Introduction

Alzheimer’s disease (AD) is a progressive neurodegenerative disorder that typically affects older adults, with incidence increasing exponentially over the age of 65 years. The cause of the disease is not fully understood yet. AD is considered the most common cause of dementia. It is characterized by inevitable deterioration affecting multiple cognitive domains like memory and performing day-today tasks. There is no definite cure for AD, and it inevitably progresses in all patients.¹

A systematic literature review conducted by El- Metwally et al. examined the epidemiology of dementia in six Arab countries. It showed that dementia is prevalent in Arab countries, reaching up to 2.3% among people aged 50+ and up to 18.5% among those aged 80+ years.² Globally, dementia is estimated to affect 47 million individuals.³ Similarly, age was the most significant risk factor for AD globally, where risk doubles every 10 years after the age of 60.^{4, 5}

With the increasing number of cases worldwide, it is essential to understand and estimate the burden of dementia. The global number of cases of dementia from 1990 to 2016 has become more than two times higher.⁶ It is anticipated that dementia will cause an increasing challenge to the healthcare systems globally.6 As of 2020, AD is considered the fifth leading cause of death in those aged above 65 years and is a leading cause of disability and poor health.⁷

In that regard, knowledge of AD in the general population is fundamental. Studies conducted in the Kingdom of Saudi Arabia (KSA) in regions like Mecca and Aseer concluded that knowledge was deficient, particularly regarding symptoms, risk factors, and life impacts.^8,9 Another study by Jernigan et al. in the United States showed moderate knowledge levels.¹⁰ In addition, a systematic review involving 40 articles concluded that most studies showed a fair to moderate level of knowledge of AD among the public.¹¹ Such gaps in knowledge are troubling, and thus, community-based awareness programs should be encouraged.

As of 2019, data reveals that 2.52% of the Bahraini population is above 65 years of age.¹² Hence, being the first of its kind in Bahrain, this study will explore the essential gaps in disease knowledge concerning AD.

Research Question

What is the knowledge level of AD among adults attending primary healthcare centers in the Kingdom of Bahrain?

Aim

To identify knowledge gaps about AD to improve the care and outcome of patients with the disease.

Objectives

• To determine the knowledge level about AD among adults attending primary care regarding risk factors, assessment, diagnosis, symptoms, disease course, and caregiving.
• To test the association between demographic factors and AD knowledge scores.

Methods

This cross-sectional study was performed in primary healthcare centers in the Kingdom of Bahrain. The target population is adults aged 18, both males and females, who understand the Arabic or English language. Illiterate individuals, those who visited the health center due to an emergency, and patients diagnosed with AD are excluded from the study. The sample size was determined using a verified online calculator.¹³

Study Design

Cross-sectional study

Setting

Primary healthcare centers in the Kingdom of Bahrain.

Study Population

Adults aged 18 and above attending primary healthcare centers in the Kingdom of Bahrain.

Sample size

AD prevalence and knowledge in Bahrain are unknown. An online sample size calculator was used, assuming the prevalence was 50%, with a confidence interval of 95% and a significance level of 5%.¹³ The recommended sample size was 383 persons.

Criteria for Inclusion and Exclusion

The inclusion criteria included Arabic or Englishspeaking adults aged above 18 years of both genders.

The exclusion criteria included patients diagnosed with AD, those who are illiterate, and any patient who came for an emergency case.

Data Collection Instrument and Variables

Our study used two self-administered tools in both Arabic and English languages.^9,14 Appendices 3 & 4 The first is an adapted questionnaire from Alhazzani et al. to assess the attitude and awareness of AD in the population.⁹ It comprises a set of 10 questions or statements to which the participant will either “agree” or “disagree”. The second is a validated questionnaire named the Alzheimer’s Disease Knowledge Scale (ADKS) with a Cronbach’s alpha = 0.71.15. Permission was granted from the original author, who developed the scale via e-mail.¹⁵

The ADKS measures AD knowledge according to seven main domains:

1. Risk factors (6 items)
2. Life impact (3 items)
3. Assessment and diagnosis (4 items)
4. Course (4 items)
5. Caregiving (5 items)
6. Treatments (4 items)
7. Symptoms (4 items)

The scale comprises 30 true or false items; the score is based on the number of items answered correctly, giving a total score of 0-30. There are no cut points for what would indicate “good” or “adequate” knowledge since that would vary from person to person and group to group. The original validation article compared the means and standard deviations for different groups (e.g., older adults without dementia, dementia caregivers, and dementia professionals).¹⁵ Moreover, because of the true/false format, a score of 15 could be expected to occur by chance alone, so scores should be substantially above 15 to indicate some degree of knowledge. Participants took around 7-20 minutes to complete the questionnaire.

Method of Scoring

We decided to document the ADKS scores as a percentage for easier comparison. A score of 1 was assigned to correct answers, and a score of 0 was assigned to incorrect answers. Then, the mean scores for overall knowledge and subscales were calculated according to the following formula:

Mean score = (Sum of scores/ Number of items) x 100

Sampling Technique and Data Collection Procedure

By convenience sampling method, we selected our population from Bahrain›s biggest five governmental health centers that cover the greatest catchment area based on Ministry of Health statistics. We chose one health center from each health region conveniently.

The selected health centers (HC) were Yousif Abdulrahman Engineer HC, Mohammed Jassim Kanoo HC, Hidd BBK HC, Shaikh Jaber HC, and Hamad Kanoo HC. As the questionnaires were already used with satisfactory results by Alhazzani et al. in a similar population in KSA, a pilot study was not conducted.⁹

Our sample was recruited from the reception area by convenience sampling. Once participants agreed to participate and their consent was obtained, the questionnaire was given to them to complete online by scanning a QR code.

Data Management and Analysis Plan

• The questionnaire was given online, and the respondents were unable to complete the survey without filling in all the required fields. Hence, there were no missing values in the analysis.
• A database was created in the statistical software “SPSS” with all the variables in the study labeled.
• Data were entered in the statistical program “SPSS”.
• Frequency checks were done to overview the data and ensure no data was missing or entered wrongly.
• Descriptive analysis was carried out to report frequencies and percentages of the variables in the study.
• T-test analysis was conducted to compare knowledge scores among males and females. 
• Correlation was used to compare knowledge scores among age as a continuous variable.

Ethical Considerations

• The tool used in the study, “Alzheimer’s Disease Knowledge Scale,” was a validated tool published online with permission to be used by any researcher.¹⁵ 
• Informed and written consent were taken from participants before distributing the questionnaire (Appendices 1 & 2).
• No intrusive questions were asked, and all information shared by the participants was kept confidential.
• Ethical approval was obtained from the research committee in the Ministry of Health in the Kingdom of Bahrain to conduct the study in the primary healthcare setting.

Results

Sample and Demographic Characteristics of Participants

A total of 620 completed the interview. Table 1 shows the respondents’ characteristics. Most of the participants were females (55.6%). Middle-aged adults (25-39 years) were the prevalent responders (52.9%). The vast majority were Bahrainis (88.9%). More than half (55.2%) had at least a bachelor’s degree. The majority of the participants (86.8%) had no family history of a relative with AD.

Respondents’ Attitude and Awareness of AD

Almost seventy percent (71.5%) of the respondents believe that it is necessary to resort to the court to save patients’ rights. Most respondents (63.4%) also believe that change in planning matters of everyday life and inability to balance finances is expected in the elderly and not related to a disease. Over half of the respondents (55.2%) said that forgetfulness and repeating stories are expected in the elderly and do not require medical attention. Only a minority of respondents (26.8%) believed that AD is a result of witchcraft or psychological stressors. Additionally, a small percentage of respondents would feel ashamed if they had a family member diagnosed with AD (11.1%) and would deny the diagnosis (11.6%) (Table 2).

Respondents’ Knowledge of AD

Among the 620 participants, 431 scored greater than 15 out of 30 (69.5%) (Table 3).

The mean respondents’ overall knowledge score about Alzheimer’s disease was 57.6 (equivalent to 17.28 out of 30), with a standard deviation of 11.8. The highest scores were in the “Assessment and diagnosis” and “Life impact” domains, with a mean of 72.9 (SD 24.5) and 67.2 (SD 28.3) respectively. The lowest scores were observed in the “Caregiving” and “Risk factors” domains, with a mean of 52.0 (SD 21) and 47.2 (SD 21) respectively (Table 4). Appendix 5 provides a more thorough breakdown of respondents’ scores for each domain.

Difference in Respondents’ Mean Score Knowledge According to Sociodemographic Characteristics

The overall knowledge mean score revealed that females (58.4) did significantly better than males (56.4) (t-tests, and p-value 0.037). Females also scored higher in life impact and treatment domains (t-tests, p-value <0.01 for both). In most domains, there was a significant difference in AD knowledge between different age groups, with the age group 25-39 years being knowledgeable in the overall score (ANOVA test, p-value < 0.01). There was no significant difference in knowledge scores based on their nationality (t-tests, p-value > 0.05). Education levels did show a significant difference in AD knowledge in almost all domains, with higher overall knowledge elicited in individuals with a bachelor’s degree or higher (ANOVA test, p-value < 0.01). People who have a family member with Alzheimer’s disease were found to be more knowledgeable in comparison to those who did not have a family member with the disease (t-tests, p-value < 0.01) (Table 5).

Discussion

The majority of the respondents (69.5%) scored more than 15 out of 30, which was satisfactory in comparison to other studies conducted in KSA and Alaska (49.9% and 86%, respectively).^{9, 10} This could be due to cultural beliefs and practices where individuals in Bahrain and the Gulf region play a role in caregiving and usually live with their extended family members, hence, allowing more exposure to patients with AD.

This study involved 620 participants and was conducted primarily to explore the knowledge of AD among the public in the Kingdom of Bahrain.

In our study, sex, age, level of education, and having a family member with AD were significantly associated with the knowledge level regarding AD.

In general, females were more knowledgeable about AD in our study. This was similar to previous studies done in the Gulf region and Europe.^{9, 16} When considering the subscale of sex; our results showed that females were specifically more knowledgeable in the domains of life impact and treatment of the disease. Gulf region mores gave females the leading role in family caregiving, possibly justifying the significance.

The present study revealed that participants with an AD family member had significantly better overall knowledge of the disease, which is also supported by Garcia-Ribas et al.¹⁶ Exposure to any disease through a close relative is a motivation itself to explore different aspects of the disease, which would rationalize the significance.

Our study elicited that adults aged 25-39 years were more knowledgeable in the overall mean score compared to other age groups. This result was evident in studies done in different parts of the world.^{9, 16, 17} These findings could be due to ease of access to the World Wide Web and increased exposure to healthcare information.

The level of education had a positive correlation with the knowledge scale; participants with higher degrees had greater overall knowledge scores. Our results were also similar to those published by Carpenter et al., the developer of the ADKS. Possibly, this can be explained by the fact that individuals with higher education are more enthusiastic about learning about their daily life experiences.¹⁸

Our population scored higher in the assessment subscale (mean of 72.9 of 100), followed by life impact, treatment, and course of the disease; while the lowest recognized subscales were care giving and risk factors. This finding was similar to a study conducted in KSA where assessment (75%) was also the highest subscale known.⁸ Another study conducted in Aseer, a different region in KSA, also reported assessment as the second-highest identified subscale.⁹ Additionally, both risk factors and caregiving were regarded as the least known subscales. This might be due to the similarities in sociodemographic characteristics of the participants in the Arabian Gulf region.

Limitations

This study was the first of its kind in the Kingdom of Bahrain. However, some significant limitations should be remarked on. The study involved a convenient sampling of participants attending primary care, which imposed a limitation when generalizing the findings. Due to this sampling method, there was also selection bias, as participants who completed the questionnaire might have been more knowledgeable.

Furthermore, the tool used in the study consisted of True-and-False questions, which gave a 50% probability of answering the question correctly by chance. Also, there was no minimum cut-off score to determine the adequate level of AD knowledge. In addition, the measure of internal consistency was 0.4 using the Cronbach’s alpha scale.

Conclusion and Recommendations

In conclusion, the results of our study identified gaps in knowledge about AD. These findings illustrate the need for health education campaigns through local and social media platforms. The health promotion acts should be tailored considering the different age groups and education levels in the Kingdom of Bahrain. Campaigns will raise public awareness about the symptoms and progression of AD. Consequently, relatives will be encouraged to accompany family members with suspected AD to a medical evaluation. This will enable AD patients to be detected and treated earlier. As a result, we will be able to provide better care and outcomes to our patients.

Conflicts of Interests

The authors declared no conflict of interest.