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Mental health
Original research
Linking knowledge with attitude: a cross-sectional study of public knowledge and attitude towards sleep disturbances and dementia
  1. Yong-Bo Zheng1,2,
  2. Le Shi1,
  3. Jian-Yu Que1,
  4. Jia-Hui Deng1,
  5. Qian-Wen Wang1,
  6. Si-Zhen Su1,
  7. Zheng-An Lu1,
  8. Yan-Ping Bao3,
  9. Jie Shi3,
  10. Lin Lu1,2,3
  1. 1Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
  2. 2Peking-Tsinghua Center for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China
  3. 3National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, China
  1. Correspondence to Dr Le Shi; leshi{at}bjmu.edu.cn; Dr Lin Lu; linlu{at}bjmu.edu.cn

Abstract

Objectives Sleep disturbances increase the risk of dementia; however, there is insufficient information regarding this. We aimed to investigate public knowledge on the relationship between sleep disturbances and dementia, as well as attitudes towards improving sleep quality and obtaining knowledge on dementia.

Design and setting A cross-sectional web-based questionnaire was administered between May and October 2019.

Participants All participants provided informed consent and were able to respond to the survey.

Primary outcomes Factors associated with the knowledge that sleep disturbances are risk factors for dementia and proportions of individuals with this knowledge; attitudes towards improving sleep quality and obtaining knowledge about dementia.

Results Of the 3329 eligible samples, 72.57% correctly recognised that sleep disturbances increased the risk of dementia. In total, 92.97% of participants were willing to take at least one measure to improve sleep quality, and the percentages of those adopting these measures are as follows: 78.73% would lead a regular life, 67.88% would engage in strengthening exercise, 28.84% would undergo psychotherapy and 19.41% would take medication. The awareness regarding sleep disturbances increasing the risk of dementia was the only factor associated with the willingness to improve sleep quality in all four categories of measures. Almost all participants (95.25%) were willing to take at least one measure to acquire knowledge about dementia, with the following participants displaying higher willingness to obtain knowledge about dementia: female, had contact with dementia and considered sleep disturbances to increase the risk of dementia.

Conclusions Our findings indicate an association between people’s knowledge and attitudes, suggesting the importance of disseminating knowledge about sleep disturbances and dementia to achieve dementia prevention in future.

  • Dementia
  • SLEEP MEDICINE
  • PUBLIC HEALTH

Data availability statement

Data are available on reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2022-067055

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • In this cross-sectional study, nearly three-fourths of the participants correctly recognised sleep disturbance as a risk factor for dementia.

    • Almost all participants were willing to take at least one measure to improve sleep quality and obtain knowledge about dementia.

    • The knowledge that sleep disturbances increase the risk of dementia was the only factor associated with the willingness to improve sleep quality in all four categories of measures, indicating the necessity of disseminating knowledge about sleep disturbances and dementia.

    • Limitations include online surveys, self-designed questionnaires, self-reported sleep disturbances and mental health problems.

    Introduction

    Sleep disturbance is a common and significant health problem. The prevalence of sleep disturbances varies with age, with sleep apnoea, insomnia and restless legs syndrome being the most common.1–3 Sleep disturbances largely affect the endocrine, immune and cardiovascular systems and increase the risk of obesity,4 diabetes,4–6 cardiovascular diseases5 7 8 and cancer.9 A growing body of evidence implies that disturbed sleep contributes to impairments in cognitive performance, including mild cognitive impairment and dementia.10–12 Medicines for sleep disturbances are related to adverse effects, such as cognitive impairment and possibly dementia,13 14 although the causal association between benzodiazepine use and dementia remains controversial.15 Thus, preventing sleep disturbance could prevent or delay the progression of dementia.16

    Sleep disturbance is a risk factor for dementia, but its dissemination and recognition among the general public remains unclear. Attitudes predict behaviour,17 and attitude towards improving sleep disturbances and obtaining knowledge may guide and shape people’s behaviour for regulating sleep disturbances and reducing the risk of dementia. Consequently, it is important to prompt the general public’s attitude towards improving sleep quality and obtaining knowledge about dementia. However, to the best of our knowledge, no existing studies have investigated people’s knowledge and their attitudes towards sleep disturbances and dementia.

    We aimed to investigate factors associated with the knowledge that sleep disturbances are risk factors for dementia and dissemination of this knowledge among the general public. Moreover, we intended to explore the factors associated with public attitudes towards improving sleep quality and obtaining knowledge about dementia.

    Materials and methods

    Study design and participants

    This cross-sectional, web-based study was conducted between 27 May 2019 and 6 October 2019. A self-designed survey was disseminated through WeChat, a social media outlet that is widely used in China. Participation in the study was voluntary, and the information collected was anonymous. All the participants met the following criteria: (1) WeChat users; (2) voluntary to participate in the survey and (3) provided informed consent. The detailed survey process was introduced in our previous paper.18 In total, 3436 participants submitted the questionnaire, and 3329 questionnaires with full available data were analysed. The whole process followed Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

    Questionnaire content

    The questionnaire was written in Chinese and the items used in this study could be briefly categorised as follows: (1) basic sociodemographic information, including sex, age, education levels, type of job, income, type of residence and whether the respondent had contact with anyone who lived with dementia; (2) sleep-related factors, such as shift work, sleep duration in the past 1 month, self-reported sleep quality in the past 1 month and self-reported diagnosis of sleep disturbances, neurological or psychiatric disorders; (3) knowledge about sleep disturbances and risk of dementia, investigated using the question ‘Do you think poor sleep will increase the risk of dementia?’ and perception of sleep medicine and risk of dementia, investigated using the question, ‘Do you think taking sleeping pills will increase the risk of dementia?’; (4) attitudes towards improving sleep quality in case of sleep disturbances, with a multiple-choice question ‘If you have sleep disturbances, what kind of methods would you use to improve your sleep quality?’ The questions had the following response options: regular lifestyle/strengthening exercise/psychotherapy/medication/others (please fill in)/not willing; and willingness to take a drug to improve sleep quality and reduce the risk of/or prevent dementia and (5) attitudes towards obtaining knowledge about dementia, with the following multiple-choice question ‘How do you obtain knowledge about dementia?’ The questions had the following response options: television and internet (eg, WeChat, Weibo, online video)/books, magazines or newspaper/lecture on medication, or doctor consultation service/others (please fill in)/unwillingness. Detailed information is listed in Online supplemental Data of a previous study (https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09665-7).

    Statistical analysis

    Descriptive statistics were used to present demographic data. The proportion of participants with the knowledge that sleep disturbances increase the risk of dementia was calculated and reported as the percentage of cases in different sociodemographic populations. χ2 tests were used to compare the differences between groups. To explore factors potentially associated with the knowledge that sleep disturbances increase the risk of dementia, multiple logistic regression analyses were performed, and adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were presented. Like the aforementioned statistical analysis, factors associated with participants’ attitudes towards ameliorating sleep disturbances, willingness to take medicines to improve sleep quality and dementia, and knowledge about dementia were explored using multiple logistic regression analyses, with AORs and 95% CIs presented. Two-sided Wald tests were performed to determine whether the ORs in the regression models were statistically significant. The level of significance was set at p<0.05. All statistical analyses were performed using SPSS statistical software V.22 (IBM Corp).

    Patient and public involvement statement

    Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    Results

    Characteristics of participants

    Table 1 presents participants’ characteristics. Data from 3329 eligible samples were included in the final analysis, with a participation rate of 96.89% (3329 of 3426 participants). The average age was 39.23±12.50 years, ranging from 15 to 97 years. Regarding sleep-related characteristics, the majority of the participants had no shift work (77.38%), 6–8 hours of sleep per night in the past month (64.73%), self-reported very good or good sleep quality in the past month (61.79%), and no diagnosis of sleep disturbances or neurological or psychiatric disorders (74.62%).

    View this table:
    Table 1

    Proportions of participants recognising that sleep disturbances increase the risk of dementia stratified by demographic and sleep-related characteristics

    In total, 72.57%. of participants correctly recognised sleep disturbances as risk factors for dementia. The proportions of participants who recognised that sleep disturbances increase the risk of dementia stratified by demographic and sleep-related characteristics were significant as follows: sex, age, education levels, type of job, income levels, type of residence, contact with dementia, shift work and sleep duration.

    Factors associated with the knowledge that sleep disturbances increased the risk of dementia

    Table 2 presents the factors associated with knowledge that sleep disturbances increase the risk of dementia. In the multivariate analysis, female sex, less than 40 years of age, high educational levels, non-manual job and contact with dementia were associated with more likelihood of recognising that sleep disturbances are risk factors of dementia; participants with different residences or income levels had no significant differences in understanding sleep disturbances as a risk factor for dementia.

    View this table:
    Table 2

    Factors associated with the knowledge that sleep disturbances increase the risk of dementia

    Participants who did not perform shift work (AOR 0.57, 95% CI 0.46 to 0.71) were less aware that sleep disturbances increased the risk of dementia compared with those who performed shift work. Compared with individuals with average sleep duration (6–8 hours), participants with longer sleep duration (>8 hours: AOR 0.71, 95% CI 0.51 to 0.99) exhibited worse understanding of the relationship between sleep disturbances and dementia, while short sleepers (<6 hours) had a better understanding of this relationship. Additionally, respondents without self-reported diagnosis of sleep disturbances or neurological or psychiatric disorders (AOR 0.76, 95% CI 0.62 to 0.92) demonstrated less understanding of sleep disturbances with the risk of dementia. Sleep quality did not significantly affect the understanding of sleep disturbances with the risk of dementia.

    Proportion and factors associated with participants willing to take measures to improve sleep quality

    Almost all participants (92.97%) were willing to take at least one measure to improve sleep quality if they were diagnosed with sleep disturbances, whereas 1.74% and 5.30% of participants showed a negative attitude towards improving sleep quality if they were diagnosed with sleep disturbances. The participants’ measures to improve sleep quality were as follows: 78.73% would lead a regular life, 67.88% would engage in strengthening exercises, 28.84% would undergo psychotherapy and 19.41% would take medication.

    Factors associated with participants’ willingness to take measures to improve sleep quality were further explored and presented in table 3. A strong association was found between knowledge that sleep disturbances increase the risk of dementia and willingness to improve sleep quality (AOR 0.22, 95% CI 0.13 to 0.38). Compared with participants who believed that sleep disturbances increased the risk of dementia, those who did not regard sleep disturbances to increase the risk of dementia or who remained uncertain displayed less willingness regarding all four measures, including adopting a regular lifestyle (AOR 0.52, 95% CI 0.36 to 0.73, vs AOR 0.79, 95% CI 0.63 to 0.99), performing strengthening exercise (AOR 0.45, 95% CI 0.33 to 0.63, vs AOR 0.77, 95% CI 0.63 to 0.94), going for psychotherapy (AOR 0.57, 95% CI 0.37 to 0.86, vs AOR 0.75, 95% CI 0.60 to 0.94) and taking medication (AOR 0.53, 95% CI 0.34 to 0.83, vs AOR 0.70, 95% CI 0.54 to 0.89) to improve sleep quality. Additionally, individuals who did not consider sleep medicine to increase the risk of dementia displayed a lower willingness to improve sleep quality than those who regarded sleep medicine as a risk factor for dementia (AOR 0.56, 95% CI 0.32 to 0.98). Other demographic or sleep-related factors were not significantly associated with participants’ willingness to ameliorate sleep disturbances in all four measures.

    View this table:
    Table 3

    Factors associated with participants’ attitudes for taking measures to improve sleep disturbances

    Factors associated with the participants’ willingness to take medicines that could improve sleep quality and reduce the risk of dementia were also explored. Participants who did not regard sleep medicine to increase the risk of dementia demonstrated at least twice the willingness to take medicines that simultaneously relieved sleep disturbances and dementia (AOR 2.23, 95% CI 1.67 to 3.00). The detailed results of the multivariate analysis are shown in online supplemental table 1.

    Proportions and factors associated with participants who were willing to take measures to obtain knowledge about dementia

    Almost all participants (95.25%) were willing to take at least one measure to increase their knowledge on dementia, while very few (4.75%) were unwilling to learn about dementia. The percentages of participants who were willing to undertake measures to obtain knowledge about dementia were as follows: 80.35% through television and the internet, 59.14% through books, magazines or newspapers, and 52.81% through lectures on medication or doctor consultation services.

    The factors associated with participants’ willingness to take measures to obtain knowledge about dementia are presented in table 4. Female participants had contact with dementia and displayed a higher willingness to obtain knowledge about dementia in all categories of measures. Compared with participants who considered sleep disturbances to increase the risk of dementia, participants who did not consider this exhibited less willingness to obtain knowledge about dementia through television and the internet (AOR 0.44, 95% CI 0.31 to 0.62), as well as books, magazines or newspapers (AOR 0.71, 95% CI 0.51 to 0.98). Participants who were not clear about the relationship between sleep disturbances and the risk of dementia were less willing to obtain knowledge about dementia on television and the internet (AOR 0.68, 95% CI 0.54 to 0.85), as well as lectures on medication or doctor consultation services (AOR 0.70, 95% CI 0.58 to 0.84). Participants’ willingness to take measures to obtain knowledge about dementia was not influenced by their perception of sleep medicines and the risk of dementia.

    View this table:
    Table 4

    Factors associated with the willingness of participants to obtain knowledge about dementia

    Discussion

    Overall, approximately three-fourths of the general population recognises sleep disturbances as risk factors for dementia. Almost all participants had a positive attitude towards improving sleep quality and obtaining knowledge about dementia. The awareness regarding sleep disturbances increasing the risk of dementia was the only factor that could independently influence participants’ willingness to improve their sleep quality and obtain knowledge about dementia. Additionally, factors such as sleep quality and knowledge that sleep medicine and risk of dementia would largely affect participants’ desire to alleviate sleep disturbances; factors including sex and dementia contact would also influence attitudes towards all categories of measures of obtaining knowledge about dementia. The findings reveal the current status of public awareness of sleep disturbances and dementia and could aid population-targeted health education.

    Sleep disturbances are widely identified as risk factors for dementia10 11; however, it remains unclear whether they have been adequately disseminated and recognised by the general public. A meta-analysis suggested that most studies focused on factors such as mental health, physical activity, hypertension, smoking and air pollution to increase the risk of dementia.19 To the best of our knowledge, this study is the first to investigate public awareness of sleep disturbances and the risk of dementia. Currently, 72.57% of participants correctly recognise sleep disturbance as a risk factor for dementia; lesser proportion of participants consider alcohol or smoking as risk factors for dementia.18 Several sociodemographic characteristics, including female sex, young age, high education levels and contact with patients with dementia, were associated with a better understanding of sleep disturbance as a risk factor for dementia, which is partially consistent with previous surveys conducted in China.20 21 Additionally, sleep-related factors such as shift work, sleep duration and previous diagnosis of psychiatric disorders were independently associated with knowledge that sleep disturbances increase the risk of dementia. These findings suggest the need to develop different approaches for populations with different sleep-related statuses to disseminate knowledge about dementia.

    Almost all participants were willing to practice at least one measure to improve their sleep quality and to obtain knowledge about dementia. Among the four measures in the questionnaire, leading a regular life and performing strengthening exercises were chosen by most participants, while undergoing psychotherapy or medication was accepted by only a small portion of participants (29% and 19%, respectively). The general public had a high willingness to improve their sleep quality if they were diagnosed with sleep disturbances; however, medical refusal was also observed in the general public. The poor medication adherence could be because of concerns about side effects, high financial burden and inadequate health literacy.22 23 Therefore, more measures should be implemented to improve the public understanding of medical therapy.

    Several factors are associated with the willingness to improve sleep quality, comprising only the participants who knew that sleep disturbances increased the risk of dementia; they demonstrated a higher willingness to practice all measures to improve sleep quality and obtain knowledge about dementia. The results suggest that knowledge of sleep disturbance plays a vital role in people’s attitudes towards relieving sleep disturbances as well as obtaining knowledge about dementia, which is similar to findings that link knowledge with attitudes.24 Additionally, perception of sleep pills and risk of dementia also influence people’s attitudes towards improving sleep quality, especially taking medicines. Although the relationship between sleep medicines and the risk of dementia remains ambiguous, sleep medicines are advocated when individuals are diagnosed with sleep disturbances. The current findings suggest that more efforts are required to disseminate knowledge about dementia and the related risk factors.

    Participants with self-reported good sleep quality displayed more willingness to improve sleep quality when they faced sleep-related problems, which suggests that more information for improving sleep quality should be disseminated among participants with poor sleep quality. Additionally, female participants who had contact with dementia also showed better attitudes towards obtaining knowledge on dementia. Thus, different approaches are required for different epidemiological and sleep-stratified populations to promote their willingness to improve sleep quality and obtain knowledge on dementia.

    This study provided information regarding the public knowledge on sleep disturbances and the risk of dementia, attitudes towards improving sleep quality and willingness to obtain knowledge on dementia. There was an association between awareness that sleep disturbances increase the risk of dementia and positive attitudes towards improving sleep quality as well as obtaining knowledge about dementia; thus, disseminating dementia knowledge is required among the general public. This study had several limitations. First, this was an online survey, and we used a convenience sampling method. This online study was conducted among internet users who were young and highly educated; thus, the study sample may be limited. Second, the questionnaires were self-designed and not sufficiently validated. Third, sleep disturbances and mental disorders were based on the respondents’ self-reports rather than clinical diagnoses. Finally, additional information, such as types of sleep disturbances and occupations, was not included in this study.

    Conclusion

    We demonstrated that most people recognised sleep disturbance as a risk factor for dementia and exhibited a positive attitude towards improving sleep quality as well as obtaining knowledge about dementia. Moreover, our findings indicate an association between people’s knowledge and attitudes, suggesting the importance of disseminating knowledge about sleep disturbances and dementia to achieve dementia prevention in future.

    Data availability statement

    Data are available on reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by Peking University Sixth Hospital natural and computational science research and community service reviewers, and the approval number was 2020-4-9-1. Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    The authors thank all the study participants and data collectors for their willingness to participate in this study.

    References

    1. ↵
      1. Ram S,
      2. Seirawan H,
      3. Kumar SKS, et al
      . Prevalence and impact of sleep disorders and sleep habits in the United States. Sleep Breath 2010;14:63–70.doi:10.1007/s11325-009-0281-3pmid:http://www.ncbi.nlm.nih.gov/pubmed/19629554
      OpenUrlCrossRefPubMedWeb of Science
    2. ↵
      1. Heinzer R,
      2. Vat S,
      3. Marques-Vidal P, et al
      . Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med 2015;3:310–8.doi:10.1016/S2213-2600(15)00043-0pmid:http://www.ncbi.nlm.nih.gov/pubmed/25682233
      OpenUrlPubMed
    3. ↵
      1. Mazzotti DR,
      2. Guindalini C,
      3. Sosa AL, et al
      . Prevalence and correlates for sleep complaints in older adults in low and middle income countries: a 10/66 dementia research Group study. Sleep Med 2012;13:697–702.doi:10.1016/j.sleep.2012.02.009pmid:http://www.ncbi.nlm.nih.gov/pubmed/22503944
      OpenUrlCrossRefPubMed
    4. ↵
      1. Schmid SM,
      2. Hallschmid M,
      3. Schultes B
      . The metabolic burden of sleep loss. Lancet Diabetes Endocrinol 2015;3:52–62.doi:10.1016/S2213-8587(14)70012-9pmid:http://www.ncbi.nlm.nih.gov/pubmed/24731536
      OpenUrlPubMed
    5. ↵
      1. Itani O,
      2. Jike M,
      3. Watanabe N, et al
      . Short sleep duration and health outcomes: a systematic review, meta-analysis, and meta-regression. Sleep Med 2017;32:246–56.doi:10.1016/j.sleep.2016.08.006pmid:http://www.ncbi.nlm.nih.gov/pubmed/27743803
      OpenUrlCrossRefPubMed
    6. ↵
      1. Tan X,
      2. van Egmond L,
      3. Chapman CD, et al
      . Aiding sleep in type 2 diabetes: therapeutic considerations. Lancet Diabetes Endocrinol 2018;6:60–8.doi:10.1016/S2213-8587(17)30233-4pmid:http://www.ncbi.nlm.nih.gov/pubmed/28844889
      OpenUrlPubMed
    7. ↵
      1. Parati G,
      2. Lombardi C,
      3. Castagna F, et al
      . Heart failure and sleep disorders. Nat Rev Cardiol 2016;13:389–403.doi:10.1038/nrcardio.2016.71pmid:http://www.ncbi.nlm.nih.gov/pubmed/27173772
      OpenUrlPubMed
    8. ↵
      1. Tobaldini E,
      2. Fiorelli EM,
      3. Solbiati M, et al
      . Short sleep duration and cardiometabolic risk: from pathophysiology to clinical evidence. Nat Rev Cardiol 2019;16:213–24.doi:10.1038/s41569-018-0109-6pmid:http://www.ncbi.nlm.nih.gov/pubmed/30410106
      OpenUrlCrossRefPubMed
    9. ↵
      1. Travis RC,
      2. Balkwill A,
      3. Fensom GK, et al
      . Night shift work and breast cancer incidence: three prospective studies and meta-analysis of published studies. J Natl Cancer Inst 2016;108. doi:doi:10.1093/jnci/djw169. [Epub ahead of print: 06 10 2016].pmid:http://www.ncbi.nlm.nih.gov/pubmed/27758828
    10. ↵
      1. Shi L,
      2. Chen S-J,
      3. Ma M-Y, et al
      . Sleep disturbances increase the risk of dementia: a systematic review and meta-analysis. Sleep Med Rev 2018;40:4–16.doi:10.1016/j.smrv.2017.06.010pmid:http://www.ncbi.nlm.nih.gov/pubmed/28890168
      OpenUrlCrossRefPubMed
    11. ↵
      1. Xu W,
      2. Tan C-C,
      3. Zou J-J, et al
      . Sleep problems and risk of all-cause cognitive decline or dementia: an updated systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2020;91:236–44.doi:10.1136/jnnp-2019-321896pmid:http://www.ncbi.nlm.nih.gov/pubmed/31879285
      OpenUrlAbstract/FREE Full Text
    12. ↵
      1. Irwin MR,
      2. Vitiello MV
      . Implications of sleep disturbance and inflammation for Alzheimer's disease dementia. Lancet Neurol 2019;18:296–306.doi:10.1016/S1474-4422(18)30450-2pmid:http://www.ncbi.nlm.nih.gov/pubmed/30661858
      OpenUrlPubMed
    13. ↵
      1. Ohara T,
      2. Honda T,
      3. Hata J, et al
      . Association between daily sleep duration and risk of dementia and mortality in a Japanese community. J Am Geriatr Soc 2018;66:1911–8.doi:10.1111/jgs.15446pmid:http://www.ncbi.nlm.nih.gov/pubmed/29873398
      OpenUrlCrossRefPubMed
    14. ↵
      1. Bronskill SE,
      2. Campitelli MA,
      3. Iaboni A, et al
      . Low-Dose trazodone, benzodiazepines, and fall-related injuries in nursing homes: a matched-cohort study. J Am Geriatr Soc 2018;66:1963–71.doi:10.1111/jgs.15519pmid:http://www.ncbi.nlm.nih.gov/pubmed/30247773
      OpenUrlCrossRefPubMed
    15. ↵
      1. Gray SL,
      2. Dublin S,
      3. Yu O, et al
      . Benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study. BMJ 2016;352:i90.doi:10.1136/bmj.i90pmid:http://www.ncbi.nlm.nih.gov/pubmed/26837813
      OpenUrlAbstract/FREE Full Text
    16. ↵
      1. Livingston G,
      2. Huntley J,
      3. Sommerlad A, et al
      . Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet 2020;396:413–46.doi:10.1016/S0140-6736(20)30367-6pmid:http://www.ncbi.nlm.nih.gov/pubmed/32738937
      OpenUrlCrossRefPubMed
    17. ↵
      1. Glasman LR,
      2. Albarracín D
      . Forming attitudes that predict future behavior: a meta-analysis of the attitude-behavior relation. Psychol Bull 2006;132:778–822.doi:10.1037/0033-2909.132.5.778pmid:http://www.ncbi.nlm.nih.gov/pubmed/16910754
      OpenUrlCrossRefPubMedWeb of Science
    18. ↵
      1. Zheng Y-B,
      2. Shi L,
      3. Gong Y-M, et al
      . Public awareness and knowledge of factors associated with dementia in China. BMC Public Health 2020;20:1567.doi:10.1186/s12889-020-09665-7pmid:http://www.ncbi.nlm.nih.gov/pubmed/33069235
      OpenUrlPubMed
    19. ↵
      1. Cations M,
      2. Radisic G,
      3. Crotty M, et al
      . What does the general public understand about prevention and treatment of dementia? A systematic review of population-based surveys. PLoS One 2018;13:e0196085.doi:10.1371/journal.pone.0196085pmid:http://www.ncbi.nlm.nih.gov/pubmed/29672559
      OpenUrlPubMed
    20. ↵
      1. Wang Y,
      2. Xiao LD,
      3. Luo Y, et al
      . Community health professionals' dementia knowledge, attitudes and care approach: a cross-sectional survey in Changsha, China. BMC Geriatr 2018;18:122.doi:10.1186/s12877-018-0821-4pmid:http://www.ncbi.nlm.nih.gov/pubmed/29801476
      OpenUrlPubMed
    21. ↵
      1. Yang H-F,
      2. Cong J-Y,
      3. Zang X-Y, et al
      . A study on knowledge, attitudes and health behaviours regarding Alzheimer's disease among community residents in Tianjin, China. J Psychiatr Ment Health Nurs 2015;22:706–14.doi:10.1111/jpm.12259pmid:http://www.ncbi.nlm.nih.gov/pubmed/26282709
      OpenUrlPubMed
    22. ↵
      1. Brown MT,
      2. Bussell JK
      . Medication adherence: who cares? Mayo Clin Proc 2011;86:304–14.doi:10.4065/mcp.2010.0575pmid:http://www.ncbi.nlm.nih.gov/pubmed/21389250
      OpenUrlCrossRefPubMedWeb of Science
    23. ↵
      1. Follath F
      . Ethical considerations in cardiovascular prevention. Fundam Clin Pharmacol 2009;23:669–73.doi:10.1111/j.1472-8206.2009.00695.xpmid:http://www.ncbi.nlm.nih.gov/pubmed/19500153
      OpenUrlCrossRefPubMed
    24. ↵
      1. Kuzminski R,
      2. Netto J,
      3. Wilson J, et al
      . Linking knowledge and attitudes: determining neurotypical knowledge about and attitudes towards autism. PLoS One 2019;14:e0220197.doi:10.1371/journal.pone.0220197pmid:http://www.ncbi.nlm.nih.gov/pubmed/31344074
      OpenUrlPubMed

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Y-BZ and LS are joint first authors.

    • Contributors Y-BZ and LS developed the proposal and designed the protocol, J-YQ and LL were involved in revising the proposal and design. Y-BZ, LS, J-HD, Q-WW, S-ZS and Z-AL were involved in data collection, and analysis. Y-BZ and LS drafted the manuscript. LS, Y-PB JS and LL revised the analysis and helped in the preparation of the manuscript. All the authors have read and approved the final version of the manuscript. LS and LL are the study guarantors.

    • Funding This work was supported by National Key Research and Development Programme of China (no. 2020YFC2003600), Young Elite Scientists Sponsorship Programme by CAST (no. 2019QNRC001) and Natural Science Foundation of China (no. 31900805). The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

    • Disclaimer The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.