help that is considered the best” (1999). Moreover, it was expressed that mental health issues can be severe and that people should take them seriously. One of the ads underscored that several hundred people have already called and received help and advice (1998). Accordingly, it was communicated that the early detection and intervention services are successful in their mission and that people can count on them. In some ads and brochures, photos and professional titles seemed to serve as a way of putting a face to mental health workers (1996–1999) . As such, their own interpretations or meaning-making capabilities were toned down, especially in the early ads (1996–1999). The main responsibility of the patient is therefore to go along with the treatment offered by professionals when in crisis and extreme distress, in order to get well and be able to continue on with their lives . If potential patients (or others around them) do not contact the services and tell them about their afflictions, there is, in fact, nothing the mental health services can do. In this way, responsibility was also given to the patient.In some of the later ads, home visits were proposed as an option. Here, mental health services are stepping out of their territory and into the context of people’s everyday life. Moreover, the language seemed less authoritative as the importance of following the professionals’ advice is toned down. A quotation from one of the Facebook ads illustrates this: “If you experience that challenges are larger than what can be solved in a confidential conversation you can ask us for help” (2017).A tentative report of the outsiders’ findings was sent to J.O.J., I.J. and S.D. from TIPS to obtain the insiders´ perspectives and viewpoints on the findings. This provided us with an opportunity to utilize elements of discourse while maintaining multiple perspectives. Involving the researchers from TIPS in this process, helped clarify the intentions behind the data material, and it became clear that the outsiders’ interpretation of the material at times diverged from TIPS’ purpose and plan.For example, the outsiders interpreted the message that psychosis is an illness in line with physical illnesses. However, the insiders wanted to underscore the same need for early intervention in mental illnesses as in physical illnesses. The insiders stressed that they did not have a “strict/traditional bio-medical” understanding, but rather a dimensional understanding of psychosis . They also pointed out that they wanted to tone down the significance of genes or heritage as important causal factors of psychosis.Secondly, the insiders stressed the need to consider the context when understanding the information material. E.g. in relation to the subtheme “to respond quickly”, they underscored that the mental health system in 1996/1997, before TIPS initiated low threshold and easy access, had been less accessible to people. Therefore, it was vital to change people’s attitudes towards the system by pointing out that they were welcome to seek help—which was a totally new signal from the mental health services at that time. They further pointed out that the outsiders’ understanding about negative consequences (e.g. domino) of not responding promptly differed from the insiders’ conception of psychosis as gradually developing in stages—and intervention could hinder worsening at any stage—not just the first. It should also be noted that at that time, psychosis (schizophrenia) was seen as an illness without hope of recovery.A third remark was related to the subtheme “To step in”. The insiders pointed out that sometimes people lacked insight into their own condition/situation, meaning it could be unethical not to act against someone’s will. Finally, the outsiders’ depiction of mental health professionals’ expert position in the subtheme “To provide an answer” was incongruent with the insiders’ aspiration to convey hope and readiness to help.In this study, we studied a broad sample of TIPS Stavanger’s information campaigns, ranging over a period of 22 years, to explore the meaning content, roles and actors built into information campaigns targeting help-seeking in first episode psychosis. Our analysis resulted in three main themes: (1) Knowledge is key, (2) (Almost) an illness among illnesses, and (3) We all have a responsibility, with the last theme comprising four subthemes: (a) to respond quickly , (b) to step in , to provide an answer , and, to tag along (patients). Our findings and research process shed light on several conflicts within the data material, and the significance of perspective and context for understanding and interpretation. We believe these tensions represent common dilemmas in the broader field of mental health. On the one side, mental health professionals clearly hold important expert knowledge that needs to be put to use for the benefit of people suffering from psychosis. At the same time, the mental health system aims to develop collaborative practices that involve more egalitarian services . How theED services represent an important step forward when it comes to providing prompt care for people who experience first-episode psychosis . ED servHowever, the dilemma we face in providing this kind of information as part of ED efforts is that it rests on an underlying assumption that potentially contradicts the competing interest of user involvement and collaborative practice. If information is the answer, lack of information or adequate knowledge  must be the problem. Adequate knowledge in this regard, seems to be understood as professional, evidence-based knowledge. As such, experience-based knowledge held by people with lived experiences of mental health issues is not presented as an important part. For information to be effective in altering help-seeking behavior, health care workers then must construct an expert position—as providers of answers/solutions through their professional knowledge . Although the expert positioning was toned down in the later ads, our findings show that primacy was given to focusing on signs and symptoms, based on professional knowledge, indicating the recipients’ need for specific action (help-seeking). This way of providing information may enable people to make more rational choices about their health. Yet, a dilemma still emerges between how to express professional knowledge from such a position and simultaneously convey a belief in the importance of people having faith that they will be able to handle their own lives.Moreover, by utilizing such a strategy actors involved are assigned rather distinct roles. In discursive approaches, roles can be understood as constructed through language and social interaction . We haveThese positions may partly be understood in light of the traditional understanding within mental health services, that psychotic patients often lack insight into their illness . ResearcHowever, new role constellations which embrace both professional and lived experience knowledge are emerging within mental health services. Collaborative practices which emphasize shared decision-making and focus on individual’s goals and life circumstances have shown promising outcomes for engagement, particularly for groups such as young adults with first-episode psychosis . ImplemeAnother dilemma following the provision of evidence-based knowledge about psychosis is how to express clear messages about the nature of psychosis when several different ways of understanding and explanatory models exist side by side. In fact, the understanding of psychosis ranges from psychosis as a chemical imbalance or brain disease to psychosocial explanation models, emphasizing the role of contextual factors such as stress, trauma, poverty, racism, sexism, etc. . AccordiMoreover, applying an illness-focus in information campaigns can be understood as placing the patient in a ‘sick’ role, which does not acquire much effort from the patient. Thus, the patient’s own actions are not regarded as an important part of treatment beyond seeking help. As pointed out under ‘Insiders reflection on the findings’, this understanding was not in line with what the insiders intended to convey. The insiders did not intend to base their description of psychosis on a medical understanding. Their intention had been to stress similarity to physical illnesses at just one point, namely—the same need for early interventions. However, the outsiders understood the illness-focus to be more pervasive. As a consequence of comparing psychosis with illness, passive roles risked being established on behalf of patients. As pointed out in the sub-theme “to tag along”, the patient’s main task then is to follow expert advice. This message does not match the knowledge we have of lived experiences of people with first-episode psychosis who were in contact with ED services which stressed the significance of self-efficacy .In addition, our findings showed that psychosis can also be communicated as something dissimilar to physical illnesses. Psychosis was for example portrayed as a process that develops in stages. As such, the underlying understanding seems to be that psychosis is a result of several factors —the amount of stressors combined with the individual’s vulnerability (stress-vulnerability model) causes development of psychosis, or for some very few, a psychotic disorder . By portThis latter way to convey psychosis, points to more active roles for potential patients, which may be a more befitting way to present psychosis in information campaigns than focusing heavily on signs and symptoms. As such, there might be something to learn from approaches which put patients in more assertive roles, such as e.g. peer support. Peer support is generally described as a model for promoting wellness, focusing on strengths and positive aspects of people as opposed to an illness model focusing on symptoms and problems , 62. PeeIn the theme “we all have a responsibility”, the outsiders in the analytical team found that psychosis was portrayed as something that should not be considered an individual concern alone, thus, the societal responsibility was emphasized. The societal level is not normally a level in which the mental health services operate on, at least not related to treatment of psychosis. By putting psychosis on the agenda, as TIPS did through the multi-targeted information campaigns, the mental health services became a visible actor in the community. The broad strategy was based on studies of available literature at the time they started, and such multi-targeted and repetitive campaigns are still regarded as effective in altering behavior .Moreover, the findings showed that people in general were encouraged to take action as delayed help-seeking is considered a serious problem in treatment for first-episode psychosis. For example, TIPS stated: “We need your help…”. This inviting tone represents something unusual coming from the mental health services, as these services have not traditionally been very assertive in asking for assistance from outsiders. People surrounding the young adults were told to be on alert and ready to step in when a close one or somebody else was in need of help. Hence, the primary roles of people around the one that struggles can be seen as helpers of the mental health system. As such, family members or school teachers, GPs or others who had concerns on behalf of a young adult were asked to step in and contact the services if needed. By applying such an action-focus, TIPS goes further than some of the other mental health information campaigns, e.g. “Depression: Let’s talk” . In addiMore specifically, research shows that families play a vital role in help-seeking related to psychosis –72 Yet, The present study draws on material developed within one program over a period of more than two decades. Thus, a strength is that it sheds light on shifting historical and social perspectives of how to present information for the public.Also, as evident from the divergence in perspectives between the insider and outsider perspectives on the material, a narrative discourse analysis does not establish intentions. Rather, the promise of such methodology is to describe how meaning is created and transported between different actors and roles in a social system, as a basis for constructive discussions. We consider it a strength that we could include both perspectives in the presentation of the findings. The different positions as insiders and outsiders to the data material, provided us with proximity and distance that necessarily impacted the interpretations. However, it also became clear that the perceptions of insiders and outsiders were not always congruent. As such, we tried to make our different positions a transparent discursive element in the discussion.Furthermore, these divergent perceptions underscore that the interpretations made by the analytical team were undoubtedly colored by the lenses of socially oriented researchers with particular interest in collaborative practice. By applying such an interpretative approach based on constructive epistemology, it was not our intention to reveal an objective truth—but to discuss the constructions in light of contextual information about the services.However, a limitation is that we did not have access to any representatives from the information campaigns’ target groups. Another limitation is that most quotes and pictures applied in the themes are retrieved from the early ads and brochures. They were chosen as they were the most distinct examples of the themes we found. It is also a limitation that our sample did not include all the various types of information provided by TIPS, such as radio programs, video clips, or dialogue-based education for youths and meetings with high school counselors, which could have provided a more nuanced picture.This is, to the best of our knowledge, the first study exploring the meaning content in information campaigns related to first-episode psychosis. A broad sample of information material made up the basis for our narrative discourse analysis. We interpreted that three main discourses were built in the material. First, professional knowledge was conveyed as key to promote help-seeking behavior. Second, psychosis was mainly presented within an illness model. Third, psychosis was conveyed as a concern for the wider society. In addition, we focused on the constructed roles and actors that we interpreted these campaigns conveyed. Professionals were usually presented in expert positions, while potential patients seemed to play rather passive roles as receivers of help, people in the surroundings were conveyed as helpers of the mental health system. The positioning of roles pointed to several dilemmas in the mental health services: How can we integrate apparently conflicting views between evidence-based professional knowledge and subjective knowledge obtained through lived experiences? How do we combine a symptom- and illness focus with the expression of belief in the persons own resources? How do we provide knowledge about psychosis when there is no consensus on what it is or what causes it? And, how can we combine the expression of a need for social responsibility with limited role constructions that seem to maintain status quo in the relationship between the mental health services and its surroundings? These are the questions that were raised and discussed based on our findings. We did not intend to provide final answers, but rather contribute to discussion by putting meaning content and discourses on the map. We have, however, tentatively pointed to several ways in which information campaigns within the context of ED services for young adults with first-episode psychosis could be advanced (Additional files Additional file 1: Figure S1. MYTH AND REALITY.Additional file 2: Figure S2. THUMBS UP.Additional file 3: Figure S3. DOMINO.Additional file 4: Figure S4. PHONE.Additional file 5: Figure S5. TIPS TEAMS.Additional file 6: Figure S6. EXPERT AND PATIENT.Additional file 7. Data material part 1. Overview over data used in the analysis.Additional file 8. Data material part 2. Overview over data used in the analysis.


Geriatric syndrome refers to a series of symptoms and observations caused by a variety of factors associated with aging, where the older adults show the treatment consciously or otherwise, and long-term care becomes important at the same time. With respect to geriatric syndrome, often the viewpoint involves the purpose of sustaining the capability for activities of daily living (ADL) and improving the quality of life (QOL), rather than just considering the disease condition according to the diagnostic name.Notably, there are geriatric syndrome symptoms that are more frequent and are largely affected by long-term care, such as, disorders associated with mobility , falls, incontinence, and cognitive impairment. These are considered issues for which early measures should be incorporated into geriatric treatment. In recent years, measures against frailty and sarcopenia, which elevate the risk of increasing the need for long-term care, are being considered important.Frailty progresses as vulnerability to stress increases due to declining physiological reserves with aging, making one prone to unhealthy conditions . It is a“Sarcopenia” is a coined word, where “sarx (sarco)” means muscle and “penia” means “loss and reduction” in Greek, and it was first proposed by Rosenberg in 1989 . OriginaIt has been reported that in frail older adults, exercise intervention is effective in improving physical functions, including gait speed . HoweverResistance training and nutritional (protein) interventions are often selected as measures for prevention and improvement of sarcopenia. In a report on increased muscle mass and muscle strength in older adults, a high load of 70–80% of 1 repetition maximum (RM) was used. However, for older adults without exercise habits, it was reported that even with a load of 40–50% of 1 RM improvement in muscle function can be expected [


Owing to the increase in life expectancy and sickliness, caring for older adults has become a major challenge in China, where the traditional care system is disintegrating and community- and home-based care have been introduced to respond to this ‘silver wave’. However, there is limited knowledge of the dilemmas associated with caring for older adults and the acceptability of community- and home-based care for this population.Participants were recruited from Xihu District, Hangzhou, from June to July 2017. In-depth interviews were conducted using semi-structured questionnaires. Audio recording, verbatim transcription, and thematic analysis were conducted.A total of 64 older adults from four communities were interviewed. Half of the participants had multiple chronic diseases. The very old individuals and those with severe diseases and in poor financial conditions were observed to be struggling the most. Health status, financial capability, and personality were the main factors affecting the care process. Participants cited the following reasons for staying away from nursing homes: misunderstanding, negative environment, a sense of shame, loneliness, and financial limitations. Community- and home-based cares are popular forms of old-age care; however, some participants exhibited a lack of knowledge about such services.A multi-layered old-age care system is urgently needed for older adults in Zhejiang Province. Further, it is important that such a system integrates the care provided through community- and home-based services with that offered by nursing homes. Community- and home-based care for older adults needs to be prioritised, and the quality of care provided in nursing homes should be improved.The online version of this article (10.1186/s12889-019-6637-0) contains supplementary material, which is available to authorized users. China is experiencing rapid and irreversible population ageing. According to a 2018 report published by China’s Civil Affairs, by 2017, the number of older adults aged above 60 years had reached 241 million, accounting for 17.3% of the total population. Further, a study predicted that, by 2030, 65.6% of the Chinese health burden will be caused by older adults, a population with a high incidence of non-communicable diseases [According to China’s social pension system, the government has set up nursing homes to support older adults labelled the ‘Three No’s’, that is, those with no children, no relatives, and no income . Those eThough all older adults in China face this problem, certain differences have been observed between those living in urban and rural areas. For instance, urban and rural older adults are covered by different welfare policies towing to the urban-rural dual structure in China. The majority of urban older adults are covered by the Urban Residents’ Basic Medical Insurance (URBMI), while rural older adults are covered by the New Rural Cooperative Medical System (NCMS). The former provides higher medical reimbursements for in-hospital and outpatient services pertaining to major diseases as compared to the NCMS. A study showed that rural older adults exhibit lower healthcare utilisation rates as compared to their urban counterparts . FurtherUnder these circumstances, we have to answer the following questions. Is it feasible for the younger generation to provide care for older adults when several families have only one adult child? Is a nursing home a good choice for older adults when they are incapable of caring for themselves? Are community- and home-based care good choices for older adults? There is an urgent need to answer these questions in the context of mainland China. Thus, the present study aimed to examine the dilemmas associated with caring for older adults; explore the acceptability of nursing homes and community- and home-based care for older adults; and provide reliable suggestions for policy making.Qualitative interviews were conducted with participants from Hangzhou, Zhejiang Province, China, from 20 June to 28, July 2017. A narrative inquiry was used to guide the interview , while others lived alone. The majority of older adults had retired from their jobs.Only community-dwelling older adults aged over 60 years were interviewed in this study. Before conducting the formal interview, the researcher had an informal conversation with the participants. Those with any type of mental illnesses, who refused to participate, or were unable to communicate normally were excluded. A total of 89 older adults from the four communities participated in this study, and finally, 64 of them completed an in-depth interview conducted using a semi-structured questionnaire Fig. .Fig. 1ThWe first contacted community leaders who were responsible for the daily operations of the home care centres in the community. The leaders facilitated opportunities for the older adults to engage in activities such as dancing, watching TV, chatting, and playing poker (or mahjong). Certain communities also conducted simple blood tests periodically. If any of the older adults living alone are unwell, they can contact the community leader for assistance. As these community leaders were liked and trusted by older adults, we arranged for them to make the necessary introduction. They informed the older adults of our intention and asked them to cooperate with us if they wished to participate in the interview. Finally, oral informed consent was obtained from each interviewee and the researcher conducted the interviews, each lasting for 30 to 60 min.The following methods were used in this study: audio recording (30 participants agreed to the recording), verbatim transcription, and thematic analysis. We attempted to record all interviews; however, 34 interviewees refused to be recorded. For such interviews, we only recorded certain key information quickly in our notes and added more detailed information after the interview.In total, 64 participants aged 60 to 88 years were interviewed. Of them, 43 were female and 21 were male; four (6.25%) were from the Huang gu shan community, 11 (17.19%) from the Ji hong community, 11 (17.19%) from the Lan li community, and 38 (59.38%) from the Zi jin gang community “Health status was a key factor influencing older adults’ lives. Healthy older adults could freely choose to stay at home or nursing homes because they did not need an external support.I have multiple diseases such as cervical spondylopathy, hypertension, chirobrachialgia, and hearing problems.” ““My health is terrible. I have tracheitis, osphyalgia, and heart disease. I have been taking medicine for two years.” I am disabled. She (my wife) helps me do everything because I almost lost my hearing and sight.” “However, the majority of participants, especially the very old individuals, reported having one or multiple diseases, which led to substantial inconvenience. Only 3 (4.69%) older adults were healthy, 27 (42.19%) reported that they were physically healthy in general, 2 (3.13%) had one disease, and 32 (50%) had multiple chronic diseases. These findings imply that the majority of participants, especially those with severe diseases, needed health services and/or daily care “I have multiple chronic diseases, for which I need to take a lot of medication consistently. However, my new rural cooperative health insurance is not applicable here (Hangzhou) and I cannot afford the medicine. So, I asked my son to buy and mail the medicine I need from my hometown, where it is cheaper” “A potential problem for participants with multiple severe chronic diseases was financial pressure. Prices continue to show an upward tendency, and the participants’ real purchasing power is falling. This could affect their use of health and care services. Further, the majority of older adults with poor health reported that they were experiencing pressure. The frail older adults lacking adequate financial capacity were cared for by their spouses. Further, certain participants reported that, to save money, they self-medicated rather than consulting a physician.Eating is difficult because I live alone. My son cooks for me, but he cannot always do it… When I visit a restaurant, I prefer to choose foods that are easy to digest…I know the young people dislike my drawling behaviour...Another big problem for me is transfusion. The hospital is too far away, and I am not good at using smartphone apps to book a taxi.” “I have to take care of my husband, who is completely bedridden. He has not gone downstairs once for the last three years.” “Life is difficult for a lonely old woman. I cannot do anything in daily life. It is difficult to even trim my nails. I experience pain in my legs and hip joint. I have hypertension, breast cancer, and cataract as well. The doctor said I cannot perform any duties…the older I get, the less labour I should be doing.” “The majority of older adults experienced physical deterioration and difficulty in performing daily activities owing to ophthalmic disease, hearing problems, and functional impairment. Certain older adults with multiple chronic diseases experienced difficulties in ‘simple’ activities such as eating, cleaning, and trimming of nails. Further, healthy older adults’ activities were limited to grocery shopping, cooking, washing, and taking care of their grandchildren.It is unrealistic to depend on my son (and daughter-in-law). He already works too hard. His son married a girl who is an only child. My grandson and his wife have to take care of their biological parents and parents-in-law. I do not want to join the ride. My granddaughter-in-law had a baby last year. She has to take care of all of them. Nobody has time to take care of me.” “are too busy. They have to work and take care of their children and grandchildren. Who will care for an old woman like me? ” “Children The majority of older adults needed formal or informal support. The former included care services offered by the government, companies, or non-governmental organisations, while the latter included the care provided by family members, friends, and neighbours. Traditionally, intergenerational care was predominant in the Chinese culture, which is characterised by filial piety. However, the majority of the present participants worried about their livelihood when they were incapable or bedridden, especially owing to the lack of caregivers and financial support.I have to provide accommodation for them (nurses). There is a possibility that we might have different eating habits. What's more, if she bullies me, I would be unable to fight back.” “Some nurses are nice, but some are evil. Last year, my mother got sick in Shenzhen. I hired a nurse to take care of her (because I have to stay in Hangzhou to look after my children). The nurse was crafty. My mother always complained on the phone that the nurse was malicious. I did not believe it until I met her.” “I receive only 1700 CNY retirement pension a month; it would not even cover the cost of a nurse's meals. How could I hire one? ” “I am a common worker. If family members are no more capable of providing informal care to a fragile older adult owing to the lack of energy and time, is there anybody who can replace them? It may be possible to hire a nurse. However, certain older adults refused to use such services citing the following three reasons: difficulty in finding a good nurse, anxiety about being mistreated, and financial limitations.I will go to a good nursing home that I can afford. Children have no time and energy to look after me. It is reassuring to go to a nursing home because they have professional doctors.” “Considering the problems associated with hiring a nurse, is it possible for older adults to live in nursing homes? The present study showed that two determinants, specifically, financial capability and perceptions regarding nursing homes, influenced the older adults’ readiness to go to a nursing home. Those with high financial capacity expressed willingness to live in nursing homes when they were incapacitated because they did not wish to be a burden to their offspring.I will not go to a nursing home. I have children. They should take care of me when I am incapacitated. Only those without a child or those with disobedient children should be sent to a nursing home.” “I will never go to a nursing home. Never.” “Meanwhile, several participants refused to go to a nursing home when they were incapacitated because they saw it as something shameful.I will never go to a nursing home. I visited a retired colleague of mine 10 years ago. All the older adults in the nursing home were cuddled up in a heap (mimicking the action)…I realized that the environment had a negative effect on people's mentality...They were alone…The environment is very important to older adults...My bosom friend was mighty and talkative before he went to that nursing home…Finally, he told me he felt sad and did not want to connect with any acquaintances because he had been abandoned by his children….His children are just too busy actually. The nursing home he stayed at was very upscale. But he still felt sad.” “This revulsion towards nursing homes was observed in both rural and urban older adults. One urban older adult shared an experience and reported the following reasons for his unwillingness to go to a nursing home: negative environment, a sense of shame, and loneliness.I will never go to a nursing home. I have no income (pension) because I am a farmer. Even if my children have money, I do not want to go to a nursing home. I would like to stay in my home.” “I will never go to a nursing home, even a public one. My retirement pension is 2000 CNY per month, and I cannot afford it.” “I visited a nursing home a few days ago. A room for two persons was 7000 CNY per month, and that was just the bunk fee. You have to pay extra for food, nursing care (if you need it) and other services...There are cheap ones too; a room for six persons with one toilet costs 3500 CNY per month. However, that is nonsense. How can so many older adults wait to use a toilet in the morning? And I cannot afford it even that...My husband's care was covered by the government. We could live in a good place without any fee. Now that I am alone, I have to pay for everything.” “Another important reason why older adults refused to go to a nursing home was financial limitations.I know about community- and home-based care, which mainly provides services to unattended older adults. They provide grooming (trimming of nails and massage services) and health services (blood pressure and blood glucose monitoring).” “I know about community- and home-based care. However, I do not care for it. I do not think need such services until I am 80 years old.” “I do not know about community- and home-based care. I have no idea about the future...I just hope I can stay at my home when I am incapable of moving around.” “I do not know about community- and home-based care. I do not know what services they provide to older adults.” “The Hangzhou government has built several community- and home-based care centres  that provide daily services for older adults. However, few older adults were aware of such communities, the community- and home-based care centres need further publicity and development.Summing up the above findings, dilemmas in caring for older adults arise from the gap between what they need  and the actual resources that allow them to access formal and informal support Fig. .Fig. 2Th’ [Half of the older adults participating in this study had multiple diseases. A previous study reported that ‘the relationship between physical function and physical activity is bidirectional’ . The car’  towing t’ . Nowaday’ . Providi’ . The pre’ , which rThe majority of participants did not look forward to relying on the younger generation for several reasons. They clearly realized that the younger generation was under a lot of pressure; they were breadwinners and dared not quit their jobs to look after older adults. In addition, some older adults were unwilling to be a burden to their offspring. These findings suggest the urgent need for developing policies to support family care. Further, older adults are often left with two potential choices in response to this plight: hiring a live-in nurse or living in a nursing home. However, these solutions were only suitable for a few open-minded older adults who were in favourable financial conditions. The majority of the present participants refused both options. Lack of trust in nurses was the primary reason for refusing to hire a live-in nurse. Further, most participants were worried about being abused by nurses, the high costs involved, and differences in lifestyle. They refused to go to a nursing home owing to the sense of shame attached to it, financial limitations, negative environment, and poor services. A previous study found that older adults believed that living in a nursing home reflected that their children are impious . Some weThe present participants expressed a low willingness to stay in nursing homes, which was consistent with the findings of a previous study . In thisHowever, the present study revealed that certain older adults did not know about community- and home-based care. Such services face the dual problem of social resistance and imperfect systems . SpecifiThis study only explored the dilemmas pertaining to old-age care in an ageing society and the related difficulties in Hangzhou. We did not consider other stakeholders’ perspectives, such as those of the younger generation and service providers. In addition, the present results were derived from a small sample because we recruited the participants using non-probability sampling. Therefore, more in-depth research on this topic is recommended.Older adults in Zhejiang faced an unprecedented dilemma related to their retirement pension. A multi-layered ageing service system composed of community- and home-based care, nursing homes, and other new forms of services should be established to meet the various needs of older adults. Only a few older adults in favourable financial conditions could afford to live freely in their own homes by hiring a nurse or living in a nursing home and enjoying high-quality services. Therefore, community- and home-based care should be prioritised to cater to the majority of older adults’ needs.Additional file 1:Semi-structured interview guide. (DOCX 22 kb)