A multi-themed and multi-format intervention program for improving dementia literacy among Chinese older adults: Study protocol for a non-randomized controlled trial

A multi-themed and multi-format intervention program for improving dementia literacy among Chinese older adults: Study protocol for a non-randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol A multi-themed and multi-format intervention program for improving dementia literacy among Chinese older adults: Study protocol for a non-randomized controlled trial nani ZHAN, zhuang ZHUANG, fan BU, yutin CAI, meilin LUO, yunjing ZHANG, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4199561/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Effective intervention is the key measure to improve the dementia literacy of older adults. However, to date, there are no studies on the effectiveness of dementia literacy interventions in China. This study aims to evaluate the effectiveness of a dementia literacy intervention program on the dementia knowledge, attitude, and self-management behavior literacy of elderly adults. Methods: This study will strictly adhere to the inclusion/exclusion criteria, recruiting 84 community-dwelling individuals aged 60 and above from two community health service centers in Guangzhou, Guangdong Province, China. Participants will be allocated into a usual care group and a dementia literacy intervention group. The intervention group will receive a multi-themed and multi-format dementia literacy intervention trial through community knowledge seminars, educational videos, WeChat group information push and answer questions, etc. Intervention themes will include dementia knowledge, attitudes toward dementia, and self-management behaviors for preventing and managing dementia. Data will be collected before the start of the intervention study and three months after the intervention study. The primary outcome measures will include dementia knowledge literacy, dementia attitude literacy, and dementia self-management behavior literacy. Data will be managed and analyzed using SPSS 26.0. Ethical approval for this study was granted on 12 June 2023. Discussion: If proven effective, this dementia literacy intervention program could be widely applied in primary community health centers to enhance dementia literacy among Chinese elderly. Also, the dementia literacy intervention program will provide a reference and a basis for further research on enhancing dementia literacy intervention programs for the elderly. Trial registration: Registered in the Chinese Clinical Trial Registry (NO. ChiCTR2300074788). aged community health centers dementia dementia literacy nursing interventions study protocol. Figures Figure 1 Background Over 10 million cases of dementia cases reside in China, which represents the highest number of cases in the world [1]. By 2040, the number of dementia cases in China is projected to surpass the combined total of all developed countries. The number of dementia cases in China is expected to reach 30 million by 2050, accounting for a quarter of the global prevalence of the disease [2] . Moreover, over 62% of dementia cases in China are still undiagnosed [3]. In order to enhance early detection of dementia and reduce its burden on society, the WHO issued the “Global Action Plan on the Public Health Response to Dementia 2017–2025” in 2017. The plan calls for countries to develop national dementia action plans by 2025, enhancing public dementia literacy to foster a more accurate understanding of dementia [4].In the 13 th Five-Year Plan for Healthy Aging in China, a key task involved promoting dementia education to enhance the dementia literacy of the elderly [5].In 2019, the National Health Commission issued the “Exploration of Specialized Services for the Prevention and Treatment of Dementia Work Plan” [6]. The plan sets the target for pilot regions to achieve public awareness of the prevention and treatment of dementia of 80% by 2022. Improving dementia literacy is beneficial for the early prevention and diagnosis of dementia, and providing more timely support for individuals with dementia [7]. Low level of dementia literacy suggests that individuals lack the necessary knowledge and skills to recognize the symptoms of dementia and establish prevention and treatment plans for dementia. It also suggests an inability to provide basic help and support to people with dementia [8]. Individuals with dementia usually delay seeking professional medical help by 3–4 years [9]. Lack of dementia literacy prevents older adults from accurately recognizing diseases and showing negative emotions such as fear and aversion [10];they may be unwilling to communicate with healthcare professionals, peers, or family members，and may avoid seeking help from professionals [11,12]. Low dementia literacy and a lack of understanding about dementia in older adults may result in failure to recognize early symptoms like recent memory loss or difficulty naming things. They might mistakenly perceive these symptoms as a normal part of aging and delay seeking medical treatment [8]. There is no effective cure for dementia, which poses a substantial burden on patients, caregivers, families, and society. Therefore, enhancing public dementia literacy is vital to equip individuals with the ability for early prevention, recognition, timely diagnosis, and management of dementia. This protocol describes a study to [1] develop and implement a dementia literacy intervention program for community-dwelling Chinese older adults and [2] assess the effectiveness of the intervention in enhancing dementia literacy in this population. This study will further enrich intervention research on enhancing dementia literacy among the elderly, providing references for developing dementia literacy programs for this population. Despite the increasing global emphasis on dementia literacy, the level of dementia literacy among older adults remains very low. A European survey involving 2,500 participants from six countries revealed that 83% of the study participants could not identify the early indications of dementia. Additionally, 76% believed that no efficient treatment was available for dementia [13,14]. A large-scale survey in South Korea found that the dementia literacy of older adults was only 62%, with only 24.8–27% accurately judging whether “people who can remember things in the past will develop dementia” [15]. The results are consistent with those from Australia , Hong Kong, Macao , Cambodia, Fiji, and the Philippines [16–18]. A study conducted in Russia demonstrated that approximately 40–50% of the participants were unaware of the signs and symptoms of dementia [19]. A systematic review of 40 studies conducted revealed that participants in these studies only possessed moderate knowledge of dementia[8]. A review of 38 population-based surveys on the prevention and treatment of dementia reported that about half of respondents believed that dementia was a normal and unavoidable part of the aging process [20]. Additionally, studies conducted in Indianaand Japan revealed that 39.2% and 66% of the participants believed that they would experience anxiety and stigma if diagnosed with dementia [21,22]. The level of dementia literacy levels in China is more severe. A survey conducted among 3439 older adults in 34 cities across 20 provinces in China found that the overall rate of dementia literacy was just 55.5% [18]. Additionally, more than 78% of respondents underestimated the prevalence of dementia. Changsha conducted a large-scale survey on dementia knowledge among people over 55 years [23]. The results showed that only 22.30% of the participants could identify dementia at an early stage, and only 24.4% of the participants knew how to prevent and treat dementia. The older adults in Shanghai were generally less aware of cognitive impairment, with only 7.61% of respondents being familiar with the disease [19]. In 2012, a survey of 4634 participants in Shijiazhuang found that the knowledge rates of early identification and prevention of dementia were 14.44% and 13.62%, and the awareness rate of caregiving knowledge was only 4.64% [24]. Effective interventions are crucial for enhancing dementia health literacy among older adults in the community. Presently, the intervention strategies for dementia literacy implemented domestically and internationally are mainly through single-knowledge education. For instance, Terayamagave two lessons on caring for patients with dementia in the outpatient departments of hospitals [25]; Commissaris held two educational seminars describing the differences between normal forgetfulness and dementia [26]; Galvinset up a site to provide dementia knowledge counseling for study participants [27]; Zhang Jie distributed posters, organized knowledge lectures, and centralized street counseling services in 21 communities in Shanghai [28]. These studies improved the knowledge literacy of dementia among the study participants to varying degrees through a single form of health education. However, the interventions were limited to improving dementia knowledge literacy. Nevertheless, new models of intervention have been emerging in recent years. In 2018, Bruns engaged 147 study participants in a sitcom on the topic of social relationships between people with dementia and caregivers [29]. The study participants completed questionnaires separately before and after the performance. The results showed a significant change in their attitudes toward dementia, from a strong negative mood to a more optimistic mood. Grigsby recruited 42 study participants to watch audiovisual novels on dementia topics and conducted separate surveys before and after the viewing [30]. The study found that the participants' knowledge of dementia significantly improved, and their attitudes toward dementia screening became more positive. Di Bona sent 41 school-aged children who had received knowledge about dementia to a local nursing home to live with 10 older adults with dementia and eight care workers [31]. This intervention program enhanced the children's dementia literacy, increased the care workers' dementia well-being and social inclusiveness, and made a new contribution to dementia-friendly communities. Most of the existing studies on dementia literacy have been conducted in developed countries like Australia, the United States, and Japan, with fewer studies in developing countries [8,32,33].Moreover, most studies only cover the fundamental dementia knowledge and do not integrate dementia attitudes and self-management behaviors for controlling dementia. By summarizing and utilizing existing research findings on dementia literacy, this 3-month community-based intervention study on dementia literacy will incorporate knowledge about dementia, attitudes toward dementia, attitudes toward people with dementia, and self-management behaviors to control dementia. Methods Registration The protocol for this non-randomized controlled trial is registered at the Chinese Clinical Trial Registry, ChiCTR2300074788 (https://www.chictr.org.cn/). We registered on August 16, 2023. Aims, objectives,and hypotheses This protocol describes the design of an innovative dementia literacy intervention program that aims to promote healthy behaviors and prevent dementia using multi-format and multi-themed intervention approaches. This study aims to: Determine the effectiveness of the elderly dementia literacy intervention program, on dementia knowledge literacy, attitude literacy, and self-management behavior literacy. Explore the difficulties and challenges of implementing the dementia literacy program among community-dwelling elderly people. We hypothesized that older adults in the intervention group would report higher dementia knowledge, attitude, and self-management behavior literacy compared to the usual care group after the three-month intervention. Additionally, they would be better equipped for early prevention, timely diagnosis, and management of dementia. Design This study will be a non-randomized controlled trial. Two community health service centers in Guangzhou have been selected based on their large numbers of older adult attendees. After sectionalization, participants will receive either the intervention or usual care. The groups will not be randomized considering the physical health status and living convenience of older adults, such as the availability of time and energy to participate in the health literacy interventions at regular intervals throughout the trial. This study will invite experts specializing in cognitive disorders to evaluate the dementia literacy intervention program. Then, according to expert opinions, the content and form of the intervention will be further modified to ensure the feasibility of the intervention plan. During the formal intervention, the first author will provide intervention measures for the intervention group and be responsible for overall project management, including raining delivery, overseeing the entire trial, and data quality assessment. Additionally, each community will have a project team consisting of a senior community nurse and four research assistants. The project team will primarily be responsible for patient recruitment, assisting in the intervention process, and data collection. Project team members will undergo standardized training before the intervention and data collection to ensure the quality of the intervention trial and data collection. The trial has been approved by our Ethical Committees and was registered with the Clinical Trial Registry. The study design is outlined in Figure 1. Participants The participants who meet the following criteria will be recruited: (a) age ≥ 60 years, (b) residing in the community for at least three months, (c) can participate in the program for one hour every two weeks, (d) having no communication or mobility barriers and being able to cooperate in completing the study, and (e) being willing to participate in this survey with informed consent. Exclude criteria will be: (a) diagnosed with dementia, (b) suffering from a severe mental illness or diagnosed with major depression, (c) with a short-term history of acute cardiovascular or cerebrovascular disease, and (d) no mobile phone and other communication devices to use WeChat. Recruitment During this study, recruitment posters will be distributed in places frequented by older adults, such as the community committee, community health service center, and exercise squares. Simultaneously, pamphlets containing relevant study information will be distributed to elderly residents, and recruitment information will be shared within community WeChat groups. The aim is to recruit 84 eligible participants willing to participate in the study. Sample size The sample size was estimated according to the formula: The n is the sample size；𝜇 a is the u-value corresponding to the Type I error probability; 𝜇 𝛽 is the u-value corresponding to the Type II error probability; 𝛿 represents the expected effect size, which is the absolute difference in means between two groups; 𝜎 2 represents the population variance and can be estimated using the sample variance, which is the average of the variances of the two groups. α was set at 0.05 and β at 0.10. Referencing the study by Ayisi-Boateng et al. a minimum sample size of 34 cases is needed [34]. The required sample size becomes at least 42 cases after factoring in a 20% dropout rate. We aim to recruit 84 participants for this study, with 42 per group. Study intervention Intervention group According to the definition of dementia literacy, we divide the intervention program into three themes: dementia knowledge, dementia attitude, and dementia self-management behavior literacy [35,36]. The content of the program considers the most recent guidelines, such as “Guidelines for the Prevention and Treatment of Senile Dementia” and “Chinese Expert Consensus on the Diagnosis and Treatment of Alzheimer’s Disease-Origin Mild Cognitive Impairment 2021” [37,38]. Intervention methods include dementia knowledge seminars, dementia knowledge popularization videos, and WeChat group information pushes and question answering. The main contents and arrangements of dementia literacy interventions for older adults are shown in Table 1. Dementia knowledge seminars: We will hold two dementia knowledge seminars per month in the community, and the theme will focus on one of the three aspects of dementia health literacy. Each seminar will last approximately 45 minutes: 20 minutes for knowledge presentations, 10 minutes for interactive games, 10 minutes for learning assessments such as word matching, and five minutes for participants to share their experiences and insights freely. Dementia knowledge popularization video: Following the theme of dementia health literacy, two dementia knowledge popularization videos will be created each month. These videos will be distributed in the WeChat groups of the intervention group. Each video will be a maximum of five minutes, with an original content. The presentation format involves lively and vivid image animations combined with explanations in simple and understandable language. WeChat Group Information Sharing and question-answering: We will set up a dedicated WeChat group to answer participants’ questions about dementia and communicate daily health knowledge together. The group will share dementia literacy-related knowledge tweets weekly, and the tweets are sourced from “Senile Dementia,” “Dementia,” “Alzheimer’s Disease,” “Alzheimer’s Disease Prevention and Treatment Association,” “Chinese Alzheimer’s Disease Association,” and other dementia public sharing platforms and public numbers. We will regularly share videos about dementia, including movies, variety shows, documentaries, and news, to help participants understand and recognize dementia better. Control group The control group will receive routine community care services, including regular health follow-ups and physical examinations, written health education, and stylistic health activities. However, they will not receive additional care services related to dementia literacy. The intervention group will receive dementia literacy interventions concurrently with routine community nursing services. Outcome measures The program will be evaluated at baseline [T0] and post-intervention [3 months—T1]. The primary outcomes measured at three months will be: dementia knowledge literacy, dementia attitude literacy, and dementia self-management behavior literacy. The primary outcomes will be measured using validated tools. Dementia knowledge literacy The Alzheimer's Disease Knowledge Scale (ADKS) will be used to measure the dementia knowledge literacy [39]. The scale contains 30 judgmental right or wrong questions that evaluate the test taker's knowledge of Alzheimer's disease assessment, diagnosis, care, life impact, prevalence, prevention, risk factors, symptoms, treatment, and management. The composite score is calculated by counting the number of correctly answered questions, and can range from 0 to 30. The Cronbach's alpha, retest reliability, and split-half reliability of the scale are 0.71, 0.81, and 0.55, respectively. Dementia attitude literacy The Dementia Attitudes Scale (DAS) is used to measure the dementia attitude literacy [40]. It includes 20 items, each assessed on a 7-point Likert scale from 1 [strongly disagree] to 7 [strongly agree], with a total scale score ranging from 20 to 140. The higher the total score, the more positive the attitude toward dementia. The Cronbach's alpha of the value for the scale is 0.83. Dementia Self-management behavioral literacy The Chinese version of the Health Promoting Lifestyle Profile-Ⅱ (HPLP-Ⅱ) is used to measure the dementia self-management behavioral literacy of the study participants [41]. The scale consists of 40 items with six dimensions: nutrition (6 items), physical activity (8 items), health responsibility (11 items), interpersonal relationships (5 items), spiritual growth (5 items), and stress management (5 items). The items are scored on a four-point Likert scale from 1 to 4 as “never,” “sometimes,” “often,” and “always,” with a total score range of 40–160. A score of 1–2, 2–3, or 3–4 indicates a low, medium, or high level of health promotion lifestyle, with higher scores indicating a better health promotion lifestyle. The Cronbach's alpha of this scale ranged from 0.63–0.81, with a retest reliability of 0.69. Data collection procedure Data collection will be conducted by two community project team members. All participants will complete the sociodemographic questionnaires, ADKS, DAS, and Chinese versions of the HPLP-II. Reassessment data will be collected at the end of the three-month intervention program. Community project members will redistribute the ADKS, DAS, and HPLP-II questionnaires to participants in both the intervention and control groups. Sociodemographic data will include participants' names, contact information, gender, age, employment status, education level, occupation, accommodation, marital status, cohabitation, family relationships, history of relevant illnesses, health status, and experience of dementia exposure. All data will be collected through paper questionnaires completed by the study participants. The project team members will assist those with visual impairments, difficulty writing, or limited education to fill out the forms after obtaining their opinions. Data analysis All data will be quantified and entered into a computer to create a database. Two persons will enter the data to ensure correct data entry. Statistical analysis will be performed using the SPSS 27.0 software. All tests will be two-sided and p-values<0.05 will be considered statistically significant. Sociodemographic information, DAS, ADKS, and Chinese versions of the HPLP-II will be described using frequencies and percentages, as well as means and standard deviation. In order to evaluate the effectiveness of the intervention program, t-tests will be used to analyze the differences in dementia literacy between the study participants before and after the intervention. Ethical considerations This study has been approved by the Ethical Committees and registered in the Clinical Trial Registry. The study participants will be informed of the purpose and methodology of the study and will be asked to sign an informed consent form before the survey and intervention. Participants and their family members or legal guardians will have the option to cancel their participation in the study at any time. Patient privacy will be ensured at all times. Discussion This study aims to determine the effectiveness of the dementia literacy intervention program in improving dementia literacy in older adults and provide valuable information on improving dementia health literacy in Chinese older adults. To our knowledge, this study is the first multi-topic and multi-format dementia health literacy intervention study on improving dementia literacy among older adults. This is a new approach to a major public health problem. If this study confirms the effectiveness and sustainability of this intervention program, it may help to promote early diagnosis of dementia, decelerate the progression of dementia, and improve the quality of life of people with dementia. Furthermore, it can enhance the implementation of health education on dementia literacy for community-dwelling older adults and influence the practice of dementia prevention in the global community. The strengths of this study include being the first to intervene on three topics: knowledge of dementia, attitudes toward dementia, and self-management behaviors to prevent and treat dementia. It is also the first study to use various forms of intervention, such as dementia knowledge seminars, dementia knowledge educational videos, and WeChat group information sharing alongside question and answering. This approach differs from the traditional health education interventions used by previous studies, which focused only on knowledge. This study strives to comprehensively improve the dementia literacy of older adults from multiple perspectives and directions. Additionally, this study will adopt a multisite approach. It will be conducted in an urban and a rural community in Guangzhou with substantial variations in the occupations, literacy levels, economic incomes, and family members of the elderly. This prevents selection bias due to a single sample selection and makes the research process, results, and experience more generalizable and applicable. Finally, project lead will implement the interventions at the different sites of this study to ensure uniformity of the interventions. The unity of cooperation and the standardized training of the project team members will ensure quality control and the successful completion of the interventions. The findings will be presented as abstracts at national and international conferences (e.g., Dementia, Nursing, and Medicine Conference) and published in medical or nursing journals. If the intervention is effective in improving dementia literacy in older adults, further research will be needed to optimize the content and format of the intervention. Lessons learned This section summarizes some of the lessons learned during the preparation phase of study recruitment and the implementation of the intervention. Only a few older adults were interested during the recruitment, although several strategies were employed to recruit potential participants into the study. This is chiefly because of their limited knowledge about dementia and the belief that dementia is part of normal aging. Therefore, we collaborated with community social workers to organize a healthy outdoor activity for the elderly in the community, such as walking, hiking, square, and dancing, and invited the elderly to participate. During the activity, we discussed the importance of dementia and answered questions about dementia to stimulate the interest of the elderly. Additionally, we presented gifts to all the participants. When implementing the intervention study, the greatest challenge is ensuring that all participants participate in the experiment as planned. During recruitment into the study, team members explained the detailed intervention protocol to the participants and emphasized the importance of adhering to the study throughout. Detailed interviews were conducted after obtaining participants' informed consent. The research assistants will maintain frequent daily phone contacts and WeChat group health communication exchanges. Positive feedback and rewards will be given to participants who persistently engage in the intervention study to foster a cooperative relationship between the subjects and the research team. We streamlined the intervention program to minimize the number of participant trips to the Community Health Service Center. Before each intervention, the research assistant would make a unified notification in the WeChat group one week in advance, followed by a reminder call 2–3 days before the intervention to ensure time participation. Two sessions at different time slots were arranged for each intervention, with identical intervention content and format. The participants can choose a convenient time to attend either session to minimize problems due to time constraints. After each session, feedback was requested from the participants to improve the content and format of the intervention. The working members of the research team also meet centrally at the end of each intervention to discuss the problems encountered and experiences gained in the study and collaborate to solve the problems. Limitation This study has some limitations, including the sample size that will limits the generalizability of the findings. If the intervention is effective, the sample size can be increased in future studies to continue the in-depth analysis to improve the generalizability and scientific validity of the results. Additionally, the study design is limited by a lack of randomization of subgroups. The frequency of centralized health education in the intervention group was twice a month in each of the two distant communities. The participants will have different time, energy, and preferences to participate in the intervention, which could jeopardize compliance with the research intervention if participants are randomly assigned to different groups. Finally, the variables analyzed in this study were primarily self-reported by the participants, which are influenced by factors such as education and socioeconomic status, and thus, the information provided is limited by subjective bias. Trial status To date we have finished our team members training and preliminary test, and we started enrolling participants in September, 2023. By January 2024, 84 [42 for the intervention group and 42 for the control group] were recruited and met our enrollment target. Currently, our research team has collected baseline data and is implementing the intervention program. Then, we anticipate that the implementation of all intervention programs and the collection of outcome measures will be completed by August 2024. Declarations Ethics approval and consent to participate The trial has been approved by the Institutional Review Board of Jinan University, Guangzhou, China (No. JNUKY-2023-0026) and registered with the Chinese Clinical Trial Registry (NO. ChiCTR2300074788). All methods were carried out in accordance with Declaration of Helsinki. Participants and their family members or legal guardians will have the option to cancel their participation in the study at any time. Patient privacy will be ensured at all times. Consent for publication Not applicable. Availability of data and materials All data included in this study are available upon request by contact with the corresponding author. Competing interests The authors declare that they have no competing interests. Funding This research is funded by National Natural Science Foundation of China (NO.72274078) and The First Affiliated Hospital of Jinan University (NO.2022106). Authors’ contributions ZNN, ZZ, and BF contributed to the design of the study and manuscript drafting. CYT, LML, and ZYJ oversaw data collection and quality control. ZXL and WY offered research space. LQY provided academic supervision and served as the final reviewer of the manuscript. All authors reviewed and approved the final manuscript. Acknowledgement We appreciate the efforts of participants who completed the questionnaire. References GBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019 May;18[5]:459–80. Jia L, Quan M, Fu Y, Zhao T, Li Y, Wei C, et al. Dementia in China: epidemiology, clinical management, and research advances. Lancet Neurol. 2020 Jan;19[1]:81–92. 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Pract Geriatr. 2016;30[10]:801–3. Dementia and Cognitive Disorders Group, Chinese Society of Neurology. Expert Consensus on the diagnosis and treatment of Alzheimer’s disease induced mild cognitive impairment in China 2021. Chin J Neurol. 2022 May 8;55[05]:421–40. Alzheimer’s Disease Guidelines. Carpenter BD, Balsis S, Otilingam PG, Hanson PK, Gatz M. The Alzheimer’s Disease Knowledge Scale: development and psychometric properties. The Gerontologist. 2009 Apr;49[2]:236–47. O’Connor ML, McFadden SH. Development and Psychometric Validation of the Dementia Attitudes Scale. Int J Alzheimer’s Dis. 2010 Mar 22;2010:e454218. Cao W, Guo Y, Ping W, Zheng J. Development and performance test of the Chinese version of HPLP-Ⅱ Health Promotion Lifestyle Scale. Chin J Dis Control. 2016;20[03]:286–9. Table Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4199561","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":289104189,"identity":"c3fc31fc-f92f-46d1-b6b6-4a62632f870f","order_by":0,"name":"nani ZHAN","email":"","orcid":"","institution":"School of Nursing, Jinan University","correspondingAuthor":false,"prefix":"","firstName":"nani","middleName":"","lastName":"ZHAN","suffix":""},{"id":289104190,"identity":"882b80e4-c4c2-4c9a-b780-4f2f58fa70ae","order_by":1,"name":"zhuang ZHUANG","email":"","orcid":"","institution":"School of Nursing, Jinan 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non-randomized controlled trial","fulltext":[{"header":"Background","content":"\u003cp\u003eOver 10 million cases of dementia cases reside in China, which represents the highest number of cases in the world\u0026nbsp;[1]. By 2040, the number of dementia cases in China is projected to surpass the combined total of all developed countries. The number of dementia cases in China is expected to reach 30 million by 2050, accounting for a quarter of the global prevalence of the disease\u0026nbsp;[2]\u0026nbsp;. Moreover, over 62% of dementia cases in China are still undiagnosed\u0026nbsp;[3]. In order to enhance early detection of dementia and reduce its burden on society, the WHO issued the “Global Action Plan on the Public Health Response to Dementia 2017–2025” in 2017. The plan calls for countries to develop national dementia action plans by 2025, enhancing public dementia literacy to foster a more accurate understanding of dementia\u0026nbsp;[4].In the 13\u003csup\u003eth\u003c/sup\u003e Five-Year Plan for Healthy Aging in China, a key task involved promoting dementia education to enhance the dementia literacy of the elderly\u0026nbsp;[5].In 2019, the National Health Commission issued the “Exploration of Specialized Services for the Prevention and Treatment of Dementia Work Plan”\u0026nbsp;[6]. The plan sets the target for pilot regions to achieve public awareness of the prevention and treatment of dementia of 80% by 2022.\u003c/p\u003e\n\u003cp\u003eImproving dementia literacy is beneficial for the early prevention and diagnosis of dementia, and providing more timely support for individuals with dementia\u0026nbsp;[7]. Low level of dementia literacy suggests that individuals lack the necessary knowledge and skills to recognize the symptoms of dementia and establish prevention and treatment plans for dementia. It also suggests an inability to provide basic help and support to people with dementia\u0026nbsp;[8]. Individuals with dementia usually delay seeking professional medical help by 3–4 years\u0026nbsp;[9]. Lack of dementia literacy prevents older adults from accurately recognizing diseases and showing negative emotions such as fear and aversion\u0026nbsp;[10];they may be unwilling to communicate with healthcare professionals, peers, or family members，and may avoid seeking help from professionals\u0026nbsp;[11,12]. Low dementia literacy and a lack of understanding about dementia in older adults may result in failure to recognize early symptoms like recent memory loss or difficulty naming things. They might mistakenly perceive these symptoms as a normal part of aging and delay seeking medical treatment\u0026nbsp;[8]. There is no effective cure for dementia, which poses a substantial burden on patients, caregivers, families, and society. Therefore, enhancing public dementia literacy is vital to equip individuals with the ability for early prevention, recognition, timely diagnosis, and management of dementia.\u003c/p\u003e\n\u003cp\u003eThis protocol describes a study to [1] develop and implement a dementia literacy intervention program for community-dwelling Chinese older adults and [2] assess the effectiveness of the intervention in enhancing dementia literacy in this population. \u0026nbsp; This study will further enrich intervention research on enhancing dementia literacy among the elderly, providing references for developing dementia literacy programs for this population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite the increasing global emphasis on dementia literacy, the level of dementia literacy among older adults remains very low. A European survey involving 2,500 participants from six countries revealed that 83% of the study participants could not identify the early indications of dementia. Additionally, 76% believed that no efficient treatment was available for dementia\u0026nbsp;[13,14]. A large-scale survey in South Korea found that the dementia literacy of older adults was only 62%, with only 24.8–27% accurately judging whether “people who can remember things in the past will develop dementia”\u0026nbsp;[15]. The results are consistent with those from Australia , Hong Kong, Macao , Cambodia, Fiji, and the Philippines\u0026nbsp;[16–18]. A study conducted in Russia demonstrated that approximately 40–50% of the participants were unaware of the signs and symptoms of dementia\u0026nbsp;[19]. A systematic review of 40 studies conducted revealed that participants in these studies only possessed moderate knowledge of dementia[8]. A review of 38 population-based surveys on the prevention and treatment of dementia reported that about half of respondents believed that dementia was a normal and unavoidable part of the aging process\u0026nbsp;[20]. Additionally, studies conducted in Indianaand Japan revealed that 39.2% and 66% of the participants believed that they would experience anxiety and stigma if diagnosed with dementia\u0026nbsp;[21,22].\u003c/p\u003e\n\u003cp\u003eThe level of dementia literacy levels in China is more severe. A survey conducted among 3439 older adults in 34 cities across 20 provinces in China found that the overall rate of dementia literacy was just 55.5%\u0026nbsp;[18]. Additionally, more than 78% of respondents underestimated the prevalence of dementia. Changsha conducted a large-scale survey on dementia knowledge among people over 55 years\u0026nbsp;[23]. The results showed that only 22.30% of the participants could identify dementia at an early stage, and only 24.4% of the participants knew how to prevent and treat dementia. The older adults in Shanghai were generally less aware of cognitive impairment, with only 7.61% of respondents being familiar with the disease\u0026nbsp;[19]. In 2012, a survey of 4634 participants in Shijiazhuang found that the knowledge rates of early identification and prevention of dementia were 14.44% and 13.62%, and the awareness rate of caregiving knowledge was only 4.64%\u0026nbsp;[24].\u003c/p\u003e\n\u003cp\u003eEffective interventions are crucial for enhancing dementia health literacy among older adults in the community. Presently, the intervention strategies for dementia\u0026nbsp;literacy implemented domestically and internationally are mainly through single-knowledge education. For instance, Terayamagave two lessons on caring for patients with dementia in the outpatient departments of hospitals\u0026nbsp;[25]; Commissaris held two educational seminars describing the differences between normal forgetfulness and dementia\u0026nbsp;[26]; Galvinset up a site to provide dementia knowledge counseling for study participants\u0026nbsp;[27]; Zhang Jie distributed posters, organized knowledge lectures, and centralized street counseling services in 21 communities in Shanghai\u0026nbsp;[28]. These studies improved the knowledge literacy of dementia\u0026nbsp;among the study participants to varying degrees through a single form of health education. However, the interventions were limited to improving dementia knowledge literacy.\u003c/p\u003e\n\u003cp\u003eNevertheless, new models of intervention have been emerging in recent years. In 2018, Bruns engaged 147 study participants in a sitcom on the topic of social relationships between people with dementia and caregivers\u0026nbsp;[29]. The study participants completed questionnaires separately before and after the performance. The results showed a significant change in their attitudes toward dementia, from a strong negative mood to a more optimistic mood. Grigsby recruited 42 study participants to watch audiovisual novels on dementia topics and conducted separate surveys before and after the viewing\u0026nbsp;[30]. The study found that the participants' knowledge of dementia significantly improved, and their attitudes toward dementia screening became more positive. Di Bona sent 41 school-aged children who had received knowledge about dementia to a local nursing home to live with 10 older adults with dementia and eight care workers\u0026nbsp;[31]. This intervention program enhanced the children's dementia literacy, increased the care workers' dementia well-being and social inclusiveness, and made a new contribution to dementia-friendly communities.\u003c/p\u003e\n\u003cp\u003eMost of the existing studies on dementia literacy have been conducted in developed countries like Australia, the United States, and Japan, with fewer studies in developing countries [8,32,33].Moreover, most studies only cover the fundamental dementia knowledge and do not integrate dementia attitudes and self-management behaviors for controlling dementia. By summarizing and utilizing existing research findings on dementia literacy, this 3-month community-based intervention study on dementia literacy will incorporate knowledge about dementia, attitudes toward dementia, attitudes toward people with dementia, and self-management behaviors to control dementia.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eRegistration\u003c/h2\u003e\n\u003cp\u003eThe protocol for this non-randomized controlled trial is registered at the Chinese Clinical Trial Registry, ChiCTR2300074788 (https://www.chictr.org.cn/). We registered on August 16, 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims, objectives,and hypotheses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis protocol describes the design of an innovative\u0026nbsp;dementia literacy intervention program\u0026nbsp;that aims to promote healthy behaviors and prevent dementia using multi-format and multi-themed intervention approaches.\u003c/p\u003e\n\u003cp\u003eThis study aims to:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDetermine the effectiveness of the elderly dementia literacy intervention program, on dementia knowledge literacy, attitude literacy, and self-management behavior literacy.\u003c/li\u003e\n \u003cli\u003eExplore the difficulties and challenges of implementing the dementia literacy program among community-dwelling elderly people.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWe hypothesized that older adults in the intervention group would report higher dementia knowledge, attitude, and self-management behavior literacy compared to the usual care group after the three-month intervention. Additionally, they would be better equipped for early prevention, timely diagnosis, and management of dementia.\u003c/p\u003e\n\u003ch2\u003eDesign\u003c/h2\u003e\n\u003cp\u003eThis study will be a non-randomized controlled trial. Two community health service centers in Guangzhou have been selected based on their large numbers of older adult attendees. After sectionalization, participants will receive either the intervention or usual care. The groups will not be randomized considering the physical health status and living convenience of older adults, such as the availability of time and energy to participate in the health literacy interventions at regular intervals throughout the trial.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study will invite experts specializing in cognitive disorders to evaluate the dementia literacy intervention program. Then, according to expert opinions, the content and form of the intervention will be further modified to ensure the feasibility of the intervention plan. During the formal intervention, the first author will provide intervention measures for the intervention group and be responsible for overall project management, including raining delivery, overseeing the entire trial, and data quality assessment. Additionally, each community will have a project team consisting of a senior community nurse and four research assistants. The project team will primarily be responsible for patient recruitment, assisting in the intervention process, and data collection. Project team members will undergo standardized training before the intervention and data collection to ensure the quality of the intervention trial and data collection. The trial has been approved by our Ethical Committees and was registered \u0026nbsp;with the Clinical Trial Registry. The study design is outlined in Figure 1.\u003c/p\u003e\n\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eThe participants who meet the following criteria will be recruited: (a) age\u0026nbsp;\u0026ge;\u0026nbsp;60 years, (b) residing in the community for at least three months, (c) can participate in the program for one hour every two weeks, (d) having no communication or mobility barriers and being able to cooperate in completing the study, and (e) being willing to participate in this survey with informed consent. Exclude criteria will be: (a) diagnosed with dementia, (b) suffering from a severe mental illness or diagnosed with major depression, (c) with a short-term history of acute cardiovascular or cerebrovascular disease, and (d) no mobile phone and other communication devices to use WeChat.\u003c/p\u003e\n\u003ch2\u003eRecruitment\u003c/h2\u003e\n\u003cp\u003eDuring this study, recruitment posters will be distributed in places frequented by older adults, such as the community committee, community health service center, and exercise squares. Simultaneously, pamphlets containing relevant study information will be distributed to elderly residents, and recruitment information will be shared within community WeChat groups. The aim is to recruit 84 eligible participants willing to participate in the study.\u003c/p\u003e\n\u003ch2\u003eSample size\u003c/h2\u003e\n\u003cp\u003eThe sample size was estimated according to the formula: \u003cimg src=\"data:image/png;base64,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\" style=\"width: 132px; height: 48.589px;\" width=\"132\" height=\"48.589\"\u003e The \u003cem\u003en\u003c/em\u003e is the sample size；𝜇\u003csub\u003ea\u003c/sub\u003e is the u-value corresponding to the Type I error probability; 𝜇\u003csub\u003e𝛽\u003c/sub\u003e is the u-value corresponding to the Type II error probability; 𝛿 represents the expected effect size, which is the absolute difference in means between two groups; 𝜎\u003csup\u003e2\u003c/sup\u003e represents the population variance and can be estimated using the sample variance, which is the average of the variances of the two groups. \u0026alpha; was set at 0.05 and \u0026beta; at 0.10. Referencing the study by Ayisi-Boateng et al. a minimum sample size of 34 cases is needed [34]. The required sample size becomes at least 42 cases after factoring in a 20% dropout rate. We aim to recruit 84 participants for this study, with 42 per group.\u003c/p\u003e\n\u003ch2\u003eStudy intervention\u003c/h2\u003e\n\u003ch2\u003e\u003cem\u003eIntervention group\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eAccording to the definition of dementia literacy,\u0026nbsp;we divide the intervention program into three themes: dementia knowledge, dementia attitude, and dementia self-management behavior literacy\u0026nbsp;[35,36]. The content of the program considers the most recent guidelines, such as \u0026ldquo;Guidelines for the Prevention and Treatment of Senile Dementia\u0026rdquo; and \u0026ldquo;Chinese Expert Consensus on the Diagnosis and Treatment of Alzheimer\u0026rsquo;s Disease-Origin Mild Cognitive Impairment 2021\u0026rdquo;\u0026nbsp;[37,38]. Intervention methods include dementia knowledge seminars, dementia knowledge popularization videos, and WeChat group information pushes and question answering. The main contents and arrangements of dementia literacy interventions for older adults are shown in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDementia knowledge seminars:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eWe will hold two dementia knowledge seminars per month in the community, and the theme will focus on one of the three aspects of dementia health literacy. Each seminar will last approximately 45 minutes: 20 minutes for knowledge presentations, 10 minutes for interactive games, 10 minutes for learning assessments such as word matching, and five minutes for participants to share their experiences and insights freely.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDementia knowledge popularization video:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eFollowing the theme of dementia health literacy, two dementia knowledge popularization videos will be created each month. These videos will be distributed in the WeChat groups of the intervention group. Each video will be a maximum of five minutes, with an original content. The presentation format involves lively and vivid image animations combined with explanations in simple and understandable language.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWeChat Group Information Sharing and question-answering:\u003c/em\u003e\u003c/strong\u003eWe will set up a dedicated WeChat group to answer participants\u0026rsquo; questions about dementia and communicate daily health knowledge together. The group will share dementia literacy-related knowledge tweets weekly, and the tweets are sourced from \u0026ldquo;Senile Dementia,\u0026rdquo; \u0026ldquo;Dementia,\u0026rdquo; \u0026ldquo;Alzheimer\u0026rsquo;s Disease,\u0026rdquo; \u0026ldquo;Alzheimer\u0026rsquo;s Disease Prevention and Treatment Association,\u0026rdquo; \u0026ldquo;Chinese Alzheimer\u0026rsquo;s Disease Association,\u0026rdquo; and other dementia public sharing platforms and public numbers. We will regularly share videos about dementia, including movies, variety shows, documentaries, and news, to help participants understand and recognize dementia better.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eControl group\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThe control group will receive routine community care services, including regular health follow-ups and physical examinations, written health education, and stylistic health activities. However, they will not receive additional care services related to dementia literacy. The intervention group will receive dementia literacy interventions concurrently with routine community nursing services.\u003c/p\u003e\n\u003ch2\u003eOutcome measures\u003c/h2\u003e\n\u003cp\u003eThe program will be evaluated at baseline [T0] and post-intervention [3 months\u0026mdash;T1]. The primary outcomes measured at three months will be: dementia knowledge literacy, dementia attitude literacy, and dementia self-management behavior literacy. The primary outcomes will be measured using validated tools.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDementia knowledge literacy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Alzheimer\u0026apos;s Disease Knowledge Scale (ADKS)\u003csup\u003e\u0026nbsp;\u003c/sup\u003ewill be used to measure the dementia knowledge literacy\u0026nbsp;[39]. The scale contains 30 judgmental right or wrong questions that evaluate the test taker\u0026apos;s knowledge of Alzheimer\u0026apos;s disease assessment, diagnosis, care, life impact, prevalence, prevention, risk factors, symptoms, treatment, and management. The composite score is calculated by counting the number of correctly answered questions, and can range from 0 to 30. The\u0026nbsp;Cronbach\u0026apos;s alpha, retest reliability, and split-half reliability of the scale are 0.71, 0.81, and 0.55, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDementia attitude literacy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Dementia Attitudes Scale (DAS)\u003csup\u003e\u0026nbsp;\u003c/sup\u003eis used to measure the dementia attitude literacy\u0026nbsp;[40].\u0026nbsp;It includes 20 items, each assessed on a 7-point Likert scale from 1 [strongly disagree] to 7 [strongly agree], with a total scale score ranging from 20 to 140. The higher the total score, the more positive the attitude toward dementia. The Cronbach\u0026apos;s alpha of the value for the scale is 0.83.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDementia Self-management behavioral literacy\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Chinese version of the Health Promoting Lifestyle Profile-Ⅱ (HPLP-Ⅱ) is used to measure the dementia self-management behavioral literacy of the study participants\u0026nbsp;[41]. The scale consists of 40 items with six dimensions: nutrition (6 items), physical activity (8 items), health responsibility (11 items), interpersonal relationships (5 items), spiritual growth (5 items), and stress management (5 items). The items are scored on a four-point Likert scale from 1\u0026nbsp;to 4 as\u0026nbsp;\u0026ldquo;never,\u0026rdquo; \u0026ldquo;sometimes,\u0026rdquo; \u0026ldquo;often,\u0026rdquo; and \u0026ldquo;always,\u0026rdquo; with a total score range of 40\u0026ndash;160. A score of 1\u0026ndash;2, 2\u0026ndash;3, or 3\u0026ndash;4 indicates a low, medium, or high level of health promotion lifestyle, with higher scores indicating a better health promotion lifestyle. The Cronbach\u0026apos;s alpha of this scale ranged from 0.63\u0026ndash;0.81, with a retest reliability of 0.69.\u003c/p\u003e\n\u003ch2\u003eData collection procedure\u003c/h2\u003e\n\u003cp\u003eData collection will be conducted by two community project team members. All participants will complete the sociodemographic questionnaires, ADKS, DAS, and Chinese versions of the HPLP-II. Reassessment data will be collected at the end of the three-month intervention program. Community project members will redistribute the ADKS, DAS, and HPLP-II questionnaires to participants in both the intervention and control groups. Sociodemographic data will include participants\u0026apos; names, contact information, gender, age, employment status, education level, occupation, accommodation, marital status, cohabitation, family relationships, history of relevant illnesses, health status, and experience of dementia exposure. All data will be collected through paper questionnaires completed by the study participants. The project team members will assist those with visual impairments, difficulty writing, or limited education to fill out the forms after obtaining their opinions.\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eAll data will be quantified and entered into a computer to create a database. Two persons will enter the data to ensure correct data entry. Statistical analysis will be performed using the SPSS 27.0 software. All tests will be two-sided and p-values\u0026lt;0.05 will be considered statistically significant. Sociodemographic information, DAS, ADKS, and Chinese versions of the HPLP-II will be described using frequencies and percentages, as well as means and standard deviation. In order to evaluate the effectiveness of the intervention program, t-tests will be used to analyze the differences in dementia literacy between the study participants before and after the intervention.\u003c/p\u003e\n\u003ch2\u003eEthical considerations\u003c/h2\u003e\n\u003cp\u003eThis study has been approved by the Ethical Committees and registered in the Clinical Trial Registry. The study participants will be informed of the purpose and methodology of the study and will be asked to sign an informed consent form before the survey and intervention. Participants and their family members or legal guardians will have the option to cancel their participation in the study at any time. Patient privacy will be ensured at all times.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aims to determine the effectiveness of the dementia literacy intervention program in improving dementia literacy in older adults and provide valuable information on improving dementia health literacy in Chinese older adults. To our knowledge, this study is the first multi-topic and multi-format dementia health literacy intervention study on improving dementia literacy among older adults. This is a new approach to a major public health problem. If this study confirms the effectiveness and sustainability of this intervention program, it may help to promote early diagnosis of dementia, decelerate the progression of dementia, and improve the quality of life of people with dementia. Furthermore, it can enhance the implementation of health education on dementia literacy for community-dwelling older adults and influence the practice of dementia prevention in the global community.\u003c/p\u003e\n\u003cp\u003eThe strengths of this study include being the first to intervene on three topics: knowledge of dementia, attitudes toward dementia, and self-management behaviors to prevent and treat dementia. It is also the first study to use various forms of intervention, such as dementia knowledge seminars, dementia knowledge educational videos, and WeChat group information sharing alongside question and answering. This approach differs from the traditional health education interventions used by previous studies, which focused only on knowledge. This study strives to comprehensively improve the dementia literacy of older adults from multiple perspectives and directions. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, this study will adopt a multisite approach. It will be conducted in an urban and a rural community in Guangzhou with substantial variations in the occupations, literacy levels, economic incomes, and family members of the elderly. This prevents selection bias due to a single sample selection and makes the research process, results, and experience more generalizable and applicable. Finally, project lead will implement the interventions at the different sites of this study to ensure uniformity of the interventions. The unity of cooperation and the standardized training of the project team members will ensure quality control and the successful completion of the interventions.\u003c/p\u003e\n\u003cp\u003eThe findings will be presented as abstracts at national and international conferences (e.g., Dementia, Nursing, and Medicine Conference) and published in medical or nursing journals. If the intervention is effective in improving dementia literacy in older adults, further research will be needed to optimize the content and format of the intervention.\u003c/p\u003e\n\u003ch2\u003eLessons learned\u003c/h2\u003e\n\u003cp\u003eThis section summarizes some of the lessons learned during the preparation phase of study recruitment and the implementation of the intervention. Only a few older adults were interested during the recruitment, although several strategies were employed to recruit potential participants into the study. This is chiefly because of their limited knowledge about dementia and the belief that dementia is part of normal aging. Therefore, we collaborated with community social workers to organize a healthy outdoor activity for the elderly in the community, such as walking, hiking, square, and dancing, and invited the elderly to participate. During the activity, we discussed the importance of dementia and answered questions about dementia to stimulate the interest of the elderly. Additionally, we presented gifts to all the participants.\u003c/p\u003e\n\u003cp\u003eWhen implementing the intervention study, the greatest challenge is ensuring that all participants participate in the experiment as planned. During recruitment into the study, team members explained the detailed intervention protocol to the participants and emphasized the importance of adhering to the study throughout. Detailed interviews were conducted after obtaining participants\u0026apos; informed consent. The research assistants will maintain frequent daily phone contacts and WeChat group health communication exchanges. Positive feedback and rewards will be given to participants who persistently engage in the intervention study to foster a cooperative relationship between the subjects and the research team.\u003c/p\u003e\n\u003cp\u003eWe streamlined the intervention program to minimize the number of participant trips to the Community Health Service Center. Before each intervention, the research assistant would make a unified notification in the WeChat group one week in advance, followed by a reminder call 2\u0026ndash;3 days before the intervention to ensure time participation. Two sessions at different time slots were arranged for each intervention, with identical intervention content and format. The participants can choose a convenient time to attend either session to minimize problems due to time constraints. After each session, feedback was requested from the participants to improve the content and format of the intervention. The working members of the research team also meet centrally at the end of each intervention to discuss the problems encountered and experiences gained in the study and collaborate to solve the problems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has some limitations, including the sample size that will limits the generalizability of the findings. If the intervention is effective, the sample size can be increased in future studies to continue the in-depth analysis to improve the generalizability and scientific validity of the results. Additionally, the study design is limited by a lack of randomization of subgroups. The frequency of centralized health education in the intervention group was twice a month in each of the two distant communities. The participants will have different time, energy, and preferences to participate in the intervention, which could jeopardize compliance with the research intervention if participants are randomly assigned to different groups. Finally, the variables analyzed in this study were primarily self-reported by the participants, which are influenced by factors such as education and socioeconomic status, and thus, the information provided is limited by subjective bias.\u003c/p\u003e\n\u003ch3\u003eTrial status\u003c/h3\u003e\n\u003cp\u003eTo date we have finished our team members training and preliminary test, and we started enrolling participants in September, 2023. By January 2024, 84 [42 for the intervention group and 42 for the control group] were recruited and met our enrollment target. Currently, our research team has collected baseline data and is implementing the intervention program. Then, we anticipate that the implementation of all intervention programs and the collection of outcome measures will be completed by August 2024.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe trial has been approved by the Institutional Review Board of Jinan University, Guangzhou, China (No. JNUKY-2023-0026) and registered with the Chinese Clinical Trial Registry (NO. ChiCTR2300074788). All methods were carried out in accordance with Declaration of Helsinki. Participants and their family members or legal guardians will have the option to cancel their participation in the study at any time. Patient privacy will be ensured at all times.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eAll data included in this study are available upon request by contact with the corresponding author.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research is funded by National Natural Science Foundation of China (NO.72274078) and The First Affiliated Hospital of Jinan University (NO.2022106).\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eZNN, ZZ, and BF contributed to the design of the study and manuscript drafting. CYT, LML, and ZYJ oversaw data collection and quality control. ZXL and WY offered research space. LQY provided academic supervision and served as the final reviewer of the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe appreciate the efforts of participants who completed the questionnaire.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019 May;18[5]:459\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eJia L, Quan M, Fu Y, Zhao T, Li Y, Wei C, et al. Dementia in China: epidemiology, clinical management, and research advances. Lancet Neurol. 2020 Jan;19[1]:81\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eLang L, Clifford A, Wei L, Zhang D, Leung D, Augustine G, et al. Prevalence and determinants of undetected dementia in the community: a systematic literature review and a meta-analysis. BMJ Open. 2017 Feb 3;7[2]:e011146. \u003c/li\u003e\n\u003cli\u003eCahill S. WHO\u0026rsquo;s global action plan on the public health response to dementia: some challenges and opportunities. Aging Ment Health. 2020 Feb;24[2]:197\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eTHE PEOPLE\u0026rsquo;S REPUBLIC OF CHINA. Notice on the issuance of the \u0026lsquo;13th Five-Year Plan\u0026rsquo; Healthy aging Plan [Internet]. 2017. Available from: http://www.nhc.gov.cn/rkjcyjtfzs/zcwj2/201703/53164cb31b494359a21c607713451342.shtml\u003c/li\u003e\n\u003cli\u003eTHE PEOPLE\u0026rsquo;S REPUBLIC OF CHINA. Notice of the General Office of the National Health Commission on Exploring and developing special services for the prevention and treatment of depression and senile dementia [Internet]. 2020 [cited 2022 Nov 14]. 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Evaluation of an Audio-Visual Novela to Improve Beliefs, Attitudes and Knowledge toward Dementia: A Mixed-Methods Approach. Clin Gerontol. 2017;40[2]:130\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eDi Bona L, Kennedy S, Mountain G. Adopt a Care Home: An intergenerational initiative bringing children into care homes. Dement Lond Engl. 2019 Jul;18[5]:1679\u0026ndash;94. \u003c/li\u003e\n\u003cli\u003eAihara Y, Kato H, Sugiyama T, Ishi K, Goto Y. Public attitudes towards people living with dementia: A cross-sectional study in urban Japan [innovative practice]. Dement Lond Engl. 2020 Feb;19[2]:438\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eBlay SL, Piza Peluso E de T. The Public\u0026rsquo;s ability to recognize Alzheimer disease and their beliefs about its causes. Alzheimer Dis Assoc Disord. 2008 Mar;22[1]:79\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eAyisi-Boateng NK, Sarfo FS, Opoku DA, Nakua EK, Konadu E, Tawiah P, et al. Educational intervention to enhance the knowledge of Ghanaian health workers on Alzheimer\u0026rsquo;s disease and related dementias. Afr J Prim Health Care Fam Med. 2022 Apr 26;14[1]:e1\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eLow LF, Anstey KJ. Dementia literacy: recognition and beliefs on dementia of the Australian public. Alzheimers Dement J Alzheimers Assoc. 2009 Jan;5[1]:43\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eWang S, Jia J. Health literacy of elderly patients with cognitive dysfunction. Pract Geriatr. 2016;30[10]:801\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eDementia and Cognitive Disorders Group, Chinese Society of Neurology. Expert Consensus on the diagnosis and treatment of Alzheimer\u0026rsquo;s disease induced mild cognitive impairment in China 2021. Chin J Neurol. 2022 May 8;55[05]:421\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eAlzheimer\u0026rsquo;s Disease Guidelines. \u003c/li\u003e\n\u003cli\u003eCarpenter BD, Balsis S, Otilingam PG, Hanson PK, Gatz M. The Alzheimer\u0026rsquo;s Disease Knowledge Scale: development and psychometric properties. The Gerontologist. 2009 Apr;49[2]:236\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Connor ML, McFadden SH. Development and Psychometric Validation of the Dementia Attitudes Scale. Int J Alzheimer\u0026rsquo;s Dis. 2010 Mar 22;2010:e454218. \u003c/li\u003e\n\u003cli\u003eCao W, Guo Y, Ping W, Zheng J. Development and performance test of the Chinese version of HPLP-Ⅱ Health Promotion Lifestyle Scale. Chin J Dis Control. 2016;20[03]:286\u0026ndash;9. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"aged, community health centers, dementia, dementia literacy, nursing interventions, study protocol.","lastPublishedDoi":"10.21203/rs.3.rs-4199561/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4199561/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eEffective intervention is the key measure to improve the dementia literacy of older adults. However, to date, there are no studies on the effectiveness of dementia literacy interventions in China. This study aims to evaluate the effectiveness of a dementia literacy intervention program on the dementia knowledge, attitude, and self-management behavior literacy of elderly adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This study will strictly adhere to the inclusion/exclusion criteria, recruiting 84 community-dwelling individuals aged 60 and above from two community health service centers in Guangzhou, Guangdong Province, China. Participants will be allocated into a usual care group and a dementia literacy intervention group. The intervention group will receive a multi-themed and multi-format dementia literacy intervention trial through community knowledge seminars, educational videos, WeChat group information push and answer questions, etc. Intervention themes will include dementia knowledge, attitudes toward dementia, and self-management behaviors for preventing and managing dementia. Data will be collected before the start of the intervention study and three months after the intervention study. The primary outcome measures will include dementia knowledge literacy, dementia attitude literacy, and dementia self-management behavior literacy. Data will be managed and analyzed using SPSS 26.0. Ethical approval for this study was granted on 12 June 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion: \u003c/strong\u003eIf proven effective, this dementia literacy intervention program could be widely applied in primary community health centers to enhance dementia literacy among Chinese elderly. Also, the dementia literacy intervention program will provide a reference and a basis for further research on enhancing dementia literacy intervention programs for the elderly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e Registered in the Chinese Clinical Trial Registry (NO. ChiCTR2300074788).\u003c/p\u003e","manuscriptTitle":"A multi-themed and multi-format intervention program for improving dementia literacy among Chinese older adults: Study protocol for a non-randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-12 15:43:01","doi":"10.21203/rs.3.rs-4199561/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"185ca141-0961-4cf5-9b5b-45687c3fe842","owner":[],"postedDate":"April 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-31T10:50:52+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-12 15:43:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4199561","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4199561","identity":"rs-4199561","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}