Issues of Risk and Responsibility in Online Dementia Prevention Information

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‘Your Brain Matters’: Issues of risk and responsibility in online dementia prevention information.

Abstract

The Internet has been argued to provide new sites for health communication and promotion, including issues that constitute major public health priorities such as the prevention of neurodegenerative disorders like Alzheimer’s disease. In this study, discursive psychology is used to examine how information about dementia risk prevention was presented on the websites of the largest English-language, non-profit dementia organisations. We demonstrate how information about dementia risk and its prevention positions audiences as at-risk of developing dementia and constructs preventative behaviour as a matter of individual responsibility. Websites represented participation in certain lifestyle practices as normative and emphasised audience members’ personal responsibility for managing dementia risk. It is argued that such representations promote a moral identity in regard to brain health in which an ethic of self-responsibility is central. The implications of such identity construction in a context of increasing prevalence of dementia diagnosis are discussed.

1. Introduction

Western media representations of dementia have been shown to encourage

older people to participate in a range of lifestyle practices, not only to improve

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cognitive functioning, but also to prevent or delay the onset of the condition (Peel,

2014; Pitts-Taylor, 2010). Certain lifestyle choices and practices are argued to

encourage the formation of new neural connections, thus preventing the onset of

cognitive impairment in older age. Drawing on insights from discursive psychology

(Edwards & Potter, 1992; Potter, 1996), we present an analysis of information

published on the websites of the largest English-language, non-profit dementia

organisations that provide information and support to people living with dementia,

their carers, and health professionals. Our focus is on how audiences are positioned

as at-risk of developing dementia and how participation in risk-prevention behaviours

is constructed as normatively relevant for all audience members. We consider how

the language used on these websites locates dementia risk as a personal issue, and

reproduces attributions of individual responsibility for brain health in older age. The

study contributes to developing understandings of how contemporary representations

of dementia risk-prevention might work to promote a repressive ethic of self responsibility

and risk-management (Pickersgill, Martin, & Cunnningham-Burley,

2014; Pitts-Taylor, 2010; Rose & Abi-Rached, 2013; Williams, Higgs, & Katz, 2011).

1.1 Brain ageing, dementia, and dementia risk-prevention

Dementia is emerging as an increasingly prevalent health concern, with the

most common variants being vascular dementia and Alzheimer’s disease (World

Health Organisation [WHO], 2016). ‘Dementia’ is a general term referring to a range

of symptoms associated with a progressive decline in cognitive functioning and selfsufficiency.

The international federation of Alzheimer’s associations (Alzheimer’s

Disease International; ADI) has predicted that by 2050, the number of people living

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with dementia worldwide will reach 131.5 million (ADI, 2015). Aside from the

economic costs associated with the disease (US $818 billion per annum; ADI, 2015),

dementia is often portrayed as a highly feared and stigmatising condition. Media

representations of those affected by dementia routinely focus on their loss of personal

identity, autonomy, and self-determination (Van Gorp & Vercruysse, 2012). With

expanding elderly populations worldwide (ADI, 2015), there is growing interest in

understanding the neural mechanisms that underlie brain ageing. The broad hope is to

develop effective interventions and treatments to delay the onset of age-related

cognitive decline and dementia. Delaying the onset of dementia symptoms for a

relatively modest five years (from an average age of 85 to 90) has been predicted to

halve the burden of the disease (Katzman, 1993; Valenzuela & Sachdev, 2009). This

possibility serves as a key motivation for encouraging people to participate in

dementia screening and lifestyle programs.

Claims about the possibility of brain enhancement and dementia prevention

are common in the media (e.g., O’Connor, Rees, & Joffe, 2012; O’Connor & Joffe,

2013; 2015; Peel, 2014; Racine et al., 2010; Thornton, 2011). Such claims regularly

involve reference to the concept of neuro- or brain ‘plasticity’, which refers to the

brain’s capacity to modify itself (i.e., generating new cells and synaptic connections)

in response to changes in its functioning or environment (Pickersgill et al., 2014).

Once thought to be restricted to early life and limited brain regions, the concept of

plasticity is now thought to apply to multiple processes of brain function and structure

across the lifespan (Mountcastle, 1998). There is some evidence that lifestyle-based

interventions (involving physical, social, and cognitive stimulation) that exploit

neuroplasticity might promote improved health, longevity, and cognitive vitality in

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1

old age (e.g., Hultsch, Hertzog, Small, & Dixon, 1999; Schooler & Mulatu, 2001).

Although the results of such studies seem promising, the nature of plasticity in later

life and the utility of brain-training interventions have been questioned (e.g., Owen et

al., 2010). Concerns have also been raised regarding the extent to which popular

representations of brain enhancement and dementia risk-prevention promote a

potentially repressive ethic of perpetual risk-management and social control (Pitts-

Taylor, 2010; Thornton, 2011). Such concerns are relevant to the notion of the

positioning of healthy people as ‘patients without symptoms’ (Finkler, 2000) as a

result of their increasing risk of developing dementia with increasing age, and the

possibility of medical intervention. Further research into popular media constructions

of the issue of dementia risk-prevention in traditional and online media platforms will

provide additional insights into how public health messages function to reproduce

notions of responsibility for the development of the condition.

1.2 Online health information

Although traditional health communication channels (e.g., print, radio, and

television) continue to be an important source of information, the Internet has created

new spaces for the dissemination of health and medical knowledge by government,

private, and non-profit sectors (Nettleton, Burrows, & O’Malley, 2005, Pitts, 2004).

Online sites – particularly those encouraging user-generated content and social

connection – also provide opportunities for sharing personal experiences of health and

illness (Hardey, 1999; Nettleton et al., 2005). The effectiveness of traditional

broadcast media has been argued to be limited due to factors that include limited

exposure rates, lack of individual specificity, and a tendency for one-way, downward-

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focused approaches to health communication (Kreps & Neuhauser, 2010). By

contrast, the features of online platforms: convenience, tailored information, social

connectivity, and interactivity have been argued to promote greater effectiveness

(e.g., Kreps & Neuhauser, 2010; Neuhauser & Kreps, 2003; Prestin & Chou, 2014).

In the context of dementia, online information provided by non-profit organisations

might play a useful role in addressing preventable behavioural factors by (a) engaging

audiences in a manner that is interactive, personally relevant, credible, and

convenient; and (b) encouraging greater participation in health screening and lifestyle

programs. Online health information may also be able to improve on traditional

media channels by alleviating communication barriers associated with literacy,

language, and culture (Neuhauser & Kreps, 2008). E-health tools (e.g., health

information websites, support groups, and tailored education programs) might, for

example, be expected to increase rates of behavioural change and improve population

health by matching information to different audiences. Despite the promise

associated with online health communication, it has also been argued that such

websites serve to perpetuate values of consumerism and individualism, often

positioning audience members as individually responsible for maintaining and

improving health (e.g., Nettleton, 2013; Gibson, Lee, & Crabb, 2015a).

1.3 A discursive perspective on online health information

Online platforms represent new sites at which contemporary discourses

surrounding health and illness are constructed, maintained, and negotiated (Nettleton

et al., 2005; Pitts, 2004; Seale, 2005). It has been argued, for example, that online

health messages about dementia have the potential to contribute to the reproduction of

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a potentially repressive neoliberal rationality of self-control and risk-management (cf.

Lawless & Augoustinos, 2017; Pitts-Taylor, 2010; Peel, 2014). According to this

perspective, an individual’s health can be regarded as reliant on the application of

self-control in various lifestyle choices that include diet, physical fitness, and mental

exercise (cf. Crawford, 2006; Lupton, 1995; Nettleton, 2013). The risk discourse

associated with neoliberal approaches to health is focused on individuals and their

practices and, as a result, can serve as a powerful tool for allocating responsibility for

poor health to individuals (Galvin, 2002). This focus on individual responsibility for

health has been documented in many contexts (Lupton, 1994; Madden &

Chamberlain, 2004; Street, 2004). However, as Peel (2014) argued, neoliberal

discourse that focuses on individual risk and prevention is relatively new in the

context of media portrayals of dementia and is potentially problematic, especially

when compared to other more treatable or controllable chronic conditions (e.g., Type

2 Diabetes). Given the importance of the Internet as a source of health information

and advice, we examine the construction of a neoliberal health discourse in online

spaces. It is hoped that such research contributes to the development of a critical

perspective on representations of dementia.

Relatively few studies have used discourse analytic approaches to investigate

how representations on health websites contribute to the construction of particular

experiences and meanings around health and illness. A recent exception is Gibson et

al.’s (2015a) multimodal critical discourse analysis (MCDA) of how breast cancer

websites position women as individually responsible for their health. In the present

study, we adopt a discursive psychological approach to examine how health messages

about dementia risk-prevention are routinely constructed online. This approach

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provides a set of methods for examining how facts, social norms, and accountability

are constructed in everyday language (Edwards, 2012). Rather than referencing

psychological models of risk, health decisions, and health behaviours (e.g., Conner &

Sparks, 1995; Waters, McQueen, & Cameron, 2014), we focus on what the language

of the websites typically constructs and accomplishes. This approach provides

insights into contemporary sense-making around the issue of dementia riskprevention,

and demonstrates how such platforms are used as vehicles for the

production of normativity via the prescription of particular actions and identities.

1.4 The present study

This study adopts a discursive psychological approach to examine information

about dementia risk and prevention that was published on dementia websites.

Specifically, analysis concentrates on the discursive resources and practices used to

position audiences as (a) at-risk of dementia; and (b) as individually responsible for

dementia risk-prevention. We aim to extend recent qualitative analyses of dementia

risk-prevention (e.g., Lawless & Augoustinos, 2017; Peel, 2014) by considering how

online information generates inferences about individual risk of developing dementia

and the normativity of engaging in dementia preventative behaviours. More broadly,

this study contributes to a discussion of how individualised health messages about

dementia risk and prevention might mediate individuals’ experiences of, and

responses to, cognitive ageing and dementia.

2. Method

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Data included in this study were drawn from the websites of eight non-profit

dementia organisations. The websites were identified via Alzheimer’s Disease

International’s list of non-profit dementia organisations (www.alz.co.uk/associations),

which included 71 websites at the time of writing (August, 2016). For practical

reasons, only English-language websites were considered. Analysis was conducted as

follows: first, websites were assessed by the first author to determine whether they

met the following selection criteria, adapted from Gibson, Lee, and Crabb (2015b):

(1) that each represented (one of) the largest and most comprehensive non-profit

organisations for the country or region; (2) that it provided information specifically

about dementia risk and prevention; (3) that it contained information relevant to

people living with dementia (including their family, friends, and carers); and (4) that

it provided links to support services/resources. This study was not intended as a

large-scale analysis of information about dementia internationally. Rather, we limited

the scope of the analysis in order to provide a more nuanced account of dementia riskprevention

information on websites from Western countries. Table 1 provides

descriptive information about the websites included in this study.

Table 1

Details of websites selected for inclusion in analysis

Organisation Country Website

Alzheimer’s Australia Australia www.fightdementia.org.au

Alzheimer’s Society of Canada Canada www.alzheimer.ca

Alzheimer’s Society of Ireland Ireland www.alzheimer.ie

Alzheimer’s New Zealand New Zealand www.alzheimers.org.nz

Alzheimer’s Scotland United Kingdom www.alzscot.org

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Alzheimer’s Society United Kingdom (except Scotland) www.alzheimers.org.uk

Alzheimer’s Research United Kingdom www.alzheimersresearchuk.org

Alzheimer’s Association United States of America www.alz.org

Analysis was carried out in two stages: a coding stage and a finer-grained

discourse analysis. In the first stage, the first author developed familiarity by

repeatedly reading the texts published on the websites; this included information,

news, personal stories, events, and links to resources/services. During this stage,

initial codes were generated, and recurrent themes were identified (Table 2). The

style of coding was inductive: the authors did not analyse the data searching for predetermined

themes; rather, identified themes were data-driven (see Braun & Clarke,

2006, for a discussion of thematic analysis as a first-stage in conducting discursive

analysis). Each author assisted in reviewing and refining the analysis by

independently checking the identified themes and illustrative extracts against the

original data. Among the most common themes in the data were (1) positioning of

audiences as at-risk of dementia; and (2) positioning of audiences as responsible for

managing dementia risk-prevention. Advice about engaging in dementia preventative

behaviors was also common in the data. The notion of ‘advice’ was treated as a topic

for investigation rather than a pre-defined conceptual category (Shaw, Potter, &

Hepburn, 2015). Heritage and Sefi’s (1992, p. 368) broad description of advice was

used to code instances in the data: that is, advice was identified as an act that

“describes, recommends, or otherwise forwards a preferred course of future action” –

in this case, health and lifestyle changes to prevent the onset of dementia. A selection

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of examples was chosen to illustrate the two most pervasive themes identified in the

analysis. These extracts are the focus of the analysis that follows.

Analysis drew on insights from discursive psychology (Edwards & Potter,

1992; Edwards, 1997). Discursive psychology is concerned with the situated,

constructive, and action-oriented nature of everyday language. Discourse is treated as

functional: talk and text are analysed as social practices that accomplish actions in the

world (e.g., attributing blame, or resisting accusations of interest). This is a major

point of difference between discursive and mainstream psychological approaches to

language, which consider it a route to understanding cognitive phenomena (motives,

attitudes, etc.). Discursive approaches analyse the rhetorical organisation of

language, focusing on the ways in which versions of reality and identity are

constructed in talk and text. Descriptions are typically assembled to counter actual or

potential alternative versions (Billig et al., 1988). This is routinely achieved by

mobilising specific discursive strategies (e.g., warrants of consensus on a particular

issue) in order to build versions as factual and disinterested (Potter, 1996). In this

sense, discourse is not only constructed (using various linguistic resources), but also

constructive: it builds particular versions of objects, events, and people. This analytic

approach allows examination of how particular discursive resources are used to

construct dementia risk as a relevant concern for audiences, and how dementia

preventative actions are established as desirable and necessary. More broadly, a

discursive psychological approach provides a useful framework for examining how

language is used to construct and negotiate norms, values, and expectations associated

with health and illness.

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Table 2

Summary of codes and themes identified on websites

Codes Themes identified

Acknowledging non-modifiable risk factors Positioning as at-risk for developing dementia

Identifying modifiable risk factors

Lifetime risk statistics and risk factor statistics

Dementia as an abnormal part of ageing

Biomedical explanations of causes and symptoms

of dementia

Advice about dementia prevention Positioning as individually responsible for dementia riskmanagement

Attributing the development of dementia to

individuals and their practices

3. Results

The following analysis is organised into two sections, reflecting two pervasive

issues identified in the corpus: (1) the positioning of audiences as at-risk of

developing dementia; and (2) the provision of health and lifestyle advice that

positioned audiences as individually responsible for dementia risk-prevention.

3.1 Positioning audiences as ‘at-risk’ of dementia: Quantification and

two-part concession structures

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In this section, the analytic focus is on how audiences were constructed as atrisk

of developing dementia. Specifically, we focus on two regularities or patterns of

textual construction that were repeatedly seen in the sampled websites to accomplish

this ‘at-risk’ positioning: (a) quantification; and (b) two-part concession structures.

Quantification, both numerical and non-numerical, frequently involved estimates of

the lifetime risk of developing dementia and quantification of specific risk factors

associated with the disease. Another common device on the websites was the use of a

two-part concession structure, which acknowledged counter-arguments about the

likelihood of developing dementia and the relevance of non-modifiable risk factors

associated with the condition. As we will show, positioning audiences as at-risk of

developing dementia via the use of these common devices routinely served to justify

claims about audiences’ need to be vigilant about dementia risk and to participate in

dementia risk-prevention behaviours. The routine patterns examined in this section

are relevant to our overall interest in how the normativity of performing certain

dementia preventative actions was established.

Extract 1 comes from the Alzheimer’s Society’s (UK) website, on a page

entitled ‘Worried about your memory?’ The page provides information about

memory problems, some of which are described as being an early sign of cognitive

decline. The extract is an example of the way audience members were routinely

positioned as ‘at-risk’ of developing dementia via the use of a two-part concession

structure.

Extract 1

1 It happens to all of us from time to time. You can’t put a name to a face. You

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2 forget where you put your keys. You can’t remember where you parked the

3 car. Most of the time such slips are a nuisance, rather than a sign of

4 something more serious. But if you are worried that your memory is getting

5 noticeably worse, or if memory loss is beginning to affect your everyday life,

6 it is worth seeking advice.

In this extract, the author’s description of common or ‘normal’ instances of

forgetfulness (ll. 1-4) arguably works to minimise the positioning of audience

members as at-risk of developing dementia. The statement that follows, initialised

with ‘But’ (ll. 4-6), undermines this initial claim however, and encourages all

audience members to be vigilant about dementia risk-management. This type of twopart

concession structure (cf. Crabb, 2006; Wetherell & Potter, 1992) was common in

the data. The format typically involved: (1) a minimisation of the likelihood that

audience members have, or will develop, dementia (‘everyone gets more forgetful as

they get older’); followed by (2) a contrastive conjunction and second statement that

undermined this initial minimisation (‘but it’s worth seeking advice’). The second

part functioned to position audience members as at-risk of developing dementia and,

therefore, needing to be vigilant about dementia risk. We argue this ‘at-risk’

positioning contributed to the construction of dementia preventative behaviours as

relevant and necessary. In the sampled websites, two-part concession structures were

frequently used to acknowledge and manage two opposing sides of arguments about

dementia risk, specifically those involving claims about individuals’ likelihood of

developing dementia, and the possibility of risk-prevention. By acknowledging and

managing potential counter-claims about these risk factors, claims and

recommendations could be presented as balanced and informed, thereby defending

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claims from accusations of interest (cf. Potter, 1996). We will expand on this point in

the examples considered below.

Extract 2 comes from Alzheimer’s Research (UK)’s website, on a page titled

Reducing the risk’. In this example, quantification of lifetime risk was combined

with a two-part concession structure to position audience members as susceptible to

developing dementia and therefore needing to participate in risk-prevention activities.

Extract 2

1 The risk of developing most dementias increases with age. That means as we

2 get older, we are more likely to develop dementia. About two in 100 people

3 aged 65 to 69 have dementia, but this figure rises to one in five for those

4 aged 85 to 89.

5 Dementia is not a normal part of getting older or an acceleration of ageing. It

6 is caused by different diseases, most commonly Alzheimer’s. We can’t

7 change our age and there is currently no way we can completely prevent

8 dementia but there may be some simple things we can all do that might

9 help lower our risk.

In lines 2-4, statistics are used to present the risk of developing dementia as a

relevant concern for audiences. The quantification of lifetime risk, also termed the

incidence of the disease (Slaytor & Ward, 1998), was the most common form of

quantification in the dataset. Statistics and other forms of quantification have been

noted to be common in a variety of contexts, including genetic counseling and health

promotional campaign material, such as pamphlets and brochures (e.g., Crabb, 2006;

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Gigerenzer, 2002; O’Doherty, 2006; Slaytor & Ward, 1998). Potter, Wetherell, and

Chitty (1991) have argued that quantification can be understood as a type of rhetoric

that accomplishes particular goals in certain contexts, such as persuading people to

engage in healthy behaviors to avoid risk. From this perspective, estimates of lifetime

risk of developing dementia served to accomplish the following functions in the

sampled websites: (a) representing dementia as a sufficiently serious and widespread

health concern; and (b) implying that with increasing age, people become increasingly

at-risk. In the corpus, quantification of lifetime risk of developing dementia

represented an important rhetorical strategy for positioning audience members as atrisk

of developing dementia and justifying proposals that preventative action is

appropriate, necessary, or desirable.

Lines 6-9 of this extract provide another example of the two-part concession

structure that was common across websites in the corpus. By contrast with the

structure in Extract 1 that involved a minimisation of audience members’ likelihood

of developing dementia followed by a statement about the relevance of dementia riskmanagement,

the two-part structure here follows the form, ‘We cannot change X, but

we can do Y’. That is, there was initial acknowledgement of risk factors that cannot

be modified, followed by a contrastive conjunction, introduced with ‘but’,

emphasising that certain lifestyle changes can or should be made to prevent the onset

of dementia. As in the previous example, the concession works to build the claims as

factual and unbiased. By acknowledging potential counter-claims about risk factors,

websites presented their claims and recommendations as balanced and informed, thus

defending against discounting due to interest or bias (cf. Edwards & Potter, 1992;

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Potter, 1996).

Extracts 3 and 4 are from the Alzheimer’s Association’s (USA) webpage,

‘Risk Factors’, and the Alzheimer’s Society of Canada’s website campaign, ‘Heads

up for healthier brains’, respectively. The websites focus on public awareness about

brain health and dementia risk-prevention, and provide advice about addressing

modifiable risk factors associated with Alzheimer’s disease. These extracts provide

examples of the way rhetorical devices of quantification and two-part concession

structures were regularly combined in order to position audiences as potentially atrisk

of developing dementia, thus establishing the relevance and necessity of dementia

risk-prevention activity.

Extract 3

1 Scientists have identified factors that increase the risk of Alzheimer’s.

2 The most important risk factors—age, family history and heredity—can’t be

3 changed, but emerging evidence suggests there may be other factors we can

4 influence.

5 The greatest known risk factor for Alzheimer’s is advancing age. Most

6 individuals with the disease are age 65 or older. The likelihood of developing

7 Alzheimer’s doubles about every five years after age 65. After age 85, the

8 risk reaches nearly 50 percent. One of the greatest mysteries of Alzheimer’s

9 disease is why risk rises so dramatically as we grow older.

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Extract 4

1 Will healthy lifestyle choices prevent Alzheimer’s disease? There are no

2 guarantees, but evidence suggests that healthy lifestyles help the brain

3 maintain connections and even build new ones. That means that a healthy

4 brain can withstand illness better. So take action today. Some risk factors you

5 can’t control, such as your genetic makeup and growing older, but there is a

6 lot you can do that may help reduce your risk of getting the disease.

The two-part concession structures in these examples (Extract 3, ll. 2-4;

Extract 4, ll. 1-3 & ll. 4-6) about the non-modifiable risk factors of age, family

history, and heredity, are structured in the same general format contained in Extract 2:

We cannot change X, but we can do Y’. This routine two-part concession structure is

again used to acknowledge potential counter-arguments about non-modifiable risk

factors for dementia, while constructing participation in dementia risk-prevention as

beneficial, appropriate, or necessary. Repeated use of such concessions can be seen

as working to protect claims about the relevance of prevention activity on the part of

audience members.

Lines 5-7 of Extract 3 contain another example of quantification rhetoric, this

time involving quantification of the risk factor of age. Factors of age and heredity

were most commonly mentioned in the sampled websites. Like quantification of

lifetime risk (Extract 2), quantification of risk factors associated with dementia served

to maximise descriptions of the susceptibility of audience members to developing

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dementia, thus working to construct risk-prevention as a relevant concern.

Quantification of the risk factor of age can be argued to position all audience

members as increasingly at-risk of the disease with increasing age, regardless of other

potentially relevant risk factors, such as family history or heredity. By creating an ‘at

risk’ subject position for audiences, websites can also be seen justify their advice

about the need for lifestyle changes.

In summary, Extracts 1-4 demonstrate how websites routinely positioned

audience members as at-risk of developing dementia, and constructed participation in

dementia prevention activities as appropriate and necessary. Key features of this atrisk

positioning included:

a) Use of quantification rhetoric (i.e., numbers and statistics to describe lifetime

risk and various risk factors such as age and heredity) that served to maximise

the construction of the likelihood of cognitive decline and dementia,

positioning audience members as at-risk.

b) Use of concessions to acknowledge counter-claims about non-modifiable risk

factors, while positioning audience members as responsible for managing

modifiable risk factors. Such concessions arguably served to protect claims

and recommendations of the need for prevention activity from being

challenged as false or interested.

3.2 Positioning audiences as responsible for dementia risk-

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prevention: Health and lifestyle advice

In this section, we focus on how health and lifestyle advice on the websites

positioned audience members as individually responsible for dementia riskprevention.

In particular, we focus on formulations designed to induce audiences to

perform a preferred course of action (i.e., a lifestyle change to reduce dementia risk).

The advice formats examined in this section presented the proposed risk-prevention

measures as highly normative (i.e., as actions audience members should take).

Advice in the sampled websites typically took the form of imperative formulations

(‘Keep your brain active’). Imperative formulations assume a high degree of

entitlement over an audience’s future conduct, and exhibit little to no orientation to

the contingencies associated with committing to the proposed course of action,

including an audience’s willingness, ability, and past experience (Curl & Drew, 2008;

Craven & Potter, 2010). In this way, advice was both normative and asymmetric, in

that it reflected an assumed difference in knowledge and authority between advisors

and advisees (Antaki & Kent, 2012; Heritage, 2012; Heritage & Raymond, 2005;

Heritage & Sefi, 1992; Stevanovic & Peräkylä, 2012). These features of advice

worked to establish the necessity of participation in dementia risk-prevention

practices, and position audience members as needing to take personal responsibility

for dementia risk-management. We argue that such directives served to promote a

moral identity with regard to brain health in which an ethic of self-care, selfresponsibility,

and risk-management is key.

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Extract 5 is from the Alzheimer’s Society of Ireland’s website, on a page

about a national health promotion campaign called ‘Forget me knot’, that focuses on

brain health and dementia risk-prevention. The following extract is an example of the

types of imperative advice formulations that were typical of the corpus.

Extract 5

1 Push it with puzzles, challenge it to figure out new things, make it earn it’s

2 keep. Stimulate it by connecting with others socially. Push it to protect itself

3 from losing every memory, name and piece of you it holds inside. Take up a

4 hobby such as painting, woodwork or craft work. Read different styles of

5 books, newspapers and magazines. Learn a language, an instrument or to

6 dance.

This example demonstrates how advice about participating in different

lifestyle choices and practices displayed entitlement over audience members’ future

conduct and little to no orientation to the possible contingencies associated with

carrying out the proposed course of action (Curl & Drew, 2008; Craven & Potter,

2010). The imperatives, which reflect an assumed epistemic asymmetry and project

a stance of high obligation to comply with the advice, worked to construct

participation in prevention activity as both normative and accountable. In the

corpus, such imperative advice formulations served to establish a ‘responsible’

subject position for audience members in relation to dementia risk-management. It

can be argued that these websites not only locate dementia risk as a personal issue

for audiences – as we saw in the previous section – but also position audience

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members as individually responsible for dementia risk-management.

Three further extracts exemplifying the use of directives to position audiences

as individually responsible for dementia risk-management will be examined.

Extracts 6, 7, and 8 are from the following sources: Alzheimer’s Society of

Canada’s website campaign, ‘Heads Up For Healthier Brains’, Alzheimer’s

Australia’s brain health program, ‘Your Brain Matters’, and Alzheimer’s Scotland’s

webpage, ‘Reducing the risk of dementia’, respectively. As was the case in many

organisations’ brain health campaigns, directives were among the main form of

advice delivery.

Extract 6

1 Keep your brain active every day. Studies show that regularly challenging

2 your brain may reduce your chances of developing Alzheimer’s disease, so it

3 is important to give your brain a regular workout. Try something new or

4 change the way you usually do a task, such as brushing your hair with your

5 less dominant hand. TPlay games to challenge your mind – chess, cards, word

or

6 number puzzles, jigsaws, crosswords, and memory games.

T

Extract 7

1 Take action:

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2 Step 1: look after your heart

3 Step 2: do some kind of physical activity

4 Step 3: mentally challenge your brain

5 Step 4: follow a healthy diet

6 Step 5: enjoy social activity

Exctract 8

1 What can you do?

2 There are practical, achievable things you can do now which could reduce

3 your chances of developing dementia or, at the very least, improve your

4 general health and wellbeing.

5 1: Eat healthily

6 2: Stay mentally active

7 3: Take regular physical activity

8 4: Keep up social networks

These extracts provide further examples of imperative formulation of dementia

risk-prevention, which (a) invoke an assumed asymmetry in knowledge and authority

between authors and audiences; and (b) construct certain brain health actions as

required or obligatory. As in the previous example, the imperatives display high

entitlement over audience members’ future conduct and little to no acknowledgment

of the contingencies that might prevent them committing to the proposed course of

action. Again, the advice serves to provide for inferences about audience members’

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capacity or opportunity to benefit from participation in risk-prevention activities, and

their personal responsibility to be vigilant in order to manage their dementia risk.

Such constructions arguably worked to promote a moral identity that entails

participation in practices of self-care and risk-management.

Overall, this section demonstrates how advice published on the sampled

websites positioned audiences as individually responsible for taking action in relation

to dementia risk-prevention. The imperative advice formulations examined in this

section communicated high entitlement over audience’s future conduct and little

acceptance of the possible contingencies that might interfere with compliance. Such

advice presented audience members as responsible for managing dementia risk, and

as active agents in dementia risk-prevention

4. Discussion

In this study, we have presented an analysis of online health information about

brain health and dementia risk-prevention. Drawing on insights from discursive

psychology, we have explored two related issues that were pervasive in the data: (1)

how information on non-profit dementia organisations positioned audiences as at-risk

of developing dementia; and (2) how health and lifestyle advice about dementia

preventative behavior positioned audiences as individually responsible for managing

dementia risk-prevention. This positioning of audiences as likely to experience

cognitive decline or dementia as a result of the normal course of ageing constructs the

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problem of dementia risk as a personally relevant issue. Such representation arguably

contributes to the reproduction of a neoliberal health discourse that emphasises

individual responsibility for accessing appropriate health information and managing

potential health risks (cf. Crawford, 2006).

In the first section, we examined how information on the sampled websites

positioned audiences as at-risk of cognitive decline and dementia. We identified two

recurring patterns that were used to accomplish this ‘at-risk’ positioning: (1)

quantification of lifetime risk and quantification of risk factors, which functioned to

maximise constructions of risk; and (2) two-part concession structures, which were

used to acknowledge and manage counter-arguments about the possibility and benefit

of dementia risk-prevention measures. These rhetorical devices were used repeatedly

to position all audiences as ‘at-risk’ of developing dementia, and served to justify

related claims about the need to engage in risk-prevention activities. This analysis of

online representations of dementia risk-prevention has shown (a) how dementia and

cognitive decline were constructed as a relevant and serious health concern for

audience members, and (b) how participation in preventative activities was presented

as an appropriate and necessary response to being at-risk of developing dementia.

In the second section of the analysis, we discussed how advice about

preventing age-related cognitive decline and dementia positioned audiences as

individually responsible for managing prevention. These health imperatives routinely

presented participation in brain enhancement and dementia preventative practices as a

desirable or necessary course of action. As in previous conversation analytic studies

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of directives in various mundane and institutional settings (Antaki & Kent, 2012; Curl

& Drew, 2008; Craven & Potter, 2010), the health and lifestyle advice examined here

demonstrated strong claims of entitlement over recipients’ future conduct (i.e.,

showing high expectation of recipients’ acceptance) and little acknowledgement of

the contingences that might interfere with compliance, including an audience’s

ability, willingness, or past experience. On the websites, advice presented audience

members as active agents in dementia risk-prevention, and served to promote a moral

identity in regard to brain health that is defined by an obligation to engage in practices

of self-care and risk-management. Exploring the ways in which issues of blame and

responsibility for dementia risk-management are handled in institutional and everyday

settings is a future avenue of enquiry.

Several studies have explained dementia risk-reduction with reference to

psychological models of health behavior (e.g., Galvin et al., 2008; Kim, Sargent-Cox,

Cherbuin, & Anstey, 2014) or in sociological terms (e.g., Katz & Peters, 2008;

Williams et al., 2011). By contrast, we have demonstrated how specific discursive

practices and linguistic resources are routinely used in online health information

settings to position audiences as at-risk of developing dementia and to construct

prevention as an appropriate and desirable future course of action. Information and

advice about dementia risk-prevention published on websites arguably reflects

broader organisational agendas relating to health promotion around dementia riskprevention.

These findings have implications for norms associated with dementia

prevention more broadly. Notions of personal responsibility may mark an

individualising turn in understandings of dementia risk and prevention (Peel, 2014;

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Pitts-Taylor, 2010). In addition, imperative-framing of advice about engaging in

brain enhancement and risk-prevention may carry moral connotations about how

individuals’ should behave to prevent the onset of dementia. Such notions are

relevant to health policies that emphase individual self-care as part of the riskmanagement

of population health (Williams et al., 2011). Representations of the

causes of dementia as preventable through lifestyle modification, and associated

discourses of self-responsibility, have been argued to be problematic given the lack of

a cure or of effective treatments for the condition. Such notions may contribute to, or

be a precursor of, victim-blaming (cf. Galvin, 2002). The link between

recommendations of the need for prevention activity and personal culpability for the

development of dementia may be detrimental to people who are living with dementia,

and result in increased stigmatisation.

We acknowledge that we are unable to explore how information and advice

published on the websites actually influences audiences’ future conduct. Future work

might investigate the trajectories of advice giving about cognitive decline and

dementia in a variety of contexts, including health counseling services, medical

encounters, and helpline interactions. This approach could provide complementary

insights into (a) how healthcare professionals establish certain lifestyle changes as

relevant and necessary (b) how they manage instances of advice resistance (cf. Butler

et al., 2010; Ekberg & LeCouteur, 2015; Hepburn & Potter, 2011; Kinnell &

Maynard, 1996; Pilnick, 1999). Future work could also examine how issues of moral

accountability are handled in contexts where professionals’ proposals for lifestyle

changes involve clients accepting some degree of personal responsibility for existing

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or anticipated brain health problems.

5. Conclusion

Dementia presents a significant public health concern worldwide. This study

has examined how the information published on the websites of dementia

organisations’ works to position audience members as at-risk of developing dementia

and as individually responsible for dementia risk-management. Existing research has

highlighted that a focus on risk-prevention in the context of dementia represents an

extension of a broader neoliberal rationality of self-care and self–responsibility for

health and illness (e.g., Peel, 2014; Pitts-Taylor, 2010). We add to these analyses by

examining how online information about dementia risk and prevention works to

construct participation in prevention as desirable, necessary, and obligatory, despite

ongoing debate about the benefit of such practices. Further research is needed to

establish a more detailed understanding of how norms, values, and expectations

around cognitive health and ageing are constructed, negotiated, and treated as

accountable in public forums.

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