0410 Hmu Version Pa Thesi

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH
HANOI MEDICAL UNIVERSITY
NGUYEN HUYNH PHUONG ANH
KNOWLEDGE, ATTITUDE, AND CONFIDENCE OF

DEMENTIA CARE AMONG NURSES IN HEALTHCARE
SETTINGS IN VIETNAM AND SOME ASSOCIATED
FACTORS
MASTER THESIS PROPOSAL: EPIDEMIOLOGY
HANOI – 2023
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH
HANOI MEDICAL UNIVERSITY
NGUYEN HUYNH PHUONG ANH
KNOWLEDGE, ATTITUDE, AND CONFIDENCE OF

DEMENTIA CARE AMONG NURSES IN HEALTHCARE
SETTINGS IN VIETNAM AND SOME ASSOCIATED
FACTORS
Major: Epidemiology
Code: 8720117
MASTER THESIS PROPOSAL

Supervisor:
Assoc Prof. Vu Thi Thanh Huyen
& Assoc Prof. Nguyen Van Huy
HANOI – 2023
ACKNOWLEDGMENT
I would like to thank my esteemed supervisors – Assoc. Prof. Vu Thi

Thanh Huyen and Assoc. Prof. Nguyen Van Huy for their invaluable supervision,
support, and tutelage during the course of my Master's degree. Their immense
knowledge and plentiful experience have encouraged me in all the time of my
academic research and daily life.
My gratitude extends to the Faculty of Epidemiology and the support of
Project NCD D43 for creating this meaningful training program as well as
providing funding opportunities to undertake my studies.
Additionally, I would like to sincerely thank the Department of Population
and Quantitative Health Sciences, Umass Chan Medical School for creating the
opportunity for me to attend an exchange course in the US and strengthen the
scientific nature of my research project.
Finally, I would like to express my gratitude to my family, classmates,
boyfriend and friends who constantly encouraged and motivated me both physically
and mentally.
Without their tremendous understanding and encouragement over the past
few years, it would be impossible for me to complete my study.
Hanoi, 4th October 2023

Student
Nguyen Huynh Phuong Anh

COMMITMENTS
Respectfully addressed to:

- School of Preventive Medicine and Public Health
- Department of Epidemiology, School of Preventive Medicine and Public
Health
- Board of Thesis Assessment
- National Geriatric Hospital
- Geriatric department - Dong Da General Hospital
- Geriatric and mental health department - E Central Hospital
- Dien Hong Nursing Center
- Nhan Ai Elderly Care Center
- OriHome Elderly Care Center
My name is Nguyen Huynh Phuong Anh, student of Master of Epidemiology –
English program 2021 – 2023, Hanoi Medical University. I would like to commit that:
1. This is my own work that I did implement under the supervision of Assoc.
Prof. Vu Thi Thanh Huyen and Assoc. Prof. Nguyen Van Huy
2. This paper isn‘t plagiarized from any previous research published.
3. Data and information in this study are completely accurate, reliable, and
equitable that had been confirmed and approved by the study participants.
I would be fully responsible for these commitments.
Hanoi, 4th October 2023
Student
Nguyen Huynh Phuong Anh

TABLE OF CONTENT
TABLE OF CONTENT
LIST OF ABBREVIATIONS
LIST OF TABLES
INTRODUCTION ........................................................................................... 1
CHAPTER 1: LITERATURE REVIEW ...................................................... 3
1.1. Dementia .................................................................................................... 3
1.1.1. Definition of Dementia....................................................................... 3
1.1.2. Epidemiology of Dementia ................................................................ 3
1.1.3. Classification of Dementia ................................................................. 7
1.1.4. Diagnosis of Dementia ..................................................................... 10
1.1.5. Dementia care ................................................................................... 12
1.2. Knowledge, attitude, and confidence about dementia care ..................... 14
1.2.1. Definition of KAP survey ................................................................ 14
1.2.2. Assess the knowledge, attitude, and confidence of dementia care .. 15
1.2.3. Knowledge, attitude, and confidence about dementia in the world . 18
1.2.4. Knowledge, attitude, and confidence about dementia in Vietnam .. 22
1.5.Conceptual framework .............................................................................. 26
CHAPTER 2: SUBJECTS AND RESEARCH METHODOLOGY ........ 28
2.1. Duration and location of the study ............................................................ 28
2.2. Study subjects............................................................................................ 28
2.3. Methods ..................................................................................................... 28
2.4. Study variables and indicators .................................................................. 31
Independent variables (exposures): ................................................................. 31
2.5. Research instruments and collection method............................................ 35
2.6. Data management and analysis ................................................................. 37
2.7. Bias and measures to control .................................................................... 38
2.8. Ethical considerations ............................................................................... 38
CHAPTER 3: RESULTS .............................................................................. 39
3.1. Participants‘ Characteristics ..................................................................... 39
3.2. Knowledge, attitude and confidence in dementia care ............................ 42
3.3. Factors associated with knowledge, attitude and confidence in dementia
care .................................................................................................................. 46
CHAPTER 4: DISCUSSION ....................................................................... 60
4.1. Knowledge about dementia ...................................................................... 60
4.2. Attitude toward dementia care ................................................................. 63
4.3. Confidence in dementia care .................................................................... 64
4.4. Key Finding .............................................................................................. 66
4.5. Limitation ................................................................................................. 66
CONCLUSION .............................................................................................. 68
RECOMMENDATION ................................................................................ 69
REFERENCE
LIST OF TABLES
Table 2.1: Sampling frame of nurses in elderly care facilities in Hanoi ........ 29
Table 3.1: Demographic characteristics among nurses................................... 39
Table 3.2: Dementia-related training and experience among nurses .............. 40
Table 3.3: Knowledge about general dementia among nurses (DKAS score) 42
Table 3.4: Knowledge about palliative care for advanced dementia among
nurses .............................................................................................. 43
Table 3.5: Attitude toward general dementia among nurses .......................... 44
Table 3.6: Attitude toward palliative care for advanced dementia among nurse 44
Table 3.7: Confidence in providing dementia care among nurses .................. 45
Table 3.8: Knowledge score about general dementia (DKAS-25) according to
nurses‘ characteristics ..................................................................... 46
Table 3.9: Knowledge score about palliative care for advanced dementia (K-
qPAD-23) according to nurses‘ characteristics .............................. 48
Table 3.10: Attitude score toward general dementia (DAS-20) according to
nurses‘ characteristics ..................................................................... 49
Table 3.11: Attitude score toward palliative care for advanced dementia (A-
qPAD-12) according to nurses‘ characteristics .............................. 50
Table 3.12: Confidence score in providing dementia care (CODE-9)
according to nurses‘ characteristics ................................................ 52
Table 3.13: Multivariable linear regression for factors associated with
knowledge about general dementia................................................. 55
knowledge about advanced dementia ............................................. 56
Table 3.15: Multivariable linear regression for factors associated with attitude
toward general dementia ................................................................. 57
toward advanced dementia.............................................................. 58
confidence in providing dementia care ........................................... 59
LIST OF FIGURES
Figure 1.1. Conceptual framework ................................................................. 27

Figure 3.1: Scatter plot matrix between K, A and C scores ............................ 54
LIST OF ABBREVIATIONS
CODE Confidence in Dementia Scale

DAS Dementia Attitudes Scale
DKAS Dementia Knowledge Assessment Scale
DSM-IV Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition
Mini-Cog Mini-cognitive screening test
MMSE Mini-mental state examination
MOCA Montreal Cognitive Assessment
MRI Magnetic resonance imaging
qPAD The questionnaire on Palliative Care for Advanced Dementia
WHO World Health Organization
1
INTRODUCTION
Dementia is currently the seventh leading cause of death and one of the
major causes of disability and dependency among older people worldwide.1
There is often a lack of community awareness and understanding about
dementia, resulting in stigmatization and barriers to timely diagnosis by
healthcare providers in primary care settings as well as effective care
coordination between healthcare facilities and social support networks,
particularly in low- and middle-income countries.2 In 2015, it was estimated
that there were more than 600,000 people suffering from dementia in
Vietnam.3 4
Vietnam has a low-resource healthcare system where the stress
of family caregiving may be amplified by a lack of community resources,
cultural stigma discouraging the seeking of outside help, and the costs of
care.5 6 There are few dementia-specific healthcare facilities in Vietnam and
there is little training in dementia diagnosis and management for health care
providers.7
In Vietnam, several epidemiological studies in the elderly have been
conducted, providing information about the prevalence of dementia,
associated factors, and patient‘s healthcare needs.8 9
In addition, for the
caregiver population, qualitative and interventional studies have also been
carried out and published respectively, revealing insights into the burden of
care, the need for social support and preliminary effects in reducing distress
and burden of caregivers through psychological interventions.10 11 12 13 14
However, little is known about the professional healthcare workforce. There

has been insufficient information available on their capacity to cope with
dementia cases as well as adequately researched and published educational
interventions to improve the quality of dementia care in various healthcare
settings.
2
Nurses play an important role in providing dementia care in hospitals,

the community, and in residential care settings. Their responsibilities include
dementia recognition, management, and reducing the burden on caregivers. 15
Nurses' dementia care practices for persons with dementia are influenced by
their knowledge, attitudes, and confidence.16 17
Information about these
factors among nurses practicing in various healthcare settings in Vietnam,
however, is lacking. The present cross-sectional study describes the
knowledge, attitudes, and confidence in providing dementia care, and factors
associated with these endpoints among nurses practicing in several geriatric
healthcare units in Hanoi, thereby desire to somewhat understand the current
capacity status of the nurses in Vietnam, as a premise for future discoveries on
health workers in other community and critical care settings.
Objectives of the study:
1. Examine nurses‘ knowledge, attitude, and confidence of dementia
care in healthcare settings in Vietnam
2. Determine factors associated with nurses‘ knowledge, attitude,
and confidence of dementia care in healthcare settings in Vietnam
3
Chapter 1
LITERATURE REVIEW
1.1. Dementia
1.1.1. Definition of Dementia
Dementia is a syndrome – usually of a chronic or progressive nature – that
leads to deterioration in cognitive function (i.e., the ability to process thought)
beyond what might be expected from the usual consequences of biological ageing.
It affects memory, thinking, orientation, comprehension, calculation, learning
capacity, language, and judgement. Consciousness is not affected. The impairment
in cognitive function is commonly accompanied, and occasionally preceded, by
changes in mood, emotional control, behavior, or motivation18.
1.1.2. Epidemiology of Dementia
Epidemiology of Dementia in the world
The older the age, the higher the prevalence of dementia.
For every five-year increase in age, the incidence of total dementia nearly
doubles, from 1.5% at age 60-69 to 40% at age 90. A panel of experts estimated the
worldwide prevalence of dementia among people aged 60 years and over at 3.9%,
Africa at 1.6%, Eastern Europe at 3.9 %, China 4.0%, Latin America 4.6%,
Western Europe 5.4% and North America 6.4%. Of the causes of dementia,
Alzheimer's disease is the most common, accounting for 50 to 70%, followed by
vascular dementia from 14 to 25%, the rest are other causes19.
About every 20 years, the number of people with dementia doubles. China
and the Western Pacific region have the highest number of people with dementia (6
million), followed by the European Community (5 million), the United States (2.9
million) and India (1.5 million). The rate of increase in the number of dementia
patients varies greatly by region, three to four times higher in developing countries
than in developed countries. As a result, the proportion of people with dementia in
developing countries will increase from 61% (in 2000) to 65% (in 2020) and 71%
(in 2040)20.
4
Epidemiology of Dementia in Vietnam

Although there has not been a representative survey on the status of
dementia in the elderly in Vietnam, through a number of studies that have been
conducted, the prevalence of dementia and Alzheimer's disease in Vietnam is
similar to other countries in the region.
A cross-sectional study by Nguyen Ngoc Hoa in 2005 determined the
prevalence of dementia in the elderly and described some factors related to
dementia in the elderly in Ba Vi district, Ha Tay province. Subjects were subjected
to neuropsychological tests to diagnose dementia. Stata 8.0 software used to process
information. The results showed that the prevalence in this community was 4.6%
(95% CI=4.03-5.12). There was no significant difference in the prevalence of
dementia between men and women (p>0.05). The older the age, the lower the
education level, the higher the dementia rate (p<0.05). A broader study is needed to
be able to have epidemiological data for Vietnamese people about this disease21.
A study by Nguyen Kim Viet in 2009 with the aim of accessing real situation
and features of dementia at community was conducted on 8,963 people (727 people
over 60 years old) in Thai Nguyen city. The results showed that dementia occurs on
7.9% of the elderly, the rate of dementia increases with age. Recent memory loss
was the core symptom of the early stages of the disease (87.9%). Language
impairment (inability to read and comply to command sentences) was 67.2%,
reduce of abstract thought (comply to command with 3 consecutive actions) was
86.2%, loss of calculating ability was 91.5%, disorientation of space was 50%. The
conclusion has been made that dementia are rather common on old people in the
community but has not been diagnosed and treated, MMSE could be used to select
and diagnose dementia at community22.
An epidemiological study on dementia and risk factors in the elderly in
community was conducted by Pham Thang and Luong Chi Thanh in 2010. To
estimate prevalence of dementia and identify the relation between dementia and risk
factors, 5892 older persons in Ba Vi district were enrolled in the study. Prevalence
5
of dementia in this study was 4.5% (4.3% in man and 4.7% in woman). This
prevalence increased by age. A significant relation between this prevalence of
dementia and age, level of education, history of stroke, Parkinson‘s disease and
familial history of dementia was observed23.
A cross-sectional study was performed in 342 elderly people (≥60 years of
age) in 2019. Information was collected through the Mini-Cog dementia screening
scale and prepared interview questions on socio-demographic characteristics, living
habits and sleep quality. The results showed that the rate of dementia in the elderly
was 33%. The proportion of elderly people with poor sleep quality was 78.1%. The
prevalence of dementia increases with age. The higher the education level, the
frequency of exercise, the frequency of social activities, the lower the rate of
dementia. People with poor sleep quality had higher rates of dementia than people
with good quality24.
A cross-sectional study was conducted by Dr. Tran To Tran Nguyen in 2019,
among inpatients aged ≥60 years in the geriatrics departments at three acute care
hospitals in Ho Chi Minh City, Vietnam to measure the prevalence of dementia,
evaluate their caregivers‘ understanding of dementia, and explore the caregivers‘
wishes for support services. Dementia was diagnosed by Diagnostic and Statistical
Manual-5 (DSM-5) criteria. A total of 367 participants were recruited with the
mean age of 77.5±9.2 years, females being 59.7%. The prevalence of dementia and
mild cognitive impairment were 24.3% and 14.4%, respectively. The vast majority
of the caregivers had a low level of understanding of dementia (92.1%), and 74.2%
of them reported a need for help in caregiving. The caregivers wished for help from
relatives and supportive home-care services from someone they could hire.9
Risk factors of Dementia25
Many factors can eventually contribute to dementia. Some factors, such as
age, can't be changed. Others can be addressed to reduce your risk.
Risk factors that can't be changed:
6
Age. The risk rises as you age, especially after age 65. However, dementia
isn't a normal part of aging, and dementia can occur in younger people.
Family history. Having a family history of dementia puts you at greater risk
of developing the condition. However, many people with a family history never
develop symptoms, and many people without a family history do. There are tests to
determine whether you have certain genetic mutations.
Down syndrome. By middle age, many people with Down syndrome
develop early-onset Alzheimer's disease.
Risk factors you can change: You might be able to control the following
risk factors for dementia.
Diet and exercise. Research shows that lack of exercise increases the risk of
dementia. And while no specific diet is known to reduce dementia risk, research
indicates a greater incidence of dementia in people who eat an unhealthy diet
compared with those who follow a Mediterranean-style diet rich in produce, whole
grains, nuts and seeds.
Excessive alcohol use. Drinking large amounts of alcohol has long been
known to cause brain changes. Several large studies and reviews found that alcohol
use disorders were linked to an increased risk of dementia, particularly early-onset
dementia.
Cardiovascular risk factors. These include high blood pressure
(hypertension), high cholesterol, buildup of fats in your artery walls
(atherosclerosis) and obesity.
Depression. Although not yet well-understood, late-life depression might
indicate the development of dementia.
Diabetes. Having diabetes may increase your risk of dementia, especially if
it's poorly controlled.
Smoking. Smoking might increase your risk of developing dementia and
blood vessel diseases.
7
Air pollution. Studies in animals have indicated that air pollution

particulates can speed degeneration of the nervous system. And human studies have
found that air pollution exposure — particularly from traffic exhaust and burning
wood — is associated with greater dementia risk.
Head trauma. People who've had a severe head trauma have a greater risk
of Alzheimer's disease. Several large studies found that in people at the age of 50
years or older who had a traumatic brain injury (TBI), the risk of dementia and
Alzheimer's disease increased. The risk increases in people with more severe and
multiple TBIs. Some studies indicate that the risk may be greatest within the first
six months to two years after the TBI.
Sleep disturbances. People who have sleep apnea and other sleep
disturbances might be at higher risk of developing dementia.
Vitamin and nutritional deficiencies. Low levels of vitamin D, vitamin B-
6, vitamin B-12 and folate can increase your risk of dementia.
Medications that can worsen memory. Try to avoid over-the-counter sleep
aids that contain diphenhydramine (Advil PM, Aleve PM) and medications used to
treat urinary urgency such as oxybutynin (Ditropan XL).
1.1.3. Classification of Dementia
Dementia is caused by damage to or loss of nerve cells and their connections
in the brain. Depending on the area of the brain that's damaged, dementia can affect
people differently and cause different symptoms26.
Dementias are often grouped by what they have in common, such as the
protein or proteins deposited in the brain or the part of the brain that's affected.
Some diseases look like dementias, such as those caused by a reaction to
medications or vitamin deficiencies, and they might improve with treatment.
1.1.3.1. Progressive dementia
Types of dementias that progress and aren't reversible include:
Alzheimer's disease. This is the most common cause of dementia.
8
Although not all causes of Alzheimer's disease are known, experts do know that a
small percentage are related to mutations of three genes, which can be passed down
from parent to child. While several genes are probably involved in Alzheimer's
disease, one important gene that increases risk is apolipoprotein E4 (APOE).
Alzheimer's disease patients have plaques and tangles in their brains. Plaques are
clumps of a protein called beta-amyloid, and tangles are fibrous tangles made up of
tau protein. It's thought that these clumps damage healthy neurons and the fibers
connecting them.
Vascular dementia. This type of dementia is caused by damage to the
vessels that supply blood to your brain. Blood vessel problems can cause strokes or
affect the brain in other ways, such as by damaging the fibers in the white matter of
the brain.
The most common signs of vascular dementia include difficulties with
problem-solving, slowed thinking, and loss of focus and organization. These tend to
be more noticeable than memory loss.
Lewy body dementia. Lewy bodies are abnormal balloon like clumps of
protein that have been found in the brains of people with Lewy body dementia,
Alzheimer's disease and Parkinson's disease. This is one of the more common types
of progressive dementia.
Common signs and symptoms include acting out one's dreams in sleep,
seeing things that aren't there (visual hallucinations), and problems with focus and
attention. Other signs include uncoordinated or slow movement, tremors, and
rigidity (parkinsonism).
Frontotemporal dementia. This is a group of diseases characterized by the
breakdown of nerve cells and their connections in the frontal and temporal lobes of
the brain. These are the areas generally associated with personality, behavior and
language. Common symptoms affect behavior, personality, thinking, judgment, and
language and movement.
9
Mixed dementia. Autopsy studies of the brains of people 80 and older who
had dementia indicate that many had a combination of several causes, such as
Alzheimer's disease, vascular dementia and Lewy body dementia. Studies are
ongoing to determine how having mixed dementia affects symptoms and
treatments.
1.1.3.2. Other disorders linked to dementia
Huntington's disease. Caused by a genetic mutation, this disease causes
certain nerve cells in your brain and spinal cord to waste away. Signs and
symptoms, including a severe decline in thinking (cognitive) skills, usually appear
around age 30 or 40.
Traumatic brain injury (TBI). This condition is most often caused by
repetitive head trauma. Boxers, football players or soldiers might develop TBI.
Depending on the part of the brain that's injured, this condition can cause dementia
signs and symptoms such as depression, explosiveness, memory loss and impaired
speech. TBI may also cause parkinsonism. Symptoms might not appear until years
after the trauma.
Creutzfeldt-Jakob disease. This rare brain disorder usually occurs in people
without known risk factors. This condition might be due to deposits of infectious
proteins called prions. Signs and symptoms of this fatal condition usually appear
after age 60.
Creutzfeldt-Jakob disease usually has no known cause but can be inherited. It may
also be caused by exposure to diseased brain or nervous system tissue, such as from
a cornea transplant.
Parkinson's disease. Many people with Parkinson's disease eventually
develop dementia symptoms (Parkinson's disease dementia).
1.1.3.3. Dementia-like conditions that can be reversed
Some causes of dementia or dementia-like symptoms can be reversed with
treatment. They include:
10
Infections and immune disorders. Dementia-like symptoms can result

from fever or other side effects of your body's attempt to fight off an infection.
Multiple sclerosis and other conditions caused by the body's immune system
attacking nerve cells also can cause dementia.
Metabolic problems and endocrine abnormalities. People with thyroid
problems, low blood sugar (hypoglycemia), too little or too much sodium or
calcium, or problems absorbing vitamin B-12 can develop dementia-like symptoms
or other personality changes.
Nutritional deficiencies. Not drinking enough liquids (dehydration); not
getting enough thiamin (vitamin B-1), which is common in people with chronic
alcoholism; and not getting enough vitamins B-6 and B-12 in your diet can cause
dementia-like symptoms. Copper and vitamin E deficiencies also can cause
dementia symptoms.
Medication side effects. Side effects of medications, a reaction to a
medication or an interaction of several medications can cause dementia-like
symptoms.
Subdural hematomas. Bleeding between the surface of the brain and the covering
over the brain, which is common in the elderly after a fall, can cause symptoms
similar to those of dementia.
Brain tumors. Rarely, dementia can result from damage caused by a brain
tumor.
Normal-pressure hydrocephalus. This condition, which is caused by enlarged
ventricles in the brain, can result in walking problems, difficulty urinary and
memory loss.
1.1.4. Diagnosis of Dementia
Diagnostic criteria (DSM IV) for Dementia of the Alzheimer's Type27
A. The development of multiple cognitive deficits manifested by both
(1) memory impairment (impaired ability to learn new information or to recall
11
previously learned information)

(2) one (or more) of the following cognitive disturbances:
(a) aphasia (language disturbance)
(b) apraxia (impaired ability to carry out motor activities despite intact motor
function)
(c) agnosia (failure to recognize or identify objects despite intact sensory

function)
(d) disturbance in executive functioning (i.e., planning, organizing,

sequencing, abstracting)
B. The cognitive deficits in Criteria A1 and A2 each cause significant

impairment in social or occupational functioning and represent a significant decline
from a previous level of functioning.
C. The course is characterized by gradual onset and continuing cognitive

decline.
D. The cognitive deficits in Criteria A1 and A2 are not due to any of the
following:
1. Other central nervous system conditions that cause progressive deficits in

memory and cognition (e.g., cerebrovascular disease, Parkinson's disease,
Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain
tumor)
2. Systemic conditions that are known to cause dementia (e.g.,

hypothyroidism, vitamin B or folic acid deficiency, niacin deficiency,
hypercalcemia, neurosyphilis, HIV infection)
3. Substance-induced conditions
E. The deficits do not occur exclusively during the course of a delirium.
F. The disturbance is not better accounted for by another Axis I disorder (e.g.,
12
Major Depressive Episode, Schizophrenia).
1.1.5. Dementia care

Based on 2005-2009 Dementia Care Practice Recommendations28
The main goals for dementia care are:
• Early diagnosis to promote early and optimal management
• Optimizing physical health, cognition, activity and well-being
• Identify and treat comorbidities
• Detect and treat challenging behavioral and psychological symptoms
• Provide information and long-term support for caregivers.
a) Care plan should be prepared in advance
As dementia progresses, the person will gradually become more dependent
on family or friends to make decisions about financial matters, health care, and
living arrangements. As the illness worsens, especially in the late stages, they may
need someone to make the complete decisions for them. It is very important for
people with dementia to discuss their wishes for future care with family and/or
friends while they are still able to express their thoughts freely. explicitly, thereby
formalizing an early care plan. This is also important to caregivers, helping them to
fulfill the wishes of the person with dementia.
Early care planning is the process of planning ahead for a future health
condition to ensure that the values, beliefs, and desires of a person with dementia
are recognized and used to guide future care. decisions in follow-up care. The early
care plan should be discussed on a regular basis with the patient, caregiver and
family and adjusted to changes in the patient's health and circumstances.
b) Access to services in the community
People with dementia, regardless of age, are not excluded from any service
on the basis of their diagnosis. In the community, doctors at primary care- family
doctors are often their closest health care provider.
13
Currently in Vietnam, we can contact the aged care service: 1800 6896
(Hanoi) or 1800 6894 (Ho Chi Minh). This is very helpful when starting a search
for a care coordinator; often, this service is often linked to home care packages.
c) Dementia and rehabilitation services
People with dementia will benefit from maintaining a healthy and active
lifestyle that contributes to improved health and well-being, including:
• Exercise regularly
• Maintain a healthy diet
• Monitor your weight periodically and contact help during weight change
• Maintain oral health through regular checkups
• Stay engaged in meaningful and enjoyable activities
• Maintain daily routines
• Maintain contact in social activities
• Manage other health problems (comorbidities)
d) Caregiver support
Taking care of and supporting someone with a disability or illness for a long
time is stressful and can be exhausting
Caregivers need support to maintain the physical and mental health of
themselves and the patients they care for. They also need advice on how to get
better. As well as having access to many services and being able to get support
when needed
e) End of life care
As the disease progresses, more emphasis is placed on palliative care (or
hospice).
Planning and preparing for this phase will help the person with dementia have
a pleasant end, consistent with the aspirations they have expressed and documented
in the ―planning‖ documents. early care‖ or a pre-prepared care plan. It should be
14
particularly noted that these documents should be prepared soon after diagnosis and
reviewed periodically to ensure that the wishes of the person with dementia are
being met. In some cases, it is possible to find a lawyer who understands the
patient's wishes.
f) Value in care
Healthcare professionals and aged care workers should provide patient-
centered care by recognizing and responding to the needs and aspirations of each
person with dementia, caregiver and the patient's family. The following 10
principles of genuine value in care serve as standards for implementing and
evaluating care. If care is not being delivered according to these guidelines, it
should be discussed with the healthcare provider.
1.2. Knowledge, attitude, and confidence about dementia care
1.2.1. Definition of KAP survey
A Knowledge, Attitude and Practices (KAP) survey is a quantitative method

(predefined questions formatted in standardized questionnaires) that provides access
to quantitative and qualitative information. KAP surveys reveal misconceptions or
misunderstandings that may represent obstacles to the activities that we would like
to implement and potential barriers to behavior change29.
A KAP survey can:
Measure the extent of a known situation; confirm or disprove a hypothesis;
provide new tangents of a situation‘s reality.
Enhance the knowledge, attitude, and practices of specific themes; identify what is
known and done about various health-related subjects.
Establish the baseline (reference value) for use in future assessments and
help measure the effectiveness of health education ability to change health-related
behaviors.
Suggest an intervention strategy that reflects specific local circumstances and
the cultural factors that influence them; plan activities that are suited to the
respective population involved.
15
1.2.2. Assess the knowledge, attitude, and confidence of dementia care

* The lack of a reliable scale for measuring dementia care practice
There are many researches about KAP of dementia that have been
international published. In which, various Knowledge, Attitude measuring
instruments are used globally, but the Practice measuring instrument is not
common. In more detail, currently there is no officially accepted scale or checklist
to evaluate Practice. Furthermore, assessing the quality of nursing care practice
should be from all three sides, including: nurse self-assessment, patient feedback,
and caregiver or patient family member assessment.
To the extent that only self-assessment scales are considered, rather than
self-assessment of practical ability, self-confidence is a more suitable alternative.30
Additionally, nurses' dementia care practices are influenced by their knowledge,
attitudes, and confidence.16 17
* Scales for measuring components that influence dementia care practice
Factors associated with dementia care practice:
Based on theories: According to Florence Nightingale's theory of factors
affecting the quality of nursing care in 1855, three main groups of factors affecting
the quality of care are: Personnel factors, Patient-related factors and Environmental
factors. In this study, only personnel factors were considered including: Socio-
demographic Characteristics, Experience related to Dementia, Knowledge about
Dementia, Attitudes toward dementia.
 Based on researches:
• Types/ titles of work 16
• Number of working years 16
• Level of confidence 16
• Knowledge 31
• Feelings 31
16
Therefore, in the scope of this study only focuses on factors associated with
the three components that influence practice: knowledge, attitude and confidence.
In this study, four tools were selected for overview: DKAS, DAS, qPAD
(two parts) and CODE. In which, DKAS, qPAD-23 for knowledge assessment;
DAS, qPAD-12 for attitude assessment and CODE for confidence assessment.32 33
34 35
In particular, the qPAD scale was introduced to measure long-term care staff
knowledge and beliefs, perceptions, and attitudes about palliative and end-of-life
care for persons with advanced dementia.36
For assessment of knowledge and attitude toward advanced dementia:

17
The Questionnaire on Palliative Care for Advanced Dementia (qPAD) is a 2-
part instrument that measures long-term care staff knowledge, and beliefs,
perceptions, and attitudes about palliative and end-of-life care for persons with
advanced dementia. Factor analyses of the Knowledge Test (coefficient a= .81)
produced 3 factors: Anticipating Needs, Preventing Negative Outcomes, and Insight
and Intuition (coefficient a = .75, .73, and .58, respectively), explaining 67% of the
total variance. Factor analyses of the Attitude Scale (coefficient a= .83) produced 3
factors: Job Satisfaction, Perceptions and Beliefs, and Work Setting Support of
Families (coefficient a = .90, .64, and .67, respectively), explaining 68% of the total
variance. These initial findings hold promise for an instrument that measures both
knowledge and attitudes of long-term care staff in the care of persons with
advanced dementia
For confidence assessment:
Confidence in Dementia Scale: This new nine-item self-report questionnaire
was used to measure confidence in working with people with dementia. The Kaiser-
Meyer-Olkin (KMO) measure of sampling adequacy assesses whether the sample
size is sufficient relative to the number of items in the scale. The KMO if an item
was deleted was above 0.8 for each item; this represents good sample adequacy.
The questionnaire was scored on a five-point Likert scale with anchored ratings of
‗not confident‘, ‗somewhat confident‘, and ‗very confident‘. This meant that it was
possible to gain a total score between 9 and 45, with a higher score representing
better confidence in working with people with dementia. The Cronbach alpha value
was 0.91 and the overall KMO was 0.90, suggesting that the scale had good internal
consistency without too much item redundancy.

18
1.2.3. Knowledge, attitude, and confidence about dementia in the world

Previous researches used DKAS for knowledge assessment:
Author & Location Sample Method Knowledge score
time
hospitals, nursing
Michael J.
homes, and respite 234 health
Annear cross- 44.92±7.60/54
centers in eight professionals
2018 37 sectional (Old version)
Australian states
296 GP Registrars:
Laura
registrars and 91 36.10±7.22/50 (pre)
Tierney et al Pre–post
Australia GP supervisors Supervisors:
2018 38 study
37.13±6.13/50 (pre)
Worldwide:
Australia (66.5%),
UK (9.8%), New
Zealand (7%),
Canada (5.9%),
Ireland (2.7%), the
Katherine 1591 allied
US (2.6%), the
Lawler et al health cross- pre-course:
39
(2.6%), the
2019 professionals sectional 35.0±8.4/50
Philippines
(0.7%), Singapore
(0.7%), India
(0.6%), China
(0.3%), Malaysia
(0.2%)
Helen Chan 218 facilitators in 1069 healthcare Pre-and- Pre: 27.7±8.6/50

et al 2020 40 China staff post study Post: 32.7±7.6/50
Universitas
Sunaryo et 334 nursing cross-
41 Gadjah Mada, Median: 24.00/50
al 2020 students sectional
Indonesia
19
Pre-and- Control group:

Hsin-Feng two home care
140 home care post study 25.54±8.14/50 (pre)
Su et al agencies in eastern
workers with control Intervention group:
2020 42 Taiwan
group 26.69±6.72/50 (pre)
Pilot
Control group:
Windy Randomize
40:40 Health 35.1±8.0/50 (post)
Chan 2020 Hongkong d
43 professionals Intervention group:
Controlled
(80) 36.9±8.0/50 (post)
Trial
Chong Kar
a private hospital Cross-
Lim et al 102 nurses 23.59±6.79/50
in Perak, Malaysia sectional
2021 44
Chee Mun 7 medical 464 final-year

cross-
Chan et al universities in medical 29.60 ± 6.97/50
sectional
2021 45 Malaysia undergraduates
Yulisna Sari 1061 cross-

Indonesia 32.1±5.1/50
et al 2021 46 physiotherapists sectional
Previous researches used DAS for attitude assessment:

Author & Location Sample Method Attitude score
time
Charles
long-care term Pre-and-
Scerri and 214 nursing Pre: 109.55±14.09/140
residential, nursing post
Anthony staff Post: 113.9±12.70/140
47
homes in Malta study
Scerri 2017
institutions of long-
Regula Blaser cross-
term care in the
and Barset 417 nurses sectiona
48
German-speaking 114.67±13.51 /140
2017 l
part of Switzerland
20
Anthony cross-
in a hospital in 132 full-time
Scerri et al sectiona 99.45±12.52/140
Malta staff
2019 49 l
Wenhong 11 public tertiary 603 cross-

Zhao et al hospitals in Hebei healthcare sectiona 91.3±15.9/140
2019 50 Province, China professionals l
1069 Pre-and-
Helen Chan 218 facilitators in Pre: 102.2±12.0/140
healthcare post
et al 2020 40 China Post: 112.0±11.2/140
staff study
Universitas cross-
Sunaryo et al 334 nursing
Gadjah Mada, sectiona 99.60±10.25/140
2020 41 students
Indonesia l
Nico cross-
University of 113
Saccasan sectiona 107.5±12.52/140
Malta, Malta practitioners
2020 51 l
Chong Kar a private hospital in Cross-

Lim et al Perak, 102 nurses sectiona 98.99±12.08/140
2021 44 Malaysia l
cross-
Anhong 325 medical
China sectiona 89.10±8.93/140
Dong 2021 52 students
l
Previous researches used qPAD for assessment of knowledge and attitude

toward palliative care for advanced dementia:
Author & time Location Sample Method Knowledge &
Attitude score
74 longterm 121 nurses Cross- K: 12.7±3.6/23

Miharu Nakanishi
care facilities in and 154 other sectional A: 43.6±5.0/60
2014
Japan care workers
21
Pre: K: 14.3±2.6/23
Miharu long-term care
60 nursing Pre-and- A: 43.8±6.2/60
Nakanishi 2014 facilities in
home staff post study Post: K: 15.1±2.8/23
53 Japan
A: 45.2±6.2/60
20 nursing RCT for

registered and
homes in two patients,
Meera Agar 2017 enrolled K: 14-16/23 each arm
54
major baseline
nurses and A: 48/60 in both arms
Australian cross for
care assistants
cities nurses
125 nurses K: 14.3±3.2/23

Long-term care
I-Hui Chen 2017 and 175 Cross- A: mean items score:
55
settings in
nursing sectional 3.7±0.5/5
Taiwan
assistants
Dementia
special care
Carol Long 129 care staff Pre-and- Pre: K: 15.13±3.46/23
units in 3 large
2017 56 and managers post study Post: K: 16.17±3.53/23
nursing homes
in New York
Australian
Tim Luckett 2019 290 nursing Cross- K: 15.2±2.8/23
57
long-term care
staff sectional A: 47.7±5.9/60
(LTC)
Previous rsearches used CODE for confidence assessment:

Author & Location Sample Method Confidence score
time
Rebecca
43 healthcare Pre-and- Pre: 32.8/45
O‘Brien United Kingdom
professionals post study Post: 38.3/45
2018 58
22
Lucy 162 qualified

Pre-and-
Garrod Oxford, UK and clinical T1: 31.72±5.01/45
post study
2019 59 support staff T2: 36.76±4.21/45
241 nursing
Three of the largest
staff, head
Mara metropolitan T1: 23.77±6.84 /45
nurses, Pre-and-
Gkioka general hospitals of T2: 31.43±6.08/45
physiotherapists post study
2020 60 Thessaloniki- T3: 32.31±5.77/45
, administrative
Greece
staff.
Acute care, mental

Sahdia health community
553 health and Cross-
Parveen care trusts, primary 35.31±7.64/45
social care staff sectional
2020 61 care and care
homes in the UK
A university
Clarissa
hospital in the Cross-
Shaw 2021 65 nursing staff 33.9±4.9/45
62
midwestern United sectional
States
The second largest 11 clinical staff

Katharina
mental health NHS of CNTW NHS Pre-and- Pre: 32.80±3.92/45
Reichelt
organization in Foundation post study Post: 37.90±3.78/45
202363
England Trust
1.2.4. Knowledge, attitude, and confidence about dementia in Vietnam

Currently, there is no international published research on KAP or KAC in
Vietnam.
There are two nationally published cross-sectional studies on knowledge and
attitudes about dementia:
23
Author & Population Screening Tool Results

time
Dang Tran 338 full-time nursing A case study Knowledge of nursing
Ngoc students at Pham (Female, 72 years old students toward dementia
Thanh et al Ngoc Thach with dementia) was limited but > 50% of
64
2017 University of them had positive attitude
Medicine people with dementia
Nguyen 142 full-time HCWs Alzheimer's Disease The prevalence of good

Trung Anh (130 nurses and 12 Knowledge Scale knowledge and very good
et al 2019 doctors) at National (ADKS) & attitudes toward dementia
65
Geriatric Hospital Dementia Attitudes was 97.2% and 29.9%,
Scale (DAS) respectively
1.3. Factors associated with knowledge, attitude, and confidence in dementia

care
Factors associated with knowledge about dementia
• Age 41
• Experience of dementia caregiving 37 41 45
• Geographic location 37
• Dementia education 37 38 43 45
• Self-rated knowledge 37 38
• Length/practice time of dementia care 46
• Work in geriatrics 46
• Highest level of education 50
• Experience of searching for dementia information 50
• Willingness to receive dementia training 50
• Unit/department size 66
24
Factors associated with attitude about dementia
• Age 41
• Gender 47
• Knowledge 41
• Types/ titles of work 47
• Types of departments 48 50
• Experience of dementia care 50
• Length/practice time of dementia care 47 50
• Interest in dementia care 50
• Dementia education 47 67
• Communication skill 66
• Ethical dilemmas 66
• Psychological factors (fear or frustration) 66
Factors associated with confidence of dementia care
• Types/ position level of work 61

• Number of working years 68
47 58 59 60 63 69 68
• Prior education/training
• Training content 61
• Availability of nearby referral services for dementia 69
• Educational level 70
• Knowledge 69 70
• Attitude 69
1.4. Overview of research healthcare settings

National Geriatric Hospital (NGH): NGH is a leading hospital specializing in
geriatrics, the highest level for the system of examination, treatment and health care
for the elderly in Vietnam. As a medical service unit directly under the Ministry of
Health, the NGH is only available at 1A Phuong Mai, Dong Da, Hanoi.
25
In terms of professional organizational structure, the hospital has 12 clinical

and 6 subclinical departments with more than 320 full-time employees including
doctors, nurses, technicians and medical assistants.
In this study, we will only conduct the study in 12 clinical departments with
181 nurses. Subclinical departments will be excluded because medical professionals
in these departments have less opportunity to examine patients directly than clinical
departments.
E Hospital (EH): E Hospital is a Grade I central general hospital since 1967,

directly under the Ministry of Health. EH is only available at 87 - 89 Tran Cung,
Cau Giay, Hanoi. EH is the satellite hospital of the National Geriatric Hospital in
the field of geriatrics.
In terms of professional organizational structure, the hospital has 4 centers,

31 clinical and 9 subclinical departments with a scale of more than 1,000 beds on an
area of 41,000 m2.
In this study, we will only conduct the study in the Department of Geriatric
and Mental Health - the satellite geriatric unit with 17 nurses.
Dong Da General Hospital: Dong Da Hospital is a Grade II provincial

general hospital of Hanoi city since 2005, directly under the Hanoi Department of
Health. The hospital is only available at 180 Nguyen Luong Bang, Dong Da, Hanoi.
This is the satellite hospital of the National Geriatric Hospital in the field of
geriatrics.
In terms of professional organizational structure, the hospital has 11 clinical

and 5 subclinical departments with more than 250 full-time employees.
In this study, we will only conduct the study in the Department of Geriatrics
- the satellite geriatric unit with 12 nurses.
Dien Hong Nursing Centre: Dien Hong Nursing Centre is a private nursing
home established in September 2014. Currently, this center become a reliable
26
address for families with elderly people, people suffering from accidents, and
occupational accidents in Hanoi and other provinces in the country.
Dien Hong Nursing Center has 4 facilities located in three urban districts of
Hanoi, with more than 100 employees. In which, the team of daily care specialists
consists of 78 nurses in all facilities.
Nhan Ai Elderly Care Center: Nhan Ai Elderly Care Center is a private

nursing home established in 2007. With the desire to bring the elderly a
comprehensive and professional care environment, Nhan Ai came into being based
on learning from other countries‘ experiences development including Taiwan and
Japan.
The center established a single 3,500-square-meter facility located in Bac Tu

Liem district, Hanoi with a scale of serving 100 beds and more than 50 employees.
In which, the team of daily care specialists consists of 30 nurses.
Orihome Elderly Care Center: Orihome Elderly Care Center is a private

nursing home established in 2013, with the application of the Japanese nursing and
care model in service.
The center established a single facility located in the city center with 72 beds
and more than 50 employees. In which, the team of daily care specialists consists of
10 nurses.
1.5. Conceptual framework
Components of framework:
Outcome variables: KAC score
Input variables: Factors associated with KAC (Socio-demographic

Characteristics, Experience related to Dementia, Knowledge about Dementia,
Attitudes toward dementia)
Diagram:
27
Figure 1.1. Conceptual framework

Statements about the problem:
What is the socio-demographic characteristics of nurses?
How is nurses‘ experience related to dementia?
What is the average grade of dementia knowledge?
What is the average grade of dementia attitude?
What is the average grade of confidence in dementia care practice?
Is there a significant relationship between personal factors and dementia
knowledge?
Is there a significant relationship between personal factors and dementia
attitude?
Is there a significant relationship between personal factors and confidence in
dementia practice?
28
Chapter 2
SUBJECTS AND RESEARCH METHODOLOGY
2.1. Duration and location of the study
Study setting: The study was conducted from 01/08/2022 - 30/05/3023. The
data was collected from 01/12/2022 – 31/03/2023 in National Geriatric hospital, E
hospital, Dong Da general hospital and three nursing homes named Dien Hong,
Nhan Ai and Orihome in Hanoi.
2.2. Study subjects
Participants in the study are nurses who work in:
+ 12 clinical departments of the National Geriatric Hospital.
+ 2 geriatric departments of 2 general hospitals: Dong Da hospital and E
hospital.
+ 3 nursing home systems: Nhan Ai Elderly Care Center, Orihome Elderly
Care Center, Dien Hong Nursing Center (4 facilities).
Inclusion criteria:
Working with full-time employment
Have worked at least 1 month in a clinical department
Exclusion criteria:
Refuse to participate in the study
2.3. Methods
Study design: A cross-sectional study
Sample size calculation: Key nonfamily long-term care sources using
nurses as the primary care workforce include nursing homes, nursing centers,
rehabilitation hospitals, geriatric hospitals and general hospitals with geriatric
departments.71
 Target population: nurses taking care of elderly patients in Hanoi, Vietnam.
 Source population: full-time nurses working in public geriatric units and

29
private nursing homes in Hanoi.
 Sampling frame: full-time nurses working a central geriatric hospital, 6

geriatric units of general hospitals and 11 private nursing home systems with at
least 10 working nurses. (Facilities with fewer than 10 nurses were excluded for not
being counted as a cluster).
Table 2.1: Sampling frame of nurses in elderly care facilities in Hanoi
N Facilities Size Number of Number
piloted of selected
nurses nurses
1 National Geriatric Hospital (12 clinical departments) (purposive) * 181 15 166

2 Dien Hong Nursing Center (4 campuses) * L 78
3 Bach Nien Thien Duc Aged Care Center (3 campuses) L
4 Lotus Elderly Care Center M
5 Nhan Ai Elderly Care Center * M 30
6 Tuyet Thai Aged Care Center M
7 Ha Noi Nursing Center (2 campuses) M
8 Javilink Nursing Home System (2 campuses) S
9 KAIGO Nursing Center (2 campuses) S
10 ALH Nursing Home S
11 OriHome Elderly Care Center * S 10
12 FDC Elder Nursing Home S
13 Geriatric department - Military Institute of Traditional Medicine S
14 Geriatric department - Dong Da General Hospital * S 12
15 Geriatric department - Rehabilitation Hospital S
16 Geriatric department - Hanoi Traditional Medicine General Hospital S
17 Geriatric and mental health department - E Central Hospital * S 17
18 Geriatric department – National Hospital of Traditional Medicine S
Total of nurses 576 15 313
Information is referenced from the Report Market outlook for elderly care services in Vietnam72,
through the website and directly calling the facilities.
* Selected facilities with updated nursing numbers up to December 2022; S (small cluster): facility
with less than 20 nurses; M (medium cluster): facility with 20 to 45 nurses; L (large cluster):
facility with more than 45 nurses.
30
 Sample size formula: The sample size was calculated based on the primary
outcome. This study used the knowledge outcome for calculating, which is the
nurses‘ dementia knowledge using the Dementia Knowledge Assessment Scale
(DKAS). An early study examined sample of nurses using the same instruments and
reported mean knowledge scores of 23.59±6.79/50.44 Using this score as a reference
for sample size calculation with a 95% confidence interval, a beta error of 10% and
an alpha of 0.05, the required sample size was calculated using this formula:
• ES = μ /σ; μ = 1; σ = 6.79
• Zα/2 = 1.96
• Zβ = 1.28
A sample size of 484 was required for an infinite population. Because the
study population is a finite population with 576 full-time nurses working in geriatric
units (Table 1), a sample correction formula called Modified Cochran Formula for
Small Populations was used to minimize the sample size:
[ ]
Hence, the sample size was minimized to 264. Considering a response rate of
86.5% from a previous survey study on healthcare workers in Vietnam, 307
participants were needed in the study. 73
Sampling: Since the study needed to select a total 307 people out of 576. In
this study, a multi-step sampling was used to recruit enough nurses.
 Purposive sampling: First, we purposely recruited all nurses working at

clinical departments in the National Geriatric Hospital (NGH) because NGH is the
central hospital that provides care for older patients and started a management
program for patients with dementia in 2008. Therefore, all 181 nurses (including 15
nurses for piloting) working in 12 clinical departments of NGH were recruited first.
 Cluster sampling: In the next step, the study needed to recruit: 307 - (181 -
31
15) = 141 more nurses out of 395 from all the rest facilities in the sample frame. In
this stage, cluster sampling was applied to cluster units that are facilities. Each
facility or department counts as a cluster and was classified into three categories
based on their size (2 large, 4 medium and 11 small). Therefore, we randomly
selected at least 1 large cluster, 1 medium cluster and 3 small clusters by computer
software to recruit enough 141 people which includes nurses from all sizes of
clusters. Then, all nurses in these selected clusters were invited to participate in the
study.
Sampling results: Dien Hong Nursing Center (large cluster), Nhan Ai Elderly
Care Center (medium cluster), OriHome Elderly Care Center, Dong Da – geriatric
department and E – geriatric and mental health department (small clusters) were
randomly selected units. In fact, combined with the nurse population in NGH, a
total number of 313 nurses in all selected facilities were eligible to enter the study.
2.4. Study variables and indicators
Dependent variables (study outcomes):
 Three primary outcomes will be K score, A score and C score.
Independent variables (exposures):
 Demographics, dementia-related experience are independent variables for

the analysis of Knowledge score outcome.
 Demographics, dementia-related experience and Knowledge score are

independent variables for the analysis of Attitude score outcome.
 Demographics, dementia-related experience, Knowledge score and Attitude

score are independent variables for the analysis of Confidence score
outcome.
32
Table of variables:
Var group Var name Definition Var type
Age Number of year old continuous
Sex Male/Female binary
Living area from childhood to high school

Childhood area binary
Urban/Rural
Living area after high school until now

Current area binary
Urban/Rural
The highest level of nursing degree:
 2-year Diploma
 3-year Bachelor of Nursing (BN)

Qualification  4-year Bachelor of Science in Nursing categorical
(BSN)
 Master of Science in Nursing or

Demographi Clinical Nurse Specialist (MSN/CNS)
c Type of the workplace
information
 Geriatric units (GU): work as a nurse
practitioner at a geriatric unit in a
Workplace binary
hospital
 Nursing homes (NH): work as a nurse

practitioner at a nursing home
Position Nurse staff/Chief nurse binary
Number of Average number of patients received their care

continuous
patients on a daily basis
Seniority in
Time (in years) of nursing experience continuous
healthcare
Previous Previous training related to dementia that

continuous
training in the nurses had received in: neuroscience,
33
workplace psychiatry, geriatrics, dementia pathology, and

hands-on care for patients with dementia.
The total score ranged from 0 (none of 5
disciplines) to 5 points (trained in all 5
disciplines).
Training and
experience Seniority in
Time (in years) spent providing dementia care continuous
related to dementia care
dementia Percentage of patients with dementia among

total patient receiving daily care:
Dementia  rare: 0-20%

categorical
percentage  less than half: 21-49%
 one-half to three quarters: 50-74%
 most: 75-100%
Dementia information-seeking actions taken

by participants through:
 Non-specialist channels (Google

keywords/hospital websites): Yes/No
 Specialist channels (guidelines of the

Information
Ministry of Health/guidelines of binary
seeking
dementia organizations/medical
textbooks): Yes/No
 Consulting information from experts

(specialist doctor/specialist nurse):
Yes/No
The rating score ranged from 0 to 10 points.

Self-rated
The higher the rating, the more self-confident
confidence in continuous
the nurse was in their knowledge of dementia
knowledge
in general.
34
The score ranged from 0 to 10 points. The

Desire of
higher the score, the more the nurse wants to continuous
training
be trained in dementia care
Dementia Knowledge Assessment Scale

(DKAS 2.0):
General
25 items continuous
knowledge
0 or1or 2 points for each item
0-50 points
Knowledge Knowledge part of the questionnaire on
of Dementia Palliative Care for Advanced Dementia (The
Knowledge of qPAD):
Palliative Care
23 items continuous
for Advanced
1 (agree), 2 (disagree), or 3 (don‘t know)
Dementia
scored as 1 (correct) or 0 (incorrect)
0-23 points
The Dementia Attitude Scale (DAS):
General 20 items
continuous
attitude Likert 7 scale
Attitude 20-140 points

toward Attitude part of the questionnaire on Palliative
Attitude
Dementia Care for Advanced Dementia (The qPAD):
toward
Palliative Care 12 items continuous
for Advanced 5-point Likert
Dementia 12-60 points
The Confidence in Dementia (CODE) scale:

Confidence
9 items
in Dementia Confidence continuous
Likert 5 scale
care
9-45 points
35
2.5. Research instruments and collection method

Instrument: A self-administered questionnaire, which took an average of 30
minutes to complete, included five major sections on respondent sociodemographic
characteristics, dementia-related experience, knowledge about dementia, attitudes
toward providing dementia care, and their confidence in providing dementia care.
 The Dementia Knowledge Assessment Scale (DKAS 2.0) is a reliable and

valid measure of dementia knowledge for diverse populations that elicits knowledge
in four domains. These include knowledge about the dementia causes and
characteristics (7 items), communication and behavior (6 items), care
considerations (6 items), and risk and health promotion (6 items).74 Response
options are true, possibly true, false, possibly false, and don‘t know. The nurse‘s
responses are then rescored to fully correct (2), partially correct (1), or incorrect (0)
and added to calculate a total score ranging from 0 to a maximum score of 50.32 The
higher the final score, the greater the individual‘s knowledge about dementia. In
this study, the scores of each domain were converted to a 100-point scale to
compare the results between domains.
 The questionnaire on Palliative Care for Advanced Dementia (The

qPAD) is a two-part instrument with 23 knowledge test items and 12 attitude
scale statements.34 75
+ Each item of the knowledge test is answered with 1 (agree), 2 (disagree), or 3
(don‘t know). Responses are scored as 1 (correct) or 0 (incorrect). The total number
of correct answers is used for the analysis. Higher scores represent greater
knowledge about palliative care for advanced dementia.
+ Each item of the attitude scale was evaluated using a 5-point Likert scale
ranging from 1 (strongly disagree) to 5 (strongly agree). Subscale scores were
computed for three dimensions: job satisfaction, perceptions and beliefs, and work-
setting support of families. Higher scores represent greater positive attitudes toward
palliative care for dementia. Satisfactory validity and reliability were reported for
36
the original version.
 The Dementia Attitude Scale (DAS) was used to assess nurses‘ attitudes
toward dementia care. It reflects the affective, behavioral, and cognitive
components of their attitudes toward dementia into a two-factor structure with the
first factor covering ―dementia knowledge‖ (cognitive items) and the second factor
covering ―social comfort‖ (affective and behavioral items forming a single factor).76
The instrument consists of 20 items on a seven-point Likert scale with responses
ranging from 1 (strongly disagree) to 7 (strongly agree). The total scores achievable
for this scale ranged from 20 to 140, with a higher score indicating a more positive
attitude toward the provision of dementia care.
 The Confidence in Dementia (CODE) scale consists of 9 items and was

used to measure the confidence in working with people with dementia. It is scored
on a five-point Likert scale with anchored ratings of ―not confident‖, ―somewhat
confident‖, and ―very confident‖. The total scores range from 9 to 45, with a higher
score representing greater confidence in providing dementia care.35
Translation and piloting: All four scales DKAS, DAS, qPAD and CODE
were translated from English to Vietnamese. First, we conducted a forward-
backward translation from English into Vietnamese involving an English translator,
a representative sample of geriatricians and nurses, and original authors of the
scales. Then, we pilot tested the Vietnamese version of the scales among a small
sample of 15 nurses and conducted a post-pilot review among the research team to
finalize the study questionnaire.
Data collection activities: Study investigators explained directly the study
protocol and invited all 313 nurses to participate in the survey. After obtaining
written informed consent, self-administered questionnaires were hand-delivered to
consenting nurses. Survey responses were checked for completeness by study
investigators and then re-completed by the nurses if any information was missing
before being collected and sealed. A small financial incentive was offered for each
nurse as an appreciation for their participation.
37
2.6. Data management and analysis

Stata software version 17.0 was used for data analysis.
For Objective 1: Continuous variables were reported as means (SD) or
medians (Interquartile range) depending on their distributions in the study sample.
Categorical variables were summarized as percentages.
For Objective 2: Bivariate analyses were carried out to examine the
association between sociodemographic characteristics, dementia-related experience,
and the individual KAC scores. Correlation analyses were used to examine the
extent of correlation between the KAC scores. Potential factors associated with the
KAC scores in the univariate analysis at a p-value threshold of less than 0.2 were
entered as independent variables in three linear mixed models. In addition,
multinomial regression models were also used on KAC outcomes as a sensitivity
analysis. In each multivariable regression model, multicollinearity was checked
using the variance inflation factor (VIF > 4 implying an issue of multicollinearity).
Conditional mean imputation was used to handle missing data of a
quantitative independent variable (less than 5%). The K, A, and C scores were
normally distributed while the data of other continuous independent variables were
not. Spearman correlations were used to examine the association between the
38
continuous independent variables with each KAC score while Pearson correlations
were used to measure the extent of correlation between the individual KAC scores.
Initial examination of the regression models indicated no multicollinearity. All
three linear mixed models have approximately zero variance in the random-effect
parts and LR tests with p>0.05, therefore multivariate linear regression models were
reported in this thesis. The assumptions required for the linear regression were not
violated.
2.7. Bias and measures to control
Mainly related to information bias due to measurement instruments used.
How to fix:
Reviewing the questionnaire.
Conduct a pilot investigation and make appropriate corrections.
Remind the research subject to read the question carefully.
Review the answer sheet for completeness and request re-completion if there
is missing information.
2.8. Ethical considerations
This study was approved by the Hanoi Medical University Institutional
Ethical Review Board (786/IRB HMU).
39
Chapter 3: RESULTS
3.1. Participants’ Characteristics
There were 269/313 nurses who completed all assessments and included
were included in the analysis (response rate 86%).
Table 3.1: Demographic characteristics among nurses
Nurse in Nurses in
nursing homes geriatric units Total
p
(n=111) (n=158)
% % %
41.3 58.7 100.0
Sex Female 74.8 81.6 78.8 0.175
Childhood area Urban 13.5 37.3 27.5 <0.001
Current area Urban 78.4 80.4 79.6 0.689
2-year Diploma 27.0 1.3 11.9

Highest
3-year BN 50.5 58.9 55.4
qualification of <0.001
4-year BSN 20.7 36.1 29.7
nursing degree
+2 years MSN/CSN 1.8 3.8 3.0
Position Chief nurse 20.7 7.6 13.0 0.002
Mean ± SD Mean ± SD Mean ± SD p

Age (year) 29.12±7.87 32.84±5.51 31.30±6.83 <0.001
Seniority in healthcare (year) 2.98±5.01 8.71±5.23 6.34±5.86 <0.001
13.02±17.2
Number of patients (person) 20.91±23.66 7.48±6.35 <0.001
4
Most of nurses were female (78.8%), lived in rural areas during their
childhood, living in urban areas currently (79.6%) and had 3-year Bachelor of
Nursing degrees (55.4%). The mean of age and seniority in healthcare were 31 and
6.34 years respectively. The average number of patients in per day was 13.
Between the two groups, very few nursing home nurses had lived in urban
40
areas during their childhood. Most nursing home nurses had 2-year Diploma and 3-
year Bachelor degrees in Nursing while 4-year Bachelor of Science and 3-year
Bachelor were common degrees accepted in hospitals. Hospital nurses have a
higher average age and seniority than nurses working in nursing homes, while the
data is contrary to the number of patients they have to care for, with nursing home
nurses having to care for nearly three times as many as hospital nurses.
Table 3.2: Dementia-related training and experience among nurses
Nurse in Nurses in
p
(n=111) (n=158)
% % %
Rare (<20%) 11.7 24.7 19.3
Percentage
Less than half (21%-49%) 21.6 46.2 36.1
of dementia <0.001
Half or more (50%-74%) 41.4 26.6 32.7
patients
Most (75%-100%) 25.2 2.5 11.9
Dementia-related training in the workplace
Trained in neuroscience Yes 37.8 47.5 43.5 0.117
Trained in psychology Yes 30.6 44.3 38.7 0.023
Trained in geriatric Yes 47.7 84.2 69.1 <0.001
Trained in dementia pathology Yes 45.9 62.0 55.4 0.009
Trained in dementia hands-on care Yes 68.5 65.8 66.9 0.650
Dementia information seeking channels
Non-specialist channels Yes 68.5 65.8 66.9 0.650
Specialist channels Yes 45.1 52.5 49.4 0.227
Expert consultation Yes 18.0 39.2 30.5 <0.001
Mean ±SD Mean ±SD Mean ±SD p
Previous training score (0-5) 2.31±1.74 3.04±1.78 2.74±1.80 <0.001
Seniority in dementia care (year) 1.79±2.54 3.79±4.03 2.96±3.63 <0.001
Self-evaluation (0-10) 5.35±2.07 5.04±1.91 5.17±1.98 0.212
Desired level in dementia training (0-10) 8.10±2.16 7.65±1.90 7.84±2.02 0.074
In terms of percentage of patients with dementia in the total number patient
41
that nurses have to care for, majority of nursing home nurses have from 20%-100%
of dementia patients with mainly more than half of patients suffering from
dementia, while this figure in the hospital ranged from 0-74% with most dementia
cases accounting for less than half of all patient (p<0.001).
In the workplace, there was no difference in the percentages of training in
neuroscience and dementia care between the two groups, while the percentages of
training in psychiatry, geriatrics and dementia pathology in the hospital nurse group
were statistically significantly higher (p<0.05). In particular, dementia-specific
training such as hands-on care was more commonly implemented in the workplace
at over 65% compared to around 50% at the undergraduate level in both nurse
groups, while pathology training for both undergraduate and postgraduate nursing
home nurses remained below 50%.
Regarding the information seeking channels, while most nurses searched for
dementia information through non-specialist channels, less than half sought
dementia information through specialist channels and consulted experts. Especially
with expert consultation, hospital nurses had a significant higher rate of consulting
(p<0.001).
Nurses had a mean of nearly 3 years in providing dementia care. Hospital

nurses have longer experience caring for dementia patients than nursing home
nurses (p<0.001).
In both groups, nurses self-rated their knowledge as relatively modest with mean
scores of approximately 5/10 points and were highly eager for dementia-related
training with mean scores of approximately 8/10.
42
3.2. Knowledge, attitude and confidence in dementia care

Table 3.3: Knowledge about general dementia among nurses (DKAS score)
Nurse in Nurses in
(n=111) (n=158) p
Mean ±SD Mean ±SD Mean ±SD
Knowledge about general dementia (max 2 points each item, max 50 points in total)
Total Knowledge score (25 items) 27.15±7.93 28.79±8.05 28.12±8.02 0.099
<0.00
Causes and characteristics (7 items) 5.95±2.87 7.51±3.24 6.87±3.18
1
Risks and health promotion (6 items) 6.68±2.25 7.32±2.58 7.06±2.46 0.034
Communication and behavior (6

6.59±2.73 5.61±2.26 6.02±2.51 0.002
items)
Care considerations (6 items) 7.93±2.81 8.35±2.75 8.17±2.78 0.223
The overall mean DKAS scores of survey respondents was 28.12±8.02/50. In

which, a quite good level of knowledge in ―care considerations‖ was reported while
the score for dementia characteristics and communication with people with
dementia was poor.
Between the two groups, hospital nurses showed better performance in
understanding the pathology and prevention of dementia (p<0.001 and p=0.034).
On the contrary, nursing home nurses showed more understanding about
―Communication and behavior‖ with 6.59±2.73/12 points compared to
5.61±2.26/12 points of hospital nurses (p=0.002).
43
Table 3.4: Knowledge about palliative care for advanced dementia among nurses
(K-qPAD-23 score)
Nurse in Nurses in
(n=111) (n=158) p
Knowledge of palliative care in advanced dementia (1 point each right item, max 23 points in total)
Total Advanced Knowledge score (23 11.85±3.17 13.37±3.44 12.74±3.41 <0.00

items) 1
3.04±1.73 3.97±1.74 3.58±1.79 <0.00

Anticipating Needs (8 items)
1
Preventing Negative Outcomes (11 items) 6.59±1.71 7.07±1.96 6.87±1.87

0.040
Insight and Intuition (4 items) 2.22±1.11 2.33±1.02 2.28±1.06

0.389
The overall mean qPAD-23 score of survey respondents was 12.74/23 points.
In which, a quite good level of knowledge in ―Preventing Negative Outcomes‖ was
reported while the score for ―Anticipating Needs‖ for people with dementia was
poor.
Between the two groups, hospital nurses showed better performance in
almost aspects of palliative care. They showed more understanding in anticipating
care needs for advanced cases and also more knowledgeable in preventing negative
outcomes for patients than nursing home nurses (p<0.001 and p=0.040).
44
Table 3.5: Attitude toward general dementia among nurses

(DAS score)
Nurse in Nurses in
p
(n=111) (n=158)
Attitude toward dementia (max 7 points each item, max 140 points in total)
Total Attitude score (20 items) 103.44±15.28 101.20±11.77 102.12±13.35 0.175
Social comfort (10 items) 48.14±8.03 46.75±7.23 47.33±7.59 0.139
Dementia beliefs (10 items) 55.30±9.94 54.44±7.57 54.80±8.62 0.425
The overall mean scores of nurses‘ attitudes measured by DAS was

102.1±13.4/140. The nurses‘ extent of social comfort in attitude was lower than
their dementia belief.
There were no differences in the attitude scores between two nurse groups.
Table 3.6: Attitude toward palliative care for advanced dementia among nurse
(A-qPAD-12)
Nurse in Nurses in
nursing geriatric
Total
homes units p
(n=111) (n=158)
Attitude toward palliative care for advanced dementia

(max 5 points each item, max 60 points in total)
Total Advanced Attitude score (12 items) 45.09±6.50 43.29±5.96 44.03±6.24 0.020
Job Satisfaction (7 items) 25.69±4.00 24.39±4.08 24.93±4.09 0.010
Perceptions and Beliefs (3 items) 11.18±2.07 10.73±1.82 10.92±1.94 0.063
Work Setting Support of Families (2 items) 8.22±1.63 8.17±1.39 8.19±1.49 0.807

45
The overall mean scores of nurses‘ attitudes measured by qPAD-12 was

44.03/60. In particular, nurses showed a very positive attitude towards inviting
families to participate and support in developing care plans as well as providing
care opinions with 8.19/10 points.
Between the two groups, nursing home nurses showed more favorable
attitude in job satisfaction as well as in total attitude score (p=0.010).
Table 3.7: Confidence in providing dementia care among nurses
(CODE score)
Nurse in Nurses in
nursing geriatric Total
p
homes (n=111) units (n=158)
Confidence in dementia care practice (max 5 points each item, max 45 points in total)
Total Practice score (9 items) 0.012

29.42±6.84 27.44±5.95 28.26±6.40
With a mean score of 28.26/45 for entire nursing sample, which corresponds
to the ―somewhat level‖ according to the author, nurses showed that they were not
confident in providing dementia care.
In comparison between two groups, nursing home nurses self-reported
greater confidence with 29.42/45 points compared to 27.44/45 points for hospital
nurses.
46
3.3. Factors associated with knowledge, attitude and confidence in dementia

care
Table 3.8: Knowledge score about general dementia (DKAS-25) according to
nurses’ characteristics
DKAS score
Mean ± SD p
Male 28.3 8.0

Sex 0.861
Female 28.1 8.0
2-year Diploma 24.9 6.8
Highest qualification of 3-year BN 27.5 8.4 0.005

nursing degree 4-year BSN 0.006ª
30.4 7.5
+2 years MSN/CNS 28.8 5.6
Nurse staff 28.0 8.0

Position 0.500
Chief nurse 29.0 8.0
Rare (≤20%) 27.3 8.5
Percent of patients with Less than half (21-49%) 29.2 8.3

0.292
dementia Half or more (50-74%) 28.0 7.7
Most (75-100%) 26.5 7.2
No 28.9 9.0
Non-specialist channels 0.268
Yes 27.7 7.5
Specialist channels No 26.9 8.2 0.009

47
DKAS score
Mean ± SD p
Yes 29.4 7.7
No 26.7 7.9
Expert consultation <0.001
Yes 31.3 7.5
rho sig
Age (years) 0.17 0.006
Number of patients (persons) 0.10 0.099
Seniority in healthcare (years) 0.21 <0.001
Previous training (0-5) 0.13 0.032
Seniority in dementia care (years) 0.20 <0.001
Self-rated confidence in knowledge (0-10) 0.06 0.362
Desired level in dementia training (0-10) 0.16 0.008
(T-test, ANOVA and spearman correlation analysis; ª post-hoc test after ANOVA)
Table 3.8 shows factors associated with the nurses‘ knowledge score about
general dementia. Having a 4-year BSN degree in comparison with 2-year Diploma,
actively seeking information about dementia through specialist channels and expert
consultation, older age, having been trained previously in more related disciplines,
greater seniority in healthcare and dementia care, and higher desired level of
dementia training were associated with a higher total knowledge score (p<0.05).
48
Table 3.9: Knowledge score about palliative care for advanced dementia (K-
qPAD-23) according to nurses’ characteristics
K-qPAD-23 score
Mean ± SD p
Male 12.7 3.1
Sex 0.989
Female 12.7 3.5
Highest qualification 3-year BN 12.3 3.5 <0.001
of nursing degree 4-year BSN 13.9 2.9 <0.05ª
Position 0.014
Rare (≤20%) 12.7 3.3
Percent of patients Less than half (21-49%) 13.3 3.8 0.039
with dementia Half or more (50-74%) 12.7 3.2 0.025ª
Most (75-100%) 11.3 2.8
No 12.5 3.4
Yes 12.9 3.4
No 12.2 3.6
Specialist channels 0.004
Yes 13.3 3.1
No 12.4 3.4
Expert consultation 0.011
Yes 13.5 3.4
rho sig
Age (years) 0.25 <0.001
Number of patients (persons) -0.06 0.348
Seniority in healthcare (years) 0.36 <0.001
Seniority in dementia care (years) 0.28 <0.001
Self-rated confidence in knowledge (0-10) 0.08 0.176
ª: Dip<BSN p=0.002, Dip< MSN p=0.043; BN<BSN p=0.004
49
Table 3.9 shows factors associated with the nurses‘ knowledge score about
palliative care for advanced dementia. Higher nursing degree, working as a chief
nurse, actively seeking information about dementia through specialist channels and
expert consultation, older age, having been trained previously in more related
disciplines, greater seniority in healthcare and dementia care, and higher desired
level of dementia training were associated with a higher total advanced knowledge
score (p<0.05).
Table 3.10: Attitude score toward general dementia (DAS-20) according to
DAS score
Mean ± SD p
Male 103.2 12.9
Sex 0.489
Female 101.8 13.5
Highest qualification of 3-year BN 101.2 13.0

0.257
nursing degree 4-year BSN 102.0 13.7

Position 0.419
Rare (≤20%) 99.3 9.9
Percent of patients with Less than half (21-49%) 100.7 13.0 0.021
dementia Half or more (50-74%) 105.6 13.1 0.039ª
Most (75-100%) 101.3 17.9
No 102.3 13.1
Yes 102.1 13.5
No 99.9 13.5
Yes 104.3 12.9
50
DAS score
Mean ± SD p
No 101.7 13.9
Yes 103.1 12.0
rho sig
Age (years) 0.08 0.215
Seniority in healthcare (years) 0.03 0.681
Seniority in dementia care (years) 0.07 0.250
Self-rated confidence in knowledge (0-10) 0.17 <0.001
Desired level in dementia training (0-10) 0.18 <0.001
The percentage of patients with dementia from 50-74% in comparison with
<20% that they cared for, specialist channels seeking, the higher average number of
patients received their care on a daily basis, self-rated knowledge, desired level of
dementia training were associated with more favorable attitudes toward dementia
care (p<0.05).
Table 3.11: Attitude score toward palliative care for advanced dementia
(A-qPAD-12) according to nurses’ characteristics
A-qPAD-12 score
Mean ± SD p
Male 44.9 6.0
Sex 0.241
Female 43.8 6.3

Highest qualification of
3-year BN 44.3 6.3 0.330
nursing degree
4-year BSN 43.1 6.0
51
A-qPAD-12 score
Mean ± SD p

Position 0.009
Rare (≤20%) 43.7 5.6
Percent of patients with Less than half (21-49%) 42.8 6.6

0.041
dementia Half or more (50-74%) 45.0 6.1
Most (75-100%) 45.8 6.2
No 44.2 6.6
Yes 44.0 6.1
No 43.4 6.1
Yes 44.7 6.3
No 44.4 6.1
Yes 43.3 6.5
rho sig
Age (years) 0.01 0.909
Seniority in healthcare (years) -0.06 0.299
Seniority in dementia care (years) -0.06 0.367
Self-rated confidence in knowledge (0-10) 0.32 <0.001
Working as a chief nurse, the higher percentage of patients with dementia,
self-rated knowledge and greater desired level of dementia training were associated
with more favorable attitudes toward advanced dementia care (p<0.05).
52
Table 3.12: Confidence score in providing dementia care (CODE-9) according to

CODE score
Mean ± SD p
Male 29.8 6.5

Sex 0.041
Female 27.8 6.3
3-year BN 28.4 6.6

Highest qualification of
0.507
nursing degree
4-year BSN 27.5 5.8
Nurse staff 27.8 6.2 <0.00

Position
1
Rare (≤20%) 28.4 6.1
Less than half (21-49%) <0.00

Percent of patients with 26.8 6.1
1
dementia
Half or more (50-74%) 28.6 6.3 0.001ª
Most (75-100%) 31.6 7.1
No 27.8 7.2
Yes 28.5 6.0
Specialist channels No 27.8 7.0 0.263

53
CODE score
Mean ± SD p
Yes 28.7 5.7
No 28.6 6.4
Yes 27.5 6.5
rho sig
Age (years) -0.01 0.915
Seniority in healthcare (years) -0.05 0.404
Seniority in dementia care (years) 0.02 0.713
<0.00
Self-rated confidence in knowledge (0-10)
0.33 1
In terms of the total confidence score, male sex, chief nurse position, the
greatest percentage of patients with dementia (75-100%) and higher self-rated
knowledge were associated with greater confidence (p<0.05).
54
(Spearman/ Pearson correlation analysis) *sig <0.2; ***sig<0.001)

Figure 3.1: Scatter plot matrix between K, A and C scores
Positive correlations were reported between the knowledge and general
attitude scores, and between the attitudes and confidence scores.
There was no correlation between the knowledge and advanced attitude
scores.
There was no correlation between the knowledge and confidence scores.
55
Table 3.13: Multivariable linear regression for factors associated with knowledge
about general dementia
DKAS score
Coef 95%CI
Highest nursing degree
3-year BN (ref)
2-year Dip -1.99 (-5.07; 1.08)
4-year BSN 1.46 (-0.72; 3.64)
+ years MSN/CNS -1.58 (-7.35; 4.18)
Specialist channels seeking 0.94 (-1.07; 2.94)
Expert consultation 3.02** (0.88; 5.16)
Age (years) -0.08 (-0.31; 0.15)
Number of patients (persons) 0.04 (-0.01; 0.10)
Seniority in healthcare
0.29* (0.03; 0.56)
(years)
Previous training (0-5) 0.02 (-0.53; 0.57)
Seniority in dem care (years) 0.15 (-0.15; 0.45)
Desired level (0-10) 0.74** (0.28; 1.20)
Adjusted R^2 0.139
*p<0.05; **p<0.01; ***p<0.001
In the condition of other variables remain unchanged, actively consulting

dementia information from experts, seniority in healthcare, and desired level of
dementia training were positively correlated with the DKAS score.
56
Table 3.14: Multivariable linear regression for factors associated with knowledge
about advanced dementia
K-qPAD-23 score
Coef 95%CI
Highest nursing degree
3-year BN (ref)
2-year Dip -0.29 -1.59; 1.02
4-year BSN 0.91* 0.01; 1.81
+ years MSN/CNS 0.38 -2.13; 2.89
Chief nurse 0.98 -0.23; 2.18
Percent of patients with dementia
21%-49% (ref)
≤20% -0.13 -1.20; 0.94
50%-74% -0.39 -1.32; 0.53
75%-100% -1.12 -2.47; 0.23
Specialist channels seeking 0.52 -0.32; 1.36
Expert consultation -0.10 -0.98; 0.79
Age (years) -0.08 -0.17; 0.02
Seniority in healthcare (years) 0.19** 0.08; 0.31
Previous training (0-5) 0.21 -0.02; 0.44
Seniority in dem care (years) 0.11 -0.01; 0.24
Self-rated confidence in knowledge (0-

10) -0.07 -0.28; 0.14
Desired level (0-10) 0.34** 0.14; 0.54
Adjusted R^2 0.237
*p<0.05; **p<0.01; ***p<0.001

57
In the condition of other variables remain unchanged, having 4-year

Bachelor of Science in nursing degree, greater seniority in healthcare, and desired
level of dementia training were positively correlated with the advanced knowledge
(K-qPAD-23) score.
toward general dementia
DAS score
Coef 95%CI
21%-49% (ref)
≤20% 0.40 (-3.81; 4.61)
50%-74% 3.96* (0.27; 7.66)
75%-100% 1.32 (-3.73; 6.36)
Specialist channels seeking 2.58 (-0.55; 5.71)
Number of patients (persons) 0.62** (0.18; 1.07)
Self-rated confidence in knowledge (0-10) 0.16 (-0.66; 0.99)
Desired level (0-10) 0.94* (0.15; 1.74)
Total general knowledge score (0-50) 0.55*** (0.28; 0.82)
Numberofpatient*DKASscore -0.02* (-0.03; -0.00)
Adjusted R^2 0.151
In the condition of other variables remain unchanged, the percentage of

50%-74% patients with dementia that they took care of, number of patients
that the nurses have to take care of, the desired level of dementia training, and
the total knowledge score were positively correlated with the DAS score.
Specifically, there was negative interaction between the total Knowledge
score and the number of patients in effectiveness to attitude, each additional
patient decreases the effectiveness of the total knowledge on attitude by 0.02
points (p<0.05).
58
toward advanced dementia
A-qPAD-12 score
Coef 95%CI
Chief nurse 2.35* 0.23; 4.46
21%-49% (ref)
≤20% 1.03 -0.95; 3.01
50%-74% 1.30 -0.41; 3.01
75%-100% 1.83 -0.55; 4.21
Specialist channels seeking 0.60 -0.87; 2.06
Expert consultation -1.72* -3.27; -0.16

10) 0.81*** 0.42; 1.20
Desired level (0-10) 0.29 -0.08; 0.66
Adjusted R^2 0.146
*p<0.05; **p<0.01; ***p<0.001

In the condition of other variables remain unchanged, working as a chief
nurse and higher self-rated confidence in dementia knowledge were positively
correlated with the advanced attitude score.
59
Table 3.17: Multivariable linear regression for factors associated with confidence
in providing dementia care
CODE score
Coef 95%CI
Female -1.28 -2.88; 0.31
Chief nurse 2.28* 0.31; 4.24

21%-49% (ref)
≤20% 1.89 -0.08; 3.70
50%-74% 0.08 -1.50; 1.66
75%-100% 3.56** 1.39; 5.73
Expert consultation -1.93** -3.33; -0.52

1.02*** 0.68; 1.35
10)
Total Attitude score (20-140) 0.16*** 0.11; 0.21
Adjusted R^2 0.307
*p<0.05; **p<0.01; ***p<0.001

In terms of their levels of confidence, in the condition of other variables
remain unchanged, chief nurse position, most patients with dementia (75-100%),
higher self-rated knowledge, and higher total general attitude scores were
associated with greater confidence in providing dementia care.
60
Chapter 4:
DISCUSSION
4.1. Knowledge about dementia

Regarding knowledge about general dementia, a deficit in dementia
knowledge was identified in the nursing population in geriatric healthcare settings
in Hanoi, Vietnam. This result is similar to the limited level of dementia care staff
in China and Hong Kong, and is slightly better in comparison with the performance
of healthcare staff in Malaysia and Indonesia. 77 40 44 78 These had once again shown
that in low- and middle-income countries, the dementia knowledge of among
nursing-care staffs is limited and inferior when compared to the health care
79 80
workforce in developed countries. More specifically in knowledge aspects, a
general lack of knowledge was found in all dimensions, however, nurses performed
worst level in ―Cause and characteristics‖ and ―Communication and behavior‖
domains of knowledge. This means the knowledge of the etiology and
pathophysiology of dementia showed the most disturbing shortfalls (49.0% correct
reference on maximum point) in the responses while the performance of knowledge
regarding patient care considerations was superior (68.1%) and consisted with those
77 78
reported in Chinese and Indonesian long-term care staff. As a result , this
indicates that nurses might misinterpret some behavioral abnormalities of patients,
communicate ineffectively and then make inappropriate care decisions. The key
cause for the lack of knowledge in both pathological characteristics and
communication is that nurses do not have access to adequate education as well as it
is recognized that there is limited training in dementia diagnosis and management in
Vietnam for health professionals.7 Currently, there have been substantial
advancements in the knowledge and confidence of healthcare providers in dementia
care as a result of educational interventions conducted in several countries. 77 40 78 38
47
Our research has also shown the geriatric nursing community's desire for
dementia training, suggesting that they are a progressive and inquisitive workforce
61
that is willing to engage in future dementia training programs. Therefore, a

nationwide program of professional education and training in dementia care is
feasible and need to be implemented.
In terms of knowledge toward palliative care for advanced dementia, with
12.74±3.41/23 points of K-qPAD-23 scale, Vietnamese nurses show that their
knowledge of caring for patients with severe dementia was poor when compared to
53 54 55 56 57
other countries, which usually score above 14 points. This proves that,
when it comes to end-of-life care, especially specific palliative care and predicting
patient care needs, nurses are still very limited. Unlike adult patients, geriatric
patients at the end of life in general and advanced dementia in particular have
difficulty presenting and expressing care needs because of extreme exhaustion or
speech dysfunction.86 Therefore, anticipating a patient's needs in the absence of
verbal communication is very important and is a skill that geriatric care staff need
to have and improve continuously. Furthermore, for patients with severe dementia,
because they have severe impairment in daily activities, specifically in digestion
and mobility, leading to common outcomes such as malnutrition and pressure
ulcers, increased risk of falls and ultimately infections due to immunodeficiency.86
In addition, patients are easily depressed or otherwise aggressive, leading to certain
87
gaps in care. Therefore, communication to achieve understanding between nurse
and patient is at the core of the goal of care focused on end-of-life comfort and
convenience, and need to be trained according to goals appropriate to the target
advanced patient population.
Potential predictors of dementia knowledge were also identified in this
study. General dementia knowledge was found to be significantly associated with
actively seeking dementia information through expert consultation. Nurses who
consulted dementia information from expert were found to have higher DKAS
scores than those who did not. Professionals were able to gather information from a
range of sources and identify what was most reliable, whilst actions taken such as
62
searching through non-specialist channels such as internet may not be accurate and
seeking through specialist channels (guidelines of the Ministry of Health/guidelines
of dementia organizations/medical textbooks) can lead to misleading without visual
explanation. Improving physician group collaboration and communication, as well
as explaining the roles of other multidisciplinary team members in dementia care,
81
were also explored. Therefore, receiving useful information and having face-to-
face discussions with specialist doctors and nurses seemed more significant to
nurses than self-learning resources and need to encouraged in the workplace as well
as ensuring quality counselors in non-hospital settings. Weaker associations with
number of years of professional experience (greater length of service associated
with higher DKAS score) and desired level in dementia training (higher self-
reported desired level associated with higher DKAS score) were also identified and
82 37 83
in line with other prior findings. This suggests that understanding is
delineated by experience and regular interaction with people who live with
dementia. The explanation might be experience of working in the caring job could
be perceived as a route into finding relevant dementia information and improving
knowledge. Understanding the processes and having frequency in interacting with
both health care professionals and patients contributed to being able to be proficient
in knowledge. Although multivariate examination of our results did not reveal an
association between prior education and dementia knowledge, they contribute to the
84
validation of existing evidence. In an earlier regional study, education seemed to
increase dementia understanding among Australian health professionals
85
independent of demographic factors and personal experience. The current study
supports these findings and suggests potential routes for developing effective
interventions. In the future, further discovery should be conducted to explore the
extent to which evidence-based dementia education can increase health professional
63
knowledge and whether this knowledge change translates into better care and
patient outcomes.
4.2. Attitude toward dementia care

Regarding attitude, a low level of social comfort in attitude towards people
with dementia was identified with the lower scores in subdomain ―Social comfort‖
compared to ―Dementia knowledge‖. Other studies on nurses and care staff have
44 78 40 47 84 88 60
discovered similar outcomes worldwide. These findings indicates
that nurses feel frustrated and uncomfortable when providing care and tends to
avoid contact with the aggressive patients in advanced stage because of
inconvenience from symptom characteristics of the dementia cases as well as
challenge to achieve effective communication. A more negative attitude could have
a negative impact on dementia care and the quality of life of persons living with
dementia and could be explained by an insufficient level of knowledge . 89 90 91 As a
result, education is critical for improving dementia-related knowledge as well as
reducing stigma among healthcare providers.
Of the factors explored, the higher level of desirability in dementia training
was a factor increasing effect to the attitude in the regression model, and this
association aligns with the findings that interest in dementia care was a significant
50
predictor of DAS scores among hospital healthcare professionals in China. In
addition, percentage of patients with dementia of more than half as well as frequent
contact with dementia cases was the positively associated factor. This also makes
sense because nurses who have a lot of exposure to dementia cases will have more
learning and practicing opportunities, thereby having more experience in caring
than nurses who do not care for major dementia cases. Interestingly, there were
studies suggested significantly association between healthcare professionals‘
85 50
attitudes and previous caring experience. In particular, a significant negative
interaction was detected between the number of patients and knowledge on the total
attitude score while these two independent variables have a positive effect on
attitude in the model. Although the regression coefficient of this interaction variable
64
contributes little to explaining the decrease in attitude scores, it still demonstrates

the impact of the burden of care on nursing attitudes. The large number of patients
reflects the greater workload including both professional and administrative work in
the workplace. Moreover, greater strain in caring for people with dementia is
connected with more in-depth dementia knowledge, particularly when perceived
80
flaws in colleagues' level of care are present. Therefore, in order to reduce stress
for nurses as well as maintain a favorable and positive attitude, healthcare facilities,
especially those with a high level of knowledge need to consider the number of
patients and the appropriate allocation of work during the day to individual nurses.
A positive attitude in clinical practice is crucial because it shows that nurses have
the potential and are eager to learn more and take better care of their patients.
4.3. Confidence in dementia care
A modest level of confidence among Vietnamese nurses had been
demonstrated in their practice of caring for the elderly with dementia. This finding
is consistent with ―somewhat‖ level at the baseline of other studies and reveals that
47 60 58 59
they are not really confident when providing dementia care. Especially,
nurses‘ confidence was considerably low when dealing with patients who cannot
communicate verbally (item 1,2 of CODE, Appendix). These highlights that the
nurses face many difficulties in understanding non-verbal language of advanced
patients as well as interpreting their care needs. This can be explained by serious
lack of adequate communication skills and is compatible with findings previously
found of healthcare professionals having trouble in understanding the behaviors and
89 91
perceptions of people with dementia. Additionally, the limited availability of
methods and time for enhancing communication between nurses and patients with
89 91
dementia was also explained. It is also why nurses who have more frequent
contact with dementia cases are more confident and communicate better as reported
in the results of this study. In summary, fresh nursing staff should invest a lot of
time in learning how to observe and listen to people with dementia in order to
comprehend their demands. Simultaneously, training in verbal and nonverbal
65
communication skills is critical and should be integrated into the theoretical

curriculum of all levels in education as well as the health care system, with special
attention paid to universalizing the training for all stakeholders involved in patient
care, not just medical professionals.
Prior actively seeking dementia information through expert consultation was
found to be significantly associated with better dementia knowledge. Improving
physician group collaboration and communication, as well as explaining the roles of
81
other multidisciplinary team members in dementia care, were also explored.
Therefore, it can be seen that receiving useful information and having face-to-face
discussions with specialist doctors and nurses seemed more significant to nurses
than self-learning resources and need to be encouraged in the workplace as well as
ensuring quality counselors in non-hospital settings. In this research, although
multivariate examination of our results did not reveal an association between prior
education and dementia knowledge, they contribute to the validation of existing
84
evidence. Education seemed to increase dementia understanding among health
85
professionals independent of demographic factors and personal experience. The
current study supports these findings and suggests potential routes for developing
effective educational interventions. In the future, further discovery should be
conducted to explore the extent to which evidence-based dementia education can
increase health professional knowledge and whether this knowledge change
translates into better care and patient outcomes.
A positive correlation was reported between the knowledge and attitude
scores, and between the attitudes and confidence scores. These correlations might
reveal that having a positive attitude can motivate a nurse to increase both
knowledge and confidence. A positive attitude in clinical practice also shows that
nurses have the potential and are eager to learn more and take better care of their
patients. Therefore, providing opportunities for them to receive professional
training is critical for improving dementia-related knowledge and attitudes among
healthcare providers. In this research, no association was determined between the
66
total knowledge and confidence score and the same situation for the previous
training factor. Therefore, future research could explore if there is a relationship
between confidence and specific categories of knowledge that might be more
pertinent to hands-on care activities. Confidence improved after training in various
interventions, which might be attributed to the program's inclusion of the factors
58 59 63
previously mentioned. Clarifying which components of knowledge are
critical to confidence will aid in the development of more successful training
programs.
4.4. Key Finding
This is the first study to explore knowledge, attitudes, and confidence in
providing dementia care among nurses in different aged care facilities in Vietnam.
Specifically, this is also the first study on the capacity of the healthcare workforce
in nursing homes in the country, a common form of elderly care facilities in the
world but still relatively new in Vietnam and only was invested in the central cities
of the three regions. The findings suggested the surveyed nurses had insufficient
knowledge, a low level of positive attitude related to social comfort towards
dementia cases and were not really confident in providing care. Ineffective
communication between nurses and patients was identified as the most challenging
of all KAC aspects in dementia care practice. Prior seeking of dementia information
through expert consultation was found to be associated with better dementia
knowledge. A positive correlation was reported between the knowledge and attitude
scores, and between the attitudes and confidence scores. This study implies that a
national strategy on dementia care training and the development of a dementia
curriculum for learners in nursing at both undergraduate institutions and workplaces
in Vietnam are critical.
4.5. Limitation
This study has some limitations. The cross-sectional study design limits the
ability to establish causal relationships, only concluding associations between
factors and KAC scores. Secondly, because the study sample included nurses from
67
the national specialty hospital, their capacity may be superior to the target nursing
population in Hanoi as well as in the region and is a limitation on the generalization
of our findings. Thirdly, the self-administered questionnaires could lead to
inaccuracies in knowledge outcomes because nurses randomly selected the correct
answer instead of honestly answering that they did not know, or positive inflations
in the responses about attitudes and confidence. For capacity assessment as well as
in real practice, checklists for evaluating clinical performance in dementia care are
ideal and need to be developed in the future. Finally, besides personnel factors that
have been studied in this study, it is necessary to consider environmental factors
and barriers that hinder good care practice in further studies.
68
CONCLUSION
Ineffective communication between nurses and patients was identified as the

most challenging of all KAC aspects in dementia care practice.
This study highlights deficits of knowledge, a low level of social comfort in
attitude and lack of confidence in providing dementia care among nurses in geriatric
healthcare settings in Vietnam.
Hospital nurses were more knowledgeable about pathology and prevention
of dementia and in almost aspects of palliative care, whereas nursing home nurses
had a better understanding of communication and dealing with behavioral
difficulties in patients, as well as having more confidence.
69
RECOMMENDATION
It is necessary to apply interdisciplinary approaches in dementia

training, especially in communication skills and anticipating patient care
needs.
Enhance ongoing consultation with specialists in clinical practice for
the long-term care workforce from both pharmacological and non-
pharmacological standpoints, with a particular emphasis on prioritizing
training based on unit characteristics.
Further studies are needed to assess the changes in knowledge, attitudes
and confidence in dementia care as curricular revisions and counseling are
carried out.
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MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH

HANOI MEDICAL UNIVERSITY

NGUYEN HUYNH PHUONG ANH

KNOWLEDGE, ATTITUDE, AND CONFIDENCE OF

MASTER THESIS PROPOSAL: EPIDEMIOLOGY

NGUYEN HUYNH PHUONG ANH

KNOWLEDGE, ATTITUDE, AND CONFIDENCE OF

MASTER THESIS PROPOSAL

I would like to thank my esteemed supervisors – Assoc. Prof. Vu Thi

Hanoi, 4th October 2023

Nguyen Huynh Phuong Anh

Respectfully addressed to:

Nguyen Huynh Phuong Anh

Figure 1.1. Conceptual framework ................................................................. 27

CODE Confidence in Dementia Scale

However, little is known about the professional healthcare workforce. There

Nurses play an important role in providing dementia care in hospitals,

Epidemiology of Dementia in Vietnam

Air pollution. Studies in animals have indicated that air pollution

Infections and immune disorders. Dementia-like symptoms can result

previously learned information)

(c) agnosia (failure to recognize or identify objects despite intact sensory

(d) disturbance in executive functioning (i.e., planning, organizing,

B. The cognitive deficits in Criteria A1 and A2 each cause significant

C. The course is characterized by gradual onset and continuing cognitive

1. Other central nervous system conditions that cause progressive deficits in

2. Systemic conditions that are known to cause dementia (e.g.,

E. The deficits do not occur exclusively during the course of a delirium.

Major Depressive Episode, Schizophrenia).

1.1.5. Dementia care

A Knowledge, Attitude and Practices (KAP) survey is a quantitative method

1.2.2. Assess the knowledge, attitude, and confidence of dementia care

For assessment of knowledge and attitude toward advanced dementia:

The Questionnaire on Palliative Care for Advanced Dementia (qPAD) is a 2-

advanced dementia. Factor analyses of the Knowledge Test (coefficient a= .81)

produced 3 factors: Anticipating Needs, Preventing Negative Outcomes, and Insight

For confidence assessment:

Confidence in Dementia Scale: This new nine-item self-report questionnaire

Meyer-Olkin (KMO) measure of sampling adequacy assesses whether the sample

consistency without too much item redundancy.

1.2.3. Knowledge, attitude, and confidence about dementia in the world

Helen Chan 218 facilitators in 1069 healthcare Pre-and- Pre: 27.7±8.6/50

Pre-and- Control group:

Chee Mun 7 medical 464 final-year

Yulisna Sari 1061 cross-

Previous researches used DAS for attitude assessment:

Wenhong 11 public tertiary 603 cross-

Chong Kar a private hospital in Cross-

Previous researches used qPAD for assessment of knowledge and attitude

74 longterm 121 nurses Cross- K: 12.7±3.6/23

20 nursing RCT for

125 nurses K: 14.3±3.2/23

Previous rsearches used CODE for confidence assessment:

Lucy 162 qualified

Acute care, mental

The second largest 11 clinical staff

1.2.4. Knowledge, attitude, and confidence about dementia in Vietnam

Author & Population Screening Tool Results

Nguyen 142 full-time HCWs Alzheimer's Disease The prevalence of good

1.3. Factors associated with knowledge, attitude, and confidence in dementia

Factors associated with attitude about dementia

• Types/ position level of work 61

1.4. Overview of research healthcare settings

In terms of professional organizational structure, the hospital has 12 clinical