Changes in Measures of Dementia Awareness in UK Church Congregations Following a ‘Dementia-Friendly’ Intervention: A Pre–Post Cohort Study

Round 1

Reviewer 1 Report

This study quantitatively evaluates the changes in dementia attitudes of church members after a “Dementia Friendly Church” intervention in an Anglican diocese in the UK. The relevance of this aim is comprehensibly described in detail. The design is a pre post cohort study employing the Dementia Attitude Scale (DAS; two subscales: Knowledge, Comfort) and an additional item (Fear). Statistical computing and reasoning is adequate. There are only some minor points that should be considered:

• The last paragraph of chapter 1 (lines 80-88) should be deleted because this is a dummy text.
• The footnote of Figure 1 should additionally indicate that item 21 is the Fear item.
• “Results and Analysis” should read “Analysis and Results” and be numbered as chapter 3 (instead of 4). ”Discussion” should be numbered as chapter 4 (instead of 5).
• It would be easier to read if the order of the Knowledge and Comfort subscale would be the same throughout the whole text.
• In line 254 “Fear T1” should be replaced by “Knowledge T1”.
• In lines 264ff. percentage increase is used as an effect size. Maybe it would be better to use Cohen’s d for within-subject designs.
• Table 3 can be shortened because N is always 61.
• The study has two important limitations: There is no control group so that causal inferences cannot be drawn. Moreover, there are many lost to follow-up patients. Both issues are adequately discussed in the paper but not in the discussion/conclusion chapters. In my view, these points should be briefly recapitulated in a limitation section.

Author Response

Thank you for your thoughtful and helpful review. We have responded to each point as outlined below. 

• The last paragraph of chapter 1 (lines 80-88) should be deleted because this is a dummy text. Completed
• The footnote of Figure 1 should additionally indicate that item 21 is the Fear item. Completed
• “Results and Analysis” should read “Analysis and Results” and be numbered as chapter 3 (instead of 4). ”Discussion” should be numbered as chapter 4 (instead of 5). Completed
• It would be easier to read if the order of the Knowledge and Comfort subscale would be the same throughout the whole text. Good point! Completed
• In line 254 “Fear T1” should be replaced by “Knowledge T1”.Completed
• In lines 264ff. percentage increase is used as an effect size. Maybe it would be better to use Cohen’s d for within-subject designs. We have added Cohen's d to Table 2 but retained the % difference in means in the text, since we believe this gives a more accessible and intuitive sense of the effect size in a Likert-type scale
• Table 3 can be shortened because N is always 61. Completed
• The study has two important limitations: There is no control group so that causal inferences cannot be drawn. Moreover, there are many lost to follow-up patients. Both issues are adequately discussed in the paper but not in the discussion/conclusion chapters. In my view, these points should be briefly recapitulated in a limitation section. Changes made to lines 341-344 in response

Reviewer 2 Report

The study is well conceived and carried out, but (as the writers explain) the results are not as generalizable as they could be with a larger sample size, especially if the response rate for the second survey (T2) had been much higher.  Although the writers suggest other plausible reasons, my concern would be that those who experienced the least change self-selected out of responding to the second survey. That may or may not be the case, but it leaves an important unanswered question.

 The main value of this study is not its results, which are not as clear as might be hoped, but in its theoretical starting point, its research questions, and in its clear identification of the need for more study.  The study is very well written, clear, and thought-provoking and the research and analysis are well done.  

Author Response

Thank you for your thoughtful review. The high rate of attrition at T2 certainly limits the confidence with which the findings may be generalized. In the text, we managed this by including an detailed discussion of the possible effect in lines 228-239 and Table 1; and in presenting the final conclusions with a great deal of caution. We have considered whether to include further qualification of the results, but believe this to be sufficient to alert the reader to the limitations of the data