Determinants of Medical Help-Seeking Behavior Following Case Finding of Early Cognitive Impairment: Semistructured...

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 early detection and active case-finding efforts and increases the risk of early institutionalization. Understanding the determinants is important for developing effective interventions in community-based case-finding.

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

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 semistructured interviews with 26 individuals (comprising 5 participant-caregiver dyads of MCI, 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 artificial intelligence (AI)-based dementia case-finding tool. Interviews were audio-recorded, transcribed verbatim, and analyzed using the framework analysis method. Two authors (SRL and XX) performed inductive coding before mapping to COM-B, with subsequent discussion and review by the remaining authors. The COM-B components informed the selection of the relevant intervention functions from the BCW.

Barriers to medical help-seeking behavior after cognitive impairment diagnosis included physical impairments, low health literacy to navigate the health care processes, inaccurate disease knowledge, complicated health care processes, inadequate physical infrastructure to navigate health care 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 profamily 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.

These findings highlight a complex interplay of individual, social, and structural determinants influencing medical help-seeking behavior following a cognitive impairment diagnosis. Rather than a linear trajectory, medical 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 (APEASE) criteria.