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Committee on the Public Health Dimensions of Cognitive Aging; Board on Health Sciences Policy; Institute of Medicine; Blazer DG, Yaffe K, Liverman CT, editors. Cognitive Aging: Progress in Understanding and Opportunities for Action. Washington (DC): National Academies Press (US); 2015 Jul 21.

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Cognitive Aging: Progress in Understanding and Opportunities for Action.

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7Public Education and Key Messages

Meeting the public health goal of maintaining cognitive health requires clear and effective communication featuring accurate, up-to-date, and consistent messages that resonate with individuals and their communities. Attention needs to be paid to whether different segments of the population are exposed to relevant information, persuaded to act accordingly, and have the environmental supports in place to change and maintain behaviors that are supportive of cognitive health. Because new research findings are constantly becoming available, stakeholders also need reliable means of keeping up with this rapidly changing field.

This chapter covers what is known about public knowledge, attitudes, and beliefs about cognitive aging (as distinct from Alzheimer's disease or dementia); how the public currently receives and could receive information about cognitive aging; and effective public health messaging. The chapter concludes with key messages to be disseminated on cognitive aging and recommendations for next steps.

PUBLIC PERCEPTIONS AND BELIEFS ABOUT COGNITIVE AGING

The term “cognitive aging” is relatively new, and therefore the public is less familiar with it than with terms for brain diseases such as dementia and Alzheimer's disease. The level of awareness of Alzheimer's disease is very high. In 2006, 93 percent of Americans age 45 or older said they had heard of Alzheimer's disease (MetLife MMI and LifePlans, 2006). Public communication about cognitive aging will need to cover its definition and scope (see Chapters 1 and 2), explain how it differs from brain disease, describe the range of cognitive abilities and how they change with age (some improve, some decline), highlight the variability among individuals in cognitive changes with age, and underscore the ways in which maintaining cognitive health preserves an individual's relationships, independence, sense of autonomy, and enjoyment of favorite activities.

When trying to influence health behavior change, such as the adoption of behaviors that protect and enhance cognitive health, it is important to understand the motives that people have for their actions, their perceptions about the efficacy of the actions and their ability to perform them, and the environmental factors that support or hinder the behaviors (Ajzen, 1991; Bandura, 1986; Fisher and Fisher, 2002; Sallis et al., 2008). Past public communication campaigns aimed at preventing negative health outcomes have made an impact on middle-aged and older adults (Snyder and LaCroix, 2013), meaning that public efforts to change the behavior of middle-aged and older individuals related to cognitive aging may be more successful than such interventions at earlier ages, when people may believe the issue is less personally relevant. Understanding how middle-aged and older adults feel about cognitive health and decline is essential.

In surveys and focus groups, midlife and older adults express significant widespread fears and concerns about cognitive decline and the loss of decision-making capacity (AARP, 2012; Anderson et al., 2009; CDC, 2013; Friedman et al., 2013; Laditka et al., 2011; Price et al., 2011). Studies in 2002 and 2006 found that more than 60 percent of the adult population feared memory loss when they were older (Cutler et al., 2002; PARADE and Research!America, 2006). In 2009, 73 percent of adults over 18 years of age reported that they were concerned or very concerned “that their memory may worsen with age,” a concern that was highest among women and those of middle age (Friedman et al., 2013). A substantial proportion of adults (66 percent) is also concerned about needing to take care of a loved one with Alzheimer's disease in the future, while 44 percent currently have a family member or friend with Alzheimer's disease (MetLife MMI et al., 2011). Sixty percent of people over 50 years of age would like to know their own risk of developing Alzheimer's disease someday (Roberts et al., 2014). Most people over 50 years old (89 percent in a recent survey) understand that genetics can play a role in Alzheimer's disease risk; fewer (55 percent) realize that stress can play a role in its development (Roberts et al., 2014).

A number of studies highlight older Americans' greater fear of dementia and memory loss, compared with other health and financial worries. In 2013 a YouGov survey supported by the Alzheimer's Association and the Centers for Disease Control and Prevention (CDC) found that Americans age 60 and older were more afraid of Alzheimer's disease or dementia than of cancer, heart disease, stroke, or diabetes (Alzheimer's Association, 2014). The primary reasons why people are afraid of Alzheimer's disease are forgetting family, becoming a burden to the family, and not being able to take care of oneself. Additional reasons are the fear of losing their personality and who they are, and having had experience with someone who had the disease (Alzheimer's Association, 2014). Similarly, a small non-representative survey found that people over 50 years of age were more afraid of “losing my mental sharpness” than other risks, which included, in declining order, “losing my overall health,” “a family member losing their overall health,” “not being able to take care of myself,” “running out of money,” “getting a terminal illness,” and “losing a spouse” (AARP, 2014).

The relatively high level of worry among older Americans about maintaining their own and their loved one's cognitive health as they age gives public education campaigns a motivator for behavior change that they should be able to tap into.

Perceptions of Actions to Maintain Cognitive Health

Surveys indicate that most members of the general public are aware of behaviors that they believe can help safeguard their cognition as they age. One survey found that 88 percent of respondents who were 42 years old or older said they believed that there was something they could do to keep their brains fit, such as doing mental challenges and eating a healthy diet (ASA and MetLife Foundation, 2006).

A large national 2010 survey that asked adults over 50 years of age about Alzheimer's disease found that most believed that keeping mentally active (93 percent), eating a healthy diet (87 percent), keeping physically active (88 percent), and taking vitamins or dietary supplements (71 percent) are very or somewhat effective in preventing the disease (Roberts et al., 2014). People who were older or were African American were more likely to endorse physical activity as a protective factor; women, African Americans, and those with lower education were more likely to endorse eating a healthy diet; and those who were 65 to 74 years old, Hispanics, African Americans, those with less education, and those who did not know anyone or who did not have a first-degree relative or spouse with Alzheimer's disease were more likely to profess a belief in taking vitamins or supplements as a preventive measure (Roberts et al., 2014).

In 2009 Friedman and colleagues (2013) added questions to a large nationally representative survey (HealthStyles Consumer Survey) that addressed beliefs about memory worsening with age, activities that may benefit abilities to think and remember, preferred sources of information, and whether health professionals had spoken to consumers about ways to “stay sharp.” Adults age 18 and older agreed with statements that they could prevent or delay cognitive impairment through intellectual stimulation (87 percent), physical activity (83 percent), a healthy diet (83 percent), maintaining a healthy weight (65 percent), social involvement (64 percent), taking vitamins or supplements (64 percent), avoiding smoking (52 percent), and taking prescribed medicines (31 percent). In contrast, slightly fewer said they actually engaged in these activities and behavior: 74 percent said they engaged in intellectually stimulating activities, 72 percent in physical activity, 65 percent in a healthy diet, 55 percent in maintaining a healthy weight, 52 percent in social involvement, 61 percent in taking vitamins or supplements, 59 percent in avoiding smoking, and 38 percent in taking prescribed medicines (Friedman et al., 2013). In another survey, conducted online in 2008, 50 percent of the African Americans surveyed said they engaged in behavior aimed at maintaining brain health (Alzheimer's Association, 2008).

Misunderstandings About Cognitive Aging

Misunderstandings about cognitive aging are common. First, brain health is often seen as limited to preserving memory, perhaps because of the devastating and observable effect of Alzheimer's disease (e.g., Laditka et al., 2013). However, as discussed in Chapters 1 and 2, cognition encompasses many brain functions.

Second, people do not generally understand that aging can have both positive and negative effects on cognition. Wisdom and expertise can increase as people age. The ability to think logically and solve problems is maintained over time in healthy adults. Overall, older adults are more likely to be satisfied with their lives in general, and they report experiencing negative emotions, such as anger and worry, less often than people in young adulthood and midlife (Carstensen et al., 2011; Charles et al., 2001; Stone et al., 2010). Older adults may be better able than younger counterparts to regulate their emotions in the face of stress (e.g., Brose et al., 2011; Neupert et al., 2007; NRC, 2006; Schilling and Diehl, 2014; Uchino et al., 2006). Older adults tend to have a more secure and complex view of themselves than do younger people (Perlmutter, 1988). Focusing only on the negative effects of aging on cognition may be inappropriately stigmatizing.

Third, the preventive actions that people should take to preserve or enhance their cognitive function are often misunderstood. Many people mistakenly believe that vitamins and supplements are effective in maintaining cognitive health (Friedman et al., 2013; Roberts et al., 2014), even though there is no compelling evidence that, in the absence of individual deficits in specific vitamin levels, such dietary additions are beneficial (see Chapter 4A). Sales of online cognitive games and training suggest that individuals see these products as beneficial to their cognitive health, although much remains to be learned about the extent to which the skills learned through games and cognitive training can transfer to activities of daily life (see Chapter 4C). Qualitative research suggests that people rely on anecdotal evidence, such as observing that a physically active friend developed Alzheimer's disease, to assess the efficacy of preventive actions, which can result in misleading conclusions (Wu et al., 2009). Messages for the public should emphasize the cognitive health actions that (1) have the strongest research evidence indicating that they improve cognitive health and preventing declines; or (2) have scientific evidence indicating that they are likely to be beneficial for cognitive health and also are proven to be beneficial for health overall.

Fourth, misperceptions exist about the science of the brain and how it works and ages. The gaps in current understanding are not surprising given the rapid gains in neuroscience knowledge in recent decades. People may believe that brain neurons die as they age and that neuron death is inevitable. In fact, neurons may lose synapses as an individual ages, but in the absence of neurodegenerative disorders such as Alzheimer's disease, neuron death is minimal (Morrison and Baxter, 2012). Mistaken understandings of brain mechanisms of cognitive decline may block people from seeing any reason to invest in prevention efforts.

Sociocultural Differences in Perceptions of Cognitive Aging

Understanding the variations in how people perceive cognitive aging is important in order to inform the development of appropriate and well-targeted public education programs. Both quantitative and qualitative data show some differences and some commonalities among diverse sociocultural groups. Other studies, although focused on risk of cognitive impairment and prevention of Alzheimer's disease, provide important information about misinformation, concerns, motivations, and current actions.

Ethnicity

Enough ethnic and racial groups differences in perceptions about cognitive aging exist to require careful testing of public campaigns among different audiences (IOM, 2002). Some surveys have suggested that African American and Latino survey participants worry slightly less about dementia than do white participants (Connell et al., 2009; Friedman et al., 2013; Roberts et al., 2003), but more recent data do not show significant ethnic differences in worry about Alzheimer's disease (Roberts et al., 2014).

Building on earlier ethnographic and qualitative studies (e.g., Fox et al., 1999; Hashmi, 2009), the Healthy Aging Research Network, which is funded by the CDC, conducted focus groups throughout the United States in order to examine perceptions of cognitive aging (see, Laditka, J. N., et al., 2009, for a description). All ethnic groups expressed fears about memory loss and used similar terms to talk about the state of decline. Many commonalities were seen across ethnicities in their perceptions of what it means to age well, including being cognitively alert and maintaining a positive outlook, having a good memory, being socially active and engaged, living to an advanced age, and having good physical health (Friedman et al., 2011; Laditka, S. B., et al., 2009). Beliefs about efficacious strategies to stay mentally sharp—such as being active socially and connected to the community, having mental stimulation such as reading, and being physically active—were also similar across groups (Friedman et al., 2011; Wilcox et al., 2009).

However, there were differences among the ethnic groups' views about the attributed causes and symptoms of people with cognitive impairment, as well as their level of concern about stigma and family reactions to cognitive impairment. These differences suggest ways in which messages may need to be tailored (Laditka et al., 2011, 2013). In addition, there may be differences in beliefs about the inevitability of dementia, which could point to differences in individuals' motivation to perform actions to prevent cognitive decline. Researchers developing messages will need to assess beliefs about the inevitability of disease.

When asked about the efficacy of prevention efforts, African American and white participants are more likely than other ethnic groups (Chinese American, Latino, and Vietnamese American) to endorse mental exercises and puzzles (Friedman et al., 2011). Other differences in beliefs about prevention behaviors, including beliefs that particular foods and supplements promote cognitive health, may need to be addressed in public communication efforts aimed at promoting evidence-based behavior (Friedman et al., 2011; Laditka, J. N., et al., 2009; Wilcox et al., 2009).

Public education efforts should begin with an exploration of the attitudes and beliefs of the particular population segments that a given program or campaign is attempting to reach. Given the wide variation in perceptions about cognitive health and dementia throughout the world (Hashmi, 2009; Henderson and Traphagan, 2005), new immigrant groups may have views that are significantly different from those of the U.S. resident populations studied in surveys to date. Furthermore, wide variations in views will exist among individuals within the broad ethnic groups surveyed.

Gender

Some studies find that women are more concerned than men about cognitive aging (Friedman et al., 2013; Wu et al., 2009), but other studies do not find a difference (Roberts et al., 2014). Women are more likely than men to know that having a first-degree relative with Alzheimer's disease increases their risk for the disease and to believe that a healthy diet can be a protective factor against Alzheimer's disease (Roberts et al., 2014). In a qualitative comparison of rural men and women, women were more likely to search for information about cognitive health and to consider reducing stress, adopting a healthier diet, and increasing their social engagement to promote cognitive health (Wu et al., 2009).

Education and Income

People with fewer economic resources and less education often have a high burden of disease and less knowledge about health promotion and disease prevention than those with more education and income. For example, people with fewer economic resources and less education are more likely to believe that there are prescription drugs, vitamins, and supplements that can help prevent cognitive impairment (Roberts et al., 2014). This is particularly concerning given that they may spend limited household resources on unproven measures instead of on physical activity and reducing cardiovascular risks, which are known to be efficacious (Chapters 4A and 4B).

People of lower socioeconomic status are less likely to have a healthy lifestyle, and they face numerous environmental barriers to changing their physical activity and dietary habits. Well-designed educational campaigns and programs will be sensitive to the contexts in which people live and to their personal resources, available and preferred ways of learning about health issues, the sources they trust for health information, and their literacy levels (see section below).

Summary

The knowledge and motivation to engage in behavior that promotes cognitive health may vary by gender, ethnicity, income, and education level, and thus educational strategies and materials need to be relevant to the needs of specific target groups. If there is evidence that broad public campaigns are not successful, it will be advantageous to target each segment of the population separately (IOM, 2002).

INFORMATION ENVIRONMENT

Efforts to educate the public about cognitive aging and to promote particular types of behavior will need to take into account the information-rich environment in the United States and how best to reach middle-aged and older adults. The existence of information in the environment hardly guarantees that people pay attention to it; there is a long tradition in communication research of studying the conditions under which information in the media has an impact and how people use the media (e.g., Bryant and Oliver, 2009). Additional studies will be needed to understand when and for whom cognitive aging information in the environment makes a difference. As one example, qualitative studies suggest that at the oldest ages people rely more on health professionals and people in their social network than on media sources to keep them up to date on information (e.g., Williamson and Asla, 2009).

News Media and Magazines

U.S. adults age 65 years and older rely more on television and newspapers for their news than do other age groups (Pew Research Center, 2015). However, the committee was unable to identify studies examining the coverage of cognitive aging in traditional news and information media (including broadcast and print).

The issue has been addressed in magazine coverage. A content analysis of articles in the top eight women's and men's magazines in 2006–2007 found an average of four messages related to cognitive health per magazine in 2006, and three in 2007, with the most common recommendations for maintaining cognitive health relating to diet, followed by vitamins and supplements, cognitive exercises, physical activity, and social interactions (Friedman et al., 2010). No mention was made of hypertension and diabetes as risk factors for cognitive health, and magazines targeting African Americans had very little cognitive health information (Friedman et al., 2010). An analysis of the top five magazines among people 50 years and older had similar findings (Mathews et al., 2009) with only a small portion of the articles promoting physical activity for brain health. In another assessment of magazines targeting U.S. older adults, the recommended amount of physical activity per week varied widely, only half of the stories explained the link between physical activity and cognitive health, and few cited the empirical evidence for the relationships (Price et al., 2011). More research is needed to understand how cognitive aging is covered in television news and newspapers in the United States, including in Spanish-language and other news media targeting specific cultural groups.

Internet and Social Media

For many people seeking health information, the Internet has become a major resource. The digital divide has shrunk, with people of most ethnicities and ages using the Internet, with the least likely users being adults 80 years and older (although 37 percent of this group was found to use the Internet) and those who have little education (Pew Research Center, 2014). About half of adults who are 65 years and older and who use the Internet say that getting health information is one of their top motivations for going online (Pew Research Center, 2014).

Studies have examined the coverage of cognitive health on websites of news organizations, health systems, state and city health departments, and senior centers. From 2007 to 2010, the top three cable news websites included about 230 stories related to cognitive health, with an emphasis on maintaining function and preventing decline through lifestyle choices (Vandenberg et al., 2012). The study authors estimated that only 18 percent of the stories were aimed at older adults and that 20 percent featured vitamins and supplements (Vandenberg et al., 2012). Not surprisingly, cognitive function and impairment were not well defined in the stories (Vandenberg et al., 2012). After reviewing the websites of 156 large health systems and health departments and 181 senior centers, Laditka and colleagues (2012) found that large health systems were more likely to promote cognitive health than were senior centers, but promotion of physical activity represented only 20 percent of the website content.

Although active monthly Twitter users are predominantly younger (only 3 percent of adults who are 65 years and older use Twitter regularly), it can be an important channel for people already interested in a topic, including activists, policy makers, and public health officials (Pew Research Center, 2014). There are studies focused on dementia as a topic of conversations on Twitter, but the committee did not find studies looking at the topics of cognitive health or cognitive aging. One content analysis of a sample of information about dementia on Twitter found that news about recent research studies was the most common type of content and that only a small number of those studies were about the prevention of dementia (Robillard et al., 2013). Most tweets about dementia were posted by health professionals, health information sites, news organizations, and commercial entities. Consistent with the way that Twitter is often used—to push readers to websites or videos with more information—most tweets about dementia contained a link to a major news outlet or health information site (Robillard et al., 2013).

About half of older adults who are online use social networking sites such as Facebook, which increases their social connections with family and friends (Pew Research Center, 2014). It is unknown how often they share information and provide encouragement for behaviors that support or undermine cognitive health.

In summary, information is available online about cognitive health and it has been covered to some degree in magazines, but it is unknown how much cognitive aging has appeared in the news sources that older adults most often use—television and newspapers. More information is needed about how people of different ages learn about cognitive aging, including which sources they actively use, features they prefer or avoid, and their ability to evaluate the quality of the information.

Entertainment Media

Knowing the extent to which entertainment fare on television and in movies depict healthy older adults engaged in behavior relevant to promoting cognitive health would be valuable information for public education efforts. Research has shown that people can become motivated and learn new skills through the modeling provided by fictional accounts as long as the actions result in positive consequences for the character (Bandura, 1986; Singhal and Rogers, 1999). Although it cannot be said for sure because of the lack of research, it is likely that the topic is not well covered, given that the entertainment media tends to underrepresent older adults compared to their presence in the U.S. population. Older adults are underrepresented in prime-time television (Signorielli, 2004), video games (Williams et al., 2009), prime-time medical dramas (Hetsroni, 2009), and children's programs (Bond and Drogos, 2008).

In a 2006 study of children's programming, older adults tended to be portrayed as healthy, morally good, attractive, and satisfied with life, but only 36 percent of older adult characters were women and only 14 percent were people of color (Bond and Drogos, 2008). Disney animated movies similarly underrepresent older women and people of color, and a study found that overall, 42 percent of older characters were portrayed negatively (e.g., grumpy, evil, helpless, or “crazy”), with almost half of the villains in the stories being older adults (Robinson et al., 2007).

Given the general lack of attention to cognitive health in past studies of entertainment fare, and the likelihood that content may have changed since existing studies were conducted, it would be beneficial to systematically study the current depiction of cognitive aging in entertainment media.

Current Public Education Campaigns and Resources

Media campaigns are needed that focus on cognitive aging and that convey the range of non-dementia cognitive issues faced by older adults and their families as well as the wide variability in cognitive function among older adults. Much of the outreach to date has concerned dementia or has addressed only a particular risk factor prevention strategy. Although some messages and materials are relevant—as reviewed below—there remains a strong need for campaigns that focus squarely on healthy cognitive aging.

In addition to its goals relevant to people diagnosed with dementia and their caregivers, the Healthy Brain Initiative seeks to improve the cognitive health of the American population (Alzheimer's Association and CDC, 2013). One goal is to support state and local needs assessments to identify disparities and ensure that educational materials are culturally appropriate (Alzheimer's Association and CDC, 2013). To date, the CDC Healthy Aging Research Network has used qualitative methods to assess the public understanding of cognitive aging and to make recommendations about public messages, such as the need to make messages more salient to people with diverse backgrounds. Much of that research is cited earlier in this chapter. A number of the objectives related to public awareness and improved access to information and resources are relevant to healthy cognitive aging, including

  • coordinating national and state efforts to disseminate evidence-based messages about risk reduction for preserving cognitive health;
  • working to ensure the consistency of cognitive health messages across national, state, and local levels;
  • decreasing stigma and promoting strategies for the public to learn how to communicate appropriately with people with dementia;
  • promoting early diagnosis of cognitive impairment; and
  • promoting research on cognitive health promotion.

As of 2011, the CDC had improved the information infrastructure relating to cognitive health for professionals by creating lesson plans for middle- and high-school science teachers, making improvements to its website, adding items related to cognitive impairment to the Behavioral Risk Factor Surveillance System survey (see Chapter 3), giving presentations at professional organizations, and publishing scientific literature on the topic (Alzheimer's Association and CDC, 2013). In 2014 the initiative funded five prevention research centers at leading universities to establish a research network to monitor attitudes and health status over time, to create and test messages and interventions to improve or maintain cognitive function, and to use that knowledge to support effective programs and practices in states and communities (CDC, 2014).

Using workshops, events, and mass media, the CDC and the Alzheimer's Association ran a demonstration project through local Alzheimer's Association chapters in Atlanta and Los Angeles aimed at increasing awareness of cognitive health, physical activity, and cardiovascular health among African American baby boomers. The evaluation found that people who had participated in the workshops had increased knowledge about brain health and were more motivated to engage in preventive behaviors related to screening for chronic cardiovascular disease risks (Fuller et al., 2012). However, the workshops and events reached only a small number of people in the target group, and it is unclear how many people were exposed to the modest media presence (Fuller et al., 2012). Furthermore, the extent to which people in the workshops or at the events changed their behavior is unknown, as is whether attendees inspired others to change their behavior. While the project showed that community partners can be engaged within a relatively short period of time to promote cognitive health and that workshops on cognitive health designed with local partners and targeted to a specific age and ethnicity can affect knowledge and some behavioral intentions, a greater media presence will be necessary to reach large numbers of people.

Federal agencies and nongovernmental organizations have made information available for interested members of the public and for public health and health care professionals to use with their patients or clients. Examples are listed in Box 7-1.

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BOX 7-1

Examples of Information Resources on Cognitive Aging. AARP, Dana Foundation, and MetLife Foundation: These organizations print and distribute a series of booklets in English, Mandarin, and Spanish on recent advances in brain studies titled Staying Sharp (more...)

RELEVANT COMMUNICATIONS STRATEGIES AND MESSAGES

Communication and public education efforts pertinent to cognitive aging can benefit from and build on the public health improvement efforts by federal, state, and local agencies, nonprofit organizations, community initiatives, foundations, and private-sector companies.

Physical Activity

Physical activity is recommended for all age groups because of its health benefits in a variety of domains, including cognitive health (see Chapter 4A). However, the concerted efforts to improve physical activity levels in the general population over the past 40 years have not managed to counter the rising levels of inactivity (Brownson et al., 2005). Most older adults are inactive, and among the very old the rate of decline in activity levels is more rapid each year (Buchman et al., 2014). Interventions to improve physical activity among older adults achieve, on average, incremental improvements, but generally the increase is not enough to meet recommended levels (Conn et al., 2003, 2012). Because people who were more active when they were younger often continue to be more active as they age (e.g., Dohle and Wansink, 2013), it might be useful if future efforts to improve cognitive health target younger age groups. Numerous strategies have been explored for increasing physical activity levels (Prohaska and Peters, 2007), and, as discussed in Box 7-2 and Chapter 6, a combination of strategies will likely be most useful in sustaining behavior change. Evaluations will continue to be needed to determine the most effective approaches to long-term behavior change.

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BOX 7-2

Strategies for Increasing Physical Activity. Counseling and small group sessions: Counseling can happen in many settings, from a clinician's office to recreation facilities, gyms, libraries, and even at home. Evidence suggests that counseling by a trained (more...)

Although evidence to recommend media campaigns as a standalone approach to increase physical activity is lacking (Brown et al., 2012; Kahn et al., 2002), targeted campaigns with links to community-based opportunities for physical activity can be an effective strategy for some population groups (Heath et al., 2012). Note that because limited-duration media campaigns may not result in sustained behavior change, they may be most effective over the long term when tied with efforts that keep people engaged, such as social support approaches.

Medication Adherence and Review

Proper medication adherence is critical for preventing many of the risk factors for cognitive decline. As detailed in Chapter 4B, some medications can impair cognition in older adults, and all older adults should have careful and periodic review of their medications, including supplements, by a clinician. Of the 67 million U.S. adults with hypertension, an estimated 54 percent are not controlling it, even though most have a source of health care and insurance (CDC, 2012b; Johnson et al., 2014; Ritchey et al., 2014). Older adults may find it difficult to adhere to their medication regimens, particularly when they need to take many medications. Many older adults, however, do recognize their own memory limits and use memory aids, and sometimes they are more conscientious than middle-aged adults about taking their medications (Park et al., 1999).

Recent reviews have suggested that educational and other interventions can promote adherence to medication regimens if they improve knowledge about the relevant medical condition, provide ongoing counseling and accountability, provide appropriate tools and strategies to help patients self-monitor, and increase access to memory aids that help people remember to take and refill their medications (Frazee et al., 2014; Zullig et al., 2013). A meta-analysis of interventions to improve anti-hypertensive medication adherence among older adults found that these interventions successfully improved adherence and knowledge and also helped improve diastolic blood pressure (Conn et al., 2009). The interventions were more effective among women and those taking three to five medications. Interventions targeting adherence plus another behavior had the same impact as interventions targeting adherence alone, which suggests that cognitive aging campaigns could focus on adherence alone or adherence and other goals, such as physical activity. Neither the mode of delivery (e.g., media, face-to-face counseling, or both) nor the type of professional conducting the counseling made any difference in the results. A meta-analysis of pharmacist-delivered interventions, which most often included medication management providing information for the patient and frequent follow-ups, found improvements in adherence and in blood pressure (Morgado et al., 2011).

Some of the more effective interventions for medication adherence among adults 60 years and older are tailoring (changing the message based on information about the individual patients), face-to-face counseling, and rehearsal of medication taking (Xu, 2014). Clinicians offering interventions should consider targeting multiple family members with high blood pressure at once; research with African Americans found that older parents were better at taking anti-hypertension medications than their adult children and that when the adult children had conversations with their parents about hypertension, the adult children had higher adherence levels too (Warren-Findlow et al., 2011). Despite the efficacy of face-to-face communication strategies, it can be difficult to recruit people to participate in small group interventions (Robare et al., 2011), so additional channels should be considered.

Financial Responsibility, Driving, and Health Decisions

The risks related to cognitive changes with age that require the greatest attention may be those related to health and financial decision making and also skills requiring complex judgment and quick reactions in high-risk situations, such as driving; these risks require attention even in the absence of Alzheimer's or related diseases (see Chapter 6) (Agarwal et al., 2009; Boyle et al., 2012; Carpenter and Yoon, 2011; James et al., 2012; Klein and Karlawish, 2010; Sabatino, 2011; Triebel and Marson, 2012; Widera et al., 2011). Efforts need to be made to improve and increase the development, testing, and evaluating of the messages that older adults and their families need on these issues.

In terms of financial decision making, surveys show a gap between people's estimates of their ability to make financial decisions and their actual financial literacy, and this gap widens with age (Lusardi and Mitchell, 2011). As discussed in Chapter 6, a number of efforts are under way to assist older adults and their families in making sound financial decisions. Messages targeted to older adults could: emphasize the need for periodic financial reviews and the steps to take to consult with financial advisors who are legally required to represent the client's financial interests, are registered, and have not violated the law in the past; alert people to common scams and unscrupulous sales practices; and identify methods for finding trustworthy information with which to raise financial literacy, if they so choose. Tools to help people select reliable and trustworthy brokers and to avoid fraud, such as the Financial Industry Regulatory Authority's (FINRA's) “BrokerCheck,” “RiskMeter,” and “ScamMeter” developed by FINRA, could be promoted more widely (FINRA, 2015). At the same time, more research is needed on the types and efficacy of financial education (including the value of these online tools) in improving decision making (Agarwal et al., 2009).

As in the case with financial literacy, older drivers often do not recognize when they need coaching to improve their skills or when to stop driving. The decision to stop driving can be emotionally laden, because driving is often linked with independence (NRC, 2006). Messages aimed at older adults, their families, and health care providers can promote older driver training programs, local transportation alternatives, warning signs of diminished driving ability, and assessments of driving skills. Older adults may be motivated to reevaluate their driving by a desire to not harm others or by the rising cost of their automobile insurance. The availability of periodic confidential driving assessments may ameliorate the fear of losing driving privileges for unwarranted reasons. Public campaigns aimed at older drivers and families could help connect people with assessment and training programs in their communities and online (see Chapter 6).

When faced with decisions on medical procedures, older adults may benefit from messages telling them where to learn more about specific treatment options and informing them of the need to review decisions with trusted others. For people of all ages, decision making is more difficult under stress, such as after a diagnosis (Keinan, 1987). Information about care options for older adults should be carefully pretested to ensure that the population can use and understand them. Communication skills training can be beneficial for both families and health professionals (Heaney and Israel, 2009; Kurtz et al., 2009; Wolff and Roter, 2011; Wolff et al., 2014).

In sum, families and people who work with older adults should be made aware of the potential challenges to health, driving, and financial decision making that may occur with age and be alert for signs indicating a need for greater involvement in decisions. Families may benefit from messages suggesting strategies for communicating with their older relatives about specific decisions and decision making in general.

CHALLENGES FOR PUBLIC EDUCATION CAMPAIGNS

Combating Stigma and Prejudice

Studies have shown that in many countries, the United States included, cognitive impairment is stigmatized, and this stigma has been a barrier to early detection and treatment (Wahl, 2012; WHO, 2012). By extension, people with healthy cognitive aging may be reluctant to seek a professional assessment of their cognitive status. Stigma may block people from communicating about their fear of cognitive decline with family and friends, making it less likely they will learn about preventive measures or ways to reverse treatable causes of decline. For example, if a memory lapse is met by ridicule or visible impatience, a person may be embarrassed or feel shame, and psychological research suggests that shame often results in escaping and avoiding the shame-inducing situations (Tangney, 2013). There is also the potential that fear and stigma will lead an individual to shy away from social interactions, and the resulting diminished social connections, support, and stimulation in turn could contribute to further cognitive decline.

Older adults with more positive views of themselves and of aging in general have better health and are less likely to be depressed (Coleman et al., 1993). At the same time, negative stereotypes about older adults in general—such as that they are losing their cognitive, physical, and communication abilities—may affect how older adults perceive themselves and also affect interactions between generations (Caporael and Culbertson, 1986; Levy et al., 1999; Pasupathi et al., 1995; Williams and Nussbaum, 2001). Negative stereotypes can affect various physical measures—increasing blood pressure and heart rate and decreasing walking speed—as well as such cognitive and attitudinal outcomes as memory decline, and even the will to live (Hausdorff et al., 1999; Hess et al., 2003; Levy et al., 1999, 2000).

Cognitively healthy older adults who experience patronizing attitudes from young adults are more likely to perceive themselves as impaired (e.g., Kemper et al., 1996). As a result, older people may avoid situations in which they may be the target of prejudice (NRC, 2006; Shelton et al., 2005). This can reduce older adults' opportunities to engage in some of the recommended behaviors that are useful in maintaining cognitive health. If, for example, older adults avoid going to the gym for fear of not “measuring up,” they may get less physical activity than they need. If they avoid social interactions with younger people, they may be missing the benefits of social engagement.

Evaluations of programs specifically related to stigma against people with cognitive aging are sparse, and this topic should be explored in future research. In the absence of research on what works to counter stigma for cognitive aging, it is useful to consider programs that counter other types of stigma and prejudices. The experiences, both positive and negative, with programs that have attempted to combat stigma against aging in general as well as those countering stigma against dementia or other mental illnesses can point to a number of strategies that could be employed.

Promote Positive Interactions

Research shows that good quality contact between individuals can help dispel a person's negative attitudes toward another group (Knox et al., 1986), and this phenomenon has been used in interventions against ageism and mental health stigmas. Meta-analyses of programs designed to reduce stigma against mental illness in the general population have found that in-person contact is an efficacious approach among adults (Corrigan et al., 2012; Griffiths et al., 2014). For example, the campaign Time to Change in the U.K. aimed to reduce mental illness stigma by fostering social contact at mass events and in places with a lot of foot traffic, such as malls and community centers (Evans-Lacko et al., 2012). The evaluation of this program found that mere contact was not enough—people needed to feel they were working together to improve conditions for people with mental illness. When they had a sense of common goals, they improved their intention to have greater social contact in the future with people with mental illnesses, even 4 to 6 weeks after the interaction (Evans-Lacko et al., 2012).

A meta-analysis of mental health stigma interventions aimed at health care workers found that the key elements of effective interventions were emphasizing the possibility of recovery from mental illness and having multiple forms of social contact with people who have experienced it (Knaak et al., 2014). On average, those programs had at least a short-term effect on stigma; the long-term effects are unknown (Knaak et al., 2014). These insights suggest an emphasis on messages that stress the importance of prevention measures relevant to cognitive aging as well as the importance of positive intragenerational contacts.

Use Real-Life Exemplars

Because reaching a large percentage of the population with in-person contact interventions can be expensive and difficult to implement, media-based approaches may be more useful in reaching larger numbers of people. Research studies have found that stereotypes can be combated through exposure to positive exemplars that run counter to the stereotype (Duval et al., 2000). Both information-oriented media programs and entertainment-oriented media programs should be considered. News and other information media should provide accurate and appropriate messages that will overcome and not reinforce stereotypes. Organizations concerned about the portrayal of cognitive aging in the media could monitor the extent to which the coverage is biased and push for change.

Public education campaigns can also put a positive face on cognitive aging. Analyses of media interventions for mental health stigma found that media messages that contain first-person testimonials—but not third-person accounts—about mental illness were successful in combating prejudice (Clement et al., 2013). An example of such a program is a current UK effort, Dementia Friends, which seeks to improve public knowledge of dementia by using news stories about real individuals living with the condition and focusing on what people can do to assist those in their community (Dementia Friends, 2015). People who want more information can watch video testimonials about the experience of dementia, attend local information sessions, or receive a free package of materials, including a booklet with tips on actions. To destigmatize dementia, the campaign employs additional tactics, including naming famous people who have had dementia and speaking about dementia's commonalities with other chronic health conditions. The campaign also uses celebrities—such as the prime minister—to gain coverage. A similar campaign has been launched in New Zealand with a famous television personality and a sports star as “champions for dementia,” with an emphasis on preventive behaviors, including physical activity, diet, and not smoking (Alzheimers New Zealand, 2012). In the United States, examples of similar efforts include the documentary I'll Be Me about a famous musician. Evaluations of these first-person campaigns will provide valuable information on the influence of media coverage.

Portray Older Adults Positively in Entertainment

To combat the stigma of cognitive aging, entertainment media can provide stories featuring older adults, incorporate accurate portrayals of people with various levels of cognitive health, and depict respectful interactions between people with and without cognitive impairments. Use of older characters who are portrayed as being engaged in complex cognitive analyses and decisions may help combat the stigma that can be associated with cognitive aging. Campaigns can also take advantage of movies and stories about cognitive health when they appear to provide timely and reliable information for the general public. Across a range of health topics, evaluations of “education-entertainment” that feature storylines related to health issues within dramas, music, games, or other entertainment fare have shown some success in increasing viewers' acceptance of people with a medical condition, as well as increasing knowledge about a condition and individuals' willingness to engage in preventive behavior (e.g., Kennedy et al., 2004; Movius et al., 2007; Singhal and Rogers, 1999). Organizations that provide health and medical information resources for television and movie writers (such as Hollywood, Health & Society) are valuable in improving the accuracy of programs and promoting the incorporation of health issues into storylines (Hollywood, Health & Society, 2014). Content analyses are helpful in documenting the state of entertainment media depictions to understand where improvements are needed; however, existing studies are out of date (e.g., Gerbner et al., 1980; Signorielli, 2004).

Overcoming Communication Barriers

Communication aimed at older adults will need to take into account those adults' physical declines in hearing and vision and their possible problems with literacy and number skills (numeracy). Almost two-thirds of adults who are more than 70 years of age experience some degree of hearing loss (Lin et al., 2011). With normal age-related declines in hearing, spoken words can become difficult to understand, particularly when there is background noise (Gordon-Salant, 2006). Vision may also decline with age and exacerbate communication challenges.

Public education messages should encourage the use of appropriate technologies to correct for impairments (e.g., hearing aids, glasses) so that people may continue to participate in social interactions, have an easier time learning new things, and move about more safely. Furthermore, it is critical that public communication campaigns focused on older adults take into account the potential hearing and vision declines and design their messages and communication strategies accordingly. Messages should be pretested to ensure that they can be seen and heard by older adults. For example, one group of researchers when designing an interactive program for older adults that checks for drug interactions, pretested prototypes in focus groups and adjusted their materials to incorporate larger type and bold lettering, large navigation buttons, and streamlined controls (Strickler and Neafsey, 2002).

Another potential communication barrier is low literacy, which is more common among older adults than among younger adults (Kutner et al., 2007). According to the National Assessment of Adult Literacy, between one-quarter and one-third of adults 65 years and older in 2003 (the latest year with statistics for older adults) had below basic skills in at least one type of literacy (Kutner et al., 2007). At that time, 23 percent of older adults could not understand information from texts like news stories and brochures; 27 percent could not use documents like forms and applications, maps, tables, and food and drug labels; and 34 percent could not identify and make calculations using numbers in printed materials, such as balancing a checkbook, calculating a service tip, or understanding interest on a loan (Kutner et al., 2007).

Another important type of literacy is health literacy, which is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (IOM, 2004, p. 2, quoting Ratzan and Parker, 2000). Relevant areas of health knowledge include the prevention and self-management of health problems; navigating the health system; and clinical tasks such as filling out forms, understanding dosing instructions, and diagnostic testing. In 2003, researchers found that 29 percent of adults more than 65 years old had below basic health literacy skills (Kutner et al., 2006). Those with below basic health literacy skills were health-information poor and less likely than those with greater skills to obtain health information from almost any source, including friends and family, health professionals, newspapers, magazines, books or brochures, and the Internet. Their only consistent sources for health information were television and radio (Kutner et al., 2006).

Low health literacy has negative consequences on public health. People with lower health literacy rate their overall health as poorer, know less about their health, use fewer preventive services, have higher rates of hospitalization, and participate less in health promotion programs (IOM, 2004). Thus, programs to support cognitive health will need to take health literacy of their target populations into account. Strategies to deal with low literacy levels include

DESIGNING PUBLIC EDUCATION CAMPAIGNS AND COMMUNICATION PROGRAMS

For public education about cognitive aging to succeed, it will be critical for public health planners to follow the principles of good communication design. Campaign planners can use the many tools available at the CDC's gateway website for health communication and social marketing practice (CDC, 2012a).

The initial phases of design involve specifying the goals and measurable objectives for each target group. This is typically an iterative process, during which the initial specifications are revised based on a variety of considerations: archival research; research into the current beliefs, behavior, and barriers faced by the target groups; analyses of the physical, organizational, political, and social environment; and consideration of resources. The main goals should be to change or maintain specific behaviors, such as following physical activity guidelines or adhering to blood pressure medications. The exact behavior (or products or services, depending on what is being promoted) should be selected and refined based on formative research. The goals should emphasize behavior change and maintenance rather than knowledge and awareness because research has repeatedly shown that what people know they should do and what they actually do are different (Andreasen, 1995). Given that the terminology for cognitive aging is new, initial campaigns might set intermediate knowledge goals focused on increasing the understanding of what cognitive aging is and is not and on ways to promote cognitive health.

Successful social marketing efforts segment the population into different groups and then strategically select target groups (Lee and Kotler, 2011). Designing a more effective communications strategy is easier when dealing with a specific, relatively homogeneous group (Slater, 1995). The criteria for segmenting groups may include risk status for cognitive decline, existing beliefs and openness to behavior change, current behaviors, environmental barriers and support, and communication patterns (Snyder, 2007). For example, a campaign focused on reducing cardiovascular disease risks might segment people into the following groups:

1.

those known to be at low risk,

2.

those at risk who are not taking preventive measures,

3.

those at risk who are taking preventive measures,

4.

those who have been diagnosed with cardiovascular disease but who are not adhering to medical advice, and

5.

those who have been diagnosed with cardiovascular disease and who are adhering to medical advice.

From a public health standpoint, the priority groups would be groups 2 and 4. These segments may be further subdivided according to the barriers they face (i.e., cannot afford medications, do not trust the medical advice given, etc.) or the opportunities for communication (i.e., regular contact with a medical practice or clinic, integration into community organizations, media usage). As reviewed earlier in this chapter, individuals' behavior may vary according to their age, ethnicity, gender, and cultural groupings related to beliefs, risks, and practices or location within specific geographic areas. Such differences would affect how segments are defined.

Generally, campaigns also might try to reach individuals who have an important influence on the people in the primary target groups through their communication and actions (e.g., family members, health care professionals) or through policy and environmental changes (e.g., local transportation officials, parks and recreation departments). Ultimately, segments can be prioritized based on the organizational mission of the campaign or program sponsor, public health needs, and effort (time, cost, and resources).

Once the goals—including target behaviors and populations—have been selected, the next step is to determine the behavior change approach that will be used. Campaign designers map out the pathways and barriers to change and maintenance for each behavior. Logic models based on behavior change theories and research with the target groups may clarify this process, and many useful theories have been applied successfully across a wide range of health behaviors and populations (for a review, see Glanz et al., 2008). When thinking about how to change new types of behavior, planners may also consider the taxonomy of behavior change techniques, which cuts across theories (Abraham and Michie, 2008; Michie et al., 2013). For established intervention domains, planners should take into account any existing systematic reviews of the effectiveness of various techniques for changing and maintaining healthy behavior (e.g., see French et al., 2014). If the target behavior is hindered by environmental barriers, then advocacy with policy makers, professionals, businesses, and the general public may be necessary (Wallack et al., 1993).

The next step is to plan the communication approach, including message content, communication channels, and message presentation (Snyder, 2007). The message content, while based on the goals, should be adapted for the target group and the behavior change strategy. For example, messages striving to persuade people to do something they already know they need to do, such as be more physically active, may address issues such as the severity and likelihood of the consequences of not following the recommendation, the benefits of compliance with the recommendations, stereotypes of people at risk, norms surrounding compliance, and skills in setting and monitoring goals or engaging in the behavior. Messages should emphasize points that are new to the target group; there is little to gain from telling people what they already know (Snyder and Hamilton, 2002). Research suggests that older adults are constantly refining their goals as they age and are more likely than younger people to actively pursue goals to protect themselves from feared outcomes (Cross and Markus, 1991; Markus and Nurius, 1986). Older adults also tend to respond better to positive feedback that emphasizes progress, however small, toward goals, rather than negative feedback that may undermine self-confidence (West and Ebner, 2013).

The communication channels for a given campaign or program may include interpersonal sources of information (e.g., friends, family, and health professionals), traditional media (e.g., television and pamphlets), and new media (websites, social media, and interactive programs or games). Media formats to consider using include news stories, editorials, messages embedded in entertainment programs or games, advertisements, public service announcements, interactive tailored programs, and testimonials. Interpersonal communication may take the form of in-person, phone, or Web-based consultations, social media messaging, lectures, small group meetings, and other approaches. Campaign planners should select channels and formats based on the target groups' usage patterns and preferences; campaigns that use multiple channels often have greater impacts (Snyder, 2007).

Note that media use patterns change across the life span (Robinson et al., 2004) and potentially from one generation to the next. For example, baby boomers are much more likely to use the Internet than people who are now more than 85 years old (Pew Research Center, 2014). Behavior change across a population is more likely when a combination of channels is used and when media can be selected so as to maximize the number of people in the target population who are reached (Hornik, 2002; Snyder and Hamilton, 2002). At the same time, interpersonal sources may have greater credibility. An AARP (2012) survey of adults more than 50 years old found that they trusted health professionals more than “mass media” reports. They wanted a single reliable source of information to help them understand conflicting research reports, which supports the suggestion of an information gateway (see Recommendation 8). Both mass media and interpersonal channels may be useful in promoting different aspects of healthy cognitive aging.

In terms of the message presentation (or campaign “look and feel”), planners should aim for high levels of attention, memorability, and believability, and the sources of the messages should be perceived as highly credible and likable. Typically, messages that are of high quality and delivered in multiple versions attract greater attention and are more memorable (Snyder, 2007). Structured conversations, such as motivational interviewing or tailored interventions, may prove effective with people of all ages (Lustria et al., 2013; Miller and Rollnick, 2002; Noar et al., 2007). As noted above, the message presentations should take into account the target group's literacy and health literacy skills, their language preferences, and potential communication impairments.

Furthermore, the emotional tone of the messages needs to be appropriate to the target group and the context. For example, laboratory studies show that older people have a greater response to positive emotions and messages about benefits than do younger adults, and they have a lesser response to negative events (Mather and Carstensen, 2005; Reed et al., 2014; Samanez-Larkin et al; 2007; Shamaskin et al., 2010). Similarly, an intervention study found that framing messages in terms of the positive benefits of change (rather than losses associated with not changing) seems to be a more effective approach with older adults (Notthoff and Carstensen, 2014).

Pretesting preliminary versions of messages and presentations with the target populations is critical in refining the communication approach and increasing the likelihood of impact. Message timing is also critical, although it is currently not known how often cognitive aging messages need to be received in order to sustain behavior change over time. Finally, campaigns can use elements that increase messages' memorability, such as logos, jingles, slogans, and taglines.

In sum, cognitive aging programs and campaigns to reach members of the public will need to develop specific behavioral goals for each target population, behavior change strategy, and communication strategy—including channels, message content, and presentation. Most likely, the most effective programs will employ a comprehensive strategy that addresses environmental constraints, individual behavior change, and social influences on the target population. In addition, ongoing feedback during planning and implementation in the form of formative and outcomes evaluation can improve program designs over time. Evaluation results should be made available broadly to enable the field of communications regarding cognitive aging to advance.

KEY MESSAGES AND RECOMMENDATION

Based on the review of the evidence throughout this report, the committee has developed several key messages for the public (see Box 7-3). The first area of emphasis is promoting an understanding of cognitive aging (what it is and what it is not) with a focus on the wide variation among individuals in the nature and extent of cognitive changes with age. Additionally, people across the life span should be informed about the actions they can take in childhood, youth, young adulthood, middle age, and older age to preserve and enhance their cognitive health. Older adults and their families also need information both on the potential for cognitive aging to affect decision making in some individuals and on strategies to protect against poor decisions, and older adults and their families can be encouraged to talk with their health care provider if they have concerns. Because of the need for and importance of research into cognitive aging, participation in research to advance the science of cognitive aging should be encouraged.

Box Icon

BOX 7-3

Key Messages. Cognitive health should be promoted across the life span. Due to the complexity of the human brain, numerous risk and protective factors may affect cognitive abilities in ways that vary among individuals. Age affects all organ systems. The (more...)

Recommendation 10: Expand Public Communication Efforts and Promote Key Messages and Actions

The Centers for Disease Control and Prevention, the Administration for Community Living, the National Institutes of Health, other relevant federal agencies, state and local government agencies, relevant nonprofit and advocacy organizations and foundations, professional societies, and private-sector companies should develop, evaluate, and communicate key evidence-based messages about cognitive aging through social marketing and media campaigns; work to ensure accurate news and storylines about cognitive aging through media relations; and promote effective services related to cognitive health in order to increase public understanding about cognitive aging and support actions that people can do to maintain their cognitive health.

Public communications efforts should:

  • Reach the diverse U.S. population with campaigns and programs targeted to all relevant groups;
  • Be sensitive to existing differences in knowledge, literacy, health literacy, perceived risk, cognitive aging–related behavior, communication practices, cultures and beliefs, speech and hearing declines, and skills and self-efficacy among target groups;
  • Include evaluation components to assess outreach efficacy in the short and long term, and research the optimal communication strategies for the key messages among the target groups;
  • Be updated as new evidence is gained on cognitive aging;
  • Emphasize a lifelong approach to cognitive health;
  • Promote succinct and actionable key messages that are understandable, memorable, and relevant to the target groups;
  • Focus on sustaining changes in behaviors that promote cognitive health; and
  • Promote effective evidence-based tools for maintenance of cognitive health and cognitive change assessment, as well as the information gateway on cognitive aging (see Recommendation 8).

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Copyright 2015 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK316211

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