Introduction

1. Background

In Korea, with the continuously growing elderly population, the prevalence of dementia in people aged 65 or older is estimated to rapidly increase from 10.3% in 2020 to 12.7% in 2040 to 17.7% in 2060 [1].

Dementia refers to a condition in which complex symptoms of cognitive decline, including memory loss, occur in people who have been leading a normal life due to various acquired causes, and seriously affect individuals’ cognitive and daily functioning, making it difficult for them to perform daily activities independently [2]. There is currently no treatment for dementia that can cure cognitive impairment and restore deteriorated cognitive functions to their previous states after a person is diagnosed with dementia. Therefore, the only realistically feasible approaches to dementia are to reduce the incidence of dementia by preventing dementia through managing risk factors for dementia, and to slow down the progression of dementia through early diagnosis and interventions in cases where a person is diagnosed with dementia [3].

Dementia prevention is generally focused on lifestyle factors, which can be managed through lifestyle changes [3]. The World Health Organization (WHO) has suggested the following behaviors as effective ways to reduce the risk of dementia: management of diseases such as diabetes, hypertension, and hyperlipidemia, regular exercise, weight management, healthy eating, smoking cessation, avoiding excessive alcohol use, improving lifestyle habits, and depression management [4]. In Korea, the National Institute of Dementia developed the ‘3.3.3 Rules for Dementia Prevention’ in 2014, which include disease management for diseases such as high blood pressure, diabetes, and hyperlipidemia, improvement of lifestyle habits such as exercise, dietary habits, and cognitive activities, and regular early dementia screening tests and health checkups, in order to encourage people, including older adults, to practice dementia preventive behaviors in their daily life [5]. In addition, as national spending on dementia care is expected to increase continuously with an increase in dementia patients, the Ministry of Health and Welfare has established the 4th National Dementia Plan (2021-2025). Accordingly, to ensure that high-risk groups for dementia can be managed mainly through dementia care centers, the Ministry of Health and Welfare has been expanding dementia screening tests for people ages 75 and older who are living alone, has been attempting to identify older adults with suspected cognitive impairment in connection with the home visiting healthcare services of public health centers to guide them to visit and use a dementia care center, and has been distributing dementia prevention programs to senior welfare centers [6]. However, a previous study by Ha [7] reported that the degree of dementia preventive behavior practice among community-dwelling older adults in Korea was found to be a low level of 42.35 points out of 100. Therefore, it is most urgently needed to develop strategies to encourage older adults to voluntarily participate in and practice dementia preventive behaviors.

A high-risk group for dementia means a group at high risk of developing dementia, so it is a group that needs to perform activities for dementia prevention more actively than other people to prevent the development of dementia. The Ministry of Health and Welfare has been managing the following groups as high-risk groups for dementia: people with mild cognitive impairment, people aged 75 and older classified as the old-old group, and older adults living alone [6]. With respect to the empirical bases for categorizing these groups as high-risk groups for dementia, mild cognitive impairment refers to the intermediate stage between cognitive decline observed in the normal aging process and mild dementia, and the annual incidence rate of dementia is reported to be 1-2% in normal older people and about 10-15% in people with mild cognitive impairment [2]. Also, old age has been shown to be a representative risk factor for dementia [2-4], and a prior study reported that the likelihood of developing dementia was found to be 5.82 times higher in the 75-80 age group and 35.15 times higher in the ≥85 age group, compared to the 60-64 age group [2]. In addition, social isolation, such as living alone and the absence of the spouse, has also been found to be a risk factor for dementia [2-4]. Older adults living alone were found to have decreased cognitive abilities, compared to those living with others [8], and the proportions of dementia risk factors, such as old age, a low education level, high nutritional risk, and depression, were reported to be higher among older adults living alone [8,9]. Moreover, older adults living alone were found to be at 2.9 times higher risk for dementia [2].

In order to prevent the development of dementia in older adults at high risk for dementia, research needs to be conducted to identify factors influencing the practice of dementia preventive behaviors. In the majority of previous studies on dementia preventive behaviors, study participants were community-dwelling older people [7,10-12] or middle-aged people [13,14]. Among previous studies of community-dwelling older people, two studies [11,12] conducted research on older adults at high risk for dementia, and the participants of these studies were older adults aged 65 or older living alone. More specifically, Kang et al. [11] conducted research on dementia knowledge, internal health locus of control, and dementia preventive behaviors, and Han & Suh [12] investigated dementia knowledge, dementia attitudes, and dementia preventive behaviors. Other studies of community-dwelling older adults have been conducted without any limitation on the age of participants, and there has been no research on people aged 75 or older, a high-risk group for dementia. Thus, there is a need for research on older adults at high risk for dementia.

The health belief model is a model developed in the early 1950s by social psychologists Hochbaum, Rosenstock, and Kegels to explain preventive behaviors, and the major concepts of this model are perceived susceptibility, perceived severity, perceived benefit, perceived barrier, and cues to action [15]. The concept of general health motivation was subsequently added to the health belief model to explain sick role behavior [16], and as the focus of health behavior has been shifted to lifestyle behaviors that need long-term changes, this model was further extended by adding the concept of self-efficacy [17]. The health belief model is a useful theory for explaining health behaviors for various diseases, but has the limitation that it does not sufficiently reflect the psychosocial factors of diseases [18]. Therefore, research has been actively conducted on the extended health belief model, which was constructed by adding general health motivation and self-efficacy to the health belief model, and it has been demonstrated that the extended health belief model is an appropriate theoretical framework for explaining influencing factors for health behaviors [19,20]. Since dementia preventive behaviors are preventive activities and mostly lifestyle habits [4], the extended health belief model can be applied as a conceptual framework for analysis of dementia preventive behaviors among older adults at high risk for dementia.

Prior studies on dementia based on the health belief model have analyzed dementia preventive behaviors [10], dementia preventive behavior intention [20,21], fear of dementia [22], and performance of the dementia screening test [23,24], and there is currently a lack of research on dementia preventive behaviors. In addition, in a previous study on dementia preventive behaviors [10], only health beliefs were analyzed among the concepts of the extended health belief model, so there is a need to analyze influencing factors for dementia preventive behaviors by applying all concepts of the extended health belief model (general health motivation, health beliefs, cues to action, and self-efficacy).

Meanwhile, the Ministry of Health and Welfare has defined high-risk groups for dementia as: people with mild cognitive impairment, people aged 75 and older, and older adults living alone. However, a previous study [2] reported that the level of awareness of dementia was significantly lower in older adults with mild cognitive impairment than those with normal cognitive function. In addition, it has been shown that a higher level of dementia knowledge was associated with a higher level of dementia preventive behavior practice [11-13]. These findings of previous studies suggest that there may be differences in the degree of dementia preventive behavior practice and influencing factors for them between older adults with mild cognitive impairment and those with normal cognitive function. Therefore, this study defined older adults at high risk for dementia as older adults aged 65 or older living alone or older adults aged 75 or older among older people without cognitive impairment, and purported to identify factors influencing dementia preventive behaviors among older adults at high risk for dementia by applying the extended health belief model with the aim of presenting basic data for the development of a dementia prevention program for older adults at high risk for dementia.

2. Objectives

The aim of this study was to identify factors influencing dementia preventive behaviors among older adults at high risk for dementia by applying the extended health belief model, and specific objectives are as follows:

1) To investigate the levels of dementia preventive behaviors, general health motivation, health beliefs, cues to action, and self-efficacy among older adults at high risk for dementia;

2) to investigate the degree of dementia preventive behaviors according to the general characteristics of older adults at high risk for dementia;

3) to examine the relationships between dementia preventive behaviors, general health motivation, health beliefs, cues to action, and self-efficacy among older adults at high risk for dementia;

4) to identify factors affecting dementia preventive behaviors among older adults at high risk for dementia.

Methods

1. Study design

This study is a descriptive correlational research to identify factors affecting dementia preventive behaviors among older adults at high risk for dementia.

2. Participants

The participants of this study are older adults at high risk for dementia living in H-gun, Gyeongsangnam-do who understood the purpose of the study and gave written informed consent to participate in the study. The inclusion criteria were as follows: older adults aged 65 or older living alone or those aged 75 or older, who are high-risk groups for dementia; no cognitive impairment (a score of 24 or higher on the Korea version of Mini-Mental State Examination (MMSE-K)); able to read and understand Korean or able to listen and verbally respond to the questions of the questionnaire. The exclusion criteria were as follows: 1) people diagnosed with dementia or mild cognitive impairment; 2) people diagnosed with and receiving treatment for a mental disorder such as schizophrenia and bipolar disorder.

The sample size was calculated using G·Power version 3.1.9 [25]. More specifically, in the multiple regression analysis, the significance level (α) was set at .05 and power was set at .80. As for the effect size, since there were no previous studies on dementia preventive behaviors among older adults at high risk for dementia, the effect size was set as a medium effect size (.15), based on the research results of a study by Ha [7] on dementia preventive behaviors among community-dwelling older adults, and the number of predictor variables was set to 11. As a result, the minimum sample size for this study was determined as 123 people. In this study, considering a dropout rate of 20%, questionnaires were distributed to a total of 148 people, and 140 respondents were finally included in the analysis, excluding 8 copies of the questionnaire with insincere responses.

3. Measures

1) Dementia preventive behaviors

The degree of dementia preventive behaviors was measured by a modified version of the assessment tool for dementia preventive behaviors developed by Lim et al. [26], and the used tool was created by the researcher by modifying and supplementing the original tool developed by Lim et al. [26]. The instrument developed by Lim et al. [26] contains a total of 15 questions on the following items: five rules of recommended behaviors (moderate-intensity exercise for 30 minutes or more, balanced intake of nuts and vegetables, three meals a day, adequate good-quality sleep, and reading and writing), five rules of prohibited behaviors (drinking, smoking, traumatic brain injury, obesity, and chronic diseases), and five rules of necessary behaviors (stress reduction, depression prevention, communication, early dementia screening test, and regular health check-ups). The researcher added one question about hand movements to the original tool, based on the Ten Rules for Dementia Prevention presented by the Ministry of Health and Welfare [27], so the tool used in this study includes 16 questions in total. Each item is assessed on a 5-point Likert scale, ranging from 1 point (=‘Never’) to 5 points (=‘Always’). Higher scores indicate higher frequencies of performing dementia preventive behaviors. As to the reliability of the instrument, the value of Cronbach’s α was reported as .77 in Lim et al. [26], and it was calculated as .79 in this study.

2) General health motivation, health beliefs, and cues to action

Among the variables of the extended health belief model, general health motivation, health beliefs (perceived susceptibility, perceived severity, perceived benefit, and perceived barrier), and cues to action were measured using the subscales from an adapted version of the scale developed by Kim et al. [28]. Kim et al. [28] devised the Motivation to Change Lifestyle and Health Behaviors for Dementia Risk Reduction (MCLHB-DRR) Scale for adults aged 50 or older, and its adapted version used in this study was developed by Choi et al. [20]. Kim et al. [28] developed the MCLHB-DRR Scale to assess motivation for changing lifestyle habits and health behaviors to reduce one’s risk of dementia by modifying questions from previous studies that applied the health belief model to breast cancer screening and cognitive tests, based on focus group interviews with 34 middle-aged and older Australians aged 50 years or older [28]. The scale contains a total of 27 questions and 7 subscales, and this study used the tool except for the self-efficacy subscale. More specifically, the scale used consists of 4 questions about general health motivation, 4 questions about perceived susceptibility, 5 questions about perceived severity, 4 questions about perceived benefit, 4 questions about perceived barrier, and 4 questions about cues to action. Each item is scored on a 5-point Likert scale, ranging from 1 point (=‘Not at all’) to 5 points (=‘Very much’), and higher scores indicate higher levels of general health motivation, perceived susceptibility, perceived severity, perceived benefit, perceived barrier, and cues to action. Regarding the reliability of each subscale, the values of Cronbach’s α were reported as .60 for general health motivation, .86 for perceived susceptibility, .72 for perceived severity, .69 for perceived benefit, .74 for perceived barrier, and .68 for cues to action in Kim et al. [28]. In this study, the values of Cronbach’s α were calculated as .83 for general health motivation, .92 for perceived susceptibility, .74 for perceived severity, .91 for perceived benefit, .92 for perceived barrier, and .82 for cues to action.

3) Self-efficacy

Self-efficacy for dementia preventive behaviors was measured using the self-efficacy scale developed by the researcher. This tool was created based on the guidelines for development of a self-efficacy scale presented by Bandura [29] by referring to the self-efficacy scale developed by Gu [30], which was also developed based on the guidelines presented by Bandura [29]. The researcher devised 10 questions in connection with the questions of the assessment tool for dementia preventive behaviors in order to measure confidence in specific dementia preventive behaviors according to Bandura’s [29] definition of self-efficacy. Then, assessment of the content validity of the developed scale was performed through evaluations by two nursing professors. As a result, the content validity index was more than 0.8 for all items, so all the items were adopted and the scale was finalized. This scale consists of 10 questions in total, and each item is assessed on a 5-point Likert scale, ranging from 1 point (=‘Not at all confident’) to 5 points (=‘Very confident’). Higher scores indicate a higher level of self-efficacy for dementia preventive behaviors. Regarding the reliability of the tool, the value of Cronbach’s α was reported as .77 in the study by Gu [30] and it was calculated as .72 in this study.

4. Data collection

In this study, data collection was conducted from April 21 to May 28, 2021 among older adults at high risk for dementia who visited a public health center and its dementia care center after obtaining consent from the director of the public health center in H-gun, Gyeongsangnam-do. Data was collected using questionnaires from the older adults at high risk for dementia who gave written informed consent after they were informed of the purpose, necessity, and procedures of the study. It took approximately 15 to 20 minutes to complete the questionnaire. When some participants had difficulty filling out the questionnaire due to presbyopia or illiteracy or needed assistance in completing the questionnaire, the researcher read aloud each item of the questionnaire to the participants and asked them to respond verbally.

5. Ethical considerations

This study was conducted only with people who gave written informed consent to participate in the study after receiving approval from the IRB of Gyeongsang National University (IRB approval No.: GIRB-A21-Y-0005) before data collection. The study participants were given explanations about the purpose and methods of the study, rights of research participants, anonymity of information collected from them, and their right to withdraw from the study at any time. They were also informed that the collected data would not be used for purposes other than research and would be stored for 3 years after the completion of the study and then discarded. To guarantee the anonymity of the participants, unique codes were assigned to the collected data and personal information. The participants were given a small gift along with a leaflet on dementia prevention as a token of appreciation for their participation in the study.

6. Statistical analysis

The collected data were analyzed using SPSS/WIN 24.0.

To analyze general characteristics, dementia preventive behaviors, general health motivation, health beliefs, cues to action, and self-efficacy of the participants, the frequency, percentage, mean, and standard deviation were calculated. The t-test and ANOVA were performed to analyze differences in the degree of dementia preventive behaviors according to the characteristics of the participants, and a post-hoc test was conducted using the Scheffé test. In addition, Pearson’s correlation coefficient was used to examine the relationships between dementia preventive behaviors, general health motivation, health beliefs, cues to action, and self-efficacy among the participants. Furthermore, a hierarchical multiple regression analysis was conducted to analyze factors influencing dementia preventive behaviors in the participants.

Results

1. General and dementia-related characteristics of older adults at high risk for dementia

With respect to the general characteristics of the participants, 78 people (55.7%) were female, and the mean age of the participants was 78.39±5.46 years. In education level, uneducated people without formal education were 39 people (27.9%), accounting for the largest proportion of the participants. For the presence of family members living together, 92 people (65.7%) lived with one or more family members. As to the presence of religion, 106 people (75.7%) believed in no religion. Regarding the presence of a job, 109 people (77.9%) had a job. In average monthly income, people with an average monthly income of ≤1 million won took up 67.9% (95 people) of the participants. As for subjective health status, 67 people (47.9%) rated their subjective health status as not healthy. As to the presence of underlying diseases, 87 people (62.1%) had underlying diseases.

Regarding dementia-related characteristics of the participants, 128 people (91.4%) had no family members with dementia, 121 people (86.4%) had no acquaintances with dementia, and 129 people (92.1%) had no experience of caring for dementia patients. In addition, 104 people (74.3%) answered that they were very interested in preventing dementia. Also, 87 people (62.1%) had experience of receiving dementia prevention education, and 102 people (72.9%) had no experience of receiving a dementia screening test (Table 1).

2. Levels of dementia preventive behaviors, general health motivation, health beliefs, cues to action, and self-efficacy among older adults at high risk for dementia

In this study, the total scores of dementia preventive behaviors in older adults at high risk for dementia ranged from 16 to 80 points, with a mean of 55.48±7.83 points, and the mean score of items was 3.47±0.49 points out of 5 (Table 2). With respect to the degree of each dementia preventive behavior, the dementia preventive behavior with the highest score was ‘I make sure to eat three meals a day’ (4.21±0.77 points out of 5), followed by ‘I take care not to hurt my head’ (4.11±0.82 points), ‘I do not smoke’ (4.09±1.52 points), ‘I maintain a healthy body weight’ (3.97±0.77 points), ‘I do not drink more than 3 glasses of alcohol at a time’ (3.89±1.44 points), and ‘I properly manage my chronic conditions such as high blood pressure, diabetes, and hyperlipidemia’ (3.78±0.91 points). The dementia preventive behavior with the lowest score was ‘I get an early dementia check-up every year’ (2.51±1.00 points), followed by ‘I read or write diligently’ (2.63±1.06 points), ‘I perform activities such as hand exercise, drawing pictures, and making things to use my hands more frequently’ (2.64±1.03 points), and ‘I exercise for more than 30 minutes a day to such a degree that I sweat a little’ (2.98±1.07 points),

Among older adults at high risk for dementia, the score for general health motivation ranged from 4 to 20 points, with a mean of 15.84±1.92 points, and the mean score of items was 3.96±0.48 points out of 5. With respect to health beliefs, the mean of total scores and the mean score of items (out of 5 points) of each subdomain are as follows. For perceived susceptibility, the total scores ranged from 4 to 20 points, with a mean of 10.81±2.95 points, and the mean score of items was 2.70±0.74 points out of 5. For perceived severity, the total scores ranged from 5 to 25 points, with a mean of 15.33±2.81 points, and the mean score of items was 3.07±0.56 points. For perceived benefit, the total scores ranged from 4 to 20 points, with a mean of 13.53±2.46 points, and the mean score of items was 3.38±0.62 points. For perceived barrier, the total scores ranged from 4 to 20 points, with a mean of 8.89±3.37 points, and, and the mean score of items was 2.22±0.84 points. As for cues to action, the total scores ranged from 4 to 20 points with a mean of 11.80±2.82 points, and the mean score of items was 2.95±0.70 points. Regarding self-efficacy, the total scores ranged from 10 to 25 points with a mean of 15.84±1.92 points, and the mean score of items was 3.49±0.50 points (Table 2).

3. Differences in the degree of dementia preventive behaviors according to the general characteristics of older adults at high risk for dementia

The characteristics that showed a significant association with the level of dementia preventive behavior among older adults at high risk for dementia were age (F=5.26, p=.002), education level (F=3.20, p=.015), presence of religion (t=2.28, p=.026), monthly income (F=4.94, p=.008), subjective health status (F=8.41, p<.001), presence of underlying disease (t=-2.42, p=.017), and presence of a family member with dementia (parents, siblings) (t=-2.39, p=.018). The Scheffé test was performed to determine whether there are significant differences between groups. In terms of age, the degree of dementia preventive behaviors was higher in the 75-79 age group (3.56±0.49), compared to the 65-69 age group (2.93±0.68). As to the presence of religion, the degree of dementia preventive behaviors was higher in the group with religion (3.52±0.51) than in the group without religion (3.32±0.42). In the case of monthly income, the degree of dementia preventive behavior was higher in the group with a monthly income of ≥2 million won (3.83±0.41) than the group with a monthly income of ≤1 million won (3.41±0.51). In terms of subjective health status, the level of dementia preventive behavior was higher in the ‘healthy’ group (3.70±0.57) than the ‘moderate’ group (3.36±0.34) and the ‘not healthy’ group (3.36±0.43). Regarding the presence of underlying diseases, the level of dementia preventive behavior was higher in the group without underlying diseases (3.60±0.54) than the group with one or more underlying diseases (3.39±0.44). As to the presence of family members with dementia, the level of dementia preventive behavior was higher in the group without family members (parents, siblings) with dementia (3.60±0.54) than the group with a family member with dementia (3.15±0.32).

4. Dementia preventive behavior, general health motivation, health beliefs, cues to action, and self-efficacy among older adults at high risk for dementia

Among older adults at high risk for dementia, the degree of dementia preventive behaviors showed a weak positive correlation with general health motivation (r=.21, p=.012) and perceived benefit (r=.26, p=.002) among health beliefs, and had a strong positive correlation with self-efficacy (r=.87, p<.001). In addition, the degree of dementia preventive behaviors showed a weak negative correlation with perceived susceptibility (r=-.24, p=.004). In other words, the level of dementia preventive behavior was associated with a higher level of general health motivation, a lower level of perceived susceptibility, a higher level of perceived benefit, and a higher level of self-efficacy (Table 3).

5. Influencing factors for dementia preventive behavior among older adults at high risk for dementia

In order to check whether the assumptions of regression analysis were satisfied before regression analysis, the P-P plot and scatter plot were examined, and they were close to a 45-degree straight line, indicating that the normality of residuals was satisfied. The residuals were evenly distributed around 0, so the linearity and homoscedasticity of the model were satisfied. The Durbin-Watson test was performed as a test for autocorrelation between error terms, and the Durbin-Watson statistic was calculated to be 1.87, a value close to 2, indicating that there was no autocorrelation between error terms. Additionally, the tolerance and variance inflation factor (VIF) values were calculated to check multicollinearity between independent variables. As a result, tolerance values were greater than 0.10, ranging from 0.13 to 0.94, and VIF values were less than 10, ranging from 1.07 to 8.02, so it was confirmed that there was no multicollinearity between the independent variables

A hierarchical multiple regression analysis was conducted to analyze the impact of variables of the extended health belief model on dementia preventive behaviors after controlling for general and dementia-related characteristics of the participants. In the first step of hierarchical multiple regression analysis, among general characteristics of the participants, the following six factors identified as significant factors affecting dementia preventive behaviors were entered into the regression model (Model 1): age (reference: ages 65-69), education level (reference: uneducated), religion (reference: having no religion), monthly income (reference: less than 1 million won), underlying disease (reference: absence of underlying disease), and subjective health status (reference: not healthy). As a result of regression analysis, compared to ages 65-69, ages 70-74 (β=0.35 p=.010), ages 75-79 (β=0.64, p=.003), and ages ≥80 (β=0.45, p=.034) were found to significantly influence dementia preventive behavior. The explanatory power of these variables was 27% (Adjusted R²=.19, F=3.50, p <.001). In Model 2 of hierarchical multiple regression analysis, among dementia-related characteristics of the participants, only the presence of a family member with dementia (reference: absence of a family member with dementia), which was found to have a significant influence on dementia preventive behaviors, was additionally entered. Regression analysis was conducted after controlling for the general characteristics of participants. As a result, among the dementia-related characteristics of the participants, the presence of a family member with dementia (β=-0.18, p=.021) was found to significantly influence dementia preventive behaviors, when people without family members with dementia were used as the reference group. In addition, in terms of age among the general characteristics of the participants, compared to ages 65-69, ages 70-74 (β=0.35, p=.008), ages 75-79 (β=0.68, p=.002), and ages ≥80 (β=0.50, p=.017) were found to be significant influencing factors for dementia preventive behaviors. Model 2 of hierarchical multiple regression analysis showed a higher explanatory power by 3%, compared to Model 1, and the variables of Model 2 explained 30% of the total variance (Adjusted R²=.22, F=3.76, p<.001). In the third step of hierarchical multiple regression analysis, regardless of whether a variable has a significant impact on dementia preventive behavior, the following seven variables of the extended health belief model were additionally entered into the regression model: general health motivation, cues to action, self-efficacy, four variables of health beliefs, which are perceived susceptibility, perceived severity, perceived benefit, and perceived barrier. Regression analysis was performed after controlling for general characteristics and dementia-related characteristics of the participants. As a result, among the variables of the extended health belief model, cues to action (β=0.17 p=.013) and self-efficacy (β=0.82, p<.001) were found to significantly affect dementia preventive behaviors. In addition, regarding age among general characteristics of the participants, compared to ages 65-69, ages 75-79 (β=0.35, p=.003) and ages ≥80 (β=0.27, p=.021) were found to significantly influence the degree of dementia preventive behaviors. In other words, the degree of dementia preventive behaviors was higher in the 75-79 age group and the ≥80 age group, compared to the 65-69 age group, and a higher level of cues to action and a higher level of self-efficacy were linked to a higher degree of dementia preventive behaviors. As a result of hierarchical multiple regression analysis, the explanatory power of Model 3 was increased by 52%, compared to Model 2, and the variables of Model 3 explained 82% of the total variance (Adj-R²=.79, F=25.21, p<.001) (Table 4).

Discussion

This study attempted to identify influencing factors on dementia preventive behaviors among older adults at high risk for dementia by applying the extended health belief model with the aim of presenting basic data for developing a dementia prevention program for older adults at high risk for dementia.

In this study, the degree of dementia preventive behaviors among older adults at high risk for dementia was measured by using a modified version of the assessment tool for dementia preventive behaviors developed by Lim et al. [26]. The modified version of the tool developed by Lim et al. [26] was created by the researcher by modifying and supplementing the original tool. In this study, the mean score for dementia preventive behaviors was 3.47 points out of 5 (69.4 points out of 100). There are no previous studies using the same tool to investigate dementia preventive behaviors among older adults at high risk for dementia. The study by Kang et al. [11] measured dementia preventive behaviors among older adults aged 65 or older living alone by using the tool developed by Lee et al. [14], and reported that the mean score for dementia preventive behavior practice was 2.29 points out of 3 (76.3 points out of 100). In addition, the study by Han & Suh [12] reported that the mean score for dementia preventive behaviors was 2.26 points out of 3 (75.33 points out of 100). A relatively low score for dementia preventive behaviors in this study may be attributed to the tools used. The tool developed by Lee et al. [14] measures the degree of dementia preventive behavior practice on a 3-point Likert scale (‘I never perform it (1 point)’; ‘I perform it sometimes (2 points)’; ‘I perform it almost every day (3 points)’), and allowed the participants to respond based on subjective judgements. On the other hand, this study assessed the behavior frequency on a 5-point Likert scale ranging from 1 point (=‘Never’ corresponding to 0 times a week) to 5 points (=‘Always’ corresponding to 6 to 7 days a week). Thus, the score for each item of dementia preventive behaviors indicates the frequency of performing the behavior per week, so the assessment tool of this study allowed respondents to give a more objective response to the question about the degree of dementia preventive behavior practice, which is thought to have had an impact on the scores. In addition, the tool developed by Lee et al. [14] did not include the following items recommended in the 3.3.3 Rules for Dementia Prevention [5] among the questions included in the tool used in this study: ‘I try to be careful not to injure my head’, ‘I get an early dementia screening test at a public health center every year’, and ‘I receive regular health checkups.’ The tool made by Lee et al. [14] did not include an item on depression prevention presented as an efficient dementia management method by WHO [4], either. In terms of the items of the tool used, it is thought that this study used a more valid tool to assess dementia preventive behaviors, and the results of this study suggest that there is a need to increase the practice rate of dementia preventive behaviors among older adults at high risk for dementia.

In the analysis of the degree of each item of dementia preventive behaviors among older adults at high risk of dementia, the dementia preventive behavior with the highest score was ‘I make sure to eat three meals a day’, followed by ‘I take care not to hurt my head’ and ‘I do not smoke’ in descending order. These results are similar to the findings of the study of older adults living alone by Kang et al. [11], which reported that participants showed a relatively high degree of practice in items such as smoking cessation, avoiding excessive drinking, and regularly eating meals among dementia preventive behaviors.

Among dementia preventive behaviors, the item with the lowest score was ‘I get an early dementia screening test every year.’ This result is consistent with the results of the study by Ha [7], which reported a low score for the item ‘I receive a dementia screening test every year.’ In this connection, according to previous studies, the most common reason for not receiving an early dementia screening test was found to be ‘I do not feel the need for receiving a dementia screening test’ among community-dwelling older adults living, and the performance rate of the dementia screening test was higher among people who had a family member or acquaintance that had undergone a dementia screening test than those who did not [23,24]. Therefore, in order to increase the performance rate of the early dementia screening test among older adults at high risk for dementia, it is necessary to actively carry out education and promotion to raise public awareness about the need for early dementia screening tests by using social networks such as the family and friends. The dementia preventive behavior with the second lowest score was ‘I read or write diligently.’ This result is consistent with previous studies that reported a relatively low score for reading and writing among dementia preventive behaviors in community-dwelling older adults [7,10-12]. A low practice rate of reading and writing is thought to be related to the age and education level of participants. In other words, the mean age of the participants of this study was 78.39 years and most of them were people aged 75 or older, and people with the education level of elementary school or less accounted for more than half (52.9%), so it is presumed that a majority of the participants had difficulty reading or writing due to illiteracy or poor eyesight. The dementia preventive behavior with the third lowest score was ‘I do activities such as hand exercises, drawing, and making things to use my hands more frequently.’ This result is consistent with previous studies [7,10] reporting a relatively low score of the item about hand movements among dementia preventive behaviors. These activities involving hand movements are required for all older people because they can improve cognitive function like reading and writing, and they are cognitive activities especially suitable for illiterate elderly people who have difficulty reading and writing. Therefore, it is necessary to provide older adults at high risk for dementia with education about methods of hand exercises as well as dementia prevention programs that include activities requiring frequent hand movements, such as drawing pictures and making things.

With respect to the results of descriptive statistical analysis of the variables of the extended health belief model among older adults at high risk for dementia, the mean score for health beliefs was 2.70 points out of 5, and the mean score for each subdomain of health beliefs was 2.70 points for perceived susceptibility, 3.07 points for perceived severity, 3.38 points for perceived benefit, and 3.38 points for perceived barrier. Regarding previous studies using the same tool, Choi et al. [20] reported that mean scores for health beliefs were 2.31 points for perceived susceptibility, 2.63 points for perceived severity, 3.49 points for perceived benefit, and 2.38 points for perceived barrier among older adults living in the community. Meanwhile, Seo et al. [21] measured health beliefs among adults diagnosed with hypertension and diabetes (mean age: 61.70 years), and reported that the mean scores for each subdomain were 2.49 points for perceived susceptibility, 2.62 points for perceived severity, 3.62 points for perceived benefit, and 2.43 points for perceived barrier. The findings described above suggest that levels of perceived susceptibility and perceived severity are higher but levels of perceived benefit and perceived barrier are lower in older adults at high risk for dementia, compared to community-dwelling older adults. In this study, the mean score for general health motivation was 3.96 points out of 5, which is a similar level to 4.10 points in a study using the same tool by Choi et al. [20]. These results seem to show that older adults at high risk for dementia consider it important to maintain health and have a relatively high level of general health motivation to avoid disease states. Cues to action refer to stimuli that prompt people to perform dementia preventive behaviors to reduce the risk of dementia, and the mean score for cues to action was 2.95 points out of 5, which was a lower level compared to 3.27 points in the study by Choi et al. [20], which measured cues to action among older adults aged 65 years or older by using the same tool. In other words, study results indicate that there are few intrinsic and extrinsic stimuli that induce older adults at high risk of dementia to perform dementia preventive behaviors. A low level of cues to action among older adults at high risk of dementia in this study may be attributed to the following reasons. First, the mean age of the participants was 78.39 years and people with the education level of elementary school or lower took up 52.9% of them, so it is thought that many of them are not likely to get information about dementia through mass media such as broadcast media or promotional leaflets. Moreover, it is presumed that since they perceive dementia as a natural aging process rather than a disease [2,3], even intrinsic stimuli such as the occurrence of dementia symptoms do not give rise to motivations for performing dementia preventive behaviors. The mean score of self-efficacy among the participants was 3.49 points out of 5 (69.8 points out of 100), which is a similar level to 3.47 points out of 5 among community-dwelling older people in a study by Ha [7], although it is difficult to directly compare study results because the study by Ha [7] used a general self-efficacy scale [31], not a self-efficacy scale specific to dementia preventive behaviors. The level of self-efficacy among participants in this study suggests that there is a need to improve self-efficacy in older adults at high risk for dementia. According to Bandura [29], who proposed the concept of self-efficacy, Self-efficacy is defined as an individual's belief that they can exert themselves sufficiently to attain designated levels of behaviors, so it should be measured as confidence for a specific behavior. However, in previous studies [7,10], since self-efficacy was measured using not a self-efficacy scale for dementia preventive behaviors but a scale for general self-efficacy [31], which refers to an individual’s belief in his or her ability to perform necessary behaviors in various areas of achievement situation, self-efficacy for dementia preventive behaviors was not measured in a valid manner. Therefore, it is necessary to measure self-efficacy for dementia preventive behaviors by using a valid measure in future research.

In this study, age among general characteristics and self-efficacy and cues to action among the variables of the extended health belief model were identified as significant influencing factors for dementia preventive behaviors among older adults at high risk for dementia. Specifically, the degree of dementia preventive behaviors was found to be higher in the 75-79 age group and the ≥80 age group than in the 65-69 age group. Among the participants of this study, people in the 65-69 age group were all older adults living alone, and the participants aged 75 or older included older adults living with others as well as those living alone. In this study, analysis of differences in the level of dementia preventive behaviors according to the general characteristics of the participants showed that there was no significant difference in the degree of dementia preventive behaviors according to the presence or absence of a family member living together. Therefore, a relatively low degree of dementia preventive behaviors in the 65-69 age group is thought to be not a characteristic of older adults living alone but show a difference between age groups. Since no previous studies on dementia preventive behaviors used the same selection criteria for participants as those of this study, it is difficult to directly compare study results, but some prior studies of older people living alone as a high-risk group for dementia [11,12] reported that there was no significant difference in the degree of dementia preventive behaviors according to age. In view of this inconsistency among studies, it is necessary to examine the impact of age on dementia preventive behaviors by dividing older adults at high risk for dementia into those living alone and those living with others in future studies. Among the variables of the extended health belief model, self-efficacy was found to have the greatest impact on dementia preventive behaviors among older adults at high risk for dementia. Previous studies of older people living in the community [7,10] used a general self-efficacy scale [31], so it is difficult to make a direction comparison of research results, but prior studies have shown that self-efficacy is a significant influencing factor for dementia preventive behaviors. Also, the study by Oh [10] reported that self-efficacy was the variable that had the greatest impact on dementia preventive behaviors, and this finding indirectly supports the results of this study.

It is thought that since most dementia preventive behaviors are lifestyle habits, self-efficacy, which is an important factor in the maintenance of particular behaviors, was shown to have a greater impact than other factors. Therefore, in order to increase the practice rate of dementia preventive behaviors among older adults at high risk for dementia, it is necessary to make an intensive effort to improve self-efficacy, which can be seen as confidence in dementia preventive behaviors. Bandura [29] proposed that individuals can develop self-efficacy through sources such as enactive attainment, vicarious experience, and verbal persuasion. Therefore, in relation to the development of intervention programs for dementia prevention, an effective strategy for improving self-efficacy among older adults at high risk for dementia would be to lead them to set step-by-step goals and perform dementia preventive behaviors so as to increase their attainment experience, and it can also be a useful strategy to help them gain vicarious experiences by giving them opportunities to talk about their experience of performing these dementia preventive behaviors in front of other older adults. Additionally, it can also be helpful to encourage them to practice dementia preventive behaviors, and apply the verbal persuasion strategy of giving them praise and encouragement when they perform dementia preventive behaviors.

Cues to action were identified as a significant factor affecting dementia preventive behaviors among the participants. Although it is difficult to directly compare study findings, a study by Seo et al. [21] reported that cues to action were identified as an influencing factor for dementia preventive behavior intention among adults diagnosed with high blood pressure and diabetes. Additionally, in Werner’s study of people aged 50 years or older in Israel [32], cues to action were found to be an influencing factor for intention to seek a cognitive status examination. The results of these two studies indirectly support the findings of this study. Therefore, in view of the fact that cues to action have been shown to be a variable that has a direct or indirect effect on health behaviors [33], there is a need to increase the level of cues to action in order to increase dementia preventive behaviors in older adults at high risk for dementia. In this study, older adults at high risk for dementia showed a low level of cues to action. Regarding the strategy for increasing cues to action as a way to increase dementia preventive behaviors among older people at high risk for dementia, this study found that there was a strong positive correlation between cues to action and perceived benefit, so it is presumed that perceived benefit generates cues to action, which are motivation for performing dementia preventive behaviors. In addition, a study of adults aged 40 or older in Turkey by Akyol et al. [34] reported that a higher level of willingness to know about one’s risk for developing dementia was associated with a higher level of cues to action. These findings suggest that it can be an effective strategy for increasing cues to action if we provide education about risk factors for dementia to older adults at high risk of dementia as a method to lead them to perceive dementia as a disease rather than an aging process, and actively give them information about the scientific bases and positive effects of recommended dementia preventive behaviors, especially focused on dementia preventive behaviors with a low rate of practice. In addition, since existing research on the relationship between cues to action and dementia preventive behaviors is highly insufficient, there is a need for a replication study.

Among the variables of the extended health belief model, general health motivation, perceived susceptibility, and perceived benefit were significantly correlated with dementia preventive behaviors, but they were found not to be significant influencing factors. In this study, general health motivation showed a significant positive correlation with dementia preventive behaviors. Although there is difficulty in comparing study results due to the lack of previous research on the relationship between general health motivation and dementia preventive behaviors, the results of this study about general health motivation are indirectly supported by the study by Choi et al. [20], which showed that general health motivation had a positive correlation with dementia preventive behavior intention among older adults aged 65 years or older. Regarding the reason why general health motivation was not identified as a significant influencing factor for dementia preventive behaviors, it may be attributed to the fact that although general health motivation was not significantly correlated with self-efficacy, the relationship between these variables closely approximated a significant correlation (r=.15, p=.075). In other words, it is presumed to be due to the relationship between general health motivation and self-efficacy that general health motivation had no effect on dementia preventive behaviors when controlling for self-efficacy. Perceived susceptibility was found to have a significant negative correlation with dementia preventive behaviors. This finding is indirectly supported by a study by Park et al. [35], which reported that a higher level of optimistic bias about health crisis was associated with a higher level of health behavior practice. However, in this study, perceived susceptibility did not have a significant impact on dementia preventive behaviors, and the reason may be attributed to the fact that perceived susceptibility showed a negative correlation with self-efficacy in this study. In other words, it is thought to be due to the relationship between these variables that perceived susceptibility did not have a significant effect on dementia preventive behaviors when controlling for self-efficacy. Perceived benefit was shown to have a significant positive correlation with dementia preventive behavior. Since there is little prior research on the relationship between perceived benefit and dementia preventive behavior, it is difficult to directly compare study findings. However, the results of this study about perceived benefit are indirectly supported by a study by Seo et al. [21], which reported that perceived benefit was significantly correlated with dementia preventive behavior intention. As to the reason why perceived benefit was not identified as a significant influencing factor for dementia preventive behaviors, it is thought to be related to the fact that perceived benefit showed a positive correlation with cues to action in this study. In other words, it is presumed that due to the relationship between these two variables, perceived benefit did not have a significant effect on dementia prevention when controlling for cues to action. In view of the fact that health beliefs such as perceived susceptibility and perceived benefit represent an individual’s beliefs about dementia preventive behavior, study findings suggest that it is necessary to increase cues to action and improve self-efficacy for dementia preventive behaviors through intrinsic and extrinsic stimuli in order to lead older adults to initiate and maintain dementia preventive behaviors.

This study attempted to identify factors influencing dementia preventive behaviors among older adults at high risk for dementia who need to more actively practice dementia preventive behaviors than other older adults by applying the extended health belief model in order to prevent the development of dementia in high-risk groups. Thus, the results of this study can be utilized as basic data for developing dementia preventive intervention programs for older adults at high risk for dementia and for establishing policies for the prevention and management of dementia. This study has limitations in generalizing the research findings since the present research was conducted only with a high-risk group for dementia living in a single region.

Conclusions

This study aimed to identify factors influencing dementia preventive behaviors in older adults at high risk for dementia by applying the extended health belief model. In this investigation, self-efficacy, cues to action, and age were identified as significant influencing factors for dementia preventive behaviors among older adults at high risk for dementia. These results suggest that it is necessary to improve self-efficacy for dementia preventive behaviors and increase cues to action, which are intrinsic and extrinsic stimuli that trigger dementia preventive behaviors, in order to improve dementia preventive behaviors among older adults at high risk of dementia.

In future research, a replication study needs to be conducted with a larger sample from diverse residential areas in size and characteristics. In addition, since the participants of this study did not include people with mild cognitive impairment among the high-risk groups for dementia presented by the Ministry of Health and Welfare, there is a need to investigate and identify factors influencing dementia preventive behaviors among older adults with mild cognitive impairment. Additionally, based on the results of this study, further research should be conducted for the development and validation of a nursing intervention program to promote dementia preventive behaviors in older adults at high risk for dementia through evaluation of the effectiveness of the intervention by its application.

NOTES

Conflict of interest

The authors declared no conflict of interest.

Funding

None.

Authors’ contributions

So Hee Jung contributed to conceptualization, data curation, formal analysis, methodology, project administration, writing - original draft, review & editing, and investigation. Mee Ock Gu contributed to conceptualization, methodology, writing - review & editing, supervision, and validation.

Data availability

Please contact the corresponding author for data availability.

Acknowledgments

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