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. Author manuscript; available in PMC: 2026 Mar 12.
Published in final edited form as: J Immigr Minor Health. 2025 Mar 12;27(3):489–500. doi: 10.1007/s10903-025-01677-y

Brain Health Attitudes, Awareness and Actions in Middle-Aged Latinos

Sophia W Light 1, Jeimmy Hurtado 1, Myriam del Salto 1, Lauren Opsasnick 1, Stephanie Batio 1, Alyssa Vela 2, Alissa Bernstein Sideman 3,4,5, Michael S Wolf 1
PMCID: PMC12249754  NIHMSID: NIHMS2092440  PMID: 40072737

Abstract

Background:

Alzheimer’s disease and related dementias (ADRD) disproportionately impact Latinos in the US. Interventions that promote engagement in established protective behaviors throughout the life course may offer an opportunity to address disparities. To inform brain health promotion efforts, this study aimed to examine current brain health-related attitudes, awareness, and actions of middle-aged Latinos.

Methods:

A cross-sectional, online survey was completed by 200 Latinos 35-64 years old. Survey items assessed concern about ADRD, beliefs related to ways to support brain health, knowledge of protective behaviors, and actual engagement in protective behaviors. Multivariable analyses examined differences in knowledge, attitudinal, and behavioral outcomes by sociodemographic and psychosocial factors including health literacy and health activation.

Results:

A third (36.0%) of participants were “very concerned” about ADRD. Nearly two thirds (61.0%) “strongly agreed” steps can be taken to reduce risk of ADRD. Less than a third (29.5%) were able to name three steps to support brain health, and 45.5% reported currently engaging in behaviors to support brain health. In multivariable analyses, participants with lower acculturation were more likely to be “very concerned” about ADRD and to “strongly agree” that steps can be taken to support brain health. Participants with low health activation were less likely to agree that steps can be taken. Those who were older and had a family member with ADRD were more likely to be able to name three steps that can be taken.

Conclusions:

Most middle-aged Latinos believed brain health is actionable, while concern for ADRD, awareness of ways to protect the brain, and engagement in science-based protective behaviors was variable. Opportunities exist for increasing education about well-established modifiable risk factors for ADRD, yet more research is needed to understand these factors in historically minoritized communities.

Keywords: Aging, Dementia, Brain Health, Hispanic/Latino, Health Promotion

INTRODUCTION

As the burden of Alzheimer’s disease and related dementias (ADRD) is increasing worldwide [1,2], various calls to action for a preventive brain health strategy have surfaced [3]. While prior work has predominantly focused on a reactive approach, working with people living with ADRD and their caregivers, in recent years there has been a shift to prioritizing a proactive approach – emphasizing brain health promotion via modifiable lifestyle factors earlier in the life course, when there is greater opportunity for producing positive health outcomes [3–5].

Importantly, some historically marginalized populations are known to be disproportionately impacted by ADRD, including Hispanic/Latino adults living in the US (hereafter: Latino) [1,6,7]. Disparities are driven by adverse social determinants of health (SDOH) [8], and increasing health literacy may be a potential mechanism by which to ameliorate negative community health effects of SDOH [9–12]. In order to design brain health literacy interventions that are culturally-informed, an important step is to understand current beliefs and behaviors of members of the target audience.

To date, the literature on Latinos’ beliefs and perceptions pertaining to ADRD and brain health suggests mixed concern about cognitive impairment, limited understanding of risk factors, and variable recognition of protective lifestyle factors [13]. However, the majority of these studies were conducted over a decade ago [14–20], and none explored how knowledge and beliefs translate to actual behaviors.

In response, we conducted a cross-sectional study among middle-aged Latinos to determine their attitudes pertaining to brain health and ADRD, their awareness of modifiable protective factors to support brain health, and actions they currently take to support brain health. We focused on the role of health literacy, health activation, and other psychosocial determinants in understanding motivation for and initiation of brain health protective behaviors.

METHODS

The Northwestern Institutional Review Board approved study procedures. Recruitment and data collection occurred between August and December 2023 in Chicago, Illinois.

Participants

Potential participants were eligible if they were 35 to 64 years old (in line with the lifespan perspective definition of middle adulthood [21,22]), self-identified as Latino/a, were fluent in English and/or Spanish, and had access to the internet and an email address.

Data Collection

Participants were recruited via multiple methods, including self-recruitment via social media posts [23,24], community exchange sites (e.g., clinics, churches), and snowball sampling. Targeted recruitment involved contacting eligible patients from a large academic medical center and those who had served as participants from prior studies conducted by the research team. All potential participants were directed to REDCap web-based survey software [25] to answer eligibility questions. If eligible, respondents provided informed consent prior to engaging in research activities. On average, surveys took 22 minutes to complete, and participants who completed the survey were mailed a $20 gift certificate for their time. In total, 295 individuals completed the eligibility screener, 246 were eligible, and 200 completed the study (Figure 1).

Fig 1.

Fig 1.

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Recruitment and Enrollment Information

Measures

Patient sociodemographics (age, gender, race, ethnicity, country of origin, years living in the US for those born outside the US, generational status, income, educational attainment, employment status, health insurance status, marital status, self-reported chronic conditions) were collected. The Consumer Health Activation Index (CHAI) was used to determine patient activation [26], with scores ranging from 0 to 100, and <80 representing low activation. A single item screener assessed health literacy: “How confident are you in filling out medical forms by yourself?” Responses are measured on a scale of 1 (Extremely) to 5 (Not at all), with scores of 3 or greater indicating inadequate health literacy [27,28]. The Short Acculturation Scale for Hispanics (SASH) was used to assess language use, media use, and social relations; acculturation scores represent an average of 12 responses, measured on a scale of 1 to 5, with 1 being least and 5 being most acculturated to US culture [29]. A single item was used to capture self-reported overall health (excellent, very good, fair, or poor) [30]. All items were available in both English and Spanish; each participant selected their preferred language. Materials were translated using a modified committee approach, as recommended by the Census Bureau Guidelines for Survey Translation [31], with the support of an established team of bilingual experts specializing in instrument translation.

Prior research and extensive literature review guided the research team’s selection and creation of survey items. Items were adapted from existing questionnaires and public health surveys [32–34]. Cognitive interviewing was completed with members of a community advisory board (CAB) made up of individuals who identified at middle-aged Latinos. Survey items were iteratively updated based on feedback from CAB participants and discussion in research team meetings.

Brain Health Attitudes

Two questions assessed participant attitudes regarding brain health. The first question asked how concerned participants were about developing ADRD [35,36] and nine other conditions based on the Center for Disease Control and Prevention’s list of leading causes of death in the US [37]. Participants were asked to rate, on a scale of 1 to 5 (1 being not at all concerned and 5 being very concerned), how concerned they felt about getting each condition. For analyses, this variable was dichotomized to compare those that rated ADRD at the highest concern compared to those who did not. The second item asked participants to rate, on a scale of 1 to 5 (1 being strongly agree and 5 being strongly disagree), how much they agree with the statement, “I believe that there are steps I can take to support my memory and thinking abilities and reduce my risk of Alzheimer’s disease and dementia” [32,33]. Responses were dichotomized to compare those who expressed total agreement versus everyone else.

Brain Health Awareness

Demonstrated awareness of brain health promotion was assessed through open-ended questions asking participants to name three actions that one can take to support their memory and thinking abilities. Two bilingual raters (SWL, JH) documented and independently coded verbatim responses, which were then thematically analyzed by members of the research team. Decisions about what to include were based on the modifiable lifestyle behaviors endorsed by the Lancet Commission report and/or the National Institute on Aging (NIA) material on cognitive health and older adults [38,39]. This variable was dichotomized based on whether participants were able to name three steps to support brain health.

Brain Health Actions

Participants were asked if they had made any lifestyle changes specifically to protect their memory and thinking. For those that answered affirmatively, an open-ended question asked what changes had been implemented. Two raters again independently coded verbatim responses based on the Lancet Commission and NIA reports, and then responses were thematically analyzed. This variable was dichotomized based on whether participants reported current engagement in one or more established protective behaviors.

Engagement in Specific Health Behaviors and Self-Management Skills

Engagement in empirically-supported brain healthy behaviors was additionally assessed by asking participants about their current engagement with eight health behaviors and self-management skills that have been endorsed by the Lancet Commission as modifiable risk factors for ADRD [38]. To assess physical activity, a validated single item screener was used [40,41]. For social contact, a previously described item was leveraged to evaluate how frequently participants gather socially with friends or relatives [42,43]. Unhealthy alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT C) [44]. Tobacco use, hearing impairment, hypertension, diabetes, and depression were all assessed with questions from the Behavioral Risk Factor Surveillance System [45,46]. For the latter four, a first item gauged whether the condition was present, and if yes, a second item assessed whether the participant was engaging in self-management behaviors.

Analysis

Descriptive statistics (means with SDs and percentage frequencies) were calculated for all participant characteristics and survey responses. Bivariate analyses examined the differences in participant characteristics and survey responses between the interview languages, using χ2 tests and t-tests. Associations between participant characteristics and responses to brain health attitude, awareness, and action items were then examined in bivariate analyses using χ2 tests, t-tests, analysis of variance, or Fisher’s exact test, as appropriate. For all binary outcomes, multivariable logistic regression was used to estimate adjusted odds ratios (aORs). To avoid overadjustment, all models included a standard set of covariates based on the study’s hypotheses: health literacy, health activation, acculturation, and presence of family member with ADRD as primary covariates of interest, as well as additional variables known to affect knowledge and behavior (age, gender, self-reported health). Adjusted Odds ratios and 95% Confidence intervals were estimated. Statistical analyses were performed using STATA, version 18.0.

RESULTS

Table 1 summarizes participant characteristics. Participants were middle-aged (M = 46.9, SD: 8.8, range 35-64), and 62% were female. Nearly one half were college graduates (47.5%). Ninety-nine (49.5%) were primary English speakers and 101 (50.5%) were primary Spanish speakers. Among those born outside the US, national origin was diverse (Table 2). About half reported low acculturation (47.5%). About half had low health activation (44.5%), and 46.2% were contending with at least one chronic health condition, including heart conditions (n=13), lung conditions (n= 21), hyperlipidemia (n=55), cancer (n=7), cerebrovascular conditions (n=4), arthritis (n=25), and chronic kidney disease (n=5). Sixteen percent were classified as having limited health literacy. Over a third reported having a family member with ADRD (39.5%).

Table 1.

Sample Characteristics

Overall (N=200) Language
English (n=99) Spanish (n=101) p-value
Age, M (SD) 46.9 (8.8) 45.7 (8.9) 48.2 (8.6) 0.05
Female, % 124 (62%) 58 (46.8%) 66 (53.2%) 0.40
US-born, % 76 (38%) 71 (93.4%) 5 (6.6%) <0.001
Years Living in US a, M (SD) 22.77 (13.06) 33.7 (11.3) 19.6 (11.8) <0.001
Married, % 114 (57%) 54 (47.4%) 60 (52.6%) 0.78
Education, % 0.002
 Less than high school degree 29 (14.5%) 7 (24.1%) 22 (75.9%)
 High school degree or equivalent 19 (9.5%) 7 (36.8%) 12 (63.2%)
 Some college or technical school 55 (27.5%) 24 (43.6%) 31 (56.4%)
 College graduate 95 (47.5%) 60 (63.2%) 35 (36.8%)
Employment Status, % <0.001
 Employed Full-Time 109 (54.5%) 69 (63.3%) 40 (36.7%)
 Employed Part-Time 55 (27.5%) 15 (27.3%) 40 (72.7%)
 Unemployed 36 (18.0%) 15 (41.7%) 21 (58.3%)
Insurance, % <0.001
 Government-Sponsored 69 (34.5%) 26 (37.7%) 43 (62.3%)
 Private 100 (50.0%) 68 (68.0%) 32 (32.0%)
 Uninsured 25 (12.5%) 3 (12.0%) 22 (88.0%)
 Prefer not to answer 6 (3.0%) 2 (33.3%) 4 (66.7%)
Income 0.002
 Less than $25,000 28 (14.0%) 11 (39.3%) 17 (60.7%)
 Between $25,000 and $49,999 52 (26.0%) 17 (32.7%) 35 (67.3%)
 $50,000 or more 93 (46.5%) 59 (63.4%) 34 (36.6%)
 Prefer not to answer 27 (13.5%) 12 (44.4%) 15 (55.6%)
Low Acculturation (SASH), % 95 (47.5%) 14 (14.7%) 81 (85.3%) <0.001
Limited Health Literacy, % (HL-1) 33 (16.5%) 12 (36.4%) 21 (63.6%) 0.099
Low Health Activation (CHAI), % 89 (44.5%) 52 (58.4%) 37 (41.6%) 0.056
Self-Reported Overall Health, % 0.001
 Excellent 27 (13.5%) 4 (14.8 %) 23 (85.2%)
 Very Good 50 (25.0%) 29 (58.0%) 21 (42.0%)
 Good 82 (41.0%) 48 (58.5%) 34 (41.5%)
 Fair/Poor 41 (20.5%) 18 (43.9%) 23 (56.1%)
Number of Chronic Conditions b, % 0.081
 0 105 (53.85%) 45 (42.9%) 60 (57.1%)
 1 50 (25.64%) 30 (60.0%) 20 (40.0%)
 2 or more 40 (20.52%) 23 (57.5%) 17 (42.5%)
Has family member with ADRD, % 79 (39.5%) 48 (60.8%) 31 (39.2%) 0.024
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a

if foreign-born

b

5 missing values

Table 2.

Frequencies of participants’ nationalities

Country of Origin N (%)
North America
United States 76 (38%)
Mexico 59 (29.5%)
South America
Ecuador 13 (6.5%)
Colombia 8 (4.0%)
Peru 5 (2.5%)
Venezuela 4 (2.0%)
Chile 2 (1.0%)
Argentina 1 (0.5%)
Bolivia 1 (0.5%)
Uruguay 1 (0.5%)
Central America
Guatemala 4 (2.0%)
Honduras 2 (1.0%)
Panama 2 (1.0%)
Caribbean
Cuba 8 (4.0%)
Dominican Republic 2 (1.0%)
Puerto Rico 5 (2.5%)
Other, Prefer not to answer 7 (3.5%)
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Brain Health Attitudes

On average, the sample expressed a moderate level of concern for developing ADRD (M = 3.6 out of 5, SD: 0.10) (Table 3). In relative terms, participants’ concern towards ADRD ranked higher than other any other medical condition except cancer. About a third reported that they were “very concerned” about getting ADRD (36.0%). Sixty-one percent “strongly agreed” that steps can be taken to support memory and thinking and reduce the risk of ADRD.

Table 3.

Overall Attitudes, Awareness, and Actions, and By Preferred Language (n=200)

Outcome Overall (N=200) Language
English (n=99) Spanish (n=101) p-value
Attitudes
On a scale of 1-5, how concerned they are about the following conditions (M, SD)
    ADRD 3.6 (0.10) 3.2 (1.40) 4.0 (1.32) <0.001
    Cancer 3.6 (0.10) 3.3 (1.31) 4.0 (1.38) <0.001
    Diabetes 3.5 (0.10) 3.2 (1.52) 3.9 (1.32) 0.001
    Heart Disease 3.4 (0.10) 3.0 (1.43) 3.8 (1.35) <0.001
    Stroke 3.4 (0.10) 2.9 (1.37) 3.9 (1.33) <0.001
    Mental Health/Psychiatric Condition 3.2 (0.11) 2.8 (1.50) 3.7 (1.42) <0.001
    Respiratory or Lung Disease 3.1 (0.11) 2.6 (1.41) 3.6 (1.44) <0.001
    Kidney Disease 3.1 (0.11) 2.4 (1.35) 3.8 (1.31) <0.001
    Influenza or Pneumonia 3.0 (0.10) 2.5 (1.29) 3.5 (1.43) <0.001
    Chronic Liver Disease & Cirrhosis 3.0 (0.12) 2.2 (1.38) 3.9 (1.40) <0.001
Very concerned about getting ADRD (N, %) 72 (36.0%) 25 (34.7%) 47 (65.3%) P=0.002
Strongly agree that steps can be taken to support memory and thinking and reduce risk of ADRD (N, %) 122 (61.0%) 48 (39.3%) 74 (60.7%) P<0.001
Awareness
Can name 3 specific steps to support brain health (N, %) 59 (29.5%) 30 (50.9%) 29 (49.2%) 0.805
Actions
Reported engaging in at least 1 empirically-supported lifestyle change 91 (45.5%) 42 (46.2%) 49 (53.9%) 0.387
Meets Physical Activity Guidelines (N, %) 64 (32.0%) 28 (43.8%) 36 (56.3%) 0.265
Socializes at least once per week (N, %) 105 (52.5%) 48 (45.7%) 57 (54.3%) 0.260
No Tobacco Use (N, %) 167 (83.5%) 78 (46.7%) 89 (53.3%) 0.075
Alcohol Consumption Within Limits (N, %) 157 (78.5%) 71 (45.2%) 86 (54.8%) 0.019
Diagnosed with Hypertension (N, %) 42 (21.0%) 19 (45.2%) 23 (54.8%) 0.534
    Taking medications to manage (N, %) a 29 (70.7%) 15 (51.7%)† 14 (48.3%)† 0.325
Diagnosed with Diabetes (N, %) 31 (15.5%) 14 (45.2%) 17 (54.8%) 0.599
    Taking steps to manage (N, %) b 26 (92.9%) 11 (42.3%)† 15 (57.7%)† 0.999
Diagnosed with Depression (N, %) 31 (15.5%) 21 (67.7%) 10 (32.3%) 0.027
    Taking steps to manage (N, %) c 25 (80.7%) 18 (72.0%)† 7 (28.0%)† 0.358
Experiencing Hearing Loss (N, %) 30 (15.0%) 20 (66.7%) 10 (33.3%) 0.041
    Using hearing aids (N, %) d 2 (6.7%) 1 (50.0%)† 1 (50.0%)† 0.999
Has Subjective Cognitive Concern (N, %) 106 (53.0%) 34 (32.1%) 72 (67.9%) <0.001
    Has discussed concern with professional (N, %) e 44 (41.5%) 16 (36.4%) 28 (63.6%) 0.426
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Note: Statistically significant values are shown in bold.

a

Out of 42 people who endorsed a diagnosis of hypertension

b

Out of 31 people who endorsed a diagnosis of diabetes

c

Out of 31 people who endorsed a diagnosis of depression

d

Out of 30 people who endorsed hearing impairment

e

Out of 106 people who endorsed subjective cognitive concerns

†

Note: Small sample size (<5 respondents in some cells of chi square)

Being very concerned with ADRD was associated with being Spanish-speaking (p=0.002), being an immigrant (p=0.046), and reporting low acculturation (p=0.001) (Table 4). No other sociodemographic variables were associated with higher ADRD concern. Strong agreement with the belief that steps can be taken to protect the brain from ADRD was associated with being Spanish-speaking (p<0.001), being an immigrant (p=0.005), reporting less than $50,000 income (p=0.023), having adequate health literacy (p=0.045), having moderate or high health activation (p<0.001), and reporting good to excellent health (p=0.017). No other sociodemographic variables were significant.

Table 4.

Attitudes, Awareness and Actions Across Sample Characteristics

Variable Attitudes Awareness Actions
Very concerned about ADRD, N (%) Strongly agrees that steps can be taken to support memory and thinking, N (%) Identified 3 ways to protect the brain, N (%) Engaging in 1+ empirically-supported behavior change, N (%)
Age group
35-44 y 28 (31.8%) 55 (62.5%) 19 (21.6%) 37 (42.1%)
45-54 y 20 (31.3%) 39 (60.9%) 22 (34.4%) 27 (32.2%)
55-64 y 24 (50.0%) 28 (58.3%) 18 (37.5%) 27 (56.3%)
P=0.068 P=0.893 P=0.088 P=0.230
Gender a
Male 23 (30.7%) 44 (58.7%) 19 (25.3%) 30 (40.0%)
Female 49 (39.5%) 78 (62.9%) 39 (31.5%) 61 (49.2%)
P=0.208 P=0.552 P=0.357 P=0.207
Preferred Language
English 25 (25.3%) 48 (48.5%) 30 (30.3%) 42 (42.4%)
Spanish 47 (46.5%) 74 (73.3%) 29 (28.7%) 49 (48.5%)
P=0.002 ** P<0.001 *** P=0.805 P=0.387
Regional Origin b
USA 20 (26.3%) 35 (46.1%) 26 (34.2%) 34 (44.7%)
Mexico 27 (45.8%) 39 (66.1%) 16 (27.1%) 29 (48.2%)
South America 13 (37.1%) 26 (74.3%) 12 (34.3%) 18 (51.4%)
Central America & Caribbean 10 (41.7%) 17 (70.8%) 5 (20.8%) 10 (41.7%)
P=0.117 P=0.010 * P=0.550 P=0.846
Generational Status c
Immigrant 51 (42.5%) 84 (70.0%) 33 (27.5%) 57 (47.5%)
1st generation 14 (28.0%) 25 (50.0%) 14 (28.0%) 21 (42.0%)
2nd generation and beyond 6 (21.4%) 12 (42.9%) 12 (42.9%) 13 (46.4%)
P=0.046 * P=0.005 ** P=0.264 P=0.805
Acculturation
Low 45 (47.4%) 64 (67.4%) 29 (30.5%) 43 (45.3%)
High 27 (25.7%) 58 (55.2%) 30 (28.6%) 48 (45.7%)
P=0.001 ** P=0.079 P=0.762 P=0.949
Married c
No 31 (36.9%) 55 (65.5%) 24 (28.6%) 44 (52.4%)
Yes 40 (35.1%) 66 (57.9%) 35 (30.7%) 46 (40.4%)
P=0.792 P=0.279 P=0.746 P=0.093
Employed
No 18 (50.0%) 21 (58.3%) 11 (30.6%) 19 (52.8%)
Yes 54 (32.9%) 101 (61.6%) 48 (29.3%) 72 (43.9%)
P=0.053 P=0.717 P=0.878 P=0.333
Education c
High school, less 19 (39.6%) 26 (54.2%) 11 (22.9%) 15 (31.3%)
Some college 20 (36.4%) 36 (65.5%) 15 (27.3%) 31 (56.4%)
College grad 33 (34.7%) 59 (62.1%) 33 (34.7%) 45 (47.4%)
P=0.851 P=0.484 P=0.307 P=0.036 *
Income d
<$25,000 14 (50.0%) 19 (67.9%) 9 (32.1%) 13 (46.4%)
$25K-49,999 16 (30.8%) 39 (75.0%) 14 (26.9%) 20 (38.5%)
≥$50,000 30 (32.3%) 49 (52.7%) 27 (29.0%) 45 (48.4%)
P=0.174 P=0.023 * P=0.886 P=0.509
Health literacy
Limited 12 (36.4%) 15 (45.5%) 8 (24.2%) 10 (30.3%)
Adequate 60 (35.9%) 107 (64.1%) 51 (30.5%) 81 (48.5%)
P=0.962 P=0.045 * P=0.469 P=0.055
Health activation
Low 31 (34.8%) 41 (46.1%) 30 (33.7%) 33 (37.1%)
Moderate 30 (36.1%) 59 (71.1%) 24 (28.9%) 43 (51.8%)
High 11 (39.3%) 22 (78.6%) 5 (17.9%) 15 (53.6%)
P=0.912 P<0.001 *** P=0.273 P=0.100
Multimorbidity e
Yes 16 (40.0%) 23 (57.5%) 9 (22.5%) 22 (55.0%)
No 53 (34.2%) 97 (62.6%) 46 (29.7%) 68 (43.9%)
P=0.494 P=0.556 P=0.368 P=0.208
Self-reported health
Fair to poor 49 (39.8%) 67 (54.5%) 35 (28.5%) 52 (42.3%)
Good to excellent 23 (29.9%) 55 (71.4%) 24 (31.2%) 39 (50.7%)
P=0.153 P=0.017 * P=0.682 P=0.247
Has family member with ADRD
Yes 28 (35.4%) 48 (60.8%) 31 (39.2%) 40 (50.6%)
No/Donť Know 44 (36.4%) 74 (61.2%) 28 (23.1%) 51 (42.2%)
P=0.895 P=0.955 P=0.015 * P=0.239
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Note: Statistically significant values show in bold

*

p <0.05

**

p <0.01

***

p <0.001

a

Missing data for 1 participant.

b

Missing data for 6 participants.

c

Missing data for 2 participants.

d

Missing data for 27 participants.

e

Missing data for 5 participants.

In multivariable analyses, participants who reported less acculturation remained more likely to report that they were “very concerned” about ADRD (OR:2.65, 95%CI: (1.38, 5.08)) (Table 5). Low acculturation was also significantly associated with strong agreement that steps can be taken to support brain health (OR: 1.96, 95% CI: (1.01, 3.78)), whereas those with low health activation were less likely to strongly agree (OR: 0.29, 95% CI: (0.10, 0.86)).

Table 5.

Multivariable Models Examining Sociodemographics and Attitudes, Awareness, and Actions (N=194)

Attitudes Awareness Actions
Variable Very concerned about ADRD
OR (95% CI)		 Strongly agrees steps can be taken for brain health
OR (95% CI)		 Identified 3 ways to protect the brain
OR (95% CI)		 Engages in 1+ empirically-supported brain health behavior
OR (95% CI)
Age Group
   35-45 y ǂ --- --- --- ---
   46-54 y 0.67 (0.32, 1.44) 0.87 (0.41, 1.81) 2.47 (1.10, 5.55) 1.10 (0.54, 2.23)
   56-64 y 1.67 (0.76, 3.67) 0.89 (0.40, 1.97) 2.93 (1.23, 6.97) 2.16 (1.00, 4.67)
Gender
   Male 0.70 (0.36, 1.38) 1.02 (0.53, 1.96) 0.93 (0.46, 1.90) 0.80 (0.43, 1.50)
   Female ǂ --- --- --- ---
Acculturation
   Low 2.65 (1.38, 5.08) 1.96 (1.01, 3.78) 1.25 (0.62, 2.50) 0.99 (0.54, 1.84)
   High ǂ --- --- --- ---
Health Literacy
   Limited 0.95 (0.39, 2.30) 0.58 (0.25, 1.37) 0.84 (0.32, 2.22) 0.62 (0.26, 1.51)
   Adequate ǂ --- --- --- ---
Health Activation
   Low 0.55 (0.20, 1.51) 0.29 (0.10, 0.86) 3.09 (0.93, 10.33) 0.53 (0.20, 1.37)
   Moderate 0.67 (0.26, 1.75) 0.69 (0.24, 1.96) 2.14 (0.68, 6.68) 0.90 (0.37, 2.19)
   High ǂ --- --- --- ---
Self-Reported Health
   Fair/Poor 1.73 (0.84, 3.56) 0.77 (0.38, 1.58) 0.49 (0.23, 1.07) 0.88 (0.45, 1.73)
   Good/Excellent ǂ --- --- --- ---
Has Family Member with ADRD
   Yes ǂ --- --- --- ---
   No 0.86 (0.45, 1.65) 0.95 (0.50, 1.81) 0.35 (0.18, 0.71) 0.70 (0.38, 1.30)
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ǂ

indicates reference group in model

*

Statistically significant values are shown in bold.

Brain Health Awareness

Under a third of participants could identify three steps that can be taken to support brain health (29.5%) (Table 3). Respondents frequently mentioned evidence-based protective behaviors including cognitive stimulation (n=134), physical activity (n=85), and diet (n=80) (coded as correct). Taking vitamins/supplements (n=28) and relaxing (n=16) were also mentioned frequently, but were not considered evidence-based and therefore coded as incorrect.

Being able to identify three ways to protect the brain was associated with having a family member with ADRD (p=0.015) (Table 4). No other sociodemographic variables were significant. In multivariable analyses, participants in the middle and oldest age terciles were more likely than younger participants to be able to name steps to protect the brain (45-54 years old: OR: 2.47, 95%CI: (1.10, 5.55) and 55-64 years old: OR: 2.93, 95%CI: (1.23, 6.97)), whereas participants without a family member with ADRD were less likely to able to name steps to protect the brain (OR: 0.35, 95% CI: (0.18, 0.71)) (Table 5).

Brain Health Actions

Approximately half of the sample reported that they had made empirically-supported lifestyle changes specifically to protect their memory and thinking (45.5%) (Table 3). Of those, participants reported having predominantly made physical health-related changes, such as diet, exercise, and sleep (N=73), followed by increased engagement in cognitively stimulating activities like puzzles and reading (N=49).

A third of participants met physical activity guidelines (32.0%) and half (52.%) met social engagement recommendations. The majority did not smoke tobacco (83.5%) or engage in hazardous drinking (78.4%). Twenty-one percent had received a diagnosis of hypertension, and of those, 70.7% reported taking medications to manage their blood pressure. Fifteen percent had been diagnosed with diabetes, and of those, the vast majority reported taking steps to manage the condition (92.9%). Fifteen percent of the sample reported a diagnosis of depression, and the majority (80.7%) endorsed taking steps to manage it. Fifteen percent of the sample endorsed hearing loss or impairment, and of those, less than seven percent reported using hearing aids. About half of the sample reported subjective cognitive concerns (53%), and less than half of those (41.5%) endorsed having discussed their concern with a healthcare provider.

Engaging in at least one evidence-supported brain health behavior was associated with at least some college education (p=0.036) (Table 4). In bivariate analyses, Spanish-speaking participants were more likely than English-speaking participants to report alcohol consumption within limits (p=0.019), and less likely to report a diagnosis of depression (p=0.027) or hearing loss (p=0.041). Spanish speakers were also significantly more likely to express subjective cognitive concern (p<0.001) (Table 3). After multivariable adjustment, no sociodemographic variables were significantly associated with brain health actions (Table 5).

DISCUSSION

We found that most middle-aged Latino respondents believed that steps can be taken to support brain health. However, level of concern for ADRD varied, as did awareness of steps to take and current engagement in science-based modifiable protective behaviors.

In line with the Sociocultural Health Belief Model, individuals who perceive their risk for developing a condition as low, or who believe that a condition is inevitable, may be less likely to participate in interventions or behavioral change [47,48]. Given the relatively high level of concern that was expressed for ADRD among this sample, connecting key risk factors with ADRD may provide an opportunity for increasing motivation for engagement in health behaviors and health self-management steps. An interesting finding was that US-born, English-speaking, more acculturated individuals were less likely to express concern for developing ADRD or to endorse their own subjective cognitive concerns, and they were also less likely to believe that steps can be taken to support brain health. At the same time, Spanish-speakers trended towards better health behavior engagement across the domains of physical activity, social contact, tobacco abstinence, limited alcohol use, and management of diabetes, and were more likely to report subjective “excellent” overall health. They were also less likely to report having a family member with ADRD, which is relevant given genetic predisposition for ADRD pathophysiology. This is consistent with extant literature demonstrating that greater acculturation has been associated with worse health outcomes and health behavior engagement [49,50], perhaps due to differences in exposure to the “Western diet,” norms around substance use, and social support [49,51]. This finding suggests the importance of increasing communication about the impact of and risk factors for ADRD across diverse sectors of the Latino population, and particularly first- and second-generation Latinos. At the same time, the higher level of concern expressed by immigrants in this study may reflect the unique barriers they face in accessing healthcare, including language barriers, insurance, and fear of deportation, which can impact health-seeking behaviors, and thus timely diagnosis and treatment [52].

Although the majority of participants expressed the belief that brain health is actionable, a minority could name three science-based behaviors or lifestyle factors to support brain health. Cognitively stimulating activities, physical activity, and diet were most frequently mentioned. Of note, many participants suggested “staying mentally active” or “exercising the brain” without indicating specific ways of doing so; therefore, it is unclear whether this represents a gap in knowledge or not. Despite believing that brain health promotion is actionable, less than half of participants reported current engagement in modifiable protective behaviors. For instance, although forty-two percent of participants recognized physical activity as a modifiable protective factor, only a third reported meeting current physical activity recommendations. This could suggest the need for increasing awareness of specific physical activity guidelines for adults, or it could highlight a disconnect between knowledge and actual behavioral intention and/or action itself. As the disconnect between knowledge and behavior is well established in the literature [53], these findings reinforce the need to translate knowledge to action.

Several evidence-based modifiable behaviors were rarely or never discussed: correcting sensory deficits; managing diabetes, obesity, hypertension, and depression; avoiding smoking and limiting alcohol consumption; and protecting the head from injury. Despite this, the majority of participants reported current alcohol consumption within limits, abstention from smoking, and self-management of chronic conditions. One exception is that among those who reported hearing impairment, less than seven percent endorsed using hearing aids. This represents a key opportunity for increasing education and access to care.

Unsurprisingly, participants who were older or who had family members with a diagnosis of ADRD were more likely to be able to identify ways to protect the brain. It may be important to reinforce the value of engaging in these behaviors, though, as previous work has indicated that individuals with family members with ADRD are more fatalistic about developing the disease [54]. This also further reinforces the need for brain health interventions that start earlier in the life course. Additionally, some participants mentioned behaviors that have not been endorsed by the Lancet Commission or the NIA. For instance, 28 participants discussed vitamins and supplements as a way of protecting the brain. This is consistent with prior work [13] and may represent a potential vulnerability to unproven ‘anti-aging’ products, as little to no benefit has been found from these treatments [55]. These findings suggest an opportunity for addressing misperceptions and increasing awareness of evidence-based approaches. At the same time, the majority of work in this field has been conducted with non-Latino White and Western, educated, industrialized, rich and democratic (WEIRD) populations, and there may be limited generalizability of current evidence to historically marginalized populations [47].

Limitations

This study has several limitations. We sought participants who could access the survey online, which limits generalizability to less digitally-literate individuals. Given the passive approach used in recruitment for this online survey, a response rate is difficult to calculate. By including social media as a recruitment source, it is possible that participants were not entirely truthful about their identities. Due to small sample sizes, we were unable to further investigate demographic differences in medical self-management practices. We acknowledge that the sample size may not be adequately powered to detect some statistically significant findings in multivariate analyses; further research should continue to examine these relationships. Some of the steps participants described to care for their brains were not counted if they did not align with current guidelines from the Lancet Commission or the NIA; while it is possible that some of these responses reflect cutting-edge knowledge, others might represent behaviors with little or no benefit, and we chose to align with these two reports as the current gold standard. We chose to utilize the 1-item measure of health literacy to reduce participant burden; however, it is possible that using a different measure would have revealed associations with health literacy. Survey items were not all validated, given the lack of existing validated measures on the topic; however, we followed best practices for the design of assessments for use among people with lower literacy [56], and all items were reviewed by a CAB to ensure readability and consideration of cultural beliefs and context within the community under study.

New Contribution to the Literature

This study found both strengths and gaps in awareness, concern, and proactive health actions pertaining to brain health among middle-aged Latinos. Findings highlight opportunities for increasing the effectiveness of brain health interventions that seek to address existing disparities, by leveraging perceived concern and self-efficacy beliefs to increase motivation to engage in protective behaviors, increasing education about specific science-based protective lifestyle factors, and supporting the translation of knowledge to behavior change. Although focusing on individual attitudes, awareness, and actions may offer the opportunity to increase empowerment and thus engagement in protective behaviors, it is also critical to acknowledge that individuals and their brain health are affected by multidimensional social, historical, political, and environmental influences, and structural change is also necessary to achieve brain health equity [47,57].

Acknowledgements:

This work was supported by the National Institute On Aging of the National Institutes of Health under Award Number F31AG084416. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This work was additionally supported by the Health Assessment Lab, and by Claude D. Pepper Older Americans Independence Center, Northwestern University, Award Number P30AG059988.

Conflict of Interest Statement:

Dr. Wolf reports grants from the NIH during the conduct of the study; grants from Merck, the Gordon and Betty Moore Foundation, the NIH, and Eli Lilly outside the submitted work; and personal fees from Sanofi, Pfizer, GlaxoSmithKline, Lundbeck, Bristol Myers Squibb, and Luto outside the submitted work.

REFERENCES

  • 1.Alzheimer’s Association. 2023 Alzheimer’s disease facts and figures. Alzheimers Dement. 2023;19(4):1598–1695. doi: 10.1002/alz.13016 [DOI] [PubMed] [Google Scholar]
  • 2.Centers for Disease Control and Prevention, Alzheimer’s Association. The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health. Alzheimer’s Association; 2020. Accessed February 3, 2023. https://www.cdc.gov/aging/healthybrain/index.htm [Google Scholar]
  • 3.Rost NS, Salinas J, Jordan JT, et al. The Brain Health Imperative in the 21st Century—A Call to Action. Neurology. 2023;101(13):570–579. doi: 10.1212/WNL.0000000000207739 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.González HM, Tarraf W, Fornage M, et al. A research framework for cognitive aging and Alzheimer’s disease among diverse US Latinos: Design and implementation of the Hispanic Community Health Study/Study of Latinos—Investigation of Neurocognitive Aging (SOL-INCA). Alzheimers Dement. 2019;15(12):1624–1632. doi: 10.1016/j.jalz.2019.08.192 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.National Institute on Aging. The National Institute on Aging: Strategic Directions for Research, 2020–2025. Published online 2020:49. [Google Scholar]
  • 6.Gurland BJ, Wilder DE, Lantigua R, et al. Rates of dementia in three ethnoracial groups. Int J Geriatr Psychiatry. 1999;14(6):481–493. [PubMed] [Google Scholar]
  • 7.Matthews KA, Xu W, Gaglioti AH, et al. Racial and ethnic estimates of Alzheimer’s disease and related dementias in the United States (2015–2060) in adults aged ≥65 years. Alzheimers Dement. 2019;15(1):17–24. doi: 10.1016/j.jalz.2018.06.3063 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Brindis C, Decker M, Gutmann-Gonzalez A, Lanshaw N, Corsack C. Taking a Pulse: Latinx Health Equity in California: Facing Disparities and Building for the Future. Hispanics in Philanthropy and the University of California; - San Francisco.; 2018. Accessed November 21, 2019. https://hiponline.org/wp-content/uploads/2018/11/HIP-Taking-a-Pulse_web.pdf [Google Scholar]
  • 9.Sørensen K, Van den Broucke S, Fullam J, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. doi: 10.1186/1471-2458-12-80 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97–107. doi: 10.7326/0003-4819-155-2-201107190-00005 [DOI] [PubMed] [Google Scholar]
  • 11.Coughlin SS, Vernon M, Hatzigeorgiou C, George V. Health Literacy, Social Determinants of Health, and Disease Prevention and Control. J Environ Health Sci. 2020;6(1):3061. [PMC free article] [PubMed] [Google Scholar]
  • 12.Schillinger D The Intersections Between Social Determinants of Health, Health Literacy, and Health Disparities. Stud Health Technol Inform. 2020;269:22–41. doi: 10.3233/SHTI200020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Light SW, Tomasino F, Wescott A, et al. Perceptions, beliefs, attitudes, and knowledge of US Latino adults pertaining to dementia and brain health: a systematic review. Aging Ment Health. 2024;28(3):396–407. doi: 10.1080/13607863.2023.2268050 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Ayalon L Re-examining ethnic differences in concerns, knowledge, and beliefs about Alzheimer’s disease: results from a national sample: Concerns, knowledge, and beliefs about Alzheimer’s disease. Int J Geriatr Psychiatry. 2013;28(12):1288–1295. doi: 10.1002/gps.3959 [DOI] [PubMed] [Google Scholar]
  • 15.Friedman DB, Laditka SB, Laditka JN, et al. Ethnically Diverse Older Adults’ Beliefs about Staying Mentally Sharp. Int J Aging Hum Dev. 2011;73(1):27–52. doi: 10.2190/AG.73.1.b [DOI] [PubMed] [Google Scholar]
  • 16.Karlawish J, Barg FK, Augsburger D, Beaver J, Ferguson A, Nunez J. What Latino Puerto Ricans and non‐Latinos say when they talk about Alzheimer’s disease. Alzheimers Dement. 2011;7(2):161–170. doi: 10.1016/j.jalz.2010.03.015 [DOI] [PubMed] [Google Scholar]
  • 17.Laditka SB, Laditka JN, Liu R, et al. How do older people describe others with cognitive impairment? A multiethnic study in the United States. Ageing Soc. 2013;33(3):369–392. doi: 10.1017/S0144686X11001255 [DOI] [Google Scholar]
  • 18.Roberts JS, McLaughlin SJ, Connell CM. Public beliefs and knowledge about risk and protective factors for Alzheimer’s disease. Alzheimers Dement. 2014;10(5S):S381–S389. doi: 10.1016/j.jalz.2013.07.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Sharkey JR, Sharf BF, St. John JA. “Una persona derechita (staying right in the mind)”: Perceptions of Spanish-Speaking Mexican American Older Adults in South Texas Colonias. The Gerontologist. 2009;49(S1):S79–S85. doi: 10.1093/geront/gnp086 [DOI] [PubMed] [Google Scholar]
  • 20.Van Liew C, Wooldridge JS, Kothari DJ, Cronan TA. Ethnic Differences in Perceptions of Alzheimer’s Disease: Implications for Seeking Assistance in Caring for an Ill Parent. J S. 2014;12(1). [Google Scholar]
  • 21.Willis SL, Martin M. Middle Adulthood: A Lifespan Perspective. SAGE; 2005. [Google Scholar]
  • 22.American Psychological Association. APA Dictionary of Psychology. November 15, 2023. Accessed January 10, 2025. https://dictionary.apa.org/
  • 23.Gioia CJ, Sobell LC, Sobell MB, Agrawal S. Craigslist versus print newspaper advertising for recruiting research participants for alcohol studies: Cost and participant characteristics. Addict Behav. 2016;54:24–32. doi: 10.1016/j.addbeh.2015.11.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Topolovec-Vranic J, Natarajan K. The Use of Social Media in Recruitment for Medical Research Studies: A Scoping Review. J Med Internet Res. 2016;18(11):e286. doi: 10.2196/jmir.5698 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42(2):377–381. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Wolf MS, Smith SG, Pandit AU, et al. Development and Validation of the Consumer Health Activation Index. Med Decis Making. 2018;38(3):334–343. doi: 10.1177/0272989X17753392 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Chew LD, Griffin JM, Partin MR, et al. Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population. J Gen Intern Med. 2008;23(5):561–566. doi: 10.1007/s11606-008-0520-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Sarkar U, Karter AJ, Liu JY, Moffet HH, Adler NE, Schillinger D. Hypoglycemia is More Common Among Type 2 Diabetes Patients with Limited Health Literacy: The Diabetes Study of Northern California (DISTANCE). J Gen Intern Med. 2010;25(9):962–968. doi: 10.1007/s11606-010-1389-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Marin G, Sabogal F, Marin BV, Otero-Sabogal R, Perez-Stable EJ. Development of a Short Acculturation Scale for Hispanics. Hisp J Behav Sci. 1987;9(2):183–205. doi: 10.1177/07399863870092005 [DOI] [Google Scholar]
  • 30.DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality prediction with a single general self-rated health question: A meta-analysis. J Gen Intern Med. 2006;21(3):267–275. doi: 10.1111/j.1525-1497.2005.00291.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.US Census Bureau. Census Bureau Guidelines for the Translation of Data Collection Instruments and Supporting Materials: Documentation on How the Guideline was DevelopedYuling Pan and Manuel de la Puente. Census.gov. Accessed November 11, 2022. https://www.census.gov/library/working-papers/2005/adrm/rsm2005-06.html
  • 32.Farrow M Dementia Risk Reduction: What Do Australians Know? Alzheimer’s Australia; 2008. [Google Scholar]
  • 33.Smith BJ, Ali S, Quach H. Public knowledge and beliefs about dementia risk reduction: a national survey of Australians. BMC Public Health. 2014;14(1):661. doi: 10.1186/1471-2458-14-661 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Wolf MS, Serper M, Opsasnick L, et al. Awareness, Attitudes, and Actions Related to COVID-19 Among Adults With Chronic Conditions at the Onset of the U.S. Outbreak. Ann Intern Med. 2020;173(2):100–109. doi: 10.7326/M20-1239 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Broadbent E, Petrie KJ, Main J, Weinman J. The Brief Illness Perception Questionnaire. J Psychosom Res. 2006;60(6):631–637. doi: 10.1016/j.jpsychores.2005.10.020 [DOI] [PubMed] [Google Scholar]
  • 36.Tang W, Kannaley K, Friedman DB, et al. Concern about developing Alzheimer’s disease or dementia and intention to be screened: An analysis of national survey data. Arch Gerontol Geriatr. 2017;71:43–49. doi: 10.1016/j.archger.2017.02.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.National Center for Health Statistics, Center for Disease Control and Prevention (CDC). National Vital Statistics System: Mortality Data. December 14, 2023. Accessed March 20, 2024. https://www.cdc.gov/nchs/nvss/deaths.htm
  • 38.Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet Lond Engl. 2020;396(10248):413–446. doi: 10.1016/S0140-6736(20)30367-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.NIH National Institute on Aging (NIA). Cognitive Health and Older Adults. National Institute on Aging. October 1, 2020. Accessed March 20, 2024. https://www.nia.nih.gov/health/brain-health/cognitive-health-and-older-adults [Google Scholar]
  • 40.Milton K, Clemes S, Bull F. Can a single question provide an accurate measure of physical activity? Br J Sports Med. 2013;47(1):44–48. doi: 10.1136/bjsports-2011-090899 [DOI] [PubMed] [Google Scholar]
  • 41.U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd Edition. U.S. Department of Health and Human Services; 2018. [Google Scholar]
  • 42.Kotwal AA, Kim J, Waite L, Dale W. Social Function and Cognitive Status: Results from a US Nationally Representative Survey of Older Adults. J Gen Intern Med. 2016;31(8):854–862. doi: 10.1007/s11606-016-3696-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Yang EZ, Kotwal AA, Lisha NE, Wong JS, Huang AJ. Formal and informal social participation and elder mistreatment in a national sample of older adults. J Am Geriatr Soc. 2021;69(9):2579–2590. doi: 10.1111/jgs.17282 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA, for the Ambulatory Care Quality Improvement Project (ACQUIP). The AUDIT Alcohol Consumption Questions (AUDIT-C): An Effective Brief Screening Test for Problem Drinking. Arch Intern Med. 1998;158(16):1789–1795. doi: 10.1001/archinte.158.16.1789 [DOI] [PubMed] [Google Scholar]
  • 45.Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Accessed February 24, 2023. http://www.cdc.gov/brfss
  • 46.Pierannunzi C, Hu SS, Balluz L. A systematic review of publications assessing reliability and validity of the Behavioral Risk Factor Surveillance System (BRFSS), 2004–2011. BMC Med Res Methodol. 2013;13(1):49. doi: 10.1186/1471-2288-13-49 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Díaz-Santos M, González DA, Henry SK, Vuong KD, Strutt AM. Re-Engaging Individuals & Societies for Structural Evolution: A Brain Health Equity Neuropsychology Research Framework. Arch Clin Neuropsychol. 2023;38(3):347–364. doi: 10.1093/arclin/acad011 [DOI] [PubMed] [Google Scholar]
  • 48.Sayegh P, Knight BG. Cross-cultural differences in dementia: the Sociocultural Health Belief Model. Int Psychogeriatr. 2013;25(4):517–530. doi: 10.1017/S104161021200213X [DOI] [PubMed] [Google Scholar]
  • 49.Allen JD, Caspi C, Yang M, et al. Pathways between acculturation and health behaviors among residents of low-income housing: The mediating role of social and contextual factors. Soc Sci Med. 2014;123:26–36. doi: 10.1016/j.socscimed.2014.10.034 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Vila-Castelar C, Fox-Fuller JT, Guzmán-Vélez E, Schoemaker D, Quiroz YT. A cultural approach to dementia — insights from US Latino and other minoritized groups. Nat Rev Neurol. 2022;18(5):307–314. doi: 10.1038/s41582-022-00630-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Fox M, Thayer ZM, Wadhwa PD. Acculturation and Health: The Moderating Role of Sociocultural Context. Am Anthropol. 2017;119(3):405–421. doi: 10.1111/aman.12867 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Kovaleva M, Jones A, Maxwell CA. Immigrants and dementia: Literature update. Geriatr Nur (Lond). 2021;42(5):1218–1221. doi: 10.1016/j.gerinurse.2021.04.019 [DOI] [PubMed] [Google Scholar]
  • 53.Glanz K, Burke LE, Rimer BK. Health behavior theories. In: Philosophies and Theories for Advanced Nursing Practice. Jones & Bartlett Learning; 2011:247–270. [Google Scholar]
  • 54.Lee W, Gray SL, Zaslavsky O, Barthold D, Marcum ZA. Association between having a family member with dementia and perceptions of dementia preventability. Aging Ment Health. 2022;26(2):270–276. doi: 10.1080/13607863.2020.1839866 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Butler M, Nelson VA, Davila H, et al. Over-the-Counter Supplement Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia: A Systematic Review. Ann Intern Med. 2018;168(1):52–62. doi: 10.7326/M17-1530 [DOI] [PubMed] [Google Scholar]
  • 56.Shoemaker SJ, Wolf MS, Brach C. Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information. Patient Educ Couns. 2014;96(3):395–403. doi: 10.1016/j.pec.2014.05.027 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 57.Elkind MSV, Albert MA, Lloyd-Jones DM. Road to Equity in Brain Health. Circulation. 2022;145(18):e869–e871. doi: 10.1161/CIRCULATIONAHA.122.059711 [DOI] [PMC free article] [PubMed] [Google Scholar]

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