Evaluating the General Population of Saudi Arabia for Their Knowledge, Attitudes, and Practices Towards Dementia

Introduction Dementia, a prevalent neurological condition, has a significant global impact on individuals and communities. Despite affecting approximately 50 million people worldwide, with an expected tripling by 2050, there are currently no widely available disease-modifying treatments. Recent efforts have concentrated on strategies involving legislation, regulations, and population-wide initiatives to address dementia risk, diagnosis, and care. Methods This cross-sectional survey engaged 6123 participants in Saudi Arabia, utilizing a multistage sampling design across provinces and cities. The study aimed to investigate the knowledge, attitudes, and practices of the Saudi Arabian general population regarding dementia. Results Participants displayed diverse opinions on dementia knowledge, with females exhibiting higher rates of knowledge, attitudes, and practices than males. Notably, 97.2% of females were aware of dementia compared to 78% of males. The perception of dementia as a healthcare priority was significantly higher in females (84.1%) than in males (59.6%). Older females (≥65) were identified as the age group most associated with dementia (92.50%) compared to males (71.10%). Conclusion While participants demonstrated excellent knowledge of hearing about dementia, understanding symptoms, and identifying modifiable factors, their knowledge regarding prevention and curability was found to be inadequate. A significant gender association was observed, with females exhibiting higher knowledge, attitudes, and practices than males.


Introduction
Dementia stands out as a major public health concern associated with the aging demographic, characterized by the gradual loss of memory, cognitive function, or both, hindering daily activities while consciousness is retained.Alzheimer's disease is widely recognized as the predominant global cause of dementia, with other contributors such as frontotemporal dementia, vascular disorders, and dementia with Lewy bodies [1].The profound impact of dementia extends beyond cognitive aspects, significantly influencing social behavior and complicating the lives of both those affected and their caregivers.It is noteworthy that dementia holds the sixth position among the leading causes of death worldwide [2].Dementia encompasses a cluster of brain disorders affecting behavior, memory, and cognition, resulting in significant morbidity and dependence among the elderly.The global prevalence of dementia exceeds 55 million seniors, a number projected to soar to 131.5 million by 2050 [3].Mild cognitive impairment (MCI) serves as a transitional stage between typical age-related cognitive decline and full-fledged dementia, marked by an estimated annual conversion rate of 20% [4].To impede the advancement of dementia, cognitive training programs and the modification of risk factors stand out as viable strategies [5].
The aging population of Saudi Arabia is on the rise.In 2016, the segment of the population aged over 60 constituted 6.5%, totaling 1.3 million, and this figure is projected to climb to around 10 million, constituting 25% of the total population, by 2050 [6].Moreover, the nation's life expectancy is expected to elevate from 74 to 82 years.As longevity increases, the likelihood of cognitive impairment is anticipated to surge.Additionally, the global prevalence of dementia is forecasted to escalate over the next two decades [7].
Recent data from the World Health Organization (WHO) indicates that the global prevalence of dementia is approximately 55 million, with an annual increase in the incidence of nearly 10 million people receiving a diagnosis.Additionally, a study conducted in Saudi Arabia reported that dementia affected 16.6% of senior patients [1].
Certain Western countries have developed diverse models of dementia care for primary care, often termed "collaborative care" or "patient-centered care," aimed at addressing the complex healthcare needs of patients and caregivers and facilitating interdisciplinary treatment [8].Dementia care in a primary care setting has proven beneficial for both patients and their caregivers [9].General practitioners (GPs) have demonstrated positive attitudes toward diagnosing and caring for dementia patients [10].However, persistent challenges exist.For instance, GPs may lack confidence in making early diagnoses or screening patients before referring them to specialists [11].Recommendations have been made for enhanced education for GPs to overcome these challenges [12].
Numerous research findings suggest that there is potential for improving diverse populations' attitudes, knowledge, and literacy about dementia [11].To fill in these gaps and provide correct information on dementia risk reduction techniques, awareness campaigns and educational interventions should be created.
In general, it is critical to raise the public, medical professional, and community health workers understanding and awareness of dementia-related issues.The aim of this study is to assess the effectiveness of awareness campaigns and educational interventions in enhancing attitudes, knowledge, and literacy about dementia risk reduction techniques across diverse populations.It is possible to lessen the effects of dementia and enhance the quality of life for both those who are caring for someone with dementia and those who are not by encouraging early detection, risk reduction, and appropriate care practices.

Study design
The research employed a cross-sectional study design, characterized by observational data collection at a specific time point.Utilizing a multistage sampling design, participants were chosen from various provinces, cities, and clusters within Saudi Arabia.

Study area
The research was conducted in Saudi Arabia, encompassing multiple provinces and cities throughout the country.With a diverse population and geographical distribution, the Kingdom of Saudi Arabia is divided into 13 provinces, including Riyadh, Qasim, Dammam, Khafji, Alhasa, Mecca, Medina, Jeddah, Asir, Najran, Jizan, Tabuk, and Jouf.This extensive coverage provided a comprehensive setting to evaluate the knowledge, attitudes, and practices of the general population regarding dementia.

Study setting
The data collection for this study was conducted in various settings within Saudi Arabia, encompassing both urban and rural areas.Community centers, public spaces, educational institutions (e.g., universities, colleges), and residential areas were included as study settings.The study duration was six months, spanning from May to November 2023.

Study population
The study encompassed individuals aged 18 years and above who resided in Saudi Arabia.The investigation targeted the general population, ensuring representation from diverse socioeconomic backgrounds, educational levels, occupations, and regions across the country.

Inclusion and exclusion criteria
Individuals aged 18 years and older were considered for inclusion, while those with a confirmed history of dementia or cognitive impairment were excluded from the study.

Sample size
The sample size for this study was calculated using the following formula: Where n is the required sample size, Z is the confidence level (standard value of 1.96 for 95% confidence), p is the estimated proportion of the population with adequate knowledge about pancreatitis (based on previous studies), q=1−p, and d is the margin of error (5% or 0.05).Assuming an estimated proportion of 50% and a margin of error of 5%, the minimum sample size was approximately 380 participants.

Sampling technique
A multi-stage sampling approach was employed, involving the selection of provinces, cities, and clusters within Saudi Arabia.In the first stage, random sampling was used to select a specific number of provinces from the sampling frame, ensuring geographic representation and diversity across Saudi Arabia.In the second stage, random sampling was employed to select a predetermined number of cities within each chosen province, representing various urban and rural areas.In the third stage, within each selected city, clusters were formed based on predefined criteria, such as neighborhoods or specific areas.Random sampling was then used to select a suitable number of clusters within each city.The selection process aimed to include a reasonable number of participants from different provinces of Saudi Arabia to ensure diversity and representation in the study.This technique ensured that the sample was representative of the study population and provided a sufficient number of participants for the study.

Data collection tools
The data were collected by multiple data collectors using a structured interviewing technique with a questionnaire.The survey was modified from one previously published [13].The questionnaire compiled for the study consisted of 27 questions divided into three groups: the first five questions focused on the participants' demographics, the following eight questions assessed knowledge, and the last 14 questions examined attitude and practice.All data collectors were trained in the Arabization of the questions through a workshop designed for this purpose to ensure consistency in data collection.A pilot study was conducted among 25 participants not included in the main study to assess the clarity, understandability, relevance, and validity of the questionnaire items.As illustrated in Table 2, the general responses of the study participants indicated an insufficient level of knowledge about dementia.Most participants correctly identified the age ≥ 65 years as when dementia could affect (n=5266, 86%).However, the understanding that dementia is a normal part of aging was inadequate, with (n=2723, 44.5%) in agreement and (n=2462, 40.2%) in disagreement.Inadequate responses were observed regarding the hereditary nature of dementia, where (n=1909, 31.2%)answered yes, and (n=2620, 42.8%) answered no.A significant portion of participants prioritized dementia as a healthcare concern (n=4698, 76.7%).Short-term memory loss was correctly identified as the most common symptom by the majority (n=4318, 70.52%).However, there was an inadequate understanding of whether dementia can be prevented by modifying certain factors, with the highest rate (n=2635, 43.03%) believing dementia cannot be prevented.Additionally, (n=2815, 46%) were uncertain about whether dementia could be cured with medication.Those who reported not knowing anyone with dementia were higher (n=2477, 56%).Participants expressed concern about developing dementia themselves when they become older, representing a significant proportion (n=3434, 56.1%).Responses regarding hiding the dementia diagnosis of a relative were inadequate, with (n=3373, 55.15%) indicating "not applicable."Regarding the health impact of caring for a relative with dementia, (n=3568, 58.3%) answered "not applicable."A substantial number of participants (n=2927, 47.8%) did not know whether doctors and nurses ignore people with dementia, while (n=2259, 36.9%)answered no.The majority expressed no shame about having a relative with dementia (n=3830, 62.6%) and were worried about close family members or friends developing dementia (n=3521, 57.5%).Most participants agreed to visit doctors if they experienced memory problems (n=4579, 74.8%) and would encourage others to do the same (n=5114, 83.5%).The majority believed they could know the diagnosis if they suffered from dementia (n=4425, 72.3%).Regarding informing patients about their dementia diagnosis when caring for someone, 2886 (47.1%) participants agreed.However, the majority did not perceive a dementia diagnosis as a death sentence (n=3481, 56.9%).About whether dementia is worse for family and friends than for the person with dementia, the majority answered yes (n=3514, 57.4%).Regarding the ability of people with dementia to drive, the majority answered no (n=4842, 79.1%).The values mentioned in Table 3 revealed a highly significant association among all participants in terms of knowledge, attitude, and practice of dementia, except for the question "Do you know anyone or have you known anyone with dementia?"where the association was non-significant (p=0.461).In terms of hearing about dementia, females exhibited higher knowledge (n=4149, 97.2%) compared to males (n=1446, 78%).Similarly, awareness of the age affected by dementia was more prevalent in females (n=3948, 92.50%) than in males (n=1318, 71.10%).Regarding the perception of dementia as a normal part of aging, females showed a higher percentage (n=2040, 47.8%) than males (n=683, 36.9%).Disagreement about the hereditary nature of dementia was more common in females (n=1906, 44.6%) than in males (n=71438, 5%).Concerning the prioritization of dementia as a healthcare issue, females demonstrated higher agreement (n=3593, 84.1%) compared to males (n=1105, 59.6%).Short-term memory loss was identified as the most common symptom by both genders, with higher frequencies in females (n=3060, 49.98%) compared to males (n=1258, 20.55%).

Question
Responses regarding the prevention of dementia through modifying factors showed that the highest frequency of answers in females was "Dementia cannot be prevented" (n=1917, 31.31%), while in males, it was "Excessive alcohol intake" (n=789, 12.89%).Both males (n=953, 51.4%) and females (n=1862, 43.6%) expressed uncertainty about whether dementia could be cured.Participants from both genders reported not knowing anyone with dementia, with females at (n=2427, 56.8%) and males at (n=1050, 56.7%).Regarding hiding the diagnosis of dementia, females responded "Not applicable" more frequently (n=2443, 57.2%) than males (n=930, 50.2%).Responses about the health impact of caring for a relative with dementia showed that both males and females marked "Not applicable" as the predominant answer (n=2613, 61.2%) for females and (n=955, 51.55%) for males.The perception that doctors and nurses ignore people with dementia was commonly expressed as "Don't know" by both females (n=1931, 45.2%) and males (n=996, 53.8%).Both genders reported no shame about having a relative with dementia, with females at (n=2700, 63.2%) and males at (n=1130, 60%).Worry about close family members or friends developing dementia was prevalent in both females (n=2680, 62.8%,) and males (n=841, 45.4%).Positive responses about visiting doctors if experiencing memory problems were higher in females (n=3429, 80.3%) than in males (n=1150, 62.1%).
Encouraging closer persons to visit doctors if they suffered from memory problems was more common in females (n=3819, 89.4%) than in males (n=1295, 69.9%).Responses about informing a patient about their dementia diagnosis when caring for someone showed a higher frequency of "Yes" in females (n=2089, 48.9%) and males (n=797, 43%).Regarding whether the diagnosis of dementia is perceived as a death sentence, the negative response was the highest frequency for both females (n=2553, 59.8%) and males (n=928, 50.15%).In response to whether it is worse for family and friends than for the person with dementia, the highest frequency of "Yes" was observed in females (n=2574, 60.3%,) and males (n=940, 50.7%).Both genders were in agreement about not allowing people with dementia to drive, with females at (n=3608, 84.5%) and males at (n=1234, 66.6%).

Discussion
Globally, dementia has emerged as a significant public health concern, affecting 50 million individuals at present, with projections indicating a surge to 152 million by 2050 as the global population ages [14].This trend is not exclusive to specific regions, as the prevalence of dementia in the Netherlands is expected to rise from 280,000 in 2018 to over 620,000 by 2050 [15].Saudi Arabia follows a similar trajectory, with an estimated dementia prevalence of 12.9%, surpassing previous local hospital-based studies and aligning with findings from Canada, Italy, and the Netherlands.Despite this, research on dementia in the Gulf region is relatively limited compared to the Western world [16].Recent years have witnessed substantial progress in scientific knowledge pertaining to cognition and dementia.Advances in understanding the causes and risk factors, including genetic considerations, have been notable [17].This growing body of knowledge underscores the importance of addressing dementia on a global scale and emphasizes the need for expanded research efforts, particularly in regions like the Gulf, where insights into this condition are relatively limited.

TABLE 1 : Sociodemographic characteristics of the study participants (n= 6123)
n: Number of participants; %: Percentage of participants.
If you were suffering from dementia, you would like to be told your diagnosis?If someone you were caring for was suffering from dementia, would you want them to be told the diagnosis?

TABLE 2 : Knowledge, attitudes, and practices toward dementia disease
n: Number of participants; %: Percentage of participants.
Is it worse for family and friends than for the person with dementia?

TABLE 3 : Association between gender groups and dementia knowledge, attitudes, and practices
Fisher's Exact TestA p-value of ≤0.05 and ≤0.01 was considered the cut-off point for statistically significant differences between variables. *