What Does the Chinese General Public Understand About Dementia Prevention?

Background: Although considerable progress has been made on the risk factors of dementia, less is known about the extent of the gaps between the general public’s understanding of dementia prevention and contemporary scientic evidence. This study aimed to determine the beliefs and knowledge of dementia prevention among the Chinese general public and examine the sociodemographic factors of the belief and knowledge of dementia prevention. Methods: The study adopted a cross-sectional design. A total of 358 Chinese adults aged over 40 years were recruited from four healthcare centers. Descriptive statistics and multivariate regression analyses were conducted. We designed questionnaires that include items on the belief of dementia prevention, risk factors for dementia, and health education needs regarding dementia prevention based on previous literature. Results: Only 32.4% of the respondents agreed that dementia is preventable. The correct response rate is low for the items that suggest that cardiovascular risk factors are dementia risk factors. Younger age, higher education, and having contact with patients with dementia are associated with stronger belief that dementia is preventable. Older age, higher income, higher education, having memory complaint, and having contact with patients with dementia are associated with a better understanding of dementia risk factors. A total of 88.9% respondents thought that they are not well informed of dementia from public education, and most respondents (65%) prefer receiving dementia-related health advice from primary care providers. Conclusion: The present study reveals the great gaps between the Chinese general public’s knowledge of dementia prevention and the latest research evidence. Public health educational programs for all age groups are encouraged to close this knowledge gap. More attention and resources should be paid to individuals with low income and low education level as they have limited access to dementia prevention information. Researchers should work in partnership with primary care providers to help translate evidence into community practice with a special focus on the link between cardiovascular risk factors and dementia.


Background
The rapid aging of the global population entails an increase in the prevalence of cognitive impairment among older adults [1]. Dementia is one of the principal causes of disability and decreased quality of life amongst the elderly. In 2020, over 50 million people worldwide are living with dementia [2]. This number is expected to increase to 63 million in 2030 and 114 million in 2050 [3]. By 2030, the annual cost for dementia globally is projected to be 2 trillion dollars [4].
Dementia has reached the forefront of the public health agenda because of its tremendous physical, emotional, and economic burden.
Dementia has no cure, but has a wide range of potentially modi able risk factors. In 2019, the World Health Organization (WHO) published the latest guideline on the risk reduction of cognitive decline and dementia [5]. This guideline reviewed existing evidence on the 12 most substantial modi able risk factors for dementia, including cardiovascular risk factors (i.e., hypertension, diabetes, dyslipidemia, and obesity), psychosocial factors (i.e., depression and social isolation), and lifestyle factors (i.e., low level of physical or mental activity, unbalanced diet, alcohol misuse and smoking, and hearing loss). Roughly one third of all dementia cases could be potentially prevented through the management of the modi able risk factors [6]. These evidences highlight the opportunity for dementia prevention.
A good understanding of the modi able risk factors for dementia may encourage preventative health behaviors, which ultimately reduce the incidence of dementia. In 2017, WHO released the Global Action Plan on Dementia, which urges all countries to implement campaigns to raise public awareness about dementia [7]. One of the major priorities to inform this action is to determine the knowledge gaps about cognitive health and related risk factors among the general public such that education programs can be most effectively targeted.
Although researchers have made considerable progress on the risk and preventive factors of dementia, less is known about the extent of the gaps between the general public's understanding of dementia prevention and contemporary scienti c evidence. Yeo and colleagues surveyed older adults in the UK and found a poor overall knowledge of the risk and protective factors for dementia [8]. Connell and colleagues surveyed the general public in the USA and found that nearly half of the respondents see dementia as unpreventable [9]. Low and Anstercy examined the patterns of beliefs underlying the behaviors and beliefs of the Australian public on what can reduce dementia risk [10]; they concluded that the public perceptions of what might reduce dementia risk are not in uenced by scienti c evidence. However, these studies are mainly conducted in developed countries. The beliefs and knowledge about dementia prevention of those living in developing countries are still largely unknown. China has the largest aging population and faces tremendous burden on dementia care. The general public's knowledge of dementia prevention is necessary to understand rst to inform dementia risk reduction public health campaigns. Therefore, the aim of this study was to compare the Chinese general public's understanding of dementia prevention and contemporary scienti c evidence and to identify the sociodemographic factors related to the beliefs and level of knowledge regarding dementia prevention. Such an assessment can provide important insights for the design of dementia risk reduction strategies.

Design and sample
A cross-sectional study design was used. This study was conducted in four public community healthcare centers in Hangzhou City, southeast China, which provide primary healthcare services to residents within the community. A consecutive sample of 358 adults aged over 40 years who visited the healthcare center from September 2019 to December 2019 was recruited. Participants were excluded if they had a diagnosis of dementia or cognitive impairment or had impaired hearing or vision, which may inhibit them from giving consent and answering the questionnaires.This study was approved by the Zhejiang Chinese

Measures
The questionnaire was designed by the research team in partnership with a neurological physician based on the most current evidence. Standardized tests, such as the Alzheimer's Disease Knowledge Scale [11], were not appropriate for this study, as they include few questions on dementia risk factors and do not have dementia prevention subscales according to the latest evidence. The self-designed questionnaire includes items on beliefs of dementia prevention, risk factors for dementia, and health education needs regarding dementia.

Attitude towards dementia prevention
The rst section of the questionnaire contains two questions. The respondents were asked to circle 1 of 3 options: "yes," "no," and "no idea." The questions include (1) "Do you think dementia is caused by normal aging?" (2) "Do you think that the risk of dementia can be reduced?"

Risk factors for dementia
The second section of the questionnaire has 12 items on dementia risk factors, which were chosen based on the latest evidence reported by the 2019 WHO guidelines on risk reduction of cognitive decline and dementia [5]. The dementia risk factors include hearing loss, smoking, alcohol misuse, unbalanced and unhealthy diet, hypertension, diabetes, dyslipidemia, obesity, physical inactivity, cognitive inactivity, depression, and social isolation. Participants were asked to identify risk factors and circle 1 of 3 options: "yes," "no," and "no idea."

Health education needs regarding dementia prevention
The last section of the questionnaire includes one item that asks the respondents whether they are well informed of dementia prevention from public education and ve items regarding their preferred health education delivery format. The education delivery format includes community bulletin board, health talks by experts, advice from family physicians and community nurses, education booklets, and regular peer sharing. Participants were asked to tick their preferred education content and delivery format in the questionnaire.

Sociodemographic information
The key sociodemographic factors include age, gender, education, and income. In addition, the respondents were also asked to indicate whether they had memory complaint and whether they were in contact with anyone who had dementia.

Statistical Analyses
Statistical analysis was performed with SPSS version 22. Continuous data are summarized in means with standard deviation (SD), and categorical data are presented as rate or ratio. We calculated the percentage of participants who correctly answered each item on the questionnaire to assess the dementia prevention beliefs and knowledge. Multiple logistic regression was conducted with each item regressed on the sociodemographic factors. Adjusted odds ratios (AORs) and 95% con dence intervals (CIs) are presented. The signi cance level α was set at 0.05, and all comparisons were two tailed.

Sample characteristics
A total of 358 adults were surveyed. The characteristics of the respondents are shown in Table 1. The mean age was 64.03 years (SD = 12.8), and most were aged 40-59 years (43.6%). A higher proportion of respondents were women (55.9%). Only 31.8% participants had an education level above high school. A higher proportion of the respondents had a monthly income less than the average city level (54.2%). Around half of the participants (45.5%) reported having contact with someone who had dementia, and around 80% of the participants had memory complaint.

Prevalence Of Beliefs And Knowledge About Dementia Prevention
Approximately 41.9% of the respondents agreed that dementia is caused by normal aging. Less than one third of the respondents (32.4%) agreed that dementia could be preventable.
The proportions of each item identi ed by the participants as a risk factor for dementia are presented in Fig. 1

Health Education Needs Of Dementia
Most respondents (88.9%) thought that they were not well informed of dementia from public education by the government, media, or medical institution. When asked about their preferred health education delivery format, most respondents would like to receive advice from family physicians and community nurses (65%), followed by education booklets (60.9%), community bulletin (53.4%), health talks by experts (45.5%), and regular peer sharing (36.6%).

Discussion
Latest evidence on the modi able risk factors of dementia provides a strong rationale for focusing on dementia prevention by reducing dementia risk factors.
The success of such efforts relies on the public's understanding of dementia. The results of the survey revealed that, although huge scienti c progress has been made on understanding the risk factors of dementia, a great gap still exists between the Chinese general public's understanding of dementia prevention and contemporary scienti c evidence. Additionally, beliefs on dementia prevention and an understanding of dementia risk factors are remarkably associated with sociodemographic variables, such as age, education level, income, having memory complaint, and having contact with patients with dementia. These ndings strongly suggest an urgent need to promote dementia prevention knowledge among the Chinese general public and develop different education strategies for people with different sociodemographic backgrounds.
Existing surveys of the general population on dementia prevention were predominantly conducted in Europe, the USA, and Australia. The results of the present study showed that 42.5% of our sample believed in the misconception that dementia is caused by normal aging and only 32.4% of them believed that dementia could be preventable. These proportions are even higher compared with those found in high-income countries, in which the survey results showed that 14-40% of the general public agreed that dementia is a part of normal aging [12][13][14] and 45-59% believed that dementia is not preventable [9,13,15].
This misconception may delay seeking professional help and taking health behaviors to reduce dementia risk factors. Overall, the knowledge level of the risk factors of dementia among the Chinese general public is poor. Among all the dementia risk factors, social and psychological risk factors were endorsed more by the respondents, and cardiovascular risk factors were less endorsed as dementia risk factors. Previous studies also found that people have less awareness of the role of cardiovascular disease management in the development of dementia [15,16]. This nding highlights the need to design health education programs that emphasize the important link between cardiovascular risk factors and dementia.
The ndings of this study regarding the factors associated with the beliefs of dementia prevention are consistent with previous studies [13,15]. People with older age, a low level of education, and no contact with dementia were less likely to believe that dementia can be preventable. This study identi ed that participants with younger age are less knowledgeable about dementia risk factors. This nding is the opposite of another web-based study conducted in Asia [17] but is consistent with the population-based survey conducted in Australia [18]. The inconsistency may be due to the different sampling methods across studies. The web-based study included young and highly educated participants, which may limit the representativeness of the samples. The nding that younger participants are positive about dementia prevention but know less about dementia risk factors may be due to the fact that the younger generation is less concerned about the onset of dementia compared with older adults. Many of the dementia risk factors, such as cardiovascular and lifestyle risk factors, are likely different at all life stages; thus, public health programs on dementia prevention education should be provided across all age groups. The effects of dementia prevention strategies can be maximized this way. Lower income and education level was also identi ed to be associated with a lower understanding of dementia risk factors. This nding is in agreement with several previous studies [10,19]. This may because this disadvantaged group has limited access to the dementia prevention information, which highlights that more attention and resources should be invested in this group. Participants who have memory complaint and contact with patients with dementia were more knowledgeable of dementia risk factors probably because the situation renders oneself to pay more attention to the knowledge of dementia.
The majority of the respondents thought that they were not well informed of dementia from public education. Thus, the government, media, and medical institutions, as well as the communities, to make efforts to better popularize knowledge of dementia. In addition, receiving advice from family physicians and health education from community nurses is the preferred health education delivery format of the participants. This nding highlights the important role of primary care providers in dementia prevention. Ongoing education on dementia prevention for primary care providers is needed to transfer the latest scienti c evidence to primary care practice.
Our study has several limitations that may in uence the interpretation of the results. First, the conclusion of causality cannot be drawn because of the limitations of the cross-sectional study design. A repeated measures design would be ideal to track the trends in dementia prevention knowledge and its predictors. Second, we adopted convenience sampling in this study; thus, selection bias may exist. Future studies should include a representative sample to increase the generalizability of the ndings. Lastly, this study only adopted a quantitative survey study to investigate the research questions. Future studies are recommended to use in-depth qualitative approaches as a supplement to enrich our understanding on the public's attitudes toward dementia prevention and its related factors.

Conclusion
The present study reveals the great gaps between the Chinese general public's knowledge of dementia prevention and the latest research evidence. The ndings highlight the need for greater public awareness of dementia prevention and enable the promotion of culturally appropriate strategies to increase public awareness. Speci cally, cardiovascular factors are the least endorsed by the public; hence, health education programs should emphasize the important link between cardiovascular risk factors and dementia. Special attention should be paid to the population with low income and low education, because they are associated with a low level of dementia prevention knowledge. We suggest this health advice could be delivered by primary care providers during routine chronic disease management, as we identi ed that the Chinese general public prefer receiving dementia-related health advice from family physicians and community nurses. The partnership between researchers and practitioners can help translate evidence into community practice in a timely manner.
Abbreviations AOR adjusted odds ratio con dence interval CNY Chinese Yuan Declarations Ethics approval and consent to participate This study was approved by the Survey and Behavioral Research Ethical Committee of Zhejiang Chinese Medical University (No. SBREC-20181231). All methods were carried out in accordance with the Declaration of Helsinki. Written consent was obtained from each participant. All information was kept strictly con dential.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Competing interest