As the world’s population ages, dementia has become a global public health concern (WHO, 2017). However, misconceptions of dementia remain, which pose discrimination and isolation to persons living with dementia (PWD) and prevent individuals from timely access to diagnosis and treatment. Research has shed light on factors associated with dementia knowledge among elders, but little has been known regarding an influence of social–cultural contexts on elder’s dementia acknowledge. Dr. Zhao and colleagues’ paper on dementia knowledge and its associates among Chinese background elders in Melbourne and Beijing generated inspirational findings in this regard. This commentary highlights major findings of Dr. Zhao et al.’s (Reference Zhao2021) paper and discusses their implications for dementia education, as well as points out limitations that future research can address.
Key findings of Dr. Zhao et al.’s work
Dr. Zhao and colleagues’ work identified factors related to dementia knowledge among older Chinese adults in Australia and China. Using the Alzheimer’s Disease Knowledge Scale (ADKS) scale with a total score of 30, older Chinese adults in Melbourne and Beijing reported similar overall dementia knowledge (mean ± SD: 17.2 ± 2.9 in Melbourne vs. 17.5 ± 2.9 in Beijing, p > 0.05) and subdomain specific knowledge.
Of the seven subdomains, the highest correct response rates were observed in the life impact of the dementia, followed by treatment, and the two lowest rates were risk factors and caregiving subdomains. Regarding the associates of dementia knowledge, younger age and dementia worry were related to higher levels of dementia knowledge in the Melbourne group, whereas family history of dementia was significantly associated with dementia knowledge in the Beijing group.
Interpretations of the findings
We like to set some parameters to help understand the above findings before discussing their practical meanings. First, the findings of Zhao and colleagues’ study have limited generalizability to adults outside their sample. Despite variance observed in sample characteristics due to their efforts to recruit from multiple sources, we cannot affirm those in the sample represented adults aged 50 in the two cities. More information about the 5 senior groups and 10 community health centers, where they recruited participants could have been offered to readers to understand where these adults came from and increase the replicability of this study. Second, this study termed adults aged 50 or above as older adults, which is unusual and contradictory to the conventional threshold (i.e. 65) used for older age. Although it is reasonable to educate people about dementia earlier, lumping adults in their 50s with adults aged 65 in analyses warrants discreet scrutiny. For example, in the Melbourne group, younger age was found to have more dementia knowledge, which could be further explored in relation to dementia worry. It is possible that the age effect was more salient in those who worry about dementia, but not for those who do not worry about dementia. Or treating age as a dichotomous variable and conducting a comparison between those below age 65 versus above can be used to justify the consideration of adults between 50 and 64 as older adults in this study.
Implications for policy and practice
Promoting dementia awareness and imparting dementia knowledge is a key component for all 34 countries including Australia and China that have developed a national dementia plan (Alzheimer’s Disease International, 2020, 2021). This study provided an evidence that adults aged 55 or above in two large cities had limited dementia knowledge, and further pointed out specific subdomains needed more education efforts. For example, both dementia risk factors and dementia caregiving had an accuracy rate of less than 50%. Risk factors of dementia and information on how to take care of PWD should be highlighted in dementia education.
The other enlightening implications for practice were derived from significant correlates of dementia knowledge found for each groups. Given that exposure to dementia was related to more knowledge for Beijing group, bringing PWD to advocate and educate people can be an effective tool. For the Melbourne group, the best practice is to include counseling in educational programs as people with more knowledge are also likely to have higher dementia worry.
Directions for future research
We provided some recommendations for future research on cross-cultural comparison of dementia knowledge among older adults. The first recommendation is to use a conceptual framework to justify the across-cultural comparison on knowledge of dementia. This framework needs to point out the underlying mechanisms via which sociocultural contexts can affect dementia knowledge, assessed against facts based upon the latest biomedical sciences. Beliefs toward dementia and an explanation of dementia from one’s personal and cultural perspectives might better reflect the influence of sociocultural environment. Or access to dementia-related information also well captures differences in different societies. A cross-cultural comparison of dementia beliefs or access to dementia-related information among Chinese adults in different countries would be more compelling in theory and more meaningful in practice. If the comparison of dementia knowledge is the goal, the conceptual model needs to at least include cultural variables such as subscription to traditional Chinese values, cultural beliefs toward dementia, or access to dementia information which can help explain commonalities or differences between societies.
Along with the first recommendation, the conceptual model adopted needs to be informed by health literacy theory and newly emerged empirical evidence. The current literature has suggested broad categories of predictors for dementia knowledge including demographics (e.g. education), beliefs toward dementia, exposure to dementia (e.g. genetically, socially, or professionally connected with someone with dementia), and physical, emotional, and cognitive health status (Sun et al., Reference Sun, Gao, Shen and Burnette2014). In cross-cultural comparisons, personal variables that can reflect the effects of macro sociocultural environment should be integrated. For example, the availability of dementia education programs and access to dementia information can be included. Zhao et al.’s (Reference Zhao2021) study selected legitimate correlates (i.e. demographics, dementia exposure, and health and mental health factors), but some important factors might be missed as the R square values for both models were low, especially for the Beijing sample (0.03).
The last suggestion is to adopt dementia knowledge measures updated with the latest scientific facts, and to document in detail any language and cultural adaptations made for the study population. It has been more than a decade since the ADKS was released in Reference Carpenter, Balsis, Otilingam, Hanson and Gatz2009 by Carpenter and colleagues. The latest breakthroughs, though limited, in dementia diagnosis and treatment need to be considered. For example, as there are many types of dementia other than Alzheimer’s disease, it is not precise to use Alzheimer’s disease as an equivalent to dementia. The authors used “dementia” throughout the paper, though this scale assesses the knowledge about Alzheimer’s disease, the most common type of dementia. If researchers conduct linguistic or cultural modifications to make the Chinese version fit well with two groups in the study, the process needs to be specified for future studies that may be interested to use the adapted scale.
This paper offers valuable information for researchers, policymakers, and practitioners invested in dementia awareness promotion among older adults in the two cities. We expect more future research that uses probability sampling and longitudinal designs to capture population-based dementia knowledge trends and informs policy and practice on a larger scale.
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As the world’s population ages, dementia has become a global public health concern (WHO, 2017). However, misconceptions of dementia remain, which pose discrimination and isolation to persons living with dementia (PWD) and prevent individuals from timely access to diagnosis and treatment. Research has shed light on factors associated with dementia knowledge among elders, but little has been known regarding an influence of social–cultural contexts on elder’s dementia acknowledge. Dr. Zhao and colleagues’ paper on dementia knowledge and its associates among Chinese background elders in Melbourne and Beijing generated inspirational findings in this regard. This commentary highlights major findings of Dr. Zhao et al.’s (Reference Zhao2021) paper and discusses their implications for dementia education, as well as points out limitations that future research can address.
Key findings of Dr. Zhao et al.’s work
Dr. Zhao and colleagues’ work identified factors related to dementia knowledge among older Chinese adults in Australia and China. Using the Alzheimer’s Disease Knowledge Scale (ADKS) scale with a total score of 30, older Chinese adults in Melbourne and Beijing reported similar overall dementia knowledge (mean ± SD: 17.2 ± 2.9 in Melbourne vs. 17.5 ± 2.9 in Beijing, p > 0.05) and subdomain specific knowledge.
Of the seven subdomains, the highest correct response rates were observed in the life impact of the dementia, followed by treatment, and the two lowest rates were risk factors and caregiving subdomains. Regarding the associates of dementia knowledge, younger age and dementia worry were related to higher levels of dementia knowledge in the Melbourne group, whereas family history of dementia was significantly associated with dementia knowledge in the Beijing group.
Interpretations of the findings
We like to set some parameters to help understand the above findings before discussing their practical meanings. First, the findings of Zhao and colleagues’ study have limited generalizability to adults outside their sample. Despite variance observed in sample characteristics due to their efforts to recruit from multiple sources, we cannot affirm those in the sample represented adults aged 50 in the two cities. More information about the 5 senior groups and 10 community health centers, where they recruited participants could have been offered to readers to understand where these adults came from and increase the replicability of this study. Second, this study termed adults aged 50 or above as older adults, which is unusual and contradictory to the conventional threshold (i.e. 65) used for older age. Although it is reasonable to educate people about dementia earlier, lumping adults in their 50s with adults aged 65 in analyses warrants discreet scrutiny. For example, in the Melbourne group, younger age was found to have more dementia knowledge, which could be further explored in relation to dementia worry. It is possible that the age effect was more salient in those who worry about dementia, but not for those who do not worry about dementia. Or treating age as a dichotomous variable and conducting a comparison between those below age 65 versus above can be used to justify the consideration of adults between 50 and 64 as older adults in this study.
Implications for policy and practice
Promoting dementia awareness and imparting dementia knowledge is a key component for all 34 countries including Australia and China that have developed a national dementia plan (Alzheimer’s Disease International, 2020, 2021). This study provided an evidence that adults aged 55 or above in two large cities had limited dementia knowledge, and further pointed out specific subdomains needed more education efforts. For example, both dementia risk factors and dementia caregiving had an accuracy rate of less than 50%. Risk factors of dementia and information on how to take care of PWD should be highlighted in dementia education.
The other enlightening implications for practice were derived from significant correlates of dementia knowledge found for each groups. Given that exposure to dementia was related to more knowledge for Beijing group, bringing PWD to advocate and educate people can be an effective tool. For the Melbourne group, the best practice is to include counseling in educational programs as people with more knowledge are also likely to have higher dementia worry.
Directions for future research
We provided some recommendations for future research on cross-cultural comparison of dementia knowledge among older adults. The first recommendation is to use a conceptual framework to justify the across-cultural comparison on knowledge of dementia. This framework needs to point out the underlying mechanisms via which sociocultural contexts can affect dementia knowledge, assessed against facts based upon the latest biomedical sciences. Beliefs toward dementia and an explanation of dementia from one’s personal and cultural perspectives might better reflect the influence of sociocultural environment. Or access to dementia-related information also well captures differences in different societies. A cross-cultural comparison of dementia beliefs or access to dementia-related information among Chinese adults in different countries would be more compelling in theory and more meaningful in practice. If the comparison of dementia knowledge is the goal, the conceptual model needs to at least include cultural variables such as subscription to traditional Chinese values, cultural beliefs toward dementia, or access to dementia information which can help explain commonalities or differences between societies.
Along with the first recommendation, the conceptual model adopted needs to be informed by health literacy theory and newly emerged empirical evidence. The current literature has suggested broad categories of predictors for dementia knowledge including demographics (e.g. education), beliefs toward dementia, exposure to dementia (e.g. genetically, socially, or professionally connected with someone with dementia), and physical, emotional, and cognitive health status (Sun et al., Reference Sun, Gao, Shen and Burnette2014). In cross-cultural comparisons, personal variables that can reflect the effects of macro sociocultural environment should be integrated. For example, the availability of dementia education programs and access to dementia information can be included. Zhao et al.’s (Reference Zhao2021) study selected legitimate correlates (i.e. demographics, dementia exposure, and health and mental health factors), but some important factors might be missed as the R square values for both models were low, especially for the Beijing sample (0.03).
The last suggestion is to adopt dementia knowledge measures updated with the latest scientific facts, and to document in detail any language and cultural adaptations made for the study population. It has been more than a decade since the ADKS was released in Reference Carpenter, Balsis, Otilingam, Hanson and Gatz2009 by Carpenter and colleagues. The latest breakthroughs, though limited, in dementia diagnosis and treatment need to be considered. For example, as there are many types of dementia other than Alzheimer’s disease, it is not precise to use Alzheimer’s disease as an equivalent to dementia. The authors used “dementia” throughout the paper, though this scale assesses the knowledge about Alzheimer’s disease, the most common type of dementia. If researchers conduct linguistic or cultural modifications to make the Chinese version fit well with two groups in the study, the process needs to be specified for future studies that may be interested to use the adapted scale.
This paper offers valuable information for researchers, policymakers, and practitioners invested in dementia awareness promotion among older adults in the two cities. We expect more future research that uses probability sampling and longitudinal designs to capture population-based dementia knowledge trends and informs policy and practice on a larger scale.