Introduction

Currently, there are over 55 million people living with dementia (World Health Organization [WHO], 2023), and this figure is expected to increase to 152 million by 2050 (Alzheimer’s Disease International [ADI], 2019). Of all people with dementia, ADI (2014) determines that around 50–75% have Alzheimer disease (AD). AD not only has a significant impact on economy but also on the healthcare, political, and social spheres, where it is stigmatised. The stigma associated with AD has serious consequences for the lives of people with this disease, their families, and their communities (Werner, 2014; WHO, 2017). The stigma related to AD is a major barrier for early detection and diagnosis (ADI, 2019). In this way, individuals living with AD can lose their identity to AD stigma, which is largely driven by symptoms (Stites et al., 2022).

Similarly, stigma emphasises the link between AD and social distance, which increases discrimination towards people with AD and their families (Stites et al., 2022). This idea hinders the use of community services by family members (Corrigan, 2004; Innes et al., 2011) and the search for assistance and support of relatives or friends because the disease entails social distance and discrimination (Smendinga et al., 2020). Considering previous studies, AD remains as a major challenge for the whole society even in the most developed countries (Michalko et al., 2022). To overcome this challenge, it is necessary to encourage countries to develop dementia-friendly initiatives and change how the disease is represented or framed (ADI, 2012); Cuadrado et al., 2021; Stites et al., 2018; Van Gorp and Vercruysse, 2012; WHO, 2017). In this sense, negative frames about AD have been associated with a set of emotionally charged metaphors that contribute to exclusion and elicit higher levels of sadness or sorrow (Zeilig, 2013).

The rest of this manuscript is organised as follows: the section “Literature review: Frames to give meaning to AD and the influence of cultural representation” summarises how AD framing influences attitudes towards AD, explains why a cross-cultural approach is necessary in this context, and sets the research questions. The section “Methods” describes the sample recruitment process, the experimental procedure, the measures and instruments applied, the stimuli design, and the statistical analysis. The “Results” section presents the empirical analysis and describes the main outcomes. The discussion of results and the proposal of new lines of research are addressed in the last section of the paper. In this section the conclusion of the study and some suggestions to increase positive attitudes and reduce the stigma towards AD are also provided.

Literature review: frames to give meaning to AD and the influence of cultural representation

Framing refers to the approach to represent or define a particular theme. In this sense, frames are tools used in communication to present a topic in a comprehensible and understandable way for different social groups, even for those who have no expertise in the field. To this end, frames focus on central cues that are usually shared by the whole society (Entman, 1993). Furthermore, frames are culturally shared ideas that become “organising principles” in the collective imaginary. Hence, they are used symbolically to structure and give meaning to the social reality (Reese, 2001). However, the perspective provided by frames is biased as it does not consider different positions. In this paper, we focus on AD framing, that is, on how AD is culturally represented and defined.

There are six dominant frames to give meaning to AD, and only one portrays the disease in a positive light; the rest of them stereotype AD, highlighting only its negative consequences (Van Gorp and Vercruysee, 2011, 2012). Thus, ‘Dualism of body and mind’ (‘Dualism’ from now on) is the most dominant and widely used frame to represent AD in Western culture (Van Gorp and Vercruysse, 2012). This frame postulates that a human being is an inseparable combination of body and mind, where the body is a mere envelope of the mind. Therefore, the disease captures the mind of the person with AD, while their body remains intact. From this perspective, a body without a mind is not considered a human being. Then, people with AD only exist at a material level, but they have lost their humanity and identity. Contrary to this dominant frame, we can find the ‘Unity of body and mind’ counter-frame (‘Unity’ from now on). This frame takes distance from dualism and aligns with the equal relevance of both body and mind, thus the body-mind is conceived as an indivisible whole. From this perspective, people with AD progressively lose cognitive abilities, but not their individual identity, personality, or emotional and sensory capacity. The stress of the Unity counter-frame is placed on what the person preserves; consequently, people with AD are never dehumanised.

The use of negative frames like Dualism to represent AD has been demonstrated to increase levels of sadness, fear, and impact on the general public (Cuadrado et al., 2022). However, they are still considered more comprehensible than typical messages of positive frames like Unity (Cuadrado et al., 2020; Van Gorp et al., 2012). Nevertheless, their use does not positively influence attitudes towards AD, as negative frames reinforce stigma and stereotyped ideas about AD, whereas positive frames have shown to have a positive influence on attitude change (Stites et al., 2018). These effects can be explained because a frame reinforces internal consistency and the rationale of a discourse. The psychological mechanism responsible for that effect on the receivers is a cognitive schema, which is activated by specific elements of the discourse. There is an internal rationale which prevents receivers from weighing schemata against each other (Wood et al., 2018). Therefore, discourses related to negative frames are not questioned by the receivers, as the main ideas are dominant in their culture. In contrast, a counter-frame can disrupt the internal consistency of a schema and motivate the receivers to reflect on the issue, as suggested by the Framing Counter-framing Theory (Van Gorp and Vyncke, 2021). Therefore, emphasising the positive frames’ ideas can challenge the dominant social representations (i.e., the dehumanisation of people with AD promoted by Dualism). Inconsistency with dominant frames and the contrast of different viewpoints are aspects that lead to reflection and may induce a favourable attitude change.

Previous research on the cultural representation of AD and its influence has predominately focused on the context of a single group or society, with minimal attention to cross-cultural comparisons (Cañabate et al., 2017; Juárez-Cedillo et al., (2014); Mushi et al., 2014). This gap in research is a significant barrier to culturally sensitive research, which could contribute to the analysis and understanding of the cultural influence on the different approaches to AD worldwide. The current study collected data from two groups of participants from two different countries (Slovakia and Spain) to address a preliminary analysis of this variable. Despite the rise in the prevalence of AD in both countries and their common membership in the European Community, each one has a different cultural background. This background involves different values and traditions that influence both how people perceive and deal with AD and the expression and management of their own emotions. In Spain, the family plays a fundamental role in care; particularly in the care of people with AD, Spain has a public care system that supports families who care for their relatives with dementia. Conversely, the role of State institutions in care is more prominent in Slovakia, as more emphasis is placed on institutionalisation (Čechová, 2020).

On the other hand, both cultures also differ in the way in which emotions are expressed and managed. Spanish people experience and express their emotions more intensely (i.e., more gesticulation) than Slovak people (Kosek, 2012; Šoltýsová and García, 2016). Likewise, Spanish people discuss openly about their emotions and are not afraid to show their joy, sadness, or anger in public. Conversely, Slovak people tend to be more reticent and moderate in this respect, reserving the expression of their feelings for more intimate or private contexts (Kosek, 2012; Kvetanová and Gutiérrez, 2018).

Based on the aforementioned information, this study had the purpose of conducting a preliminary analysis of the attitudes towards AD in young Slovak and Spanish laypersons and their emotions as mediators of framing effects on attitudinal change. To this end, posters about AD were designed displaying messages inherent to both Dualism and Unity frames, as these are the most widely used frames in Western countries (Van Gorp and Vercruysse, 2012). The same messages were translated into participants’ native language to test several research questions. Firstly, to our knowledge, this is the first study addressing attitudes towards AD on the Slovak population. Therefore, we raised the following research question (RQ): Would attitudes towards AD differ between young Slovak and Spanish laypersons groups? (RQ1). Secondly, previous research on AD framing in the Spanish population has found that messages of the Unity frame induce favourable attitudes towards AD, contrary to the Dualism frame (Cuadrado et al., 2020). Then, our RQ2 refers to the possibility of finding this effect in young Slovak people. Thirdly, previous literature points out that emotions and impact reported by participants differ depending on the message frame. Specifically, Dualism-framed messages produce higher levels of negative emotions (i.e., sadness, anger, fear, and disgust) and greater impact; whereas Unity-framed messages induce higher levels of happiness, which is related to positive attitude change (Cuadrado et al., 2021; Cuadrado et al., 2022). Nevertheless, would there be differences between young Slovak and Spanish people in self-reported emotions or their mediation role in the framing effects? (RQ3).

The findings of this study can be considered a preliminary analysis that contributes to a better understanding of the mechanisms by which attitudes towards AD can be influenced in different cultural groups. Alongside future research on this topic, this study may help us understand both cultural differences in attitudes towards AD and the role of emotions in changing attitudes through framing.

Methods

Participants

The sample size was determined using statistical power analysis programme G*Power 3.2.9.7 (Faul et al., 2007). The a priori power analysis (p = 0.05, two-tailed, 95% statistical power) yielded a total sample size of 90 participants. This sample size allows to detect a medium effect size (i.e., f = 0.25 based on Cohen’s f) in a mixed-design ANOVA (Cárdenas and Arancibia, 2014) to compare pre-post measures in six groups with two measurements (see the procedure section). However, we increased the target sample size to account for potential withdrawals throughout the study.

Finally, 275 participants (Mage = 21.23 years, SDage = 5.13, 81.1% females) were randomly recruited from both Pan European University (Slovakia) and the University of Cordoba (Spain). Then, the sample involved two cultural groups: Slovak (n = 134; Mage = 23.41 years, SDage = 6.35; 83.58% females), and Spanish (n = 141; Mage = 19.16 years, SDage = 2.11; 78.72% females). Both Slovak and Spanish participants were undergraduate students enroled in the Bachelor’s Degree in Primary Education or Psychology programmes.

Procedure

The Research Ethics Committee of the Cordoba University authorised the study and confirmed its compliance with the ethical and data protection standards required by European legislation. To guarantee participants’ anonymity, all questionnaires were identified using a code. Participants voluntarily agreed to take part in the study and all of them received the same instructions.

Three terms need to be clarified before explaining the research design. In the first place, ‘framing’ refers to the approach process to represent or define a particular topic, in this case AD, which can influence both the beliefs and the behaviour of people. Second, the term ‘frames’ refers to the tools or assemblages of the knowledge that people have and use when communicating. Finally, ‘Dualism/Unity-framed messages’ are messages framed in said AD frames that have been used as a research instrument.

Taking all this into account, a mixed design was used to explore how messages framing in AD influenced the evoked emotions, the perceived impact, and the attitudes towards AD, considering the recipients’ culture. Data were collected in two phases: pre-test (T1) and post-test (T2). There was a time interval of one week between T1 and T2.

At the T1 of the study, all participants provided information about their socio-demographic characteristics, their experience with AD, and the importance of AD to them. Furthermore, participants completed the Attitudes towards Dementia Scale (ADS; Serrani, 2011) in their native language. At the T2, both the Slovak and Spanish groups were randomly divided into three sub-groups: two experimental ones and a third as a control. All sub-groups performed the same kind of task consisting of the passive visualisation of different stimuli (posters including pictures of people and a brief framed message). The only difference between sub-groups was the kind of messages to which they were exposed. One experimental sub-group viewed posters with Dualism-framed messages, the other experimental sub-group viewed posters with Unity-framed messages, and the control sub-group viewed posters with neutral messages unrelated to AD. Each sub-group was presented with six posters on a large screen in a silent and isolated room. The whole presentation lasted one minute (10 s per poster). After viewing the posters, participants individually completed the ADS again and answered some questions about the emotions elicited by the messages and the level of impact that the posters had on them.

Measures

All participants were asked to provide some sociodemographic information (country, age, and gender) and to answer two questions using a five-point Likert scale. Specifically, they were asked about the importance attributed to AD (1 = Not important; 5 = Very important), and their experience with AD (1 = I barely know about AD and have never known anyone with AD; 5 = I have or have had a family member or close acquaintance with AD and live or have lived with him/her).

Dependent variables

Attitudes towards dementia scale (ADS; Serrani, 2011)

The ADS comprises 20 items using a seven-point Likert scale (1 = Strongly disagree; 7 = Strongly agree) to measure attitudes towards dementia. Its score range is 20–140, with higher scores indicating more positive attitudes. The internal consistency of the scale is good (Cronbach’s alpha = 0.89), as its goodness-of-fit indices are (CFI = 0.92; GFI = 0.94; AGFI = 0.90; PGFI = 0.91; RMSEA = 0.05). The ADS has been used in previous studies examining the influence of AD framing on attitudes towards AD (Cuadrado et al., 2022).

Self-reported emotions and impact

To measure the level of basic emotions elicited (happiness, sadness, anger, fear, and disgust) and the impact experienced by participants, they were asked six questions (one for each basic emotion plus one extra question related to the experienced impact). Specifically, they were asked: “What level of happiness/sadness/anger/fear/disgust/impact have you felt after seeing the posters?”. These questions were answered using a five-point Likert scale (1 = Not at all; 5 = Extremely). Previous research on AD framing has already measured these variables in the same way (Van Gorp et al., 2012).

Independent variables

Framing (framing condition)

This variable was manipulated by means of three conditions that were used in the design of the posters created for the study: Dualism (Dualism-framed messages), Unity (Unity-framed messages), and control (neutral messages unrelated to AD).

Cultural group (culture condition)

This variable refers to the participants’ culture of origin. It was manipulated at the initial stage of the research when decided to select the targeted cultural groups, and comprises two conditions: Slovak and Spanish culture.

Stimuli design

Eighteen posters were designed and translated into the native language of each group. These posters contained messages from the three different conditions: six of Dualism frame (Fig. 1a), six of Unity frame (Fig. 1b), and six of control (Fig. 1c). All posters include a message with an image. Messages showed to the experimental groups were related to the targeted frames (Dualism and Unity) and were taken from the Van Gorp and Vercruysse’s (2012) inventory of dementia frames and counter-frames, while messages used in the control condition were neutral and completely unrelated to AD. On the other hand, images consisted of sepia photographs downloaded from the Pixabay website and free of copyright under the Creative Commons CC0 license. Specifically, pictures of faces of the elderly were used in both experimental conditions, while neutral images of objects were used for the control condition. To control the influence of message, the same images were used in all experimental conditions.

Fig. 1: Examples of posters conditions.
Fig. 1: Examples of posters conditions.The alternative text for this image may have been generated using AI.
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a Poster with messages of the Dualism condition, b Poster with messages of the Unity condition, c Poster of control condition. Top: Posters presented to the Slovak group. Bottom: Posters presented to the Spanish group. Posters presented to both groups were identical, the only difference was the language of the written messages.

Statistical analysis

Data analysis was performed using the Statistical Package for Social Sciences (IBM®, SPSS Statistics version 25) and a p value of 0.05 (two-tailed) was generally considered to be significant throughout the statistical analysis.

Firstly, normality was checked using the Shapiro-Wilk test and by evaluating skewness and kurtosis. A one-way analysis of variance (ANOVA) was performed on the variables attitudes towards AD, experience with AD, and importance of AD to check the homogeneity of the three sub-groups within each cultural group.

Secondly, a multivariate analysis of variance (MANOVA) was performed with ‘emotions’ and ‘impact’ as dependent variables and ‘framing’ and ‘culture’ conditions as fixed factors; η² was used to assess the effect sizes of the main effects and interactions, assuming small (η² < 0.05), medium (η² = 0.05–0.24), high (η² = 0.25–0.50), and very high (η² > 0.50) effect sizes (Cohen, 1988). Furthermore, Pearson’s correlation coefficient (r2) was used to check whether there was a relationship between attitude change (the difference between ADS scores in T2 and T1) and the different emotions experienced.

Lastly, the main effects and interaction estimate of interest on attitudes towards dementia (ADS scores) were analysed using a 2 × 3 × 2 mixed-design ANOVA, with ‘culture’ (Slovak/Spanish) and ‘framing’ (Dualism/Unity/control) as the between-participant variables, and ‘phase’ (T1: ADS pre-test/T2: ADS post-test) as the within-participant variable. When a study condition effect was significant, pairwise contrasts of the estimated marginal mean (EMM) corrected by Bonferroni were used to determine the significance of differences between the levels of the condition in the outcome measures. The effect sizes of the main effects and interaction were also obtained through η².

Results

The descriptive statistics of ADS scores on T1, importance of AD, and experience with the disease for each sub-group are summarised in Table 1. No significant between-group differences were yielded in these variables; thus, the sub-groups were comparable.

Table 1 Participants’ initial attitudes, experience, and importance related with AD.
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Self-reported emotions, impact, and AD framing effect

Regarding self-reported emotions and impact, the MANOVA result was significant for framing (Pillai’s trace = 0.84, F(12,530) = 32.07, p < 0.001, η2 = 0.42), indicating differences in these variables. Overall, happiness (F(2,269) = 65.89, p < 0.001, η2 = 0.33), sadness (F(2,269) = 92.14, p < 0.001, η2 = 0.41), anger (F(2,269) = 12.03, p < 0.001, η2 = 0.08), fear (F(2,269) = 23.82, p < 0.001, η2 = 0.15), disgust (F(2,269) = 7.85, p < 0.001, η2 = 0.06), and impact (F(2,269) = 41.31, p < 0.001, η2 = 0.24) were influenced by framing. Specifically, the Unity messages were considered more cheerful compared to the Dualism (estimated marginal means difference [EMMD] = 1.53, p < 0.001, d = 1.62, CI = 1.20/1.86) and the control ones (EMMD = 1.02, p < 0.001, d = 0.96, CI = 0.70/1.35) (Table 2 and Fig. 2). Likewise, the Dualism messages were considered less cheerful than the control ones (EMMD = −0.51, p < 0.01, d = −0.65, CI = −0.84/−0.18). Regarding sadness, the Dualism-framed messages elicited sadness to a greater extent compared to the Unity-framed (EMMD = 0.60, p < 0.01, d = 0.54, CI = 0.21/0.99) and the control ones (EMMD = 2.36, p < 0.001, d = 1.89, CI = 1.74/2.53). Moreover, the Unity-framed messages were considered significantly sadder in comparison with the control ones (EMMD = 1.54, p < 0.001, d = 1.38, CI = 1.15/1.93). In addition, the Dualism messages elicited more anger than the Unity (EMMD = 0.51, p < 0.001, d = 0.51, CI = 0.19/0.82) and the control ones (EMMD = 0.58, p < 0.001, d = 0.62, CI = 0.27/0.90); but no significant difference was found between the Unity and the control messages in this emotion (p = 1). Regarding fear, the Dualism-framed messages induced fear at a higher level than the Unity-framed (EMMD = 0.68, p < 0.001, d = 0.57, CI = 0.31/1.05) and the control ones (EMMD = 1.03, p < 0.001, d = 0.98, CI = 0.66/1.39); but no significant difference was found between the Unity and the control messages in fear either (p = 0.07). Furthermore, the Dualism messages were considered more disgusting than the Unity ones (EMMD = 0.29, p < 0.001, d = 0.53, CI = 0.11/0.46), but no significant difference was found between the control messages and either the Dualism (p = 0.36) or the Unity ones regarding disgust (p = 0.05). On the other hand, the Dualism and the Unity messages were considered more impactful than the control ones (Dualism: EMMD = 1.41, p < 0.001, d = 1.23, CI = 1.03/1.78; Unity: EMMD = 0.70, p < 0.001, d = 0.60, CI = 0.33/1.08). Likewise, the Dualism-framed messages were considered more impactful than the Unity ones (EMMD = 0.71, p < 0.001, d = 0.60, CI = 0.33/1.08). Finally, the correlation analysis only yielded a significant relationship between attitudinal change and happiness (r2 = 0.17, p < 0.01).

Table 2 Mean and standard deviation for ADS, self-reported emotions, and impact.
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Fig. 2: Self-reported emotions and impact scores of both culture groups.
Fig. 2: Self-reported emotions and impact scores of both culture groups.The alternative text for this image may have been generated using AI.
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The range score for these variables was 1–5.

Moreover, MANOVA analysis yielded a significant main effect for the culture condition (Pillai’s trace = 0.29, F(6,264) = 18.15, p < 0.001, η2 = 0.29). Specifically, participants’ culture influenced the level of sadness (F(1,269) = 16.56, p < 0.001, η2 = 0.06), anger (F(1,269) = 27.86, p < 0.001, η2 = 0.09), and impact (F(1,269) = 82.53, p < 0.001, η2 = 0.24) experienced (Table 2 and Fig. 2). Thus, Spanish participants reported higher rates of sadness (EMMD = 0.54, p < 0.001, d = 0.41, CI = 0.28/0.80), anger (EMMD = 0.56, p < 0.001, d = 0.62, CI = 0.35/0.76), and impact (EMMD = 1.15, p < 0.001, d = 0.99, CI = 0.90/1.40) compared to the Slovak ones.

Finally, the MANOVA analysis also revealed a significant interaction between framing and participants’ culture (Framing×Culture) (Pillai’s trace = 0.15, F(12,530) = 3.69, p < 0.001, η2 = 0.08). This interaction was significant for happiness (F(2,269) = 6.26, p < 0.01, η2 = 0.04), anger (F(2,269) = 3.38, p < 0.05, η2 = 0.02), and disgust (F(2,269) = 6.27, p < 0.01, η2 = 0.05) (Table 2 and Fig. 2). Specifically, Slovak participants experienced similar levels of happiness after viewing Dualism messages as the Spanish ones (p = 0.36); however, the Slovak group reported higher levels of happiness compared to the Spanish one after the exposure to Unity-framed messages (EMMD = 0.47, p < 0.05, d = 0.40, CI = 0.09/0.84). Regarding the control messages, the Spanish group experienced higher levels of happiness compared to the Slovak one (EMMD = 0.47, p < 0.05, d = 0.52, CI = 0.09/0.84). Furthermore, similar levels of anger were experienced by both Slovak and Spanish participants after the exposure to Unity messages (p = 0.24), whereas the Spanish group reported higher levels of anger than the Slovak one in the Dualism (EMMD = 0.89, p < 0.001, d = 0.79, CI = 0.53/1.25) and the control conditions (EMMD = 0.57, p < 0.01, d = 0.87, CI = 0.21/0.92). Lastly, regarding disgust, Slovak and Spanish participants reported similar levels of this emotion after viewing Unity-framed (p = 1) and control messages (p = 1), whereas the Slovak group experienced higher levels of disgust after the exposure to Dualism-framed messages with respect to the Spanish group (EMMD = 0.36, p < 0.001, d = 0.52, CI = 0.16/0.56).

Attitudes towards AD and framing effect

There was no significant main effect of the framing condition (p = 0.06), but the mixed-design ANOVA yielded a significant main effect of the phase of study condition (F(1,269) = 22.21, p < 0.001, η² = 0.08) and a significant (Phase × Framing) interaction (F(2,269) = 6.75, p < 0.01, η² = 0.05). The pairwise contrasts of the EMM revealed significant differences in ADS at T2. Therefore, the Unity-framed messages promoted significantly more positive attitudes towards AD than the Dualism ones (EMMD = 4.60, p < 0.01, d = 0.51, CI = 1.61/7.59) after the exposure to the posters (Table 2).

There was also a significant main effect of the culture condition (F(1,269) = 25.35, p < 0.000, η² = 0.09), where the Slovak participants displayed positive attitudes towards AD but to a lesser extent than the Spanish ones (EMMD = −4.83, p < 0.001, d = −6.94, CI = −6.71/−2.94). The (Phase×Culture) interaction was not significant (p = 0.40). Thus, the attitudes towards AD were more positive after the exposure to the Unity messages in both the Slovak and Spanish groups (Fig. 3).

Fig. 3: ADS scores in T1 and T2 of both culture groups.
Fig. 3: ADS scores in T1 and T2 of both culture groups.The alternative text for this image may have been generated using AI.
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ADS Attitudes towards Dementia Scale (score range: 20–140).

Finally, no significant difference was yielded in attitudes in the threefold interaction between study phase, framing, and participants’ culture (Phase × Framing × Culture): p = 0.76.

Discussion and conclusion

Framing influence on emotions and attitudes towards AD has been studied in different countries like Belgium (Van Gorp et al., 2012), USA (Stites et al., 2018), and Spain (Cuadrado et al., 2020). However, to our knowledge, this is the first study addressing this topic on the Slovak population. Moreover, the present study has adopted a cross-cultural approach comparing the emotions and attitudes elicited by different AD-related messages in young Slovak and Spanish laypersons to carry out a preliminary analysis of the influence of both cultures on them.

First, we wondered if the attitudes towards AD would be different between young Slovak and Spanish laypersons (RQ1). In this sense, our findings have highlighted cultural differences in attitudes towards AD, as the Slovak group displayed positive attitudes towards AD to a lesser extent than the Spanish one. On the other hand, our second research question was interested in knowing if the Unity frame would induce favourable attitudes towards AD, contrary to the Dualism frame, in young Slovaks (RQ2), as shown by previous research that has been carried out with the Spanish population. In this case, we found a similar effect of framing in both Slovak and Spanish participants, where both groups increased their positive attitudes after viewing the Unity-framed messages.

Different media such as literature (Simonhjell, 2017; Zimmermann, 2017), cinema (Segers, 2007), or magazines (Kessler and Schwenderm, 2012) have focused on AD trying to promote the AD visibility worldwide. However, this effort has not been sufficient yet to eradicate AD stigmatisation, as most media still use dominant frames to give meaning to AD. Given this scenario, several organisations and researchers advocate for the use of awareness campaigns (ADI, 2012; WHO, 2017) and different informative resources on AD (Grigsby et al., 2017; Vrijsen et al., (2021)) to reduce negative stereotypes and AD stigmatisation. Nonetheless, they do not explicitly indicate what type of portrayal should be used to fulfil that goal. Negative frames are known to be exceptionally effective for certain purposes like stimulating financial donation; however, they are not effective for others, such as the promotion of positive attitudes towards AD. For this reason, before designing any campaign, it is necessary to clarify the intended goals. For campaigns targeted at improving positive attitudes towards AD, the present study provides strong evidence on the influence of framing; thus, it may help to reconsider and decide the most appropriate frames to effectively communicate and raise awareness about AD. Specifically, our findings align with previous studies (Cuadrado et al., 2022; Van Gorp et al., 2012) in pointing out that the use of positive frames like Unity significantly increases positive attitudes towards AD, regardless of the audience’s culture. Therefore, the key element to foster positive attitudes is the identification and selection of those messages related to positive frames, as they reduce the stigma associated with the disease. In line with other authors (Kessler and Schwenderm, 2012; Stites et al., 2018; Werner et al., 2022), we advocate for the use of feasible positive frames (not idealised) to represent AD. This implies the avoidance of negative dominant frames worldwide, as these guidelines are generalisable to all potential audiences, regardless of their culture.

Likewise, the emotions and impact experienced after the exposure to the different messages are also worthy to be considered when analysing attitudes towards AD. For this reason, we proposed RQ3 that tried to find out if there would be differences between young Slovak and Spanish people in their self-reported emotions or the mediation role in the framing effect. We found the Dualism-framed messages induced more negative emotions (i.e., sadness, anger, fear, and disgust) and had greater impact in both Slovak and Spanish participants. However, some cultural differences were yielded in this aspect: anger was found more intense in the Spanish sample, while the Slovak participants reported higher levels of disgust. By contrast, the Unity frame elicited a modest but still significant increase in the rates of positive emotions (happiness) in both Spanish and Slovak participants. This increase does not imply that participants reported happiness after viewing the posters in any condition (in fact these rates were low in all cases). This means that the Unity frame made a slightly more positive impact on both groups of spectators compared to the Dualism one. Even so, this slight increase in happiness rates was enough to achieve a change in the attitudes towards AD, regardless of participants’ culture.

Our findings revealed that negative emotions did not lead to any attitudinal change, despite having been experienced to a greater extent with respect to the positive ones. Conversely, positive emotions (i.e., happiness) elicited by the Unity-framed messages led to a positive attitude change. In this respect, these data comply with the Elaboration Likelihood Model, which explains how emotions may impact on attitudinal change (Petty and Briñol, 2015). Tacking all this into account, it is not surprising that fear-based and very impactful approaches undermine the empathy and support for people with AD and their caregivers (Devlin et al., 2007), despite that the discourse on AD used in media often relies on this type of approach (Swaffer, 2014).

In summary, the Unity messages influenced positively on both Slovak and Spanish young laypersons and changed their attitudes towards AD. Thus, the targeted frames (Dualism and Unity) performed similarly regardless of the group’s culture. Particularly, the Unity counter-frame reduced stigma to a higher extent compared to the Dualism dominant frame. Furthermore, each frame elicited different emotions, which contributed to explain the attitudinal change. In this sense, emotions such as happiness, anger, and disgust were reported differently by Slovak and Spanish participants. Hence, more research in this regard is still needed to draw firmer conclusions and to continue this cultural-targeting approach.

On the other hand, it is important to highlight some limitations of this study. Firstly, the results cannot be generalised to the entire population. In this regard, the age range of participants should be larger and other characteristics such as participants’ studies, their degree of responsibility towards people with the disease and their care should be considered in the composition of the sample in future studies to increase the outcomes generalisability. Secondly, we used the ADS to assess attitudes towards AD. This scale evaluates the three components of attitudes (cognitive, emotional, and behavioural) altogether; nevertheless, we also assessed the framing effect on the emotional component independently. In this respect, it could also be interesting to independently measure the other components (cognitive and behavioural) to analyse how each one is influenced by framing and to what extent there is congruence between the three components. Thirdly, the reliability of results could also be questioned, considering that people often state things but act in a different way due to social desirability. This inconsistency is mostly evident in controversial topics (LaPiere, 1934) such as attitudes towards AD, as people tend to have prejudices towards this dementia. To overcome this limitation in future research, it would be interesting to focus on the proximal determinants of specific actions (i.e., attitudes towards behaviour and behavioural intentions), instead of on general attitudes towards an object (such as AD in our case) (Ajzen and Fishbein, 2005). Additionally, this study only provided information about two cultures, but both were framed on Western countries. Nevertheless, in recent years, research related to the subject has also been carried out in Eastern cultures such as Korea (Jun et al., 2021), China (Dandan, 2022), and Turkey (Arica et al., 2022). In this sense, it would be interesting to include more variability of cultures in future studies and compare groups from Western and Eastern cultures, which would provide valuable knowledge on the topic. Moreover, in this study we only considered the Dualism and the Unity frames; therefore, it would also be worthwhile to analyse all frames and counter-frames used to give meaning to AD.

In conclusion, AD representation should be carefully planned to avoid maintaining and justifying the negative stereotypes associated with this dementia. In this sense, the relevant role of culture (i.e., characteristics or beliefs) within the framing process must also be considered. More research is needed in this regard to more firmly support a cultural-targeting approach in advocacy and AD awareness campaigns. However, findings from this and previous studies highlight that it is still necessary to reframe AD in all possible media (e.g., world political policies on dementia, health resources) using positive frames (i.e., Unity) to help improve emotions and attitudes towards this disease in laypersons worldwide.