Perceptions About and Engagement in Behaviors to Reduce the Risk of Dementia Among Adult Persons in Israel

Abstract

Background

Engagement in behaviors aimed at reducing the risk of developing dementia is a leading recommendation in most National Dementia Strategy programs.

Objective:

In an effort to advance knowledge regarding the implementation of this recommendation, the current study examined the perceptions and engagement of the adult population in Israel regarding behaviors aimed at reducing the risk of developing dementia, and its correlates.

Methods:

A cross-sectional survey was conducted among 502 Israeli adults aged 40 and over. Approximately half of the participants (51.2%) were female, and the majority (80.1%) were Jewish.

Results:

Overall, while the percentage of participants reporting that the examined activities were important for brain health was moderate, percentages reporting engaging in these behaviors were low. The most important correlate of engagement in health behaviors was participants’ perceptions about the importance of these behaviors for their brain health. Increased age, being Jewish, and enhanced perceived susceptibility to develop dementia were also significantly associated with increased engagement in behaviors to reduce the risk of dementia.

Conclusion:

The results of this study emphasize the need to develop intervention programs aimed at promoting engagement in behaviors to reduce the risk of dementia development. These programs will benefit from assessing participants’ perceived importance of these behaviors, and from identifying the needs of unique groups, such as older persons and those pertaining to ethno-cultural groups.

Keywords

Behavior brain health dementia perceptions prevention risk-reduction

INTRODUCTION

With the anticipated increase in the number of persons with dementia [1], but with no foreseeable treatment or cure to it, reducing the risk of cognitive deterioration has become a public health priority. Referred to as “risk reduction”, “prevention”, or “securing brain health”, the core of this priority is to maintain cognitive health and/or to delay the development of dementia [2].

Accordingly, during the last years considerable efforts have been invested to detect and examine modifiable factors to reduce the risk of cognitive deterioration. Evidence from numerous observational studies shows that midlife obesity, high blood pressure, high cholesterol, diabetes, decreased physical activity, and smoking are among the most important dementia risk factors. Less robust, but still consistent findings show that poor diet, low levels of cognitive activity, and excessive alcohol consumption are also correlates of cognitive decline [3 –6].

Following this epidemiological knowledge and the findings of several recent single and multi-domain interventions (for a review, see Lee and colleagues [7]), dementia-oriented strategic initiatives worldwide stress the importance of enhancing laypersons’ awareness and engagement in behaviors aimed at reducing these risk factors in order to improve brain health [8, 9]. Reducing the risk of developing dementia is a common and leading recommendation in most of these initiatives [10, 11]. The most notable one is the recent publication of the World Health Organization guidelines on how to address the most significant risk factors for developing dementia. Twelve modifiable risk factors are evaluated within these guidelines, and implementation recommendations are offered based on the strength of the accumulated evidence [12].

Accordingly, several studies have evaluated laypersons’ perceptions regarding dementia risk factors [13 –16]. However, only four studies examined actual engagement in risk-reduction behaviors [15 , 18], and to the best of our knowledge, no prior study has yet examined the correlates of this engagement. Moreover, since the main priority is to move toward the implementation of these recommendations at an individual level [19, 20], the aim of this study was to examine perceptions about and engagement in behaviors aimed at reducing the risk of developing dementia among the adult population in Israel.

METHODS

Design and sample

A cross-sectional survey was conducted with a sample of participants aged 40 and above, taken from the Israeli population. This age group was selected because of its relevance to the study topic. Potential participants were recruited from a comprehensive internet panel through a major Israeli internet panel company (P value, https://www.p-value.co.il), which maintains panels of potential participants for the entire Israeli population. Participants in this panel are recruited from a pre-registered pool of participants who agreed to respond to questionnaires and receive credits for small redeemable rewards in exchange for their participation. Prior to sending the questionnaires, participants are randomly chosen according to gender and age. In this study, potential respondents were invited to participate in an online survey for a limited period (June 18, 2019 through July 10, 2019). Once quotas by gender, age, and ethno-cultural group were reached for each parameter, the survey was closed.

Measures

Based on previous surveys assessing brain health perceptions among laypersons [14 , 17], a structured questionnaire was used to assess the variables listed below.

Perceptions about the importance of engaging in behaviors to reduce the risk of dementia

Participants were asked to rate on a 5-point Likert-type scale (1 = not at all important, 5 = very much important) the extent to which they believe each one of eight behaviors are important for reducing the risk of dementia. Four of these behaviors were issued with strong recommendations by the WHO guidelines (physical activity, tobacco cessation, management of hypertension, and reduced cholesterol levels). The other four were issued with conditional recommendations (health nutritional activity, reduction or cessation of alcohol use, cognitive training, and weight management). Two overall indices— one for behaviors with strong recommendations and one for behaviors with conditional recommendations— were calculated by averaging participants’ responses.

Engagement in behaviors to reduce the risk of dementia

Participants were requested to report whether they participate (1) or don’t participate (0) in each one of the above-mentioned behaviors in order to reduce their risk of developing dementia. Two overall indi-ces, one for behaviors with strong recommendations and one for behaviors with conditional recommendations, were calculated by summing the number of behaviors in which participants reported engaging to maintain their brain health.

Dementia-related perceptions

Similar to previous studies [21], these included subjective knowledge about dementia, perceived susceptibility and worry about developing dementia, and familiarity with dementia.

Subjective knowledge about dementia was assessed with a single question: “How much do you know about dementia?” Answers were rated on a 5-point Likert-type scale, ranging from 1 = not much at all to 5 = very much.

Perceived susceptibility

Perceived susceptibility was assessed with a single question: “How likely do you think it is that you will develop dementia?” Answers were rated on a 5-point Likert-type scale, ranging from 1 = not at all likely to 5 = very likely.

Worry

Worry was assessed with a single question: “How much do you worry that you will develop dementia?” Answers were rated on a 5-point Likert-type scale, ranging from 1 = not at all worried to 5 = very worried.

Familiarity

Familiarity was assessed by asking participants if they knew someone with AD among their relatives or acquaintances.

Socio-demographic variables

These included gender, age, education (non-aca-demic and academic), ethno-cultural group (Jewish or Arab), religiosity (secular, traditional, religious, or orthodox), and perceived economic status (very bad, bad, fair, good, or very good).

Health-related variables

These included perceived general health (very bad, bad, good, very good or excellent) and perceived brain health (very bad, bad, good, very good or excellent).

Statistical analysis

The data were cleaned, coded and analyzed using SPSS version 25.0. Descriptive statistics (percentages, means, standard deviations) were used to describe the sample and the main variables. An Ordinary Least Squares (OLS) hierarchical regression was conducted in order to examine correlates of engagement in strongly and conditionally recommended behaviors for reducing the risk of dementia. In the first step, we included background variables. In the second step, dementia-related perceptions were entered, followed by perceptions regarding the importance of risk reduction behaviors. We tested for multicollinearity, and the results indicated that the variance inflation factor (VIF) exceeded 2.3 for susceptibility and worry about developing dementia. Thus, only the first one was included in the regression. A p value of <0.05 was considered statistically significant for all the analyses.

Ethical considerations

The study was approved by the University of Haifa’s Ethics Committee.

RESULTS

Participants’ background characteristics

A total of 502 adults participated in the study. As can be seen in Table 1, the mean age was 52; approximately half of the participants were female and the rest were male. The majority of the participants (80.1%) were Jewish, secular or traditional, and the rest non-Jewish (44% of them were Muslim, 35% Christian, and 21% Druze). Finally, the majority of the participants reported having an academic education. Regarding their health characteristics, the majority of the participants reported having very good or excellent general and brain health.

Table 1

Study participants’ background characteristics (n = 502)

Socio-demographic characteristic
Gender (%)
Female	48.8
Male	51.2
Mean age (SD; range)	51.7 (8.2; 40– 75)
Education (%)
Non-academic	39.0
Academic	61.0
Perceived economic status (%)
Very bad + bad	53.4
Fair + good + very good	46.6
Ethno-cultural group (%)
Jewish	80.1
Arab (Muslim, Christian, Druze)	19.9
Religiosity (%)
Secular + traditional	83.9
Religious + orthodox	16.1
Health characteristics
Perceived general health (%)
Very bad + bad	20.1
Good	12.0
Very good + excellent	67.9
Perceived brain health (%)
Very bad + bad	22.1
Good	18.3
Very good + excellent	59.6

Dementia-related perceptions

As seen in Table 2, less than half of the participants reported knowing someone with dementia, having a high to a very high chance of getting dementia, and worrying about it. The majority, however, perceived themselves as having high to very high knowledge about the disorder.

Table 2

Dementia perceptions (n = 502)

Perceptions	Percentage
Knows someone with AD	47.6
Perceived knowledge about dementia
Very high + high	64.7
Moderate + low + very low	35.3
Susceptibility of getting dementia
Very high + high	47.0
Moderate + low + very low	53.0
Worry about getting dementia
Very high + high	44.2
Moderate + low + very low	55.8

Perceptions about the importance of behaviors for reducing the risk of developing dementia

As seen in Table 3, the majority of the participants (between 62% to 72%) believed reducing the use of alcohol, adhering to a healthy diet, and cognitive training are important activities for reducing the risk of developing dementia. Somewhat lower percentages believed that no smoking and reducing cholesterol levels (59% and 53%, respectively) are also important. Overall, participants attributed a significantly higher importance to activities with a conditional recommendation than to activities with a strong recommendation (mean = 3.6 and 3.4, respectively, t₍₅₀₁₎ =−6.1, p < 0.001).

Table 3

Perceptions of importance and engagement in activities for brain health (n = 502)

Activity	Importance	Engagement
	(% 4 + 5)	(% yes)
Activities with strong recommendations
Physical activity	47.1	41.2
Tobacco cessation	59.4	44.8
Management of hypertension	47.2	40.4
Reduce cholesterol levels	53.0	45.2
Overall mean (SD)	3.4 (0.61)	1.7 (1.0)
Activities with conditional recommendations
Healthy nutritional activity	62.5	49.0
Reduction or cessation of alcohol use	72.5	51.8
Cognitive training	62.2	49.8
Weight management	43.6	37.8
Overall mean (SD)	3.6 (0.60)	1.9 (1.2)

Engagement in behaviors for reducing the risk of developing dementia

Relatively low percentages of participants reported engaging in behaviors specifically with this aim (Table 3). Overall, participants reported engaging in a significantly higher number of activities with a conditional recommendation than with a strong recommendation (mean = 1.9 and 1.7, respectively, t₍₅₀₁₎ =−2.8, p < 0.01).

Correlates of engagement in behaviors

The results of the regressions performed to assess the correlates of engagement in behaviors to reduce the risk of dementia, are presented in Table 4. Demographic variables were entered in the first step, as dummy or continuous variables: gender (1-male, 0-female), age (continuous), education level (1-above high school, 0-high school and below), and economic status (1-very bad, 5-excellent, Skewness = 0.49, SE = 0.11), ethnicity (1-Jewish, 0-Arab), and religiosity (1-secular, 0-religious/partly religious). Perceived general health and perceived brain health were entered in the second step as dummy variables (1-very good, 0-good/moderate). Subjective knowledge (1-good, 0-lower), susceptibility of being sick with dementia (1-higyh, 0-lower), and familiarity with a person with dementia (1-yes, 0-no) were entered in the fourth step. Finally, perceptions of importance (continuous) was entered in the fourth and final step. Skewness values for all continuous variables, including the dependent ones, ranged between -0.37 and 0.49 (SE = 0.11), thus indicating no diversion from normality.

Table 4

Correlates of engagement in risk reduction behaviors¹ (n = 502)

	Activities with
	strong recommendations	conditional recommendations
Socio-demographic characteristics
Gender-male	0.02	0.01
Age	– 0.14^***	– 0.15^***
Education- above high school	– 0.01	0.05
Perceived economic status	0.05	0.01
Ethnicity- Jewish	0.08^*	0.13^***
Religiosity- secular	– 0.06	0.02
Adjusted R²	0.03^**	0.04^***
Health characteristics
Perceived general health- very good	– 0.03	– 0.08
Perceived brain health- very good	0.01	– 0.01
Adjusted R²	0.03^**	0.04^***
Dementia-related perceptions
Subjective knowledge- high	0.08^*	0.10^**
Susceptibility of getting dementia- high	0.15^***	0.15^***
Knows someone with dementia- yes	0.01	0.01
Adjusted R²	0.07^***	0.08^***
Perceptions of importance	0.61^***	0.52^***
Overall adjusted R²	0.45^***	0.35^***

¹Numbers in the table are standardized betas. ^*p < 0.05; ^**p < lt;0.01; ^***p < 0.001.

Several interesting findings can be observed. First, identical factors were found to be significantly associated with activities with a strong or conditional recommendation. Second, perceptions about the importance of the different activities for reducing the risk of developing dementia was found to be the most important correlate of engagement in both types of activities. Indeed, this variable added 38% and 27% to the explained variance of engagement in activities with a strong and a conditional recommendation, respectively. Third, of the socio-demographic characteristics, increased age and being Jewish were significantly associated with increased engagement in behaviors. Fourth, health characteristics did not contribute at all to the explanation of the dependent variables. Finally, higher subjective knowledge and higher perceived susceptibility were associated with increased engagement in both types of behaviors.

DISCUSSION

Overall, the percentage of participants reporting that the examined activities were important for brain health was moderate. The three activities with the highest percentage of participants who perceived them as important were: reducing or stopping the consumption of alcohol, adhering to a healthy diet, and cognitive training. Interestingly, these activities received only conditional recommendations in the WHO guidelines, meaning that the balance between the desirable and undesirable effects of the activity remains uncertain [12]. These findings might simply reflect the fact that these are well-known health behaviors, which are frequently mentioned in the media and other channels as being important to maintaining an overall healthy lifestyle [22]. Moreover, in Israel, around the time of this study, the Ministry of Health launched a healthy diet campaign [23] which, although not specific to cognitive functioning, stressed the benefits of this behavior. Finally, it should be noted that the WHO recommendations were publicized on the Israeli Alzheimer’s Association’s website, and through an international conference only shortly before we collected our data. Thus, we can assume that this information either did not reach the entire adult population or was not understood, especially in regards to the strength of evidence behind each recommendation.

Similar to surveys conducted in Australia [15, 18], but contrary to a survey conducted in the United States [24], low percentages of participants in our study considered management of hypertension and reducing cholesterol levels as important activities for reducing the risk of developing dementia. It should be noted that the WHO guidelines made strong recommendations in regard to these factors, despite the continuing debate about the strength of evidence behind the protective effect of vascular factors for cognitive functioning [6, 25].

Finally, although the percentage of participants engaging in specific activities was consistently lower than the percentage that reported considering each activity as being very important, the disparity between perceptions of importance and reported behavior was smaller in our study than in other surveys [15, 18]. This difference might stem from the age composition in our study, which included persons aged 40 and over, compared to other surveys in which a third of the participants were between 20 to 40 years of age. Moreover, as stated in the Introduction section, in the last five years since the other studies were conducted, worldwide efforts to increase awareness and engagement in behaviors to reduce the risk of developing dementia have increased considerably.

Our multivariate analyses revealed that several of the examined variables were significantly associated with engagement in behaviors to reduce the risk of developing dementia. With regard to socio-demographic variables, evidence showed that age was negatively associated with engagement in both types of activities. While a similar trend was reported by Hosking and colleagues [15], Smith and colleagues [18] found that the direction of the associations vary according to the type of activity examined. Future studies should try to further elucidate these relationships, especially since a better understanding might help develop effective interventions to involve older adults in health behaviors geared toward improving their physical and brain health [26].

Consistent with studies examining associations between ethno-cultural groups and health behaviors in a variety of countries [27], as well as in Israel [28], we found specifically that the Arab sector in Israel was associated with lower levels of engagement in both types of behaviors. This is an important finding, since it has been demonstrated that the prevalence of Alzheimer’s disease is especially high among the Arab population in Israel [29]. This finding suggests that engaging in behaviors to reduce risk of the disorder might be especially needed in this group.

Susceptibility to develop dementia was the only dementia-related perception significantly associated with engagement in behaviors to reduce the risk of dementia. This is not surprising, as this variable, which reflects participants’ beliefs about the likelihood of developing the disease, is one of the central constructs in the Health Belief Model— the most commonly used framework to understand the adoption of preventive behaviors [30]. We recommend that future studies will also examine the contribution of the model’s other main constructs (perceived severity, perceived benefits, and perceived barriers), to increase the model’s validity regarding explaining the adoption of health behaviors aimed at reducing the risk of cognitive decline.

However, our study showed that the most important correlate of engagement in health behaviors was participants’ perceptions about the importance of these behaviors for their brain health. Indeed, this variable by itself added a substantial portion to the explained variance in the dependent variable for both types of behaviors. This finding contributes to the conceptual and practical advancement of the field. Conceptually, although similar to several of the constructs included in cognitive health behavior models (such as perceived benefits in the Health Belief Model), very few studies have examined the specific contribution of this notion to engagement in health behaviors, in general [31], and none for brain health, in particular. Future studies should therefore expand the understanding of this concept with the aim of including it in interventions in order to promote brain health.

Several limitations of the current study are important to note. First, the generalizability of the study is limited based on the convenience sample recruitment method, resulting in a highly-educated sample, which might undermine the validity of the findings. Second, the study’s cross-sectional design does not allow us to draw causal relationships. Third, we relied on participants’ subjective reports, which might have resulted in social desirability bias. Fourth, we used measures that did not have known psychometric properties (such as reliability and validity) and several concepts were assessed using single questions. Fifth, although we assessed a variety of health behaviors, our multivariate analyses concentrated on the examination of a global measure of engagement. Although the use of a broad definition of health behavior is recommended with older adults [26], examining different types of behaviors separately might provide richer information for the development of interventions.

Conclusions and future perspectives

As the understanding of modifiable factors to reduce the risk of cognitive decline and dementia expands, there is an urgent need to translate this knowledge into practice. Several conclusions are evident from our findings. These show that the strategic policy documents developed worldwide, including Dementia National Strategy Programs in many countries, as well as the WHO guidelines have not had enough of an impact on what adult persons actually do in order to reduce their risk for cognitive decline and developing dementia. While these initiatives are certainly important when it comes to highlighting priorities and directions, in order to implement recommendations at the individual level, there is need to establish direct communication with the target population. Health professionals, who are in direct and continuous contact with this population, can disseminate knowledge and motivate engagement in behaviors aimed at improving brain health to achieve this goal.

However, this knowledge should be geared to the unique needs and preferences of different sectors of the population. For example, our findings showed that special attention should be invested to clarify the motivations behind the lower levels of engagement among older persons and among those pertaining to minority ethno-cultural groups. Finally, intervention programs aimed at promoting involvement in behaviors to reduce the risk of developing dementia will benefit from assessing participants’ perceived importance of these behaviors.

DISCLOSURE STATEMENT

Authors’ disclosures available online (https://www.j-alz.com/manuscript-disclosures/20-0780r1).

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