Assignment 2

Knowledge of Alzheimer’s Disease Among Norwegian Undergraduate Health and Social Care Students:

A Survey Study

Sundaran Kada

Faculty of Health and Social Sciences, Bergen University College, Bergen, Norway

With an aging general population and a concurrent increase in the prevalence of dementia, health and

social care professional students are increasingly exposed to this group of patients during their clini-

cal placements and after graduation. A sound dementia-related knowledge base among health and

social care students is important in providing high-quality dementia care. The present study assessed

dementia-related knowledge in health and social care students. The Alzheimer’s Disease Knowledge

Scale (ADKS) was utilized to measure the level of dementia knowledge. A total of 321 undergrad-

uate students from various disciplines in their final years of study, but prior to graduation, partici-

pated in this study. The study identified a moderate dementia knowledge base (mean score: 23.51

out of 30) among health and social care students. The results revealed that the students were also

ignorant of many facts and had many misconceptions pertaining to Alzheimer’s Disease (AD). In

addition, significant differences in knowledge were evident between student groups. These results

suggest that the current dementia curriculum should be evaluated in an attempt to improve the

dementia knowledge base of health and social care students.

Dementia is a condition affecting a large number of people of advanced age. The most common

cause of dementia is Alzheimer’s disease (AD), which accounts for 50–75% of all dementias (Alzheimer’s Disease International, 2012). Approximately 36 million people suffered from

dementia worldwide in 2010, and this number is expected to increase to 115 million by 2050

(World Alzheimer’s Report, 2009). In Norway, approximately 71,000 people of the total popu-

lation of 5 million currently suffer from some form of dementia, and this number is expected to

surpass 205,000 by 2060 (Engedal & Haugen, 2009). As dementia progresses, patients might

become unable to stay at home or family caregivers might become unable to continue caring

for these patients at home, leading to the need for institutional care. Dementia is the most com-

mon reason for admitting older individuals into nursing homes in Norway (Engedal & Haugen,

2009), and behavioral symptoms are cited as a frequent reason for admission (Nygaard, 1991).

Approximately 40% of Norwegian people with dementia live in nursing homes (Engedal & Haugen, 2009), and this percentage is expected to increase to 50% by 2030 (Selbæk, 2006). Thus, a large proportion of these people will require the expertise of health and social care

professionals.

Address correspondence to Sundaran Kada, Faculty of Health and Social Sciences, Bergen University College, Post

Box 7030, 5020, Bergen, Norway. E-mail: [email protected]

Educational Gerontology, 41: 428–439, 2015

Copyright # Taylor & Francis Group, LLC

ISSN: 0360-1277 print / 1521-0472 online

DOI: 10.1080/03601277.2014.982009

Early diagnosis is a key element of comprehensive and high-quality dementia care (Iliffe

et al., 2002), benefitting both the patient and caregiver. Early diagnosis allows for the

possibility of pharmacological interventions that can slow the progression of the disease

and could even delay institutionalization (Rosler et al., 1999; Rimmer, Wojciechowska, Stave,

Sganga, & O’Connell, 2005). In addition, it enables persons with dementia and their caretakers

to plan the patients’ futures and to mobilize support (Kennedy & Rossor, 1993) for making

decisions regarding financial and legal issues (Solomon & Murphy, 2005) while self-advocacy

remains feasible (Woods, 2001). However, only one in four people, or fewer, receives a formal

diagnosis of dementia globally (World Alzheimer’s report, 2009). Studies in Norway have

indicated that dementia is underdiagnosed in the primary care setting in one-third of

persons admitted to long-term care in nursing homes (Nygaard & Ruths, 2003) and in approxi-

mately 50% of persons with dementia who live at home (Lystrup, Lillesveen, Nygård, & Engedal, 2006).

Studies have also reported on a number of dementia-specific concerns, including the need for

stimulating daytime activities and companionship during daytime hours (Hancock, Wood,

Challis, & Orrell, 2006) and the issue of neglect (e.g., not receiving necessary help with every-

day tasks) (Hawes, 2003). These studies reported that persons with dementia spent only 50

minutes of a six-hour observation period (14% of the time) communicating with staff members or other residents and less than 12 minutes (3% of the time) participating in constructive every- day activities (Ballard et al., 2001). An investigation of Norwegian nursing homes reported that

most patients did not participate in leisure activities, such as going out for walks (Kirkevold &

Engedal, 2006), and persons with dementia received a lower quality of care (Kirkevold &

Engedal, 2008). Although efforts have been undertaken to improve the quality of dementia care,

these efforts can be negated by providers’ limited knowledge (Chodosh et al., 2004). The knowl-

edge of dementia possessed by persons with the condition, family caregivers, and health and

social care professionals has a positive impact on the quality of dementia care. Persons with

good knowledge of dementia tend to seek medical help at earlier stages. Family members raise

alerts earlier, and health professionals recognize the symptoms and can facilitate early diagnosis

if they are cognizant of dementia (Perry et al., 2008; Millard, Kennedy, & Baune, 2011; Low &

Anstey, 2009). In contrast, poor knowledge results in inadequate utilization of treatment services

(Steckenrider, 1993) and delayed diagnosis, thereby resulting in poor outcomes for persons with

dementia and their caregivers (e.g., misinterpretation of behavior and increased stress)

(Steckenrider, 1993; Spector, Orrell, Schepers, & Shanathan, 2012). Dementia-related knowl-

edge is, therefore, important for health and social care professionals who work with people with

dementia. However, studies have indicated that many professionals have limited specialized

educations to prepare them for working with this group of people (Adams, 2001; Aveyard,

2001). A recent study revealed poor AD knowledge among undergraduate health and social care

students in Hong Kong (Kwok, Lam, & Ho, 2011). Measuring levels of knowledge in health and

social care professional students could be an important step in providing evidence for the need to

improve dementia care training in the curriculum. Dementia care is interdisciplinary and requires

efforts from a team of health and social care professionals (Goins, Gainor, Pollard, & Spencer,

2003). Identifying patterns in knowledge could be helpful for educators in anticipating the need

for knowledge (Carpenter, Zoller, Balsis, Otilingam, & Gatz, 2011). It is, therefore, important to

understand health and social care professional students’ current knowledge of dementia to

evaluate geriatric issues in the study curriculum. The current study’s aim was to assess the

DEMENTIA 429

dementia-related knowledge base of undergraduate health and social care professional students

in their final years of training prior to graduating.

The present study attempted to address the following research questions:

. What is health and social care students’ level of knowledge regarding dementia?

. Are there any differences between different professional student groups?

METHODS

Design and Subjects

This was a descriptive study using a one-time survey with a convenience sample. The current

study was performed in Bergen, the second largest city in Norway with a population of approxi-

mately 300,000 people. Faculty of medicine and the university college were asked to participate

in this study. Norwegian undergraduate medical education consists of a six-year university

degree program, and health and social care (nursing, physiotherapy, occupational therapy,

radiography, social work and social education) undergraduate studies consist of a three-year

bachelor’s degree university college curriculum. The data were collected by means of a self-

administered questionnaire that required approximately 5–10 minutes to complete.

Participants

A total of 321 undergraduate health and social care professional students in the final terms of

their graduating years (scheduled to graduate in 2014) participated in this study. This cohort

included medical (n¼27), nursing (n¼122), physiotherapy (n¼47), occupational therapy (n¼19), radiography (n¼23), social work (n¼32), and social educator students (n¼51).

Measurements

Knowledge of dementia was assessed utilizing the Norwegian version of a validated English

assessment tool, the Alzheimer’s Disease Knowledge Scale (ADKS) (Carpenter, Balsis,

Otilingam, Hanson, & Gatz, 2009). This instrument is an updated version of the original

Alzheimer’s Disease Knowledge Test (ADKT) (Dieckmann, Zarit, Zarit, & Gatz, 1988). The

ADKS has adequate psychometric properties (reliability test-retest correlation¼ .81, p < .001; internal consistency reliability¼ .71 with split half reliability of .55, p < .001; predictive validity correlation¼ .50, p < 0.001; for undergraduates, r¼ .20). This tool has been used in studies with health care staff (Smyth et al., 2013) and psychologists (Nordhus, Sivertsen, & Pallesen, 2012).

The ADKS consists of 30 true=false items that cover domains including life impact (items 1, 11 and 28); risk factors (items 2, 13, 18, 25, 26 and 27); symptoms (items 19, 22, 23 and 30); treat-

ment and management (items 9, 12, 24 and 29); assessment and diagnosis (items 4, 10, 20 and

21); care giving (items 5, 6, 7, 15 and 16); and the course of the disease (items 3, 8, 14 and 17).

In the analysis, a true answer was given one mark, and no mark was provided for false answers.

Thus, the total score ranged from 0 to 30, with higher scores signifying good knowledge about

430 S. KADA

Alzheimer’s disease. Furthermore, the participants were asked to state their dementia knowledge

on an 11-point Likert scale from 0 (I know nothing at all) to 10 (I am very knowledgeable). The Norwegian version of the ADKS was adapted by a standard translation-back translation

procedure. The study also collected demographic information, including sex, age and pro-

fessional qualifications, after completion of the program.

Procedures

The heads of the medical faculty and the faculty of health and social sciences at the university

colleges were contacted to request their consent regarding their institutions’ participation in this

study. After approval, the questionnaire was distributed. For the health science and social

science students, the questionnaire was distributed on site to all nursing, physiotherapy, occu-

pational therapy, radiography, social work, and social educator undergraduate students attending

classes. Before distributing the questionnaire, the aim of the project was explained to students. In

addition, students were informed that their participation was voluntary, that they were guaran-

teed anonymity, and that no personal names or identifiers would be collected. Participants were

informed that they could access the results by contacting the investigator. For the medical

students, a link to an online questionnaire and an information letter was sent to the medical

faculty; the letter requested that faculty distribute the questionnaire and information letter to

medical students. The information letter outlined the aim of the project, provided assurances

of the confidential treatment of the information gathered from the questionnaire, emphasized

the voluntary nature of participation and informed the participants that they could access the

results of the survey by contacting the investigator. Considering the low priority given to ger-

iatric specialty training among Norwegian medical students (Album, 1991; Album & Westin,

2008), a low participation rate of approximately 30% was anticipated.

Ethical Considerations

The study followed the standard ethical guidelines for research conducted on students in

Norway. The heads of the faculty of medicine and the faculty of health and social care at the

university college granted permission for the study. The participants were provided detailed

information about the purpose of the research and participation so they could make informed

decisions regarding participation. The students were also assured that the material that they

provided would remain confidential, and that only the researcher would have access to their

answers. In addition, they were assured that any information they provided would be of a generic

and confidential nature and would not identify them personally. Approval from the Medical

Research Ethical Committee and the Norwegian Social Science Data Services was not required

for this study.

Statistical Analysis

Summary statistics (frequencies and percentages) are presented for sociodemographic character-

istics such as sex, education, and ADKS summary scores. Independent t tests were used to

DEMENTIA 431

compare the ADKS score between sexes (male versus female students) and between students’

self-rated dementia knowledge (less knowledge¼�5 versus more knowledge¼6–10). Statisti- cal comparisons were performed using one-way analysis of variance (with Tukey’s post hoc test)

to assess the mean ADKS score and ADKS domain scores as the dependent variable with the

students’ graduating education. A p value of �.05 was considered to indicate statistical signifi- cance. All of the statistical analyses were conducted using the Statistical Package for the Social

Sciences (SPSS) software, version 21.0 for Windows (SPSS Inc., Chicago, IL, USA).

RESULTS

Of a total of 296 questionnaires that were distributed among nursing, physiotherapy, radiogra-

phy, occupational therapy, social work, and social educator students attending classes, 294 stu-

dents completed and returned the questionnaire, yielding a response rate of 99.3%. Among medical students (n¼80), only 27 students completed and returned the questionnaires, yielding a response rate of 34%. Thus a total of 321 questionnaires (294þ27) were analyzed. The mean age of the students included in this study was 25.68 (standard deviation (SD) 5.91) years old, and 84% were female (Table 1). In assessing their own knowledge of dementia on an 11-point scale, 205 students reported having less knowledge, and 116 students reported having more

knowledge.

The summary score of dementia knowledge, as measured by the ADKS, was 23.51 (SD 2.90; range 15–29). Nursing, medicine and physiotherapy students attained the highest mean total

ADKS scores (24.34, 24.22 and 24.21, respectively), followed by occupational therapy and

social educator students. Radiography students reported the lowest mean score (19.70). The total

mean ADKS score and ADKS domain mean scores are presented in Table 2. Independent t � tests demonstrated no significant difference in ADKS mean scores between sexes (male students

mean score 23.20 versus female mean score 23.57, p¼ .401), and students that rated themselves as having more knowledge scored significantly higher than those who rated themselves as

having less knowledge (mean score 24.26 versus 23.06, p < .001).

TABLE 1

Baseline Characteristics of the Participating Students

Variable n(%) Mean age (SD)

Education

Nursing 122(38) 25.52(6.44)

Physiotherapy 47(15) 23.63(2.01)

Occupational therapy 19(6) 24.11(2.70)

Radiography 23(7) 25.57(5.96)

Medicine 27(8) 26.19(1.82)

Social educator 51(16) 29.10(9.05)

Social worker 32(10) 25.91(6.00)

Sex

Male 50 (16)

Female 271(84)

432 S. KADA

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433

Analysis of variance revealed a statistically significant difference in mean ADKS score based

on the students’ graduating educations (p < .001). Post hoc comparisons using Tukey’s honest significant difference (HSD) test indicated that the mean ADKS score of radiography

students (mean score 19.70, SD 3.12) was significantly lower compared with nursing students (mean score 24.34, SD 2.37, p < .001); medical students (mean score 24.22, SD 3.58, p < .001); physiotherapy students (mean score 24.21, SD 2.10, p < .001); occupational therapy students (mean score 23.58, SD 2.87, p¼ .001); social educator students (mean score 23.14, SD 2.54, p < .001); and social work students (mean score 22.03, SD 2.86, p¼ .021). The mean ADKS score for social work students (22.03, SD 2.86) was significantly lower com- pared with nursing students (mean score 24.34, SD 2.37, p¼ .001); physiotherapy students (mean score 24.21, SD 2.10, p¼0.006); and medical students (mean score 24.22, SD 3.58, p¼ .025).

With regard to the ADKS domains, the mean score for social work students in the symptoms

domain (mean score 2.94, SD 0.84) was significantly lower compared with nursing students (mean score 3.43, SD 0.76, p < .017); occupational therapy students (mean score 3.63, SD 0.59, p¼ .022); and physiotherapy students (mean score 3.72, SD 0.57, p < .001). Radiography students’ mean score (mean score 3.00, SD 0.91) was significantly lower compared with physio- therapy students (mean score 3.72, SD 0.57, p¼ .003). For the risk factors domain, the mean score of radiography students (3.22, SD 1.04) was significantly lower compared with nursing students (4.17, SD 1.10, p¼ .006) and physiotherapy students (4.28, SD 1.17, p¼ .006). For the course of the disease domain, the mean score of social work students (2.38, SD 1.07) was significantly lower compared with social educator students (mean score 3.00, SD 0.93, p¼ .046). Radiography students’ mean score for the care giving domain (mean score 2.91, SD 1.16) was significantly lower compared with nursing students (mean score 3.98, SD 0.98, p < .001); medical students (mean score 3.96, SD 1.01, p¼< .004); physiotherapy students (mean score 3.96, SD 0.95, p¼ .001); occupational therapy students (mean score 3.95, SD 0.84, p¼ .015); social work students (mean score 3.88, SD 1.01, p < .008); and social educator students (mean score 3.96, SD 0.97, p¼ .001). For the life impact domain, the mean score of radiography students (1.96, SD 0.47) was significantly lower compared with nursing students (mean score 2.70, SD 0.47, p < .001); medical students (mean score 2.70, SD 0.66, p < .001); physiotherapy students (mean score 3.962.57, SD 0.54, p < .001); occupational therapy students (mean score 2.74, SD 0.45, p < .001); social work students (mean score 2.69, SD 0.47, p < .001); and social educator students (mean score 2.51, SD 0.57, p¼ .002). The mean scores of medical students (mean score 3.74, SD 0.52) and nursing students (mean score 3.57, SD 0.60) for the assessment and diagnosis domain were significantly higher compared with radiography students

(2.87, SD 0.76, p¼ .001; p¼ .004, respectively); social work students (3.00, SD 1.04, p¼ .001; p¼0.003, respectively); and social educator students (mean score 3.18, SD 0.88, p¼ .030; p¼ .029, respectively). For the treatment and management domain, the nursing students’ mean score (3.76, SD 0.44) and medicine students’ mean score (3.63, SD 0.56) were significantly higher compared with radiography students (3.09, SD 0.84, p < .001; p < .001, respectively); social work students (3.31, SD 0.78, p¼ .003; 3.31, SD 0.78, p¼ .004, respectively); and social educator students (3.37, SD 0.72, p¼ .002; 3.37, SD 0.72, p¼ .030, respectively). The mean score of physiotherapy students on this domain (3.68, SD 0.51) was significantly higher compared with radiography students (3.09, SD 0.84, p¼ .002).

434 S. KADA

The mean scores for the risk factors (67% correct answers), course of the disease (71% correct answers) and caregiving (78% correct answers) domains were lower than those on the other domains (i.e., less than 80% correct answers).

DISCUSSION

The aim of this study was to identify dementia-related knowledge among Norwegian undergrad-

uate health and social care students in the final term of their graduating year. One of the key

findings of the present study was that students reported moderate knowledge (mean score

23.51 out of 30.00 [78.4% correct]). The study findings were similar to those of earlier studies that were performed by Smyth et al. (2013) in health care staff (mean score 23.6) and by

Nordhus et al. (2012) in Norwegian psychologists (mean score 24.1). The scores of the current

study were higher than those in the original study of nonhealth profession students (mean score

20.19) conducted by Carpenter et al. (2009). The ADKS mean score of Norwegian nursing stu-

dents (mean score 24.34, SD 2.37) was significantly higher than that of the Maltese nursing stu- dents (mean score 20.18, SD 3.48, p¼< .001) (Scerri & Scerri, 2013). Similarly, the Norwegian health and social care undergraduate students reported higher AD knowledge (78.4% correct answers) than the Canadian professional health caregivers (58% correct answers) and undergrad- uate students (41.9% correct answers) (Rust & See, 2007). Comparing the Norwegian students’ findings with those for Hong Kong health and social care students, the analyses of the percent-

age of correct answers reveals the following: for nursing students there is a difference of 32.5% (Norwegian 81% vs. Hong Kong students 48.5% correct answers); for occupational therapy stu- dents the difference is 29.6% (Norwegian 78.6% vs. Hong Kong students 49% correct answers); and for social work students the difference is 48.3% (Norwegian 74.3% vs. Hong Kong students 26% correct answers) (Kwok et al., 2011). However, it must be noted that the Canadian professional caregivers and undergraduate students and the Hong Kong health and social care

undergraduate students AD knowledge test was assessed using the modified version of ADKT

that contains only 18 and 20 multiple choice questions, respectively. Potential reasons for

this finding could be the introduction of a national dementia plan in Norway (Norwegian

Ministry of Health and Care Services, 2008) emphasizing the need for increased dementia-

related knowledge and skills among healthcare professionals, the importance of implementing

dementia topics in undergraduate health care students’ study curricula, and the increased

exposure to people with dementia during their practical placements. Dementia education has

a positive impact on the dementia knowledge of health professionals (Jackson, Cherry,

Smitherman, & Hawley, 2008); there is a positive relationship between dementia knowledge

and the quality of care provided, and education is critical in improving care (Moyle, Borbasi,

Wallis, Olorenshaw, & Gracia, 2011). Personnel who care for individuals with dementia should

have knowledge of symptoms and understand how to address cognitive symptoms and how to

maximize individual independence (McGilton et al., 2007).

Another key finding was that there were significant differences in mean total ADKS scores

and content domains scores among undergraduate students. A potential reason for these knowl-

edge differences could be the variation in the number of teaching hours and the coverage of

dementia topics. Studies have reported that the coverage of dementia has varied in numbers

of hours, and that not all dementia-related topics were covered (Pulsford, Hope, & Thompson,

DEMENTIA 435

2007). In addition, a positive association between the number of teaching hours and AD knowl-

edge has been reported (Kwok et al., 2011). Medical students answered 93.5% of questions correctly in the assessment and diagnoses domain. The study findings were positive and encour-

aging, and these results supported earlier studies that identified the highest levels of knowledge

among medical students (Kwok et al., 2011) and reported that younger general practitioners had

better knowledge of diagnostic, therapeutic, and management approaches with regard to

dementia care (Downs, Cook, Rae, & Collins, 2000; Kaduszkiewicz, Wiese, & van den Bussche,

2008). Physicians with good knowledge of dementia make earlier diagnoses and more timely

referrals (Reimer, Slaughter, Donaldson, Currie, & Eliasziw, 2004). General practitioners play

an important role in dementia recognition and management (Downs, 1996), and a diagnosis

of dementia should generally be made within the primary health care system (Engedal, 2000).

Exposure to this discipline in an undergraduate medicine program could increase interest in

geriatric medicine as a career and could positively influence the management of older patients

(Ni Chróinı́n et al., 2013). For example, one third of senior medical students reported that they

would consider geriatric medicine as their future specialty (Ni Chróinı́n et al., 2013). Radiogra-

phy students reported the least knowledge among health and social care profession undergrad-

uate students (58% correct answers). This finding was surprising and was not expected because imaging examinations, such as computed tomography (CT) or magnetic resonance imaging

(MRI), are routinely performed in evaluations of AD patients. The low knowledge among radi-

ography students suggests that current dementia education is not adequate, or that students are

receiving inappropriate supervision during their clinical placements. Radiographers reported

negative attitudes toward individuals with dementia (Kada, 2009).

The participants in this study obtained lower ADKS scores on the risk factors (67% correct answers), course of the diseases (71% correct answers), and caregiving (78% correct answers) domains. The current study findings supported an earlier study that identified deficient knowl-

edge on the risk factors (65% correct answers) and course of the disease (75% correct answers) domains among Australian health care staff (Smyth et al., 2013). Possible explanations for these

results could be that some of the questions on the risk factors and course of the disease domains

were medically oriented. On the caregiving domain, although the mean total score was less than

80%, it was positive that nursing students who play a major role in care of persons diagnosed with dementia attained a score of 80%, thereby potentially indicating that the participants lacked specific knowledge about dementia. Studies have reported that the curriculum of health care

professional students should include a sufficient geriatric component covering all aspects of

dementia (Goins et al., 2003), and that dementia-specific education could be an important

contributor to improving knowledge (Smyth et al., 2013).

Limitations

The limitations of this study were as follows. First, convenience samples were used due to a lack

of time and resources. Because data regarding the students’ previous exposure to persons with

dementia (frequency of indirect exposure to dementia through patients in roles of family mem-

bers and percentages of patients with dementia whom students met in clinical experience) were

not collected, there is a possibility that students with and without exposure to persons with

dementia might have biased the result. Furthermore, data regarding the semester during which

436 S. KADA

this education was provided were not available. If the students completed their education

immediately before the questionnaires were distributed, it might have affected the results of

the knowledge scores. Another limitation was that the data collection occurred on site on the

day of data collection, and it was possible that not all of the groups of students were represented

in the sample. The ADKS questionnaire focuses exclusively on AD and, therefore, did not

evaluate the students’ knowledge of other dementias. Further research is needed to explore

actual dementia care practices and knowledge of dementia.

Clinical Implications

It is essential that health and social care professionals working in dementia care be educated and

supported in the development of their skills and knowledge in this area given the increasing

number of people with dementia globally. The number of teaching hours in geriatrics, therefore,

must be increased and must cover all aspects of dementia.

Conclusion

Performance on the ADKS indicated that health and social care professional students in the final

term of the graduating year exhibited a moderate knowledge base regarding AD, but they were

also ignorant of many facts and had many misconceptions regarding AD.

Knowledge of AD is essential for providing appropriate care to individuals with dementia,

and dementia education plays an important role in securing the quality of care. Therefore, the

geriatric component in the present curriculum should be evaluated to ensure that it covers all

aspects of dementia and to raise awareness of AD. Education should focus on the biomedical

aspects of dementia (cause, treatment, and prognosis); the course of the disease; and caregiving.

Participation in theoretical and practical training in dementia should be compulsory in study

programs.

ACKNOWLEDGMENTS

The author is indebted to all of the participating institutions and participants.

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