Association of Knowledge About Dementia with Two Dimensional Attitudes Among a Community Population in South Korea

Abstract

Background:

Providing correct information about dementia and people living with dementia and improving the attitude toward the disease have important implications in overcoming prejudice and negative perceptions and strengthening the social support system. However, studies are limited about which aspects of dementia knowledge affect attitudes toward it and the influence of such knowledge on particular aspects of such attitudes.

Objective:

This study examined which part of dementia knowledge affects attitudes toward dementia and, furthermore, the influence of such knowledge on two aspects of attitudes in the general population.

Methods:

A population-based cross-sectional survey of 1,200 participants aged 20 years or older was adopted. A landline and wireless telephone survey was conducted from October 12 to October 22, 2021. The survey data included self-report questions about dementia knowledge, dementia attitudes, demographics, and family information. Multiple linear regression analysis was performed.

Results:

Dementia knowledge was positively associated with global dementia attitudes. In terms of the relationship between the two dimensions of dementia attitudes and knowledge, the latter displayed a significant positive association with accepting attitudes (β= 0.121, p < 0.001) but not with affective attitudes (β= 0.064, p = 0.084). Among dementia knowledge, dementia symptom/diagnosis and policy categories were positively associated with accepting attitudes (β= 0.198, p = 0.006; β= 0.357, p < 0.001).

Conclusion:

Our study suggests that people with more dementia knowledge have more accepting attitudes toward dementia. It may be effective to continue education on dementia to improve the public accepting attitudes. However, to improve negative emotional attitudes toward dementia, various approaches beyond education may be needed.

Keywords

Attitude dementia knowledge population

INTRODUCTION

More than 55 million people worldwide live with dementia. It is estimated that this number will reach 78 million by 2030, which will be a significant social burden in the future [1]. In the case of people living with dementia, social stigma is still a barrier to receiving a diagnosis, and it has been reported that about half of people living with dementia and caregivers do not have appropriate information about available support at the time of diagnosis [1, 2]. The International Alzheimer’s Association reports that a lack of awareness and understanding of dementia is associated with not seeking care when symptoms are present, refusal to seek early screening, not utilizing available treatment resources, and refusal to utilize support systems [3]. Good knowledge about the symptoms of Alzheimer’s disease is related to a higher intention to approach information on healthcare services [4]. Lack of information and understanding about dementia increases the burden of care on the family and lowers the level of care [5, 6]. Therefore, it can be argued that providing correct information about dementia and people living with dementia and improving the attitude toward the disease have important implications in overcoming prejudice and negative perceptions and strengthening the social support system[7 –9].

Many studies have investigated the level of knowledge of dementia. A systematic review reported that the understanding of dementia in the general population is fair to moderate [10]. The results indicated that age, education, gender, and ethnicity were related to knowledge of dementia [11 –15]. In terms of the attitude toward the disease, some studies evaluated attitudes by dividing them into several categories [16, 17]. These studies have also demonstrated an association between demographic characteristics and attitudes.

A cross sectional study in Ireland reported that greater knowledge about dementia was rather related to negative feeling to dementia [18]. A systematic review study reported that stigmatizing attitudes were more prominent in people with limited AD knowledge and in little contact with people living with dementia, reporting inconsistent result [19].

However, it is important to determine which aspects of dementia knowledge affect attitudes toward it and the influence of such knowledge on particular aspects of such attitudes. These investigations could help to establish evidence-based policies for educating and promoting knowledge about dementia in the general population.

In this study, 1) we investigated the level of dementia knowledge and attitudes toward dementia in the general public (laypersons) representing the entire country, 2) investigated the association of dementia knowledge on dementia attitudes, and 3) divided dementia attitudes into accepting and affective attitudes to study the relationship between dementia knowledge and specific dementia attitudes.

MATERIALS AND METHODS

Participants

From October 12 to 22, 2021, a total of 1,200 general citizens over the age of 19 in 17 cities and provinces nationwide were included to understand the general public’s knowledge and attitudes about dementia. Landline and wireless telephone surveys were conducted. The subjects were assigned to 17 metropolitan cities, and provinces nationwide and stratified by gender and age group (19–29, 30–39, 40–49, 50–59, 60–69, and ≥70 years). A sample of fixed size was selected using random digit dialing from the population with all members having the same probability of being selected. Participants who consented to the interview via telephone completed a self-report questionnaire.

Questionnaire

The scale of dementia attitudes in this study reflected the contents of the Dementia Attitudes Scale (DAS) [20]; however, when it was translated, awkward phrases were corrected, and items with little relevance were excluded to match the purpose of the evaluation tool to check the level of dementia attitudes of ordinary people (e.g., “I am confident when I am with people living with dementia.”, “I am comfortable when I am in physical contact with an older people living with dementia.”, etc.). In addition, 13 items were derived by adding questions that considered emotional and behavioral aspects. Finally, a total of 12 items were applied to the final analysis, except for one item because, due to ambiguity, the internal agreement was less than 0.6. Each item was scored on a 4-point Likert scale, ranging from 1 = not at all likely to 4 = very likely.

In the present study, moderate reliability of the dementia attitude measure was demonstrated (Cronbach’s α= 0.66), and five experts with clinical and research knowledge in the field of geriatric psychiatry examined the content validity of the dementia attitude measure. To confirm the factor structure of the scale, factor analysis was performed and defined as two dimensions. In a previous study, existing attitudes had three aspects: cognitive, emotional, and behavioral [21]. The DAS was also defined as two dimensions, considering that cognitive and emotional aspects of attitudes [20]. The first dimension named accepting attitudes, was composed of aspects such as “caring for people living with dementia is rewarding”, and “I will do my best to help people living with dementia if they ask for help.”. In the second dimension, items that revealed the emotional aspect of dementia, such as ‘I am afraid of people living with dementia” and “the family of people living with dementia will be desperate.” were named affective attitudes.

In terms of the dementia knowledge scale, the early diagnosis, treatment, prevention, and policy regarding dementia were clearly explained, except for the content that were difficult for the general public to know the answer to or only have fragmentary knowledge about. There were taken from the content developed for the Ministry of Health and Welfare’s 2008 survey on the prevalence of dementia and have been expanded to questions that are practically helpful in coping with dementia, consisting of 20 questions in four dimensions (cause, symptom/diagnosis, treatment/prevention, and policy of dementia), with five questions in each. For each question, a respondent could only answer true or false; if they answered each question correctly, it was scored as 1, and the total score ranged from 0 to 20.

Additionally, the questionnaire included demographic information such as age, gender, education (less than 9 years, 9–12 years, 12–16, 16<), occupation, marital status, religion, economic status (monthly income), and Person living with dementia in family or relatives. This study was approved by the Ethics Committee of Myongji Hospital of South Korea (2021-08-003).

Statistical analysis

Descriptive statistics with mean, standard deviation, and percentage were used to describe the demographic data and dementia knowledge and attitudes. Multiple linear regression was used to investigate the association between dementia knowledge and attitudes toward dementia. In the case of dementia attitudes, items 2, 5, 6, 11, and 12 were inverse weight items, and the score was changed inversely during the analysis (4 to 1, 3 to 2, 2 to 3, and 1 to 4). Model 1 was adjusted for age, gender, and education, and Model 2 was adjusted for occupation, marital status, economic status, and Person living with dementia in the family or relatives, as well as for model 1. Jamovi ver. 2.2.5 was used for the statistical analyses. Statistical significance was set at p < 0.05 with a two-sidetest.

RESULTS

Characteristics of participants

Table 1 summarized the characteristics of the 1,200 participants. The participants included 631 women (52.6%). A total of 256 participants (21.3%) were in the 51–59 years group, which was the largest number of participants in all age groups, and 224 (18.7%) were 70 years of age or older. Among the participants, 812 (67.7%) were married, and 778 (64.8%) responded that they had a person living with dementia in their family or relatives.

Table 1

Respondent characteristics

Variable	N (%)
Sex
Female	631 (52.6)
Male	569 (47)
Age (y) (%)
19∼29	184 (15.3)
30–39	156 (13.0)
40–49	187 (15.6)
50–59	256 (21.3)
60–69	193 (16.1)
≥70	224 (18.7)
Education (%)
0–9	579 (48.2)
10–12	346 (28.8)
≥13	266 (22.2)
No response	9 (0.8)
Occupation (%)
Employed	705 (58.8)
Unemployed/other	495 (41.2)
Marital status (%)
Married	812 (67.7)
Unmarried	314 (26.2)
Other/no responder	74 (6.2)
Monthly income^*
Low	314 (50.8)
High	404 (33.7)
No responder	187 (15.6)
Person living with dementia in the family or relatives
Yes	778 (64.8)
No	422 (35.2)

^*Low and high income were defined as <4 and ≥4 million won (about 3,080 dollars).

Dementia knowledge

The mean overall knowledge score was 15.4±2.2 out of 20 points. When converted to a 100-point scale, this corresponded to 77 points. For each question, the percentage of correct answers ranged from 36.5% to 95.2%. “Dementia can be cured depending on the type.” had the lowest correct answer rate at 36.5%, followed by “People living with dementia always have problem behaviors.” with a rate of 43.9%. “Early diagnosis and treatment can delay the deterioration of dementia.” Had the highest correct answer rate at 95.2%, followed by “You can receive a dementia screening test at the Dementia Counselling Center (DCC).” with a 95% correct rate. When divided by category, the symptom/diagnosis category obtained a relatively low correct answer rate of 69.8%, while the highest rate was for the care and policy category at 87.9% (Table 2).

Table 2

Dementia knowledge questionnaire

Category	Questions	True/False	Correct answer n (%)	Overall correct rate %
Cause	1 Dementia is a brain disease	T	1097 (91.4)	75.8
	2 The most common cause of dementia is Alzheimer’s disease	T	894 (74.5)
	3 Stroke can lead to dementia	T	880 (73.3)
	4 Excessive drinking can cause dementia	T	1068 (89.0)
	5 Head injuries can lead to dementia	T	611 (50.9)
Symptom/Diagnosis	6 Dementia should be suspected if personality changes in old age	T	937 (78.1)	69.8
	7 Depression and dementia often coexist	T	744 (62.0)
	8 If you remember things from a long time ago well, you do not suffer from dementia	F	899 (74.9)
	9 People living with dementia always have problem behaviors	F	527 (43.9)
	10 To be diagnosed with dementia, a neuropsychological examination and brain imaging examination must be performed	T	1080 (90.0)
Prevention/treatment	11 Dementia can be cured depending on the type	T	438 (36.5)	74.3
	12 Regular exercises can prevent dementia	T	1020 (85.0)
	13 Dementia can be prevented if hypertension/hyperglycemia /hyperlipidemia is well treated	T	840 (70.0)
	14 If you are diagnosed with dementia, you should take cognitive function improvement drugs	T	1020 (85.0)
	15 Early diagnosis and treatment can delay the deterioration of dementia	T	1142 (95.2)
	Policy	16 You can receive a dementia screening test at the Dementia Counselling Center	T	1140 (95.0)	87.9
	17 People living with dementia are not eligible for long-term care services	F	924 (77.0)
	18 People living with dementia can use day care centers	T	1065 (88.8)
	19 An adult guardian can be appointed to help people living with dementia make decisions	T	1116 (93.0)
	20 All people living with dementia must be admitted to a nursing home	F	1030 (85.8)

Association of dementia knowledge with dementia attitudes

Multiple linear regression was used to evaluate the relationship between dementia knowledge and global dementia attitude (Table 4). Adjusting for age, sex, education, occupational history, income, person living with dementia in the family or relatives, and marital status, dementia knowledge exhibited a positive association with global dementia attitudes (β= 0.185, p < 0.001). In terms of the relationship between the two dimensions of dementia attitudes and dementia knowledge, after adjusting for age, sex, education, occupation, income, Person living with dementia in the family or relatives, and marital status, dementia knowledge displayed a significant positive association with accepting attitudes (β= 0.121, p < 0.001). In contrast, dementia knowledge did not present a significant association with affective attitudes (β= 0.064, p = 0.084).

Table 3

Dementia attitudes questionnaire

Category	Questions (Attitude)	Mean (SD)
2 affective	I am afraid of people living with dementia.	2.1 (0.9)
3 accepting	Caring for people living with dementia is rewarding.	2.8 (0.8)
4 accepting	People living with dementia also feel joy and sorrow	3.1 (0.8)
5 affective	Families of people living with dementia will be desperate.	3.0 (0.8)
6 affective	I don’t want to be close to people living with dementia.	2.5 (0.8)
7 affective	Behavioral issues of people living with dementia can be sufficiently alleviated	2.5 (0.8)
8 accepting	When people living with dementia ask for help, I will do my best to help.	3.1 (0.6)
9 Affective	Even if people have dementia, they can live happily enough.	2.6 (0.8)
10 accepting	People living with dementia have the right to be respected.	3.4 (0.6)
11 affective	I don’t want to associate with people living with dementia.	2.5 (0.8)
12 accepting	Having dementia is a shame.	3.1 (0.7)
13 accepting	If there are people living with dementia. around, I will help them obtain dementia support services.	3.4 (0.6)

Table 4

Association of dementia knowledge with dementia attitude

Dementia knowledge	Total attitude			Accepting attitude			Affective attitude
	Beta	SE	p	Beta	SE	p	Beta	SE	p
Model 1^†	0.197	0.051	<0.001	0.128	0.030	<0.001	0.069	0.037	0.061
Model 2^‡	0.185	0.051	<0.001	0.121	0.030	<0.001	0.064	0.037	0.084

^†Adjusted for age, sex, and education. ^‡Adjusted for age, sex, education, occupation, marital status, economic status (monthly income), person living with dementia in the family or relatives.

Association of the categorical score of dementia knowledge with accepting dementia attitudes

Regarding the association of the categories of dementia knowledge with accepting dementia attitudes, dementia symptoms/diagnosis and policy items were significantly associated with acceptance attitudes (β= 0.198, p = 0.006; β= 0.357, p < 0.001) (Table 5). However, the cause and prevention/treatment categories were not significantly associated.

Table 5

Association of dementia knowledge category with dementia attitude

Dementia knowledge	Total attitude			Accepting attitude
	Beta	SE	p	Beta	SE	p
Model 1^†
Cause	–0.355	0.167	<0.001	0.016	0.064	0.797
Symptom/Diagnosis	0.493	0.121	<0.001	0.213	0.072	0.003
Prevention/Treatment	0.352	0.114	0.002	0.048	0.068	0.484
Policy	0.646	0.141	<0.001	0.371	0.084	<0.001
Model 2^‡
Cause	–0.358	0.107	<0.001	0.014	0.064	0.831
Symptom/Diagnosis	0.462	0.121	<0.001	0.198	0.072	0.006
Prevention/Treatment	0.353	0.114	0.002	0.049	0.068	0.471
Policy	0.625	0.142	<0.001	0.357	0.085	<0.001

^† Adjusted for age, sex, and education. ^‡Adjusted for age, sex, education, occupation (binary), marital status, economic status binary (monthly income), person living with dementia in the family or relatives.

DISCUSSION

The general public’s average dementia knowledge was found to be 15.4 out of 20, indicating fair knowledge of dementia, but two-thirds of the participants (63.5%) responded incorrectly to the question that dementia could be cured depending on its type. For dementia attitudes, the overall average score was 2.8 points, which equaled 70 points when converted to a 100-point scale. Among the two dimensions of the dementia attitude scale, the accepting dimension score was higher than the affective dimension score. Finally, regarding the effect of dementia knowledge on dementia attitudes, higher knowledge of dementia was associated with the higher the dementia attitude score that displayed a positive association. Specifically, this association appeared only for the accepting attitudes, not for affective attitudes.

This study revealed that the general public had reasonable knowledge regarding dementia, which is in line with studies in other countries [11 , 23]. However, several studies on dementia knowledge, targeting the general population, revealed limited or poor knowledge in some areas or items [10 , 25]. A common misconception is that dementia is a normal part of aging. The general population displayed good knowledge about the symptoms, but poor knowledge about the causes, treatment, and prevention of dementia. In our study, less than 50% of the responses to the questionnaire items “Dementia can be cured depending on the type” and “Dementia patients always have problem behaviors” were correct, indicating a large deviation in some areas of knowledge. However, we found that the symptom/diagnosis category had the lowest scores. This inconsistent result with previous studies may be explained by the fact that our questionnaire included an item about neuropsychiatric symptoms, which was not included in previous studies. Among the general public, the perception of the neuropsychiatric symptoms of dementia may be lower than that of other typical dementia symptoms, such as memoryimpairment.

Regarding the item that regular exercise and control of hypertension/hyperglycemia /hyperlipidemia were related to dementia prevention, respondents showed fair knowledge with 85% and 70% correct answers, respectively. This good knowledge about prevention areas may be considered as a result of improved overall knowledge through various dementia prevention education and publicity activities. In addition, the improvement and publicity of public services through the National Dementia Prevention Project [26] may have contributed to the highest score for care and policy among dementia knowledge.

In terms of dementia attitudes, acceptance attitudes were higher than affective ones. This means that even though there is an inclusive attitude of maintaining good relationships with people with dementia and helping them, if necessary, the general public experience emotional discomfort about being with or associated individuals with dementia. This is consistent with a cross-sectional Japanese study in which 90% of the participants wanted to help people with dementia, but half reported being ashamed of their family members with people living with dementia [27]. In our study, the item “I am afraid of people living with dementia” had the lowest core, which suggests that public anxiety about dementia is still high. This finding was consistent with reports that claim there is a great deal of fear and shame about public disclosure of dementia in Asian societies [28, 29]. For some Asian cultures, the belief that disease is caused by bad luck or dishonorable deeds of their ancestors may lead to a fear of being ostracized from family members and members of society [30]. The attitude question mentioned, “Caring for people living with dementia is rewarding,” was an item to evaluate the general attitude perception of caring for dementia patients. Therefore, the item was evaluated by all participants regardless of the presence or absence of the dementia patient’s family. Table 1 describes whether there were people living with dementia among family members or relatives in the response item, and 442 people (35.2%) answered yes. Although not shown in the results, there was an item about whether they had lived with dementia families or relatives. Of the 422 people, 226 (46.4%) said they had experience living together. Interestingly, further analysis showed that there was no significant difference in the “Caring for People living with Dementia is Rewarding” according to the presence or absence of living experience with a person living with dementia in families or relatives.

We classified and examined the dementia attitudes into two types. Dementia knowledge was found to have a significant positive association with overall attitudes toward dementia. Previous studies have not presented consistent results regarding the relationship between dementia knowledge and attitudes. Rosato et al. reported that knowledge of dementia was inversely associated with negative emotional attitudes toward dementia [18], but a study in Ireland reported that more knowledge about dementia did not lead to more favorable attitudes toward people living with dementia [22].

In this study, a high level of dementia knowledge was positively associated with an accepting attitude toward dementia but was not significant in terms of affective attitude. These findings suggest that knowledge about dementia may lead to an inclusive attitude toward the disease, but may be less effective in improving negative emotions, fear, and anxiety. Furthermore, among dementia knowledge, policy items displayed the strongest significance in accepting attitudes. This result may be explained by the fact that being familiar with public services and resources for dementia reduces the burden of accepting people living with dementia, leading to an inclusive attitude.

However, in this study, there was no significant of dementia knowledge with affective attitude toward the condition. Previous results regarding the relationship between knowledge of and emotion about dementia are not consistent results. Rosato et al. reported that knowledge about dementia in the general population was inversely associated with antipathy for dementia [18]. Another study found that simple biomedical knowledge about dementia was not significantly associated with anxiety about the disease [31]. Several studies reported that increased knowledge in caregivers of patients with dementia was associated with increased anxiety [32, 33]. Taken together, the stigma of dementia and recognition of the severity of symptoms may be linked to anxiety and fear regarding dementia. Affective attitude can be considered to be related to stigma to dementia. Stigmatization is generally associated with severe and chronic disorders, and the influence of stigma is gradually increasing for people living with dementia [8]. The experience of Stigmatization is negatively correlated with social support and quality of life, which results in ignorance and avoidance to people living with dementia, and forming an obstacle against dementia friendly community [8 , 35].

This study has several strengths: we not only investigated the knowledge and attitudes toward dementia in a random community-dwelling sample, but by classifying dementia attitudes, we also revealed the relationship between dementia knowledge and particular aspects of attitudes.

This study has some limitations that should be mentioned. First, since this study included only those who responded to the questionnaire, there was no information on those individuals who refused/declined to respond, and the former may have been more interested in dementia than the latter, so their knowledge about dementia might have been higher. Second, since this was a cross-sectional study, it was difficult to determine the causal relationship between knowledge and attitudes, and we could only demonstrate therelationship.

Conclusion

Our study provides new information on the general public’s dementia knowledge and attitudes in South Korea. Our study highlights that an accepting attitude toward dementia is related to knowledge of the dementia, but not to emotional attitude. To improve the public’s accepting attitudes toward dementia, it may be effective to continue education on dementia for the general public. However, to improve negative emotional attitudes and reduce stigma toward dementia, various approaches beyond dementia education may be needed. For better understand how negative attitude in the public can be improved to foster a dementia-friendly community, further studies are required.

DATA AVAILABILITY

The datasets generated and analyzed during the present study are not publicly available, owing to ethics considerations. Data might be obtained from the corresponding author after approval by the Institutional Review Board of the Myongji Hospital, South Korea.

Footnotes

ACKNOWLEDGMENTS

We thank Dr. Hoo Rim Song for assistance with comments that greatly improved the manuscript.

FUNDING

This study was supported by a grant from the National Institute of Dementia (NID) of South Korea (NDR-2101-0037).

CONFLICT OF INTEREST

The authors have no conflict of interest to report.

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