| 32 Theme 6: Societal factors The expected outcomes of a diagnostic trajectory could be affected by cultural perceptions on the benefits or drawbacks of a diagnosis and its societal consequences. Some PwMCs and SOs perceived a diagnostic trajectory as harmful due to a fear of being stigmatized for mental health problems (42, 45, 46). Cultural beliefs on family hierarchy, the family responsibility of taking care of older family members, and ceding household duties later in life also lead to views that diagnostic testing is not beneficial (39, 46). ‘You don’t want to bring in outside agencies unless you have to . . . because it’s intrusive . . . and when you can’t deal with it we’ll go to outside agencies who will help us deal with it. That’s where we’re coming from’ (46). Moreover, a lack of knowledge due to societal factors like a minority background can impact views on the necessity and accessibility of a diagnostic trajectory as mentioned by a few participants in Koehn et al. (45). Financial motives related to a diagnosis (e.g. social security income), can be a reason to pursue a diagnostic trajectory (41). Discussion This integrative review is the first to explore and map preferences of PwMCs and SOs on starting a diagnostic trajectory for dementia. PwMCs and SOs, who decided to pursue a diagnostic trajectory, were driven by uncertainty about symptoms, believed testing was necessary to help deal with symptoms, or expected to start treatment or have access to other forms of support after a diagnostic trajectory. PwMCs and SOs who delayed or decided to refuse a diagnostic trajectory believed they did not need help, prioritized physical problems, or expected diagnostic testing to be harmful in living (mentally) healthy. These views do not exist independently but are influenced by normalization or validation of symptoms, support or wishes of their social network, interactions with HCPs, health status of the PwMC, and societal factors such as stigmatization, cultural beliefs, and socioeconomic status. Although in theory the identified feelings, beliefs and expectations are defined as parts of the concept preferences (32), in this study beliefs on the necessity and expected outcomes of starting a diagnostic trajectory appeared to be partly circular. That is, when the expected outcomes are favourable, beliefs on the necessity of starting a diagnostic trajectory are likely to be heightened and vice
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