JMIR Publications

ABSTRACT

Background:

Timely medical follow-up after a diagnosis of cognitive impairment, such as mild cognitive impairment (MCI) or dementia, is imperative for initiating appropriate medical treatment and accessing comprehensive care management and psychosocial support. However, many community-dwelling older adults who receive a positive case-finding result default on their medical follow-up appointments. This persistent challenge undermines the potential benefits of early detection and active case-finding efforts, with far-reaching consequences including an increased risk of early institutionalization in long-term care facilities.

Objective:

This qualitative study aimed to explore the barriers and facilitators influencing medical help-seeking behaviour among community-dwelling individuals in Singapore diagnosed with MCI or dementia following a positive case-finding result. The COM-B (Capability, Opportunity, Motivation-Behaviour) framework of the Behaviour Change Wheel (BCW) was used to systematically identify these determinants.

Methods:

Using maximum variation sampling based on age, gender, ethnicity, living arrangement, relationship with caregiver, prior memory concerns, and whether participants had sought medical follow-up after their cognitive impairment diagnosis, we conducted 21 unique household semi-structured interviews with 26 individuals (comprising 5 participant-caregiver dyads, 6 participants diagnosed with MCI, 1 caregiver of a participant with MCI, and 9 caregivers of participants diagnosed with dementia). These participants were a subset of individuals and caregivers recruited from a community-based study validating an AI-based dementia case-finding tool. Interviews were audio-recorded, transcribed verbatim, and analyzed using framework analysis method. Two authors performed inductive coding before mapping to the COM-B framework, with subsequent discussion and review by the remaining authors. The COM-B components informed the selection of the relevant intervention functions from the BCW.

Results:

Barriers to medical help-seeking behaviour after cognitive impairment diagnosis included physical impairments, low health literacy to navigate the healthcare processes, inaccurate disease knowledge, complicated healthcare processes, inadequate physical infrastructure to navigate healthcare organizations, oversimplified cultural representation of dementia, perceived inaccuracy of the case-finding tool, and lay beliefs about seeking medical care when sick. Facilitators included adopting strategies to track medical appointments, a case-finding result letter as a cue for action, caregivers with pro-family workplace policies, and valuing proactive medical disease management. Notably, social capital, (in)ability to recognize symptoms, and strong affective states triggered by the case-finding results were both barriers and enablers.

Conclusions:

These findings highlight a complex interplay of individual, social, and structural determinants influencing medical help-seeking behaviour following a cognitive impairment diagnosis. Rather than a linear trajectory, help-seeking is shaped by a dynamic interplay across the COM-B domains. Drawing on these findings, we developed a set of comprehensive and actionable recommendations grounded in the BCW intervention functions to support timely medical follow-up after a cognitive impairment diagnosis. To maximize their impact, these recommendations should be collaboratively refined and evaluated with stakeholders using the Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity criteria.