1. Background
Dementia is a major public health concern affecting around 55 million people worldwide [
1]. This number is expected to rise to 152 million by 2050 [
2]. In Israel, dementia was the third leading cause of death among the elderly in 2019 [
3], and its prevalence is projected to rise to 290,000 cases in 2030 [
4]. In Israel, due to a high (97%) prevalence of people aged 65 and over living in the community, the impact of dementia on health and the development of health services for dementia prevention is broadly emphasized [
5]. Dementia, recognised as a syndrome, primarily affects older adults, but is not only limited to this population [
1]. It is highly prevalent in women [
2], and higher in Black and Asian ethnic minority groups [
6,
7]. Dementia is considered to be one of the risk factors for morbidity, the seventh cause of all-cause mortality, and the fourth cause of death among people 70 years of age and older globally [
8].
Given the growth of the world’s ageing population and the economic, health, and societal burden of dementia, early prevention of risk of dementia is highly prevalent in health research [
2]. According to specialists, the assessment of dementia should incorporate multi-domain measures combining non-modifiable (age, genetics) and modifiable factors (socio-demographic, health, and lifestyle) [
9]. Modifiable risk factors accounted for up to 48% of the risk of dementia onset [
10], resulting in considerable research efforts on health and lifestyle changes that can reduce this risk. These risk factors, include alcohol consumption, obesity, hearing loss, traumatic brain injury, and hypertension [
11]. Other modifiable risk factors include social isolation, diabetes, and physical inactivity [
10]. On the contrary, beneficial lifestyle changes can reduce the risk of dementia, including regular exercise, an optimal diet, stimulating cognitive activity, and moderate alcohol consumption [
10].
The original version of the Motivation to Change Lifestyle and Health Behaviours for Dementia Risk Reduction (MCLHB-DRR) questionnaire was developed by Kim et al. [
12] in Australia. This questionnaire includes 27 items across seven subscales reflecting the seven concepts of the health belief model (HBM) [
13], and measures attitudes and beliefs related to health behaviours and lifestyle changes for dementia risk reduction. It was shown to be reliable and valid for adults aged 50+ years among the Australian population (the Cronbach’s alpha ranges from 0.608 to 0.864) [
12], for adults between 30 and 80 years old among the Dutch population (the Cronbach’s alpha ranges from 0.69 to 0.93) [
14], and for people aged 40+ years among the Turkish population (the Cronbach’s alpha ranges from 0.682 to 0.847) [
15].
Understanding the importance of prevention and reduction of dementia in at-risk populations has led to a variety of multi-centre lifestyle interventions. The scale’s effectiveness in addressing dementia was shown in the Finnish Geriatric Intervention Study (FINGER) [
16], the Healthy Ageing Through Internet Counselling in the Elderly (HATICE) trial [
17], the Multidomain Alzheimer Preventive Trial (MAPT) [
18], and the Prevention of Dementia by Intensive Vascular Care (PreDIVA) trial [
19]. Findings from these studies showed that multidomain interventions that include a combination of healthy lifestyle factors, such as physical activity, cognitive training, a healthy diet or nutritional advice, social stimulation, or internet counselling, may contribute to cognitive performance in at-risk older adults [
16,
17,
19]. In addition, future studies should investigate the potential associations between vascular factors (e.g., hypertension, obesity, hypercholesterolemia, etc.), cognitive perceptions, and participation in multidomain interventions [
16,
17,
19]. Social cognitive theories and models suggest that health behaviour is a stage-based, complex cognitive process that involves attitudes and beliefs about behaviour change, such as an individual’s current stage of change, reinforcement management, and perceived benefits and barriers [
5]. To the best of our knowledge, there is no tool that measures attitudes and beliefs related to health behaviours and lifestyle changes for dementia risk reduction in the Israeli population. Nevertheless the MCLHB-DRR [
12] questionnaire can contribute to the development of future health interventions and community programmes for dementia prevention in society. This study sought to translate and validate the MCLHB-DRR questionnaire among the general Israeli population, and to explore the factors affecting attitudes and health beliefs concerning behavioural and lifestyle changes for the risk of dementia reduction in middle-aged and older adults.
4. Discussion
The aim of this study was to translate and validate the MCLHB-DRR questionnaire among the general Israeli population. EFA showed that the seven-factor model, reflecting seven subscales of the MCLHB-DRR, had one cross-loaded item that was deleted (Item 15). Almost all items were loaded on their intended subscales with factor loadings of above 0.3. Two items (Items 6 and 8) were deleted due to low factor loadings and low correlations. The conducted CFA showed that a 24-item model (without Items 6, 8 and 15) was a better fit for the data than the 27-item model (χ
2/df = 2.146, CFI = 0.930, TLI = 0.916, RMSEA = 0.049). The value of χ
2/df = 2.146 was higher than that among the Dutch general population (χ
2/df = 2.130), the value of CFI = 0.930 was higher compared to that among the Australian population (CFI = 0.920), the RMSEA value of 0.049 was slightly above that indicated by (RMSEA = 0.047). The internal consistency reliability for subscales of the MCLHB-DRR questionnaire ranged from Cronbach’s alpha values of 0.610 to 0.920 (moderate to high). Out of the total three excluded items, two items were from the perceived severity subscale. These emotionally driven items are related to fear, which, according to previous research, tends to be higher among females, people with higher education, and poor self-rated health [
34]. Consequently, in this study lower Cronbach’s alpha values can be attributed to population differences regarding perceptions of dementia at the personal level and discrepancies in personal knowledge regarding dementia between people of different socioeconomic or gender groups. The results of this study suggest that the Hebrew version of the Motivation to Change Lifestyle and Health Behaviours for Dementia Risk Reduction (MCLHB-DRR) questionnaire is a valid and reliable tool for the assessment of attitudes and beliefs related to lifestyle and health behaviour changes for dementia risk reduction in people aged 50 years and above. These findings are not surprising, considering that dementia is associated with high fear levels and recent statistics show an increase in dementia diagnosis among individuals younger than 60 [
34]. Fear is a prominent predictor of lifestyle and habit changes [
34]. However, the current study had an unequal spread between male and female participants on items that were designed to measure individuals’ motivation to change lifestyle and health behaviours in order to reduce dementia, which may impact factor loadings.
Another point to consider which may have affected the results of the current study is the correlation between gender and socioeconomic status concerning dementia. According to a nationwide, population-based study, higher rates of dementia were observed among females and in people with a higher socioeconomic status. In the current study, more than half of the participants reported a high level of income and a mean number of 16.0 ± 3.0 years of education. Item 15—“My financial situation doesn’t allow me to change my lifestyle and behaviour”—had a significant cross-loading. It might be assumed that the larger proportion of females in this study and their reported, mainly average (34.6%), income level versus that of the males (23.4%) is related to fears of socioeconomic instability to change the motivation for lifestyle and health beliefs to reduce dementia, despite the fact that we did not find statistically significant differences between genders concerning income level. Findings of the current study highlight similarities and differences between our sample and those of the Australian study population [
12]. Generally, the Israeli sample demonstrated lower scores than those obtained in other studies. Moreover, due to low factor loadings, the emotionally driven, fear-related Items 6 and 8 were deleted from the final version of the Israeli questionnaire. These differences can be attributed to increased awareness about dementia among the Israeli population [
35]. These findings reinforce one of the major aims of the Israeli National Strategy: to disseminate information on dementia in a culturally adapted manner [
35].
5. Limitations
The current study has several limitations: First, the study is based on a convenience sample and therefore may not represent or be generalised to the entire Israeli population. Future studies should address this limitation and use representative sampling to decrease the probability of a sampling error and to generalise the study findings to the population at large. Second, we translated a questionnaire from a previously validated English version of the MCLHB-DRR. This raises the problem of ethnocentricity and rejects the assumption of a primary language (i.e., translating a questionnaire word-by-word literally from the original version versus creating the questionnaire from a primary language maintaining the main meaning of the items) [
36]. Third, the response rate cannot be calculated in this study, as we used social media for data collection, which may limit the generalisability of interpreting the results. This should be addressed in future studies by using different sampling techniques. Fourth, we cannot conclude what lifestyle and behaviour change strategy participants were informed about related to reducing the risk of dementia, nor how the absence of this knowledge may have influenced their answers. Future research is recommended to provide health professionals with a deeper understanding of prior dementia-related knowledge and risk/motivation perceptions. Fifth, although the study had an adequate sample of 328 participants, it is somewhat modest. However, based on the assumptions of a factor analysis, sample size can be at least 300 participants [
33]. In addition, as a “rule of thumb”, a minimum of 10–15 participants should be adequate for each item of a factor analysis, which ranges from 270 to 405 participants in our study based on a total of 27 items of the MCLHB-DRR questionnaire to satisfy the participant assumption of the factor analysis [
33]. Moreover, an equal spread of female and male participants is desirable in future studies. Our study is characterised by a relatively high proportion of non-secular participants (35.1%). According to the literature, religious individuals may lead a lifestyle that includes a strict diet, a sedentary lifestyle, and the under-usage of medical services, all of which may increase their risk of dementia compared to non-religious individuals [
37]. Therefore, study findings may be affected by the responses of non-religious participants, who may have a better knowledge of health behaviours to decrease the risk of dementia development. Nevertheless, future studies should explore complex associations between religion and dementia awareness and consider informing participants about dementia prevention health behaviours before answering the MCLHB-DRR questionnaire. Another limitation of the current study is a relatively low percentage (3.3%) of widows/widowers compared to married participants. According to research, social interaction level and day-to-day cognitive stimulation are lower among individuals who have experienced the loss of meaningful others [
38]. Widowers may also be less aware of dementia due to limited social support and feelings of loneliness and social isolation [
38], as well as limited education and access to healthcare [
39]. This may have some impact on the study findings. Despite the above limitations, the current study is the first to analyse the psychometric properties of a Hebrew translation of the MCLHB-DRR questionnaire, which measures attitudes and beliefs for health behaviours and lifestyle changes for dementia risk reduction among the general Israeli population. The translation of the questionnaire was carried out in accordance with the multi-stage process, and the Hebrew version can be used in future intervention studies to prevent dementia in the Israeli population.