Past studies on knowledge and attitudes towards dementia among students were identified using the following electronic databases: Academic Search Complete, Psychology and Behavioural Sciences Collection, Medline Complete, SocINDEX with full text, Education Research Complete and Education Resources Information Centre (ERIC). Papers published since January 2010 until March 2017 are selected and reviewed.

Key words used in the search were “knowledge,” or “attitude,” or “perception,” or “opinion,” or “belief,” and Dementia,” or “Alzheimer’s,” and “students.” These key words were selected based on the most frequent terms used in the papers. The inclusion criteria were published papers from January 2010 until March 2017, peer-reviewed, English language, focusing on knowledge, attitude, perception, opinion or beliefs towards Dementia or AD and studies that include college and university students as the sample. The exclusion criteria are papers published before January 2010, papers other than English language, topics not related to knowledge, attitude, perception, opinion or beliefs towards Dementia or AD disease and the sample of the study does not include college and university students. Studies using school students as a sample are also excluded from this study.

Overall, the initial search strategy yielded 508 papers, 230 from Academic Search Complete, 85 from MEDLINE Complete, 68 from Educational Research Complete, 54 from Psychology and Behavioural Sciences Collection, 51 from SocINDEX with full text, and 20 from ERIC. After limiting the search findings to English language, six papers were excluded, yielding 502 papers. After limiting to Scholarly (Peer Reviewed) journals, 411 papers were left. Subsequently, 274 papers were excluded after screening as titles and abstracts were not related to knowledge, attitude, perception, opinion or beliefs towards dementia or AD disease and 118 papers excluded as the studies did not focus on students, leaving 19 papers. One paper was then excluded as the study focussed on adolescent school students rather than university or college students. This leaves the number of papers eligible to 18 papers. The [Table/Fig-1] shows the PRISMA flow diagram for the review.

[Table/Fig-1]:

PRISMA flow diagram of study.

The [Table/Fig-2] represents the following important features of relevant studies: 1) Author, year published and country; 2) objective of study; 3) number of participants and course enrolled; 4) study design; 5) assessment tools used in the study; 6) results; and 7) discussion key points [4,17-33].

It was essential that information gathered from the studies in this review would provide directions for future research. The year published was important to focus on current research {[Table/Fig-2]; Column 1}. The country in which the research was done would provide information on which region studies have been mostly done and which regions need more research {[Table/Fig-2]; Column 1}. The objective of study was to identify which studies focussed on knowledge, attitudes towards dementia, or both {[Table/Fig-2]; Column 2}. Number of participants and course enrolled were identified to give a sense of the sample covered by these studies, larger sample sizes would give more reliable results than smaller sample sizes and whether certain courses enrolled by students would have an impact on the knowledge and attitudes {[Table/Fig-2]; Column 3}. Study design is important to show the range of methodological approaches used in previous studies {[Table/Fig-2]; Column 4}. The assessment tools used in the study are essential in identifying the studies that used psychometrically sound instruments to measure the variables. This was of particular interest in this review as a way of identifying which scales that have been validated in the use of respective countries {[Table/Fig-2]; Column 5}. Results and discussion is to highlight the level of knowledge and attitudes of students towards dementia and to identify the directions of future research and clinical practice {[Table/Fig-2]; Column 6 and 7}.

A total of 18 studies from 2010 to 2017 fulfilled the reviews inclusion criteria on the knowledge and attitudes towards dementia among college and university students. Out of the 18 papers, nine (50%) studies were conducted in United States of America (USA; [4,17,19,20,26,28,29,32,33]). Three papers were from Europe, which are Norway [27], Germany [30] and Malta [31]. There are two papers studied in Asia, specifically in Hong Kong [21] and South Korea [22]. Other countries include Trinidad and Tobago [23], Canada [24] and Australia [25]. Only one study was conducted a cross-national which include USA and United Kingdom [18].

Six papers focussed on studying attitudes [4,17,18,20,24,28]. Out of these six studies, one paper [24] studied ‘beliefs’ rather than ‘attitudes’ or ‘knowledge,’ but this study is categorized under ‘attitudes’ for the purpose of this review, as Wilkinson and Ferarro [34] stated that ‘beliefs are associated with attitudes, in which attitudes are positive or negative evaluations of beliefs.’ Seven papers studied knowledge [19,21,22,25,27,29,30] and the remaining included both knowledge and attitudes [23,26,31-33] in their studies.

Only one study did not report the number of sample size [30]. Among the remaining 17 papers, a total of 3,105 participants were studied, in which all of them were college or university students. The sample sizes ranged from 11 [20] to 691 participants [23]. A large majority of the students enrolled in courses related to clinical healthcare services such as medical [17,18,20,21,23,27-29,33], nursing [18,21,22,23,25,27,31-33], audiology and speech [4], pharmacy [18,23,30] occupational therapy [21,27] and physiotherapy [27]. Other healthcare service courses include social work [21,27], family services [19], psychology [19] and social education [27]. Only few studies included students who enrolled in courses not related to healthcare services [19,23]. One study did not report the major course enrolled by the students, but the participants were undergraduate students who joined an introductory psychology class [24].

The study design varied across the studies reviewed. Ten of the studies (55.56%) were experimental intervention programmes, in which nine papers included pre and post measurements [4,17,20,25,28-30,32,33] and one study was a post-test only randomized control group design [26]. Among these ten intervention studies, five used quantitative measures [20,25,26,28,30], two used qualitative [17,33] and another three used a mix method design [4,29,32]. Seven studies (38.89%) were questionnaire surveys, in which four of them are cross-sectional studies [18,21-23] and the remaining three are descriptive questionnaire surveys [19,27,31]. One study did not report the study design [24].

Among the ten intervention programmes, seven studies focussed primarily on hands-on experience and exposure with dementia patients. These studies are the creative group-based story telling with dementia patients [17], interdisciplinary service learning experience in a nursing home residents with dementia [4], poetry workshop with dementia people [20], placement in a residential aged care facility [25], communication training with patients who have advanced dementia [26], museum-based art-centered program with dementia patients and caregivers [28] and Partnering in Alzheimer’s Instruction Research Study (PAIRS) Program^TM [29]. One study focussed on medical humanities teaching module as part of the pharmacy course [30], but did not involve hands-on experience with dementia patients. Another experimental study included two experimental groups, one which went through an AD online module but with no clinical experience, and another which engaged with people with AD at a memory care unit and dementia day centre [32]. Another study focussed on an interprofessional approach to clinical education between nursing and medical students [33].

There was also a large variety in the assessments used to measure the variables. The most popular instrument used to measure attitudes is the Dementia Attitudes Scale [35], which is used in four studies [20,28,31,32]. In assessing knowledge, the most frequently used instrument is Alzheimer’s Disease Knowledge Scale [36], also used in four studies [19,27,31,32]. A number of studies reported using self-developed questionnaire to measure attitudes [23,24,26,33] and knowledge [19,23,30,33]. Other instruments used include Attitudes to Dementia Questionnaire {ADQ; [18,37]}, modified version of Alzheimer’s Disease Knowledge Test {ADK; [21,38]}, Korean version of Dementia Knowledge Questionnaire [22,39], Dementia Knowledge Assessment Tool 2.0 {(D-KAT2; [25,40]}, The Buddy Program Dementia Knowledge Test [29,41] and The Boston University PAIRS Program Dementia Knowledge Test [29,42].

Results of the intervention studies revealed that the intervention programmes improved student’s attitudes [4,17,20,26,28]. Qualitative findings suggest that students felt surprised that they actually enjoyed spending time with dementia patients and the experience left a personal impact on them [17] as well as feelings of increased hope, humanity, creativity, confidence and comfort in interacting with dementia patients [20]. They were also surprised at the effectiveness of management techniques which were non-biomedical in nature [20]. Communication training with dementia patients was effective in increasing the understanding of the skills in approaching, talking, understanding verbal and non-verbal cues, as well as assessing pain indicators. However, the effectiveness had limitations in terms of increasing comfort level or perceived skills [26].

Students knowledge also improved through the intervention programmes [25,26,29,30]. Communication training helped students understand the emotional aspect, needs and abilities of patients who have dementia [26]. Qualitative findings suggest that the program was beneficial in integrating scientific knowledge and how to practically apply the knowledge in real settings. One student wrote, “tie all my knowledge together while providing much more data – both scientific and experience related” ([29], p.4). It also revealed the humanistic side of the disease, as one student wrote, “My buddy allowed me to see Alzheimer’s through his eyes (and) to better understand his difficulties, frustrations and concerns” ([29], p.5).

In a comparison, between the group of students who experienced engaging with people with Alzheimer’s disease and students who only completed the online module (without engagement with Alzheimer’s disease people) or had no dementia-specific intervention, those who engaged with Alzheimer’s disease patients experienced increased knowledge and improved attitudes [32]. An inter-professional education programme also improved students knowledge and attitudes towards Alzheimer’s disease as well as improving attitudes towards inter-professional teamwork and collaboration. A medical student wrote, “now I have a better picture of how different members function in the team,” while a nurse practitioner students wrote, “the physician and nurse worked very well as a cohesive team” ([33], p.536).

Findings from questionnaires survey shows that the attitudes of students are positive [18,31] and students believe that dementia affects cognitive but enhances physical prowess [24]. In terms of knowledge, findings reveal diverse results. Studies report that the knowledge was poor [21], moderate [27], adequate [31] and reasonably good, but relatively low on prevention, treatment and causes [22]. Some studies found that students reported lower understanding of risk factors [19,27] and causes [27] related to dementia, such as high blood pressure and increased cholesterol [19]. However, most students understood that it is not effective to remind people with Alzheimer’s disease that they are repeating themselves and most knew that Alzheimer’s impacts short-term memory worse than long-term memory [19].

Medical students scored high on assessment and diagnosis domain [27], while nursing students showed more positive attitudes and preferred the Person Centred approach than medical and pharmacy students [18]. Another result showed that those who enrolled in courses pertaining to dementia or AD showed more knowledge [19] and more positive attitudes [23] than those who did not. Higher grade level and more clinical experience were associated with increased knowledge towards dementia [22,23,31] and more positive attitudes [4,23,31]. Age and previous care of dementia patients were also associated with higher knowledge and positive attitudes [31]. Hours of teaching dementia related courses were also related to the level of dementia knowledge among students [21].

It is evident from this review that most studies highlight the importance of improving the current curricular module of courses related to dementia [4,18,19,21-27,29,30,32,33]. It shows that specific modules on dementia that focuses on understanding dementia theoretically and practically is important in improving student’s knowledge and attitudes towards people living with this disease. The modules must target in improving the gaps of knowledge in understanding dementia which, as highlighted in previous research are prevention methods [22], risk factors [19,27], causes [22,27] and treatment [22].

This review also sheds light on the importance of integrating these modules with clinical hands-on experience to expose students with people living with dementia. Studies have consistently shown that students who have experience and exposure with dementia patients have higher knowledge [20,22,23,25,29,30,32,33] and more positive attitudes [4,17,20,23,28,32,33]. We now understand that students who have the direct experience report better attitudes as it leaves them a personal impact [17], increase confidence, comfort [20] and understanding on how to approach and interact with the patients [26]. In terms of knowledge, students learn the humanistic side of the disease [26] and discover the integration between scientific findings and practical experience [29].

Another interesting finding from this review may direct future plans to incorporate creative activities into the service learning modules, rather than confined to clinical encounters. Studies have shown that creative programmes such as storytelling [17], communication training [26], arts [28] and poetry [20] have been successful in connecting the bridge between students and dementia patients, particularly in terms of knowledge regarding cognitive abilities and need for meaningful contact [26], comfort [20,28] and positive attitudes [17,28].

One study found that medical students are better in assessment and diagnosis while nursing students are more Person Centred in nature [18]. This indicates that different courses focus on different perspectives about the disease and also shows that there are different gaps of knowledge in each course. Hence, another important finding in the literature is how the combination of interprofessional approach between different courses in clinical education helps students to observe and work on inter-professional teams during their clinical placements. Competency in interprofessional collaboration is vital to ensure quality and comprehensive care for dementia patients.

It is difficult to standardize the results of the quantitative research findings into categorical measurements (positive or negative attitudes; low, moderate or high knowledge) as a variety of assessments have been used to measure the variables and different assessments have different cut-off scores. Some studies even use self-developed questions which are not validated [23,24,26,30,33]. Moreover, not all papers report findings in a categorical manner. Based on the current literature, most papers have used the Alzheimer’s Disease Knowledge Scale [19,27,31,32,36] to measure knowledge and Dementia Attitudes Scale [20,28,31,32,35] in evaluating attitudes. Future researches are suggested to use these scales whenever possible to obtain standardized results.

It is important to note that most studies in looking at knowledge and attitudes among college and university students towards dementia were conducted within American and European population. Only few studies involved higher education students from other parts of the world. Hence, it is necessary to report that the findings are limited to a certain population and must not be generalized to other societies and communities which may apprehend different values and understandings of the disease. Thus, more research regarding knowledge and attitudes towards dementia are needed in other continents including Asia and Africa.

Majority of the samples in the studies are medical and nursing students and very few studies focussed on students from other important healthcare field, such as physiotherapy, occupational therapy etc. Therefore, findings in these studies might not be generalizable to the whole clinical healthcare student population, but limited to medical and nursing courses only. It is vital to study knowledge and attitudes among all courses related to dementia as these students will be the professionals working with dementia patients in their future practice.

The main strength of present review is the focus on college and university student’s knowledge and attitude towards dementia which is first kind of review in the field. As part of synthesizing previous findings, present review highlighted the most common lacking in students knowledge and attitudes about dementia. Furthermore, this review also indicates that exposure to theoretical and practical aspect of dementia would facilitate better understanding and attitude towards dementia among students. However, present review has limitation whereby this review only focuses on papers published since 2010, thus, not fully reflects the entire knowledge in the field.

Considering the increasing population of people with dementia, there is a need for college and university students, particularly healthcare service students to gain appropriate knowledge and attitudes towards people living with dementia. They will be the future generation that will be directly working with this population. Current evidence suggests that there are room for improvement in the course modules. This review provides basis for future planning to improve the current curricular by addressing the gaps in knowledge, incorporating hands-on clinical experience and creative non-clinical programmes as well as integrating interprofessional approaches into the modules.