Knowledge, Awareness, and Attitude Towards Dementia Amongst Medical Undergraduate Students: Can a Sensitization Program Help?

Abstract

Background:

Current undergraduate medical academic curriculum does not emphasize on evaluation and management of dementia. The knowledge and attitude of medical students towards patients with dementia in India has not been ascertained previously.

Objective:

We aimed to assess the knowledge and attitude of final year medical students about dementia and Alzheimer's disease. We also aimed to assess if a dedicated sensitization cum teaching session by a group of interns doctors guided by a neurologist could help improve students’ knowledge and awareness towards dementia or not.

Methods and Materials:

82 consenting final year medical students answered questionnaires of Alzheimer Disease Knowledge Scale (ADKS) and Dementia Attitude Scale (DAS) at a baseline level. A sensitization cum teaching session by intern doctors was conducted to enhance students’ knowledge about dementia. A post sensitization reassessment of students was done to assess impact of the session.

Results:

The ADKS score was 57% at baseline which was increased to 71% post sensitization program. The mean DAS score was 3.2 at baseline which was reported to be 3.4 after sensitization program. Students reported significant improvement in their knowledge level but did not show the same improvement in their attitude and comfort level in caring for dementia after the sensitization program. Students were still not comfortable dealing with patients with dementia.

Conclusion:

Medical students lack significant knowledge and training about dementia. Patient contact and practical training for basic assessment and care of dementia needs to be incorporated in the current academic curriculum. Dedicated sensitization sessions on dementia care can help improve the gap. Practical exposure to management of patients with dementia would be required to enhance the comfort level and attitude of students towards dementia.

INTRODUCTION

Dementia is a worldwide health problem which has affected 43.8 million people all over the world by 2016[1] and the number is estimated to be doubled up to 115 million by the year 2050. Approximately, 58% of patients with dementia (PWD) belong to lower or middle-income countries and estimates suggest that this would be increased to 71% by the year 2050.[2] Around 3.7 million elderly Indian people have been affected with dementia and it has increasingly become a social, economic and health-related hurdle.[3]

Although dementia is distinct from normal ageing,[4] lay persons, due to lack of knowledge, illiteracy and social stigma, still believe that it is a process of normal ageing.[5,6] Not only lay person but medical practitioners also may have a tangential knowledge about the understanding, diagnosis, course and prognosis of dementia as per some studies.[7,8] In a survey conducted in Australia on adults aged 40-65 years, it was noted that half of the participants could not have meaningful conversations with PWD, 34% reported that the patients were irritating and about 60% agreed to have considered themselves shameful if they were diagnosed with dementia.[9] A similar negative response was received from a survey in the UK regarding the progression of disease among student participants.[10] Few studies have been published on evaluation of medical students’ attitude towards older patients,[11,12] geriatric medicine as a speciality[13] and even mental health issues.[14] There is a lack of such studies on assessment of knowledge and attitude towards PWD amongst medicine students in India. The amount of knowledge and skillset required to deal with PWD may not be displayed by medical students and thus, proper strategies, in-depth but easy to learn teaching designs and delivery by professionals in the realm become imperative.[15] So, we initiated this study, aiming to assess the knowledge, attitude and awareness towards dementia amongst final year medicine students. We also planned to evaluate whether a teaching symposium with a sensitization program conducted by motivated interns guided by a neurology professor lead to any improvement in the knowledge and attitude amongst the students or not.

MATERIALS AND METHODS

Participants: A cross-sectional study was conducted in a medical college situated in western India in Karamsad, Gujarat. All the students of final year MBBS from Pramukhswami medical college were approached to participate in the study along with a symposium and sensitization program on dementia and Alzheimer's disease. A total of 82 students amongst a batch of 100 agreed for participation in the study. Any student refusing for consent and any student absent on the day of conduct of the survey and sensitization program was excluded from the study.

Procedure: Before conducting this study, opinions of the faculties of curriculum designing and teaching implementation groups and the Dean were sought for, to plan the methodology of this program. Amongst different teaching-learning methodologies, the groups felt that a Peer-mentored Collaborative form of teaching-learning methodology should be the most appropriate to have such a sensitization program. Everyone in this core teaching group agreed that interns had good bonds with last year medical students, students would be more comfortable asking about any queries or difficulties they might have during the program and so peer mentoring would lead to more retention compared to a plain didactic lecture by a neurologist. Also, this preparation for the symposium would improve the knowledge of interns as well. These interns were guided by a neurology professor over a duration of 4 weeks to prepare an interactive 2 hours’ symposium amongst the medical students covering important aspects of epidemiology, risk factors, symptoms, diagnosis and management of dementia and Alzheimer's disease. They even underwent 2 practice sessions of conduct of the symposium prior to the final program. All the participating medical students were provided 2 questionnaires which they had to answer anonymously in a time of 20 minutes to respond to the questionnaires. Following the collection of questionnaires, the group of motivated trained interns conducted a sensitization program to their colleagues about Alzheimer's disease. The neurology professor was present during the entire symposium to facilitate the teaching-learning program and facilitated the program by providing inputs at various phases of the program. Along with the teaching session, a sensitization program was also conducted by a geriatric social worker with keen interest and experience in caring patients with dementia/Alzheimer's disease. Post sensitization program, on the same day, all participants were given the same 2 questionnaires to answer to assess the response after sensitization program.

Instruments: The questionnaires given to the students to assess their knowledge and attitude were Alzheimer's Disease Knowledge Scale (ADKS)[16] and Dementia Attitude Scale (DAS)[17] respectively. ADKS is a validated scale with good psychometric properties to assess the knowledge regarding seven main categories covering all major aspects of Alzheimer's disease which are: Life impact, Risk factors, Symptoms, Treatment and Management, Assessment and Diagnosis, Care giving and Course of disease. ADKS consists of 30 questions in true/false format whose total score is to be calculated by summing up the correct answers of each questions, creating a score range of 0 to 30.

Dementia Attitude Scale (DAS) consists of 20 questions in true/false format, which enlightens affective, cognitive, and behaviour components. The scale has been developed after incorporating various convergent validity testing, exploratory and confirmatory factors analysis and conducting many structured interviews.[17] DAS is a validated tool for assessing attitude towards dementia patients.[18,19,20]

Ethical approval: Ethical approval was taken from Institutional Review Ethical Board (IREB) before beginning this study. A permission from the Dean of the medical college was also taken to allot a time slot for a dedicated 3 hours’ session (2 hours for symposium, one hour for pre and post assessment) to conduct the sensitization program as well as pre and post evaluation amongst the final year MBBS students. All 82 participants provided their written consent before participation.

Statistical analysis: Data from filled questionnaires were manually added in Microsoft Excel software. All data from excel was exported to Statistical Package for the Social Sciences (SPSS) version 11 which was used to analyse the data. We used descriptive statistics including group mean, standard deviation and percentages to describe ADKS and DAS scores. We also used t test to compare pre and post sensitization difference of individual groups in ADKS and DAS scales.

RESULTS

A total of 82 students participated with consent in the study. ADKS form consisted of 30 questions which were distributed into seven categories (mentioned in the instrument subheading of method and material) to cover all the features to be assessed in the study. Result of all 7 aspects of ADKS before sensitisation program was 72%, 50%, 49%, 61%, 73%, 51% and 52% respectively [Table 1] whereas result of the same after sensitisation program was 72%, 69%, 79%, 70%, 76%, 55% and 85% respectively. Six of the categories assessed in the scale showed improvement to some extent post sensitization program. Among all aspects of the scale, “Course of Disease” which covered 4 questions showed the highest improvement from 52% to 85% (33%) while “Assessment and Diagnosis” feature which also covered 4 questions showed minimum improvement from 73% to 76% (3%) and “Life Impact” feature did not show any improvement at all after sensitization. Out of 30 questions, 22 questions were reported with some improvement whereas 5 and 3 questions showed a decline and no change, respectively. At the baseline evaluation, mean ADKS scores were 57%, which significantly improved after the sensitization program to 71%.

Table 1.

Comparison of ADKS and DAS Scores Pre and Post Sensitisation Program

	Groups	Question numbers	Pre-sensitisation (%)	Post-sensitisation (%)	Difference (%)	t test	Alpha value
Alzheimer’s Disease Knowledge Scale (ADKS)	Life impact	1, 11, 28	72	72	0	-	-
	Risk factors	2, 13, 18, 25, 26, 27	50	69	19
	Symptoms	19, 22, 23, 30	49	79	30
	Treatment and Management	9, 12, 24, 29	61	70	9
	Assessment and Diagnosis	4, 10, 20, 21	73	76	3
	Care giving	5, 6, 7, 15, 16	51	55	4
	Course of disease	3, 8, 14, 17	52	85	33
	Mean total ADKS score	1-30	58.28 (mean)	72.28 (mean)	-14.00	0.003	0.05
Dementia attitude Scale (DAS)	Comfort	1, 2, 4, 5, 6, 8, 9, 13, 16, 17	3.26 (mean)	3.44 (mean)	-0.18	0.09	0.05
	Knowledge	3, 7, 10, 11, 12, 14, 15, 18, 19, 20	3.27 (mean)	3.40 (mean)	-0.13	0.08	0.05
	Comfort + Knowledge	1-20	3.27 (mean)	3.42 (mean)	-0.15	0.02	0.05

DAS form consisted of a total 20 questions assessing 2 categories ‘Comfort’ and ‘Knowledge’. Baseline evaluation of all 20 questions together demonstrated mean DAS to be 3.27 which was later reported to be 3.42 after the symposium. There was a statistically significant improvement (t = 0.02, P < 0.05) in the students’ attitude towards PWD when assessed as a whole. Baseline evaluation of both features ‘Comfort’ and ‘Knowledge’ showed mean DAS to be 3.26 and 3.27, respectively, while evaluation of both the features post sensitization program demonstrated mean DAS to be 3.44 and 3.40 respectively. Thus, there was no statistically significant difference in ‘comfort level’ (t = 0.09, P > 0.05) and ‘knowledge level’ (t = 0.08, P > 0.05) of medical students after the sensitisation program when assessed as individual features of DAS.

DISCUSSION

This study was conducted with the aim of assessing the knowledge, awareness and attitude of final year medical students towards dementia and Alzheimer's disease. We found that students had average knowledge and caregiving attitude towards the condition itself and PWD. We also wanted to assess if a dedicated symposium-cum-sensitisation program by interns and social worker under the guidance of a neurologist could lead to any improvement in the knowledge, attitude and practice (KAP) or not in the same students. We found that the sensitization program exhibited significant improvement notably in knowledge of the students about dementia but no significant improvement in attitude and comfort towards care of patients with dementia.

In our study, medical students were found comfortable answering questions regarding assessment and diagnosis, management and treatment and even overall life impact of dementia whereas they were proven weak in questions like identifying risk factors, signs and symptoms, course of disease and even care giving by correctly answering only 50%, 49%, 52% and 51% respectively. Our sensitization program managed to enhance students’ knowledge in those weak areas by 19%, 30%, 33% and 4% respectively. We even realized that there were lot of misconceptions regarding disease itself and its treatment. 54% of students thought that mental exercise is a preventing step for a person to get Alzheimer's disease, 66% students thought when people with Alzheimer's disease begin to have difficulty taking care of themselves, caregivers should take over right away and 70% of students thought when a person has Alzheimer's disease, using reminder notes is a crutch that can contribute to decline. After the sensitization program, we managed to stop 2% of students believing about mental exercise being a preventive measure and also stopped nearly 11% of students who considered that use of reminder notes contributed to declining. But, there was no change in “when people with Alzheimer's disease begin to have difficulty taking care of themselves, caregivers should take over right away” statement. Overall, the sensitization program in our study managed to decrease the misconception in various areas about dementia. We also identified some of the weaker areas of dementia knowledge in students. Our findings should help notifying teachers and trainers the necessary areas to focus in depth in order to increase students’ overall knowledge about the condition. Even after the teaching session, questions assessing the comfort level and attitude of students towards the dementia patients are still not reporting marked improvement. The current medical teaching curriculum as well as future training programs should have critical changes in order for students to improve their comfort level as well as to demonstrate a positive attitude towards patients with dementia.

Different studies evaluating the KAP in health care professionals with regards to dementia have chosen diverse methods for assessment. A study conducted in Malaysia on university students of pharmacy and medicine streams has used tools like The Adolescent Attitudes towards Dementia Scale (AADS), The Adolescent Level of Contact Scale (ALoCS), The Attitudes Towards Older People Scale (ATOP) and The Illness Perception Questionnaire (IPQ). The study after pre- and postworkshop evaluation noticed a significant change in attitude towards dementia patients and no change in attitude towards older people.[21] In one of the study conducted in Australia, university students demonstrated good KAP towards dementia (81% measured by ADKS score).[22] A study conducted in Malta among nursing undergraduates of first, second and third year showed adequate knowledge and positive attitude towards dementia patients when assessed by ADKS and DAS scores.[23] In a study conducted in Brazil, medical students did not report to have had a greater amount of training, knowledge and comfort level in dealing with dementia patients as compared to other non-healthcare professionals.[22] There is a significant heterogeneity in the study methodology as well as subject population and so a direct comparison of these studies would not be feasible. Most of these studies suggest that health care professionals, especially students lack in their knowledge and attitude towards patients with dementia. With the growing burden of dementia worldwide and with aging population, general/family physicians would have a higher role in managing these patients. Thus, incorporating useful interventions in current medical academic curriculum is imperative to demonstrate changes in KAP of students towards dementia patients worldwide.

There is a lack of insight about dementia as an emerging health condition amongst general population, especially in developing countries.[24,25] The social stigma and attitude in the society towards dementia can only be changed if general population can understand the difference between normal ageing and dementia, gain relevant knowledge about the condition and develop care giving attitude towards patients with dementia. The link that connects general population and their understanding of dementia is basic health care professionals like MBBS physicians and family doctors. With the increasing rate of dementia in India, the number of neurologists and super specialists who have the utmost part in managing and treating patients with dementia are still not rising. In order to reduce the burden of neurologists, to cope with the increasing cases and to continue providing essential follow-up care to dementia patients, ground-level doctors such as MBBS doctors, primary care physicians and family physicians will need to shoulder the responsibility. Neurologists are mainly involved in diagnosis and evaluation of the dementia especially ruling out reversible causes and providing pharmacological treatment. Primary care physicians and MBBS doctors, on the other hand, should have the major responsibility of not only managing and dealing with the patients, but also teaching caregivers the essential measures to help PWD in their daily living activities. Therefore, dementia care and management must be given an important role in medical undergraduate academic curriculum. If training of medical professionals includes importance of care and focuses on students’ attitude since the beginning of their training, it will improve and mold their perspective to have a better attitude and proximity in caring old PWD when they start practicing.[26] On the basis of our study findings, we suggest that didactic conferences, lectures or symposiums can only improve awareness of the medical students about the condition and improve their knowledge theoretically. In order to improve students’ attitude and enhance their comfort level while managing dementia patients, they need to be practically exposed with the patients. Incorporating tasks like attending outpatient dementia/neurology clinics, visiting inpatient wards managing PWD, going for home visits of PWD, in the current undergraduate medical curriculum may be necessary to prepare students to be able to comfortably treat and deal with patients with dementia. Such a strategy may eventually change their perception and attitude towards PWD and this may subsequently improve the care of patients with dementia in the population.

Our study was conducted in a single medical college with 82 third MBBS students only. While this could be considered a limitation, we felt that including first- and second-year medical students would not serve the purpose as they would still be naive with regards to understanding of neurology and dementia anyways. Another limitation of our study is that ideally such sensitization programs should be conducted over a series of several months and serial change should be observed over time. However, it was not feasible to accommodate multiple such programs only on dementia awareness in the current medical teaching curriculum. We found that even a single day sensitization program does improve the knowledge and awareness of students towards dementia. The strength of our study is that our study participants were from a single college, who had received medical training in a uniform manner and from same teachers and so our study population was indeed a homogenous one. Another strength of our study is that we could highlight important aspects of dementia where students had difficulty in learning. Our study findings can guide teachers on the areas they should focus specifically on during teaching the subject of dementia in undergraduate medicine classes.

CONCLUSIONS

There is a lack of appropriate teaching on dementia care in the current undergraduate medical curriculum, especially with regards to attitude and comfort while caring for PWD. There is a need to introduce more interaction of undergraduate students with PWD in their undergraduate clinical postings to improve their comfort and attitude towards dealing with PWD and sensitization programs like the one done by us may help refine this lacuna.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.