The current study revealed that some participants found the CBB test to be time-consuming and challenging to complete independently. Despite these challenges, participants acknowledged the test's benefits in understanding their attention and memory, and they expressed willingness to undergo testing again in the future. Participants with lower levels of education or less familiarity with playing cards showed less confidence in completing the test independently. Therefore, having clinical staff available to provide consultation and assistance during the test execution may be beneficial.
For patients with dementia, clinical observers found the CBB test difficult to understand and use independently. Additionally, the test duration was prolonged due to numerous errors, potentially leading to patient impatience. Therefore, it is recommended to use this tool under clinical supervision for patients with dementia.
Despite significant time savings compared to traditional neuropsychological batteries, nearly 40% of participants found the CBB to be time-consuming in this study. Several studies have reported similar findings regarding perceived lengthy test duration.[14, 16, 17]. In the Brooklyn Cognitive Impairments in Health Disparities Pilot Study, 58 adults aged 40 or older (mean age 67.9 ± 9.8 years, range 43–91) completed the CBB test and a 5-item liking survey in both traditional and nontraditional primary care settings. The results indicated that 80% of participants perceived the test duration as lengthy [14]. In another study by Gamaldo et al., 87 black adults aged 66.31 ± 7.32 years (range 55–86) without cognitive impairment participated in an assessment of satisfaction using computer-based cognitive and neuropsychological batteries. The results revealed that 16.1% of participants perceived the CBB as time-consuming. Correlational analyses indicated that factors such as age, sex, birth country, income, health conditions, education, computer use, comfort with computers, everyday discrimination, stigma consciousness, and Wide Range Achievement Test-3 scores were not associated with time consumption [16]. The rates of time-consuming perception varied among studies, likely due to differing participant characteristics. However, factors influencing this perception have not been conclusively identified. Future studies could explore the impact of factors such as testing environments and devices on the perception of CBB as time-consuming [13, 18].
In contrast to participants' subjective perception of time consumption, clinical observers reported a significantly higher positive perception rate of time consumption, reaching 83.3%. This discrepancy may be attributed to participants' subjective experiences while dealing with challenging tasks.
In this study, 78.8% of participants with MCI and 98.0% with normal cognition found the assessment instructions easy to understand. However, there was a decrease of 15.3–26% in the number of participants who believed they could complete the assessment without assistance. This suggests that despite the simplicity of the instructions, some participants may have difficulty or lack confidence in completing the assessment independently. Similarly, the Brooklyn Cognitive Impairments in Health Disparities Pilot Study reported that 95% of participants found the test instructions easy to understand, and 71% of them felt confident enough to retake the test without assistance. [14]. In another study conducted by Ashford et al., 11,553 participants aged 55 or older were recruited from the Brain Health Registry to assess the relationship between participant characteristics and their feedback on taking the CBB test. The results revealed that 74.6% of participants rated the instructions for taking the CBB test as 'very clear'. Additionally, 30% of participants found human support to be 'somewhat useful' or 'very useful' [19]. These findings align with our study despite differences in participant characteristics and study designs across studies. Ashford et al. also demonstrated that in their logistic regression model, with every 10-year increase in age, participants were less likely to find the CBB instructions clear and more likely to find additional human support useful. Education level influenced perceptions as well, with postgraduates finding human support less useful, while those with secondary education or less found it more useful. Ethnicity also played a role, with non-Latino White participants finding the instructions clearer and the support less useful compared to Latino, non-Latino Asian, and non-Latino Black participants [19]. Moreover, Gamaldo et al. demonstrated that an increase in the number of health conditions was associated with reduced comfort levels in self-administering the CBB [16]. Similarly, our study revealed a correlation between total years of education and self-efficacy perception, although factors influencing each item were not assessed. Additionally, we found that familiarity with playing cards was associated with self-efficacy perception, given that the CBB exclusively utilizes playing card stimuli. This aspect might be appealing to certain individuals, particularly those who enjoy card games during their leisure time. However, some individuals may not have a preference for cards or may not engage in card playing activities, opting instead for a variety of visual stimuli rather than repetitive ones, which could impact their performance. Further exploration in this area could help identify cognitive test stimuli that engage and resonate with individuals from diverse backgrounds [15–17].
The current study indicated that participants with normal cognition and MCI held a positive perception of empowerment. Likewise, the Brooklyn Cognitive Impairments in Health Disparities Pilot Study revealed that over 90% of participants preferred to complete the CBB test while waiting for a physician's appointment and were willing to retake it at the clinic after 6 months or a year [14]. Gamaldo et al. also reported that 93.1% of participants were willing to complete the CBB test in the future [16]. Our study further revealed that the CBB test aided participants in understanding their attention and memory, motivating them to actively improve these cognitive functions. Additionally, participants expressed a willingness to seek advice from a healthcare professional when their scores were low.
This study provided a comprehensive analysis of users’ perceptions of the CBB across three dimensions: time consumption, self-efficacy, and empowerment. It evaluated the perceptions not only of individuals with normal cognition but also of patients with MCI and dementia, although the perceptions of those with dementia were assessed by an observer. In addition to age, sex, and education, this study further analyzed other satisfaction-related factors, such as cognitive levels and familiarity with smartphones, tablets, and playing cards.
However, this study has several limitations. Firstly, being a cross-sectional study, it was not possible to determine the directionality of the observed relationships. It was also challenging to ascertain whether participants would maintain their satisfaction with the CBB over time. Moreover, participants’ responses to the CBB might reflect a time-of-measurement effect rather than their typical impressions. Secondly, our findings may not be generalizable to other countries or ethnicities. Thirdly, emotional responses, such as levels of anxiety and depression, to the CBB were not evaluated. The impersonal nature of computerized assessments could make users feel vulnerable. Lastly, due to cognitive impairment, the subjective perceptions of the CBB cannot be assessed in patients with dementia.