Introduction
Dementia is one of the fastest growing health problems in the world. Currently, around 50 million people are living with dementia worldwide and due to the aging population this number will increase to an imposing 152 million in 2050 [
1]. Also in the Netherlands, it is expected that the number of people suffering from dementia will increase from 280,000 people in 2018 to more than 620,000 in 2050 [
2]. However, delaying the onset or progression of dementia could help to tackle these increasing prevalence rates. Therefore, the World Health Organization set up a global action plan which includes multiple actions such as making dementia a public health priority worldwide, increase dementia awareness and reduce the risk of dementia [
3].
Livingston et al.(2020) found that 40% of all dementia cases worldwide are attributable to 12 modifiable risk factors, including less education, hearing loss, midlife hypertension, midlife obesity, smoking, depression, physical inactivity, diabetes, low social contact, excessive alcohol consumption, traumatic brain injury, and air pollution [
4,
5]. However, despite the large potential for prevention, previous research showed that most people have little knowledge of these modifiable risk factors and the possibility to reduce their risk of dementia [
6‐
8]. Furthermore, changing health behaviour is difficult and complex [
9].
A number of health behaviour models were developed in order to understand health behaviour and the determinants of health behaviour change (e.g., health belief model (HBM), Trans Theoretical Model) [
10,
11]. Subsequently, these models contributed to the development of the Integrated Change model, which assumes that the process of health behaviour change can be distinguished in three phases: 1) Awareness, 2) Motivation and 3) Action [
12,
13]. In the first phase, individuals need to become aware of their unhealthy behaviours, where important factors are derived from the HBM, such as an individual’s subjective risk assessment of getting a condition, how serious this condition and its consequences are and cues to action [
10]. In the motivation phase, individuals need to become motivated to change health behaviour, where factors as the perceived benefits of health behaviour change, social influence and the confidence in being able to perform the desired behaviour are important. Subsequently, an intention to change health behaviour is formed [
11]. In the last phase, depending on the perceived barriers, this intention to change health behaviour is leading to actual health behaviour change by conducting preparatory actions [
12,
13].
Two studies examined the health beliefs and attitudes towards dementia (risk reduction) using the Motivation to Change Lifestyle and Health Behaviours for Dementia Risk Reduction (MCLHB-DRR) scale among the Australian (50 years and older) and Turkish (40 years and older) population [
14,
15]. Akyol et al. (2020) found that males had lower perceived severity and cues to action scores and higher perceived barriers scores compared to females. Older individuals had lower perceived benefits, cues to action and self-efficacy scores compared to younger individuals. Furthermore, less educated individuals had lower perceived benefits and self-efficacy scores and higher perceived barriers scores [
15]. However, Kim et al. (2014) only found significant age differences in males, but not in females [
14]. Furthermore, a few studies conducted in Australia and the United States of America investigated how these health beliefs influence the intention to engage in dementia risk reduction behaviours and showed that age, perceived benefits and barriers, self-efficacy and knowledge about dementia risk reduction are associated with the intention to adopt a healthy lifestyle for dementia risk reduction in general [
16,
17].
To our knowledge, no research is conducted to examine the knowledge, health beliefs and attitudes towards dementia (risk reduction) in the Netherlands and its association with the intention to change individual health behaviours. Therefore, the aim of this study was firstly, to investigate the knowledge, health beliefs and attitudes towards dementia (risk reduction) among the Dutch general population, secondly to what extent the knowledge, health beliefs and attitudes differ between demographic subgroups and finally, to investigate the association between these determinants and the intention to change health behaviours.
Discussion
This study shows that the knowledge about dementia (risk reduction) is poor among the Dutch general population. In addition, older participants perceived dementia as a more severe disease compared to younger participants, but they perceived less benefits and barriers of performing health-enhancing behaviour for dementia risk reduction and had less confidence in their ability to perform the desired behaviour. Highly educated participants perceived less barriers and more benefits, but also had more confidence in their ability to perform the desired behaviour compared to less educated participants. Furthermore, a large proportion of the participants had an unhealthy behaviour, of which only a small proportion had the intention to change health behaviour. Perceived benefits and cues to action were associated with the intention to change physical activity and alcohol consumption. Among younger excessive alcohol consumers, also perceived severity was associated with the intention to change alcohol consumption. Perceived barriers were associated with the intention to change diet. Among highly educated participants, also perceived benefits were associated with the intention to change diet, but inversely associated among the less educated participants. Smokers who perceived more barriers to change their smoking behaviour were less likely to have the intention to change this behaviour.
Knowledge about dementia and dementia risk reduction
A large proportion of the participants was unaware or had insufficient knowledge about dementia (risk reduction), especially older and less educated individuals. For instance, the majority (62%) of the participants had the misconception that dementia is a normal part of the ageing process. This percentage is slightly higher compared to the findings of previous studies over the world, where nearly half of the participants (median 48%, range 39–75%; 13 studies) believed that dementia is a normal part of ageing [
6]. Further, although 68% of the participants were aware of the possibility to reduce dementia risk by maintaining a healthy lifestyle, still a considerable proportion of the participants (25%) did not know whether it is possible to reduce dementia risk and only around a third (31%) of the participants indicated high blood pressure as a risk factor for dementia. These findings are quite similar to the findings of a recent survey conducted in the Netherlands [
7].
Health beliefs and attitudes towards dementia and dementia risk reduction
Older participants perceived dementia as a more severe disease compared to younger participants. This can be explained by the fact that dementia incidence increases with age and were therefore older individuals are more likely to know someone with dementia. On the other hand, older participants perceived less benefits, and barriers of performing health-enhancing behaviours and had less confidence in their ability to perform the desired behaviour compared to younger participants. This could suggest that older individuals may think that they benefit less from behavioural changes or do not benefit at all, reflecting the misconception that dementia is an inevitable age-related disease for which health behaviour changes might not be effective anymore to prevent of postpone cognitive decline. Further, highly educated participants perceived more benefits and less barriers to perform healthy behaviours and had more confidence in their ability to perform the desired behaviour. These findings are in line with previous findings [
15,
20]. Only two previous studies reported MCLHB-DRR subscale scores reflecting the health beliefs and attitudes towards dementia (risk reduction) among the Australian (50 years and older) and Turkish (40 years and older) population [
14,
15]. In comparison to our study, these studies showed slightly higher scores on a number of subscales of the MCLHB-DRR scale. However, these differences in subscale scores are relatively small when taking into account the different scoring possibilities in the Australian, Turkish and Dutch version of the MCLHB-DRR (see Additional file
1: Appendix 6). Furthermore, similarly to our study, they also found relatively high scores on perceived benefits and general health motivation.
Intention to change health behaviours
Among participants with unhealthy behaviours, perceived benefits and cues to action were associated with the intention to change physical activity and alcohol consumption, and perceived barriers were associated with the intention to change diet and inversely associated with the intention to change smoking behaviour. Moreover, perceived severity was associated with the intention to change alcohol consumption among younger individuals and perceived benefits was associated with the intention to change diet among higher educated individuals. These findings suggest that providing information about dementia symptoms and the benefits of health behaviour change for dementia risk reduction may enlarge the intention to change physical activity and alcohol consumption. In case of diet, we found that having more barriers could lead to the intention to change diet for reducing dementia risk. This is not what we would expect. However, this may also reflect that people are having problems (barriers) with changing their diet. A previous study has shown that healthy eating comes with a lot of barriers, such as time and taste related factors [
31]. Therefore, individuals who are taking preparatory actions in order to improve their diet might experience more barriers compared to individuals who do not have the intention to change their diet. Among higher educated individuals, we found that perceiving more benefits of changing lifestyle for dementia risk reduction could lead to the intention to change diet, while the opposite is true for lower educated individuals. These results could indicate that lower educated individuals might think that they have a healthy diet and do not need to change their diet. Therefore, education about a healthy diet is important, especially among the lower educated individuals. Further, we found that having less barriers could lead to the intention to change smoking behaviour for reducing dementia risk. Therefore, interventions to change smoking behaviour should focus more on lowering the barriers to enhance the intention to change smoking behaviour. More research is needed to get insight in the specific barriers for changing smoking behaviour. In general, our findings are consistent with previous studies [
16,
17].
Strengths and limitations
This is the first study that investigated the health beliefs and attitudes towards dementia (risk reduction) in the Dutch general population. A major strength of this study was the stratified random sample and its adequate sample size of 655 participants. This study had, however, certain limitations. First, the response rate was relatively low (17%), despite several attempts to increase the response rate (i.e., an easily accessible link to the survey, lottery to win a voucher and an offer to receive the findings of the survey). Furthermore, 60% of our study population consisted of highly educated individuals, which is a representative sample of the municipality of Groningen, but not for the Dutch general population. Further, it might not be clear to which behavioural changes participants were referring to when completing the MCLHB-DRR questionnaire. For instance, with the statement ‘Changing my lifestyle and health habits can help me reduce my chance of developing dementia’, participants could refer to a specific health behaviour, for example smoking or physical activity. Participants possibly did not even know whether and which health behaviours are important risk factors for dementia.
Implications
The findings of this study indicate that individuals’ knowledge, health beliefs and attitudes towards dementia (risk reduction) need to be improved, which can be done in several ways. First, especially younger individuals should become more aware of the symptoms and severity of dementia. For example, by creating a more dementia friendly society in which lessons are given on what dementia is, what difficulties patients with dementia may experience and how this affects their families. This may help younger individuals to acknowledge the importance of a healthy lifestyle for reducing the risk of developing dementia later in life. Second, the perceived benefits of health behaviour change should be emphasized, especially among older and less educated individuals. This may help to motivate these individuals to adopt a healthier lifestyle in order to reduce their dementia risk. Finally, further research should explore the perceived barriers to change their smoking behaviour and diet and the cues to action to change their physical activity and alcohol consumption.
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