Advances in Medicine and Rehabilitation Sciences

INTRODUCTION

Dementia represents one of the most significant public health challenges of the twenty-first century. Currently, more than 55 million people globally are living with the condition, a figure projected to scale dramatically over coming decades due to rapid population ageing (World Health Organisation, 2025). Although age remains the strongest non-modifiable risk factor, dementia is increasingly understood as a condition in which proactive prevention and delay may be possible. The 2024 Lancet Commission on Dementia Prevention, Intervention and Care identified fourteen modifiable life-course risk factors accounting for approximately 45% of dementia cases worldwide [1]. These findings firmly reinforce risk reduction as a critical global health priority (Appendix 1).

Despite this growing epidemiological evidence base, public understanding of dementia risk reduction remains limited and inconsistent. Global systematic data reveals widespread variations in how communities perceive modifiable versus non-modifiable risks, with many individuals continuing to view cognitive decline as an unavoidable consequence of growing old [2]. Consequently, general awareness of modifiable risk factors does not consistently translate into meaningful behavioural change [3]. This gap highlights a fundamental issue in traditional health education: the raw availability of information does not guarantee engagement, interpretation, or behavioural action. Instead, individuals actively construct personal meaning from health information in ways that are deeply shaped by cognitive, social, and environmental factors.

Digital health technologies have significantly expanded opportunities for public health outreach, offering a highly scalable infrastructure to help bridge current prevention gaps for midlife and older adults [4,5]. However, systematic evidence indicates that digital improvements in raw knowledge do not necessarily produce downstream behavioural change, and translation outcomes continue to vary widely across distinct user types and contexts [6,7].

These limitations reflect broader developments in health literacy theory. Nutbeam’s model emphasises that individuals do not passively receive health information but must actively interpret and apply it within their unique lived experience [8]. Similarly, behaviour change theory, particularly the COM-B model, conceptualises behaviour as an interactive product of capability, opportunity, and motivation rather than knowledge exposure alone [9].

Implementation science further demonstrates that educational intervention outcomes are highly context-dependent, while realist evaluation provides a robust explanatory framework for evaluating this real-world variability through Context–Mechanism–Outcome (CMO) configurations [10,11]. Within this theoretical convergence, a key gap remains in explaining how individuals transform digital dementia education into psychological behavioural readiness. This article addresses that gap through a structured programme of conceptual scholarship culminating in an integrated, realist-informed framework (Figure 1).

Background Narrative: The Knowledge-to-Action Gap

Over recent years, a central question has shaped this programme of research: why does greater awareness of dementia risk factors so rarely translate into meaningful behavioural change?

Despite strong epidemiological evidence that many dementia risk factors are modifiable, public understanding remains inconsistent, and uptake of preventive behaviours is limited. While dementia prevention information is increasingly available through public health campaigns and digital platforms, access alone does not appear sufficient to influence behaviour. This observation has guided the comprehensive programme of conceptual scholarship evaluated below, establishing an analytical pipeline moving from information availability to real-world behavioural impact.

Materials and Methods (Conceptual Synthesis Strategy)

The conceptual evidence underpinning this synthesis comprises a cumulative programme of five interconnected publications that progressively developed the theoretical foundations of digital dementia risk-reduction education. Rather than being treated as independent contributions, these publications are synthesised as successive stages in an integrated programme of scholarship culminating in the Realist-Informed Conceptual Framework presented in this paper. The developmental sequence of this programme is illustrated in Appendix 2 (Carey, 2026g). The methodology relies on an integrated synthesis of literature spanning health literacy, behavioural psychology, and implementation science.

Rather than treating these domains as isolated contributions, they are analysed as cumulative stages in the development of an integrated explanatory framework. Table 1 maps this progression, demonstrating how each stage contributed to increasing theoretical refinement. Across this programme, a consistent finding emerged: outcomes are shaped not only by exposure to information but by how individuals engage with, interpret, and apply that information within their personal and social contexts.

Table 1: Conceptual Evolution and Framework Strand Integration

The Integrated Conceptual Framework Architecture

The integrated conceptual framework presented in Figure 1 emerged directly from this synthesis. The synthesis of these five strands culminated in the development of the Realist-Informed Conceptual Framework for Evaluating Digital Dementia Education (presented in Figure 1), bypassing standard linear evaluation structures and positioning digital health education as a complex adaptive intervention whose success depends entirely on context-sensitive mechanism activation. The architecture breaks down the digital public health ecosystem into four core operational dimensions:

• Wider Context & Access Conditions (C): Individual baselines (digital health literacy, cultural backgrounds) and structural boundaries (socioeconomic status, geographic location) that shape how a user approaches a digital resource (Components 1 and 2 of Figure 1).
• The Resource vs. User Engagement (C/O): The simple conversion of Resource Availability into superficial User Engagement (metrics such as logins, attention duration, and click frequencies) as outlined in Component 2 of Figure 1.
• Generative Mechanisms (M): The vital transition from passive user interaction to Interpretative Engagement (Component 3 of Figure 1). This represents the internal cognitive and emotional "sense-making" loop where an individual processes personal relevance and constructs risk perceptions, directly generating Behavioural Readiness (Component 4 of Figure 1: advancements in self-efficacy and an explicit intention to act).

Real-World Outcomes (O): The final translation of psychological readiness into sustained, real-world risk-reduction behaviours (Components 5 and 6 of Figure 1), mediated or moderated by immediate contextual factors like social circles and environmental demands.

Figure 1: Realist-Informed Conceptual Framework for Evaluating Digital Dementia Education

Integrative Explanation of the Research Programme and the Conceptual Foundations

This doctoral research is grounded in a coherent programme of prior conceptual and theoretical work that collectively informs its design, focus, and methodological orientation. Across a series of interrelated publications, the research candidate has developed an integrated body of scholarship examining how dementia-related knowledge is translated into public understanding, how educational interventions are interpreted and engaged with, and why improvements in knowledge do not consistently translate into behavioural change.

To visually map this intellectual progression, the image entitled From Information to Impact illustrates the systematic timeline of the research journey tracing how the initial foundational frameworks iteratively built upon one another to culminate in the proposed realist PhD study.

Conceptual Development Across the Five Papers

The persistent gap between dementia prevention knowledge and behavioural change suggests that existing models of health education are insufficient. While information provision is necessary, it is not sufficient to explain behavioural outcomes. This observation forms the basis for reconceptualising dementia education as a process of engagement and interpretation rather than transmission. This evolutionary process spans five core papers mapped across six progressive structural stages of the research journey:

Stage 1: Dementia Prevention Literacy Framework – Established by Paper 1, which introduced the concept of dementia prevention literacy and identified critical variability in public understanding of modifiable risk factors (Carey, 2026c).

Stage 2: Reconceptualising Dementia Education – Driven by Paper 2, which reframed traditional dementia education as an active process of interpretative engagement, shifting the academic emphasis from linear information delivery to complex meaning-making processes (Carey, 2026b).

Stage 3: Realist Framework for Digital Education – Anchored by Paper 3, which integrated system-level health literacy theory with behaviour change models to conceptualize digital educational platforms as multi-component ecosystems structured through explicit Context-Mechanism-Outcome (CMO) logic (Carey, 2026a).

Stage 4: Integrated Theoretical Synthesis – Formulated in Paper 4, which executed a comparative conceptual analysis to reconcile cross-framework boundaries, unifying the public health literacy landscape with explicit evaluator pipelines (Carey, 2026d).

Stage 5: Synthesis & Operational Design – Developed in Paper 5, which established the methodological blueprint for aligning qualitative sense-making with quantitative platform analytics to track internal user mechanisms empirically (Carey, 2026e).

Stage 6: Doctoral Operationalisation – The practical, real-world culmination of the entire five-paper conceptual architecture, translating the synthesized framework into an active, mixed-methods PhD study evaluating engagement, interpretation, and behavioural readiness among midlife adults aged 40–65 years (Carey, 2026e).

Empirical Operationalisation of the Realist Engine

To ground this theoretical synthesis empirically, the mixed-methods realist design will explicitly evaluate how quantitative data and qualitative insights interact to map Context-Mechanism-Outcome (CMO) configurations:

• Quantitative Strands: System-level user analytics, platform interaction frequencies (Component 2 of Figure 1: User Engagement), and validated digital health literacy scales will be utilized to baseline individual user characteristics (Wider Context) and map structural access boundaries (Access Conditions).
• Qualitative Strands: Longitudinal semi-structured interviews and cognitive mapping protocols will uncover the underlying reasoning, psychological responses, and meaning-making processes triggered within users (Component 3 of Figure 1: Interpretative Engagement and Component 4 of Figure 1: Behavioural Readiness).

Data Analysis and Synthesis Plan (RAMESES II Compliant)

To systematically evaluate how digital dementia risk-reduction education influences user trajectories, data analysis will follow a realist synthesis approach adhering strictly to the RAMESES II reporting standards (Wong et al., 2017). Rather than analysing quantitative and qualitative datasets in isolation, an iterative, retroductive analysis strategy will be employed to identify, test, and refine Context-Mechanism-Outcome (CMO) configurations. The analysis is structured around operationalising the core realist generative equation:

C+M=O

The systemic mapping, data pathways, and convergence points of this mixed-methods architecture are visually structured in Figure 2, which serves as the operational roadmap for the analytical stages detailed below.

Figure 2: Mixed-Methods Realist Data Analysis Workflow

Quantitative Data Analysis (Context and Structural Outcomes)

Quantitative strands will focus primarily on mapping the structural boundaries of the Wider Context (C) and auditing User Engagement (O/C).

• Descriptive & Inferential Statistics: System-level user analytics and platform interaction frequencies (e.g., attention, participation) will be cross-tabulated against socio-demographic factors and validated digital health literacy scales using descriptive and inferential statistics.
• Access Boundary Profiling: This analysis will define the baseline structural access boundaries and demographic contexts (C) that shape how varying users access the digital resource.
• Proximal Outcomes: Longitudinal changes in health literacy scores, risk perception, and self-efficacy will be analysed using paired t-tests or repeated-measures ANOVA to quantify proximal behavioural readiness outcomes (O).

Qualitative Data Analysis (Mechanism Elicitation)

Qualitative data from longitudinal semi-structured interviews and cognitive mapping protocols will be analysed using a realist-informed thematic analysis approach.

• Retrospective Coding: Transcripts will be coded using an initial deductive framework derived from the integrated conceptual model (e.g., Interpretative Engagement, Resource Availability, and Behavioral Readiness).
• Inductive Logic Application: This framework will remain open to inductive coding to capture unexpected reasoning patterns.
• Eliciting Latent Mechanisms: The analysis will specifically focus on extracting the latent reasoning, psychological responses, and meaning-making processes (M) triggered within specific types of users when they interact with the educational material.

Mixed-Methods Realist Integration and Synthesis (CMO Pattern Synthesis)

The final analytical phase involves the configuration and synthesis of both strands using CMO pattern-matching. To achieve the precision required for realist evaluation, the analytical framework explicitly differentiates between two dimensions of Context (): the user's baseline sociodemographic and structural background () and the technological or material attributes embedded within the digital educational intervention (). Quantitative data identifying what works and for whom will be systematically matrix-mapped against qualitative themes explaining how and why.

The analysis will progress through iterative rounds of testing configurations to determine under what specific user circumstances () a particular digital resource architecture () triggers an internal interpretative or emotional mechanism (), thereby producing or inhibiting specific behavioral enactment outcomes (). Per the RAMESES II standards, contradictory findings or instances where the intervention failed to trigger the expected behavioural loops will be treated as critical analytical pivot points to refine the boundaries of the final, transferable explanatory framework.

By investigating how specific structural and wider circumstances () trigger underlying cognitive or psychological reasoning () to produce varied behavioral changes (), the study operationalises the classic realist proposition that . This operational approach bypasses standard linear evaluation models to explain exactly what elements of digital platforms work, for whom, and under what specific socio-demographic circumstances. The empirical phase of this research is designed and will be monitored in strict accordance with the RAMESES II reporting standards for realist evaluations to ensure methodological transparency and validity.

Publication-to-PhD Research Trajectory

The systematic evolution of this research programme follows a direct trajectory from initial macro-level literacy concepts to an integrated, empirically testable evaluation design:

[Stage 1: Dementia Prevention Literacy Framework]

Established by Paper 1, which introduced the concept of dementia prevention literacy and identified critical variability in public understanding of modifiable risk factors (Carey, 2026c).

│
▼

[Stage 2: Reconceptualising Dementia Education]

Driven by Paper 2, which reframed traditional dementia education as an active process of interpretative engagement, shifting the academic emphasis from linear information delivery to complex meaning-making processes (Carey, 2026b).

│
▼

[Stage 3: Realist Framework for Digital Education]

Anchored by Paper 3, which integrated system-level health literacy theory with behaviour change models to conceptualize digital educational platforms as multi-component ecosystems structured through explicit Context-Mechanism-Outcome (CMO) logic (Carey, 2026a).

│
▼

[Stage 4: Integrated Theoretical Synthesis]

Formulated in Paper 4, which executed a comparative conceptual analysis to reconcile cross-framework boundaries, unifying the public health literacy landscape with explicit evaluator pipelines (Carey, 2026d). unifying the public health literacy landscape with explicit evaluator pipelines (Carey, 2026d).

│
▼

[Stage 5: Conceptual Architecture]

Developed in Paper 5, which established the methodological blueprint for aligning qualitative sense-making with quantitative platform analytics to track internal user mechanisms empirically (Carey, 2026e).

│
▼

[Stage 6: Doctoral Operationalisation]

The practical, real-world culmination of the entire five-paper conceptual architecture, translating the synthesized framework into an active, mixed-methods PhD study evaluating engagement, interpretation, and behavioural readiness among midlife adults aged 40–65 years (Carey, 2026e).

Digital Knowledge Translation Architecture and Public Stakeholder Mobilisation

The proposed research recognises that generating evidence alone is insufficient to influence dementia risk reduction and behaviour change. Effective translation of research findings into policy, practice, and community action is essential to maximise public health impact. Accordingly, a comprehensive dissemination strategy will be implemented throughout the candidature.

Research findings will be disseminated through peer-reviewed journal publications, conference presentations, professional networks, and stakeholder engagement activities involving health professionals, policymakers, dementia advocacy organisations, and community groups. The research will also utilise digital communication platforms, including professional websites, webinars, and social media channels, to increase awareness and accessibility of evidence-based information relating to dementia risk modification and behaviour change.Rather than working as linear, unidirectional broadcasting tools, the selected digital translation channels (see Table 2) are conceptualized as infrastructure for bidirectional engagement. Public commentary, digital dialogue, and community feedback on these platforms will actively serve to validate, refine, and stress-test emerging CMO theories with midlife audiences in real time. These activities will complement, rather than replace, traditional academic dissemination pathways.

Social Media Dissemination Platforms and Knowledge Translation Channels

Digital communication platforms, including professional networking and social media channels, will support broader dissemination and public engagement activities alongside traditional academic dissemination pathways. The dissemination strategy aims to ensure that research outcomes contribute not only to academic knowledge but also to practical interventions, public awareness, and policy development that support healthy ageing and dementia prevention.

Table 2: Digital Knowledge Translation (KT) Architecture and Stakeholder Mobilisation Channels

Note: Active links to all research platforms, repositories, and professional profiles are provided through the author's ORCID profile and publisher metadata to ensure persistent access.

Digital research profiles and repositories:
ORCID: https://orcid.org/0000-0003-3033-9809
Figshare Research Repository: https://doi.org/10.6084/m9.figshare.32691471
Additional professional communication channels (LinkedIn, X, and Facebook) are maintained to support ongoing knowledge translation and stakeholder engagement.

DISCUSSION

This programme contributes to a growing body of literature challenging linear assumptions in health education. The findings suggest that digital dementia risk-reduction education does not operate as a direct driver of behaviour but as a contextual trigger for interpretative processes. Interpretative engagement emerges as the central mechanism through which individuals construct meaning from dementia prevention information. This extends health literacy theory by embedding it within a realist explanatory structure.

The integration of COM-B theory further clarifies how interpretative engagement interacts with capability, opportunity, and motivation to shape behavioural readiness. Rather than acting as independent determinants, these constructs are activated through interpretative processes.

From an implementation science perspective, variability in outcomes is not evidence of intervention failure but of context-sensitive mechanism activation (Nilsen, 2015). This positions digital dementia education as a complex adaptive intervention rather than a linear educational tool.

CONCLUSION

This article presents a structured programme of conceptual scholarship that integrates dementia prevention literacy, health literacy, behaviour change theory, implementation science, and realist evaluation into a unified explanatory framework. The programme identifies interpretative engagement as the central mechanism linking digital dementia risk-reduction education to behavioural outcomes. It demonstrates that behavioural change emerges not from information exposure alone but from context-dependent interpretative processes. This complete framework establishes the necessary theoretical and methodological foundations to guide future empirical, mixed-methods realist evaluations of digital health education resources.

Looking Ahead

Scholarly discussions are welcome with researchers, clinicians, educators, public health practitioners, and others interested in dementia prevention, health literacy, behaviour change, digital health, and realist evaluation. Exploring opportunities for ongoing collaboration and scholarly discussion helps ensure the continuous refinement of interactive educational systems.

DECLARATIONS

CONFLICT OF INTEREST

None declared.

AUTHOR CONTRIBUTIONS

Sole author conceptualisation and manuscript development.

FUNDING STATEMENT

No external funding was received.

DATA AVAILABILITY STATEMENT

No datasets were generated or analysed during this conceptual review.

ETHICAL APPROVAL / INFORMED CONSENT

Not required for this conceptual scholarship and theoretical framework study.

ACKNOWLEDGMENTS

Not applicable.

Appendix 1: Program Visual Graphic Asset

The poster was informed by the findings of Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet Standing Commission. The Lancet. 2024;404(10452):572–628.

While evidence suggests that up to 45% of dementia cases may be preventable or delayed through modification of known risk factors, awareness of these risks does not consistently lead to engagement with risk-reducing behaviours. This observation underpins my proposed PhD research, which examines how midlife adults engage with, interpret, and apply digital risk-reduction education in real-world settings (Carey, 2026f).

Appendix 2: Publications and Scholarly Outputs Supporting the Proposed PhD

Relationship of Publications to the Proposed PhD

These publications constitute a coherent programme of conceptual scholarship underpinning the proposed doctoral research. Collectively, they informed the development of the Dementia Prevention Literacy Translation Framework (DPLTF), the reconceptualisation of dementia education beyond information-transfer models, and the Realist-informed Framework for evaluating digital dementia education interventions. Together, they provide the conceptual, theoretical, and methodological foundation for the proposed PID study.

The publications comprise four peer-reviewed publications, one manuscript currently under review, and associated preprints and a research repository that collectively informed development of the proposed doctoral study.

Peer-Reviewed Publications

• Carey, P. (2026a). Beyond Information Delivery: Towards a Realist-Informed Conceptual Framework for the Evaluation of Digital Dementia Education. Journal of Preventive Medicine & Healthcare, 8(2), 1048. https://doi.org/10.47739/preventivemedicine.1048
• Carey, P. (2026b). Reconceptualising Dementia Education: From Information Transfer to Behavioural and Contextual Change. International Internal Medicine Journal (IIMJ): OA, 4(2), 01-09. https://doi.org/10.33140/IIMJ.04.02.03
• Carey, P. (2026c). A Conceptual Framework for Understanding Dementia Prevention Literacy: Bridging the Translation Gap Between Epidemiological Evidence and Public Action. Epidemiology and Public Health, OA, 2(1), 01-12. https://doi.org/10.65157/EPHOC.2026.008
• Carey, P. (2026d). From Dementia Prevention Literacy to Realist-Informed Digital Dementia Education: An Integrated Theoretical Perspective. International Journal of Natural Sciences and Interdisciplinary Research: OA, 1(2), 01-07. https://doi.org/10.33140/IJNSIR.01.02.14
• Carey, P. (2026e). Understanding How Digital Dementia Risk-Reduction Education Works: A Realist-informed Mixed-methods Study of Engagement, Interpretation and Behavioural Readiness in Midlife Adults. Biomedical Science and Clinical Research: OA. 5(3), 01-25. https://dx.doi.org/10.33140/BSCR.05.03.01

Preprints

• Carey, P. (2026a). Beyond Information Delivery: Towards a Realist-Informed Conceptual Framework for the Evaluation of Digital Dementia Education. Preprints. https://doi.org/10.20944/preprints202605.1316.v2
• Carey, P. (2026b). Reconceptualising Dementia Education: From Information Transfer to Behavioural and Contextual Change. Preprints. https://doi.org/10.20944/preprints202605.1879.v1
• Carey, P. (2026c). A Conceptual Framework for Understanding Dementia Prevention Literacy: Bridging the Translation Gap Between Epidemiological Evidence and Public Action. Preprints. https://doi.org/10.20944/preprints202606.0612.v1

Research Repositories

• Carey, P. (2026, June). From Dementia Prevention Literacy to Realist-Informed Digital Dementia Education: An Integrated Theoretical Perspective. figshare. Journal contribution. https://doi.org/10.6084/m9.figshare.32691471.v1
• Carey, P. (2026e). Understanding How Digital Dementia Risk-Reduction Education Works: A Realist-Informed Mixed-Methods Study of Engagement, Interpretation and Behavioural Readiness in Midlife Adults. f igshare Journal contribution. https://doi.org/10.6084/m9.figshare.32917325.v1
• Carey, P. (2026f). Dementia Forms, Risk Reduction Factors and Strongest Interventions Ages 40-65. figshare. Poster. https://doi.org/10.6084/m9.figshare.32781693.v1
• Carey, P. (2026g). A Programme of Conceptual Scholarship Underpinning the Development of a Realist Evaluation of Digital Dementia Risk-Reduction Education. figshare. https://doi.org/10.6084/m9.figshare.32746245.v1
• Carey, Peter (2026). Dementia Forms, Risk Reduction Factors and Strongest Interventions Ages 40-65. figshare. Poster. https://doi.org/10.6084/m9.figshare.32781693.v1
• Carey, Peter (2026). From Information to Impact: Building a Research Programme in Dementia Risk-Reduction Education. figshare. Poster. https://doi.org/10.6084/m9.figshare.32786724.v2