| 164 Canada, this should not be interpreted as an absence of stigma and its’ effects on help-seeking behaviours in these countries. As stigma was not an explicit topic in our projective techniques, Dutch and Canadian participants did not reflect on stigma as it might be experienced as less important or that they did not perceive there to be any stigma for them as individuals. Healthcare systems offering formal support are perceived as complex, which was reiterated by Australian, Canadian and Polish caregivers (51, 52). Dutch people with dementia and caregivers are typically assigned a case manager who helps them navigate the healthcare system (53). Whilst Dutch caregivers in our study reflected less negatively on the complexity of the care system, they still experienced frustration and uncertainty with regard to accessing support. These findings suggest that although case managers could potentially aid the navigation of healthcare systems, it is not a cure-all solution in improving experiences of formal support. We need less complex healthcare systems, and an improved understanding of case management and care planning could be helpful (54). Navigating life with dementia as a caregiver is challenging and negatively impacts caregivers’ mental health (55, 56). Our results highlight navigating formal support systems as difficult thus adding to caregiver burden. Paradoxically, those same healthcare systems caregivers perceive as difficult to navigate, are responsible for providing e-health and educational interventions to address caregiver burden (57, 58). Although interventions to address caregiver burden are deemed effective, access may be hampered due general perceived lack of information in relation to support and the difficulty of navigating those complex healthcare systems (59). Caregivers across countries tended to focus more on navigating formal support while people with dementia tended to focus more on the importance of informal support. The stronger emphasis on support from family and friends from people with dementia can be partly explained by a finding of Clare and Wu (60) who posit that people with dementia value their psychological health most in relation to living well with dementia. People with dementia might hold misconceptions about what formal support can offer them and experiencing stigma may prevent them from seeking formal support (61, 62). They see maintaining health as a way to prevent deterioration (63). People with dementia tend to focus on living well with dementia in the present whilst
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