Beyond Information Delivery: Towards a Realist-Informed Conceptual Framework for the Evaluation of Digital Dementia Education

Peter Carey

doi:10.20944/preprints202605.1316.v2

Submitted:

03 June 2026

Posted:

03 June 2026

You are already at the latest version

Abstract

Dementia represents a growing global public health challenge, driving the rapid expansion of educational interventions aimed at improving awareness and promoting risk-reduction behaviours. Despite this growth, existing research demonstrates a persistent gap between knowledge acquisition and meaningful behavioural change. This paper presents a realist-informed conceptual analysis and proposes an integrative conceptual framework for evaluating the real-world effectiveness of digital dementia education. Integrating health literacy theory, the Capability–Opportunity–Motivation Behaviour (COM-B) model, and implementation science, the framework conceptualises dementia education as a dynamic, multi-component process involving resource availability, user engagement, interpretative engagement, behavioural readiness, contextual influences, and real-world outcomes. Particular emphasis is placed on interpretative engagement, grounded in constructivist and sensemaking perspectives, as a key mechanism linking exposure to educational content with behavioural intention and action. The paper identifies critical limitations in current evaluation approaches, including overreliance on knowledge-based outcomes and insufficient consideration of contextual, emotional, and implementation influences. By advancing a user-centred and context-sensitive framework, this study contributes to the development of more theoretically informed and implementation-oriented approaches for evaluating digital dementia risk-reduction education, particularly among midlife populations.

Keywords:

dementia education

;

health literacy

;

behaviour change

;

COM-B model

;

digital health

;

engagement

;

implementation science

;

prevention

;

realist evaluation

;

conceptual framework

Subject:

Biology and Life Sciences - Aging

Introduction

Dementia is one of the most significant and rapidly growing global public health challenges, with major implications for individuals, families, healthcare systems, and economies worldwide. Global prevalence is projected to increase substantially over coming decades, particularly within ageing populations such as those in Australia (World Health Organization, 2023; Livingston et al., 2020). In response, dementia prevention and risk-reduction strategies have become an increasing focus of public health policy and research, contributing to rapid growth in educational interventions designed to improve awareness, knowledge, and behavioural risk reduction.

Digital technologies now play a central role in this expansion. Online learning platforms, mobile applications, web-based programs, and public health campaigns provide scalable opportunities for dementia education across diverse populations (Eccleston et al., 2019; Murray et al., 2016). Contemporary initiatives increasingly target not only healthcare professionals and caregivers but also midlife populations who may benefit from early prevention and risk-reduction strategies.

However, despite increasing availability and participation, evidence regarding the real-world effectiveness of dementia education remains inconsistent. Educational interventions often improve knowledge and attitudes, but are less consistent in achieving lasting behavioural change and longer-term implementation outcomes (Webb & Sheeran, 2006; Prestwich et al., 2014; Bailey et al., 2020; Portela Dos Santos, 2022; Arlinghaus & Johnston, 2018). This limitation reflects a broader challenge within behavioural and implementation science: informational access alone rarely produces meaningful behavioural change.

Existing dementia education research has largely focused on intervention development, dissemination, and knowledge acquisition, with comparatively limited attention to the mechanisms through which individuals interpret, internalise, and apply educational content within everyday contexts (Mazzucca et al., 2021; Kumah et al., 2022). Consequently, many evaluations emphasise participation, reach, or short-term learning outcomes while under examining contextual influences, interpretative processes, and behavioural enactment in real-world settings.

In this paper argues that dementia education is better conceptualised as a dynamic interplay of context, engagement, interpretation, behavioural readiness and implementation conditions (Surr et al., 2017) rather than a linear delivery of information. Drawing on realist evaluation principles (Pawson & Tilley, 1997), health literacy theory, the Capability–Opportunity–Motivation Behaviour (COM-B) model, and implementation science, this paper presents a realist-informed conceptual framework for evaluating digital dementia education.

Rather than asking only whether educational interventions increase knowledge, the framework seeks to explain how, for whom, and under what conditions digital dementia education contributes to meaningful behavioural and health-related outcomes. In particular, interpretative engagement is highlighted as a key mechanism linking exposure to educational content with behavioural intention and enactment (Perski et al., 2017). By integrating behavioural, contextual, and implementation perspectives, the framework advances a more comprehensive approach to evaluating the effectiveness of digital dementia education in practice.

Expansion and Diversification of Dementia Education

Dementia education has expanded substantially in scope, delivery, and target population over the past decade, reflecting broader public health priorities surrounding prevention, early intervention, and evidence translation. Educational initiatives now encompass public awareness campaigns, workforce training programs, community-based interventions, digital learning platforms, and blended educational models.

Digital technologies have become increasingly central to this expansion because they offer scalable and potentially cost-effective approaches for delivering health education across geographically dispersed populations (Lustria et al., 2013; Murray et al., 2016). In dementia contexts, digital education has been used to support caregiver education, workforce development, and public awareness initiatives through online modules, mobile applications, webinars, and Massive Open Online Courses (MOOCs) (Eccleston et al., 2019).

Evidence suggests that dementia education programs can improve knowledge, confidence, and attitudes among both healthcare staff and community participants (Surr et al., 2017; Rasmussen et al., 2023). Increasing attention has also been given to culturally responsive and person-centred educational approaches designed to improve accessibility and relevance across diverse populations (Hulko et al., 2024).

Despite this growth, implementation research consistently demonstrates that educational effectiveness is strongly influenced by contextual and delivery conditions. Knowledge improvements do not always translate into sustained behavioural or practice change (Proctor et al., 2011; Chowdhary et al., 2022; Cullen, 2022). Many interventions continue to be evaluated primarily through participation metrics, satisfaction scores, or short-term knowledge gains rather than through meaningful behavioural, implementation, or long-term outcomes (Glasgow et al., 2019; Gkioka et al., 2020).

As a result, there remains limited understanding of how individuals engage with, interpret, and apply dementia education in everyday life. This represents a critical gap within current approaches to evaluating digital dementia education.

The Knowledge–Behaviour Gap

A central assumption underpinning many educational interventions is that increased knowledge naturally leads to behavioural change. However, this assumption has been repeatedly challenged within behavioural science and health education research. Research continuously shows that awareness, intention, and sustained action differ significantly (Webb & Sheeran, 2006; Prestwich et al., 2014; Conner & Norman, 2022). Within dementia prevention contexts, individuals may understand risk factors and recommended behaviours without successfully adopting or maintaining lifestyle changes. This gap reflects broader insights from behavioural science, which emphasise that behaviour is shaped by multiple interacting influences, including capability, opportunity, motivation, social environment, emotional readiness, and contextual constraints.

The COM-B model provides a useful framework for understanding these interactions by conceptualising behaviour as emerging through relationships between capability, opportunity, and motivation (Michie et al., 2011). From this perspective, knowledge represents only one component of behavioural capability and is insufficient on its own to produce sustained behavioural enactment.

Consequently, educational interventions that focus predominantly on information transmission may improve awareness while failing to address the broader contextual and motivational conditions required for behavioural change. This limitation highlights the need for evaluation approaches capable of examining not only what information is delivered, but also how individuals interpret, internalise, and apply educational content within real-world contexts.

Health Literacy and Interpretative Engagement

Health literacy is increasingly recognised as a critical determinant of health engagement and behavioural outcomes. Contemporary models define health literacy not simply as reading comprehension or information access, but as the capacity to access, understand, appraise, and apply health information within social and contextual environments (Sørensen et al., 2012). Furthermore, health literacy is becoming recognised as a more comprehensive social indicator of health that influences inequality in outcomes, participation, and access (Nutbeam & Lloyd, 2021). Importantly, individuals do not passively receive educational information. Instead, individuals actively analyse, assess, and create meaning based on their lived experiences, cultural background, emotional reactions, past knowledge, and beliefs (Alhazmi & Kaufmann, 2022). This process, referred to in this paper as interpretative engagement, represents a central mechanism linking exposure to educational content with behavioural readiness.

Interpretative engagement extends beyond basic participation or attention. It involves reflection, sensemaking, appraisal of personal relevance, and integration of new information into existing understandings and identities. Individuals exposed to identical educational content may therefore experience substantially different outcomes depending on how meaning is constructed within their particular context.

Interpretative engagement is still understudied in dementia education research, despite its significance (Surr, 2017). Existing evaluations frequently focus on measurable indicators such as participation rates, completion metrics, or knowledge scores while overlooking the interpretative processes through which educational content becomes behaviourally meaningful.

Behaviour Change and Implementation Context

Behavioural and implementation sciences both emphasise that interventions function differently across contexts. Educational interventions that demonstrate effectiveness under controlled conditions may produce weaker or inconsistent outcomes when implemented in routine practice.

The COM-B model highlights how behavioural enactment depends on interactions between psychological and physical capability, environmental opportunity, and reflective and automatic motivation (Michie et al., 2011). This perspective helps explain why knowledge acquisition alone rarely predicts sustained behaviour change.

Implementation science further extends this understanding by emphasising usability, scalability, acceptability, implementation fidelity, and contextual adaptation (Craig et al., 2008; Skivington et al., 2021). Real-world implementation is shaped by organisational systems, competing demands, policy environments, social support, and broader contextual conditions (Damschroder et al., 2009).

Digital inequality research also demonstrates that disparities in digital access, literacy, and technological confidence continue to influence who benefits from digital health interventions (Van Dijk, 2006). Consequently, educational resources that appear accessible in principle may remain inaccessible or ineffective for particular populations.

Together, these perspectives highlight the need for evaluation approaches capable of examining not only whether interventions produce outcomes, but how contextual conditions shape the mechanisms through which outcomes emerge.

Emotional and Contextual Influences

Engagement with dementia education is shaped by a wide range of emotional, social, and contextual influences. Emotional responses such as fear, anxiety, denial, stigma, or perceived vulnerability may either facilitate or inhibit engagement with dementia-related information (Bandura, 2004; Brewer et al., 2007).

Similarly, social and environmental conditions influence individuals’ capacity to engage with and apply educational content. Family support, peer influence, cultural norms, work demands, socioeconomic conditions, and access to supportive environments all affect behavioural enactment and maintenance.

These findings reinforce the importance of person-centred and context-sensitive educational approaches. Educational interventions that fail to account for emotional and contextual variability may overestimate their effectiveness by assuming uniform engagement and behavioural capacity across populations.

The Real-World Implementation Gap

Despite substantial advances in digital health innovation, a persistent gap remains between intervention efficacy under controlled research conditions and effectiveness within real-world settings.

Evidence from digital health research suggests that online and mobile interventions can demonstrate positive outcomes within structured environments; however, their effectiveness frequently declines during routine implementation because of variability in engagement, context, usability, and delivery conditions (Murray et al., 2016).

Many evaluation studies continue to prioritise short-term or proximal outcomes while under examining implementation sustainability, behavioural maintenance, and contextual adaptation. Consequently, interventions may appear successful within research environments while producing weaker or inequitable outcomes in practice.

This implementation gap is particularly important within dementia prevention, where meaningful behavioural change often requires long-term engagement, sustained motivation, and supportive environmental conditions.

These limitations underscore the need for more theoretically integrated and context-sensitive approaches to evaluating digital dementia education.

Framework Development Process

The conceptual framework presented in this paper was developed using a realist-informed narrative synthesis approach. This approach was selected to enable the integration of diverse theoretical perspectives across health literacy, behavioural science, implementation science, and digital health engagement research, without restricting the analysis to a single disciplinary methodology.

The development process was iterative and interpretive rather than protocol driven. Relevant literature was identified through targeted and iterative searching of peer-reviewed publications and foundational theoretical works, including realist evaluation, COM-B behaviour change theory, health literacy frameworks, and implementation science models. Key concepts and explanatory mechanisms were extracted and mapped across these domains to identify areas of conceptual convergence, complementarity, and tension.

Through successive cycles of analysis, synthesis, and refinement, core constructs were organised into a preliminary explanatory structure describing how digital dementia education may lead to behavioural outcomes. Attention was given to mechanisms of engagement, interpretation, behavioural readiness, and contextual influence. The concept of interpretative engagement emerged through this synthesis as a central explanatory mechanism linking exposure to educational content with behavioural intention and enactment.

Rather than seeking statistical aggregation or formal realist program theory testing, the aim of this process was to generate a coherent, theory-driven conceptual framework capable of guiding future empirical validation. The resulting framework is therefore intended as an explanatory model rather than an empirically tested theory.

Conceptual Framework: From Information Accessibility to Practical Application

To address limitations in existing evaluation approaches, this paper proposes a realist-informed conceptual framework that conceptualises digital dementia education as a dynamic and context-dependent process through which educational resources may—or may not—produce meaningful behavioural outcomes (Figure 1).

The framework is informed by realist evaluation theory (Pawson & Tilley, 1997), which conceptualises outcomes as emerging through interactions between contexts, mechanisms, and outcomes (CMO configurations). Within this perspective, digital dementia education does not operate as a universally effective intervention; rather, its impact depends on how individuals engage with, interpret, and apply educational content within specific social, emotional, and environmental contexts.

The framework integrates three complementary theoretical perspectives:

health literacy theory,
the COM-B model of behaviour,
implementation science.

Health literacy operates across all stages of the framework, shaping individuals’ capacity to Health literacy influences people's ability to access, comprehend, evaluate, and use knowledge at every level of the framework (Sørensen et al., 2012; Sørensen et al., 2021; Nutbeam & Lloyd, 2021; Dodds et al., 2025). The COM-B model explains how capability, opportunity, and motivation influence behavioural readiness and enactment (Michie et al., 2011), while implementation science contributes attention to contextual variability, usability, scalability, and real-world delivery conditions (Craig et al., 2008; Skivington et al., 2021).

The framework consists of six interrelated domains:

Resource Availability (Context)

Access to digital educational resources, including technological accessibility, usability, and opportunity for engagement.
User Engagement (Mechanism)

Initial interaction with educational content, including attention, participation, and motivational engagement.
Interpretative Engagement (Core Mechanism)

The process through which users actively construct meaning from educational content by reflecting on relevance, personal applicability, and lived experience.
Behavioural Readiness (Mechanism)

Development of understanding, self-efficacy, risk perception, and intention to act.
Contextual Influences (Context)

Social, cultural, emotional, and environmental factors that facilitate or constrain behavioural enactment.
Real-World Outcomes (Outcome)

Adoption of dementia risk-reduction strategies, altered behaviour, enhanced wellbeing, and long-lasting effects (Dodds, 2025).

A central innovation of the framework is the explicit positioning of interpretative engagement as a core explanatory mechanism linking exposure to educational information with behavioural outcomes. Existing evaluation models frequently assume that engagement or knowledge acquisition alone predicts behaviour change. In contrast, this framework argues that individuals must actively interpret and contextualise information before behavioural readiness can emerge.

The framework also incorporates feedback loops, recognising that outcomes reshape future engagement, perceptions, and contextual conditions over time. This reflects the iterative and non-linear nature of behaviour change and implementation processes in real-world environments.

Illustrative Context–Mechanism–Outcome (CMO) Configurations

To strengthen the realist orientation of the framework, several illustrative Context–Mechanism–Outcome (CMO) configurations are presented below. These configurations demonstrate how differing contextual conditions activate specific mechanisms that generate variable outcomes.

CMO Configuration 1: Low Literacy Context

Context: Limited digital literacy and low prior health knowledge
Mechanism: Limited interpretative engagement (difficulty interpreting and contextualising educational content)
Outcome: Minimal behavioural readiness and limited adoption of risk-reduction behaviours.

In this context, the availability of digital dementia education alone is insufficient to produce behavioural change. Users may struggle to interpret or contextualise information, constraining engagement at a deeper interpretative level.

CMO Configuration 2: High Literacy and Supportive Design Context

Context: Higher digital and health literacy, supported by accessible and user-centred design features
Mechanism: Interpretative engagement and reflective processing (relevance appraisal and meaning-making)
Outcome: Increased behavioural readiness and adoption of risk-reduction behaviours.

In this context, educational content is more likely to activate reflective and interpretative processes, facilitating translation into behavioural intention and action.

CMO Configuration 3: Emotional and Social Environment Effects

Context: Emotionally supportive and socially reinforcing environments vs. environments characterised by stigma, isolation, or competing demands
Mechanism: Strengthened or inhibited behavioural motivation and enactment processes
Outcome: Sustained behavioural adoption or reduced maintenance of behaviour change despite initial engagement.

These contrasting contexts illustrate how emotional and social conditions can either enable or constrain the maintenance of behavioural change over time.

Summary

Collectively, these configurations illustrate that outcomes are not produced by educational exposure alone, but through interactions between contextual conditions and underlying mechanisms. This reinforces the realist proposition that outcomes are contingent on specific Context–Mechanism–Outcome configurations rather than uniform causal effects.

Discussion

This framework advances digital dementia education research by shifting emphasis from information delivery and knowledge acquisition toward the mechanisms through which educational content is interpreted, contextualised, and translated into behavioural readiness and action. It positions interpretative engagement as a central explanatory mechanism within a realist-informed structure that integrates behavioural science and implementation science.

A key contribution of the framework is that it challenges the assumption that informational exposure alone is sufficient to produce behavioural change. Existing research often evaluates dementia education interventions through knowledge gain, participation, or short-term attitudinal change, yet these outcomes provide limited insight into whether learning is meaningfully interpreted or translated into sustained behavioural action.

From a realist perspective, these findings suggest that outcomes are not produced by the intervention itself, but by the interaction between context and mechanisms that shape how individuals engage with and respond to educational content. Rather than linear effects, the framework proposes that outcomes emerge through specific Context–Mechanism–Outcome (CMO) configurations, where variation in context activates different interpretative and behavioural mechanisms, leading to divergent outcomes across individuals and settings.

This interpretation aligns with established implementation science and behaviour change theory. The Consolidated Framework for Implementation Research (CFIR) reinforces the importance of context in shaping implementation outcomes, highlighting that organisational, external, and individual-level conditions influence whether and how interventions are adopted and sustained (Damschroder et al., 2009). Within a CMO logic, CFIR primarily strengthens understanding of contextual conditions (C) that enable or constrain mechanisms.

Similarly, the Behaviour Change Wheel provides a complementary explanation of mechanisms (M) by conceptualising behaviour as arising from interactions between capability, opportunity, and motivation. This reinforces the premise that knowledge alone is insufficient unless it activates motivational and opportunity structures that translate learning into action (Michie et al., 2011). In realist terms, the Behaviour Change Wheel helps specify the psychological and behavioural mechanisms through which educational interventions may generate outcomes.

In addition, the framework integrates previously siloed perspectives by combining health literacy theory, behavioural science, realist evaluation, and implementation science. This synthesis enables a more comprehensive understanding of how educational interventions function in complex real-world settings, where outcomes are contingent on specific CMO configurations rather than uniform causal pathways.

Finally, the framework strengthens implementation-oriented evaluation by explicitly accounting for feedback loops, contextual moderators, and variability in behavioural enactment. It supports a shift away from assuming uniform intervention effects toward examining what works, for whom, and under what conditions (i.e., across differing CMO configurations), thereby improving explanatory depth and transferability across settings.

Collectively, the framework offers a theoretically integrated and context-sensitive approach to evaluating digital dementia education, with stronger explanatory power for understanding differential outcomes and guiding more effective intervention design and implementation.

Implications for Research, Practice, and Policy

The proposed framework has several implications for future research, intervention design, and public health policy.

For research, the framework highlights the importance of moving beyond outcome-only evaluations toward approaches capable of examining Context–Mechanism–Outcome configurations. Future studies should investigate how interpretative engagement develops across different populations and how contextual conditions shape behavioural enactment and sustainability over time. Mixed-methods and realist-informed evaluation approaches may be particularly valuable for capturing these complex interactions.

For intervention design, the framework emphasises the importance of tailoring educational resources to users’ digital literacy, health literacy, emotional readiness, and sociocultural context. Digital dementia education should move beyond static information delivery toward adaptive, user-centred approaches that facilitate reflection, relevance appraisal, and behavioural capability development.

For policy and implementation, the framework supports the development of equity-focused digital health strategies that recognise variability in access, opportunity, and engagement. Policymakers should avoid assuming uniform benefit from digital educational initiatives and instead prioritise accessibility, inclusivity, and implementation support across diverse populations.

Collectively, these implications suggest that improving dementia prevention outcomes requires alignment between educational design, contextual support, implementation conditions, and evaluation strategy.

Limitations

Several limitations of the proposed framework should be acknowledged. Consistent with realist-informed programme theory development, the proposed Context–Mechanism–Outcome relationships require empirical refinement and testing (Pawson & Tilley, 1997).

First, the framework is conceptual and has not yet been empirically validated across diverse populations or intervention settings. Future research is required to test the proposed Context–Mechanism–Outcome configurations and examine how the framework operates within different demographic and implementation environments.

Second, while the framework integrates multiple theoretical perspectives, additional mechanisms and contextual influences may emerge through empirical application. Behavioural and implementation processes are inherently complex and may vary substantially across cultural, organisational, and technological contexts.

Third, the framework focuses primarily on digital dementia education related to prevention and risk reduction. Adaptation may be required for other contexts such as caregiver education, workforce training, or clinical dementia education.

Despite these limitations, the framework provides a theoretically grounded foundation for more comprehensive and context-sensitive evaluation of digital dementia education.

Conclusion

Digital dementia education has expanded rapidly in response to growing public health concern surrounding dementia prevention and risk reduction. However, existing evaluation approaches remain heavily focused on information delivery and knowledge acquisition, often overlooking the contextual and interpretative processes that shape whether educational interventions produce meaningful behavioural outcomes in practice.

This paper proposes a realist-informed conceptual framework that reconceptualises digital dementia education as a dynamic interaction between context, engagement, interpretation, behavioural readiness, and implementation conditions. By integrating health literacy theory, the COM-B model, and implementation science, the framework provides a theoretically grounded structure for understanding how digital dementia education functions across diverse real-world settings.

The framework's explicit acknowledgment of interpretative engagement as a crucial mechanism connecting educational exposure with behavioural enactment is one of its main contributions (Wang, 2019). This shifts evaluation beyond simplistic assumptions that access to information alone leads to action and instead highlights the importance of meaning-making, contextual fit, and behavioural capability.

The explicit inclusion of interpretative engagement as a core mechanism strengthens the explanatory capacity of the framework by highlighting how individuals actively construct meaning from educational content within specific contextual conditions. This shifts evaluation beyond assumptions that information exposure alone leads to behavioural change and instead emphasises the importance of meaning-making, contextual fit, and behavioural capability.

Ultimately, improving dementia prevention outcomes requires evaluation approaches capable of identifying not only whether digital education works, but how, for whom, and under what conditions change occurs. The proposed framework provides a foundation for more context-sensitive and implementation-oriented evaluation of digital dementia education and offers a basis for future empirical validation.

Ethical Statement

Ethical approval was not required for this study as it is a conceptual paper based on analysis of existing literature and does not involve human participants, primary data collection, or identifiable data.

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Figure 1. Realist-Informed Conceptual Framework for Evaluating Digital Dementia Education. NOTE: The framework illustrates how digital dementia education produces outcomes through interactions between context, mechanisms, and outcomes. It conceptualises dementia education as a dynamic process involving resource availability, engagement, interpretative engagement, behavioural readiness, contextual influences, and real-world outcomes. The framework is informed by realist evaluation theory, the COM-B model of behaviour, health literacy theory, and implementation science.

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