Abstract
Objectives
This study was aimed to evaluate the knowledge and attitudes of healthcare professionals in Somaliland towards dementia.
Methods
Between June and July 2023, we administered an adapted online survey consisting of 30 Alzheimer’s disease Knowledge Scale (ADKS) true or false statements and 10 Dementia Care Attitude Scale (DCAS) Likert-scale items. The reliability of the Likert-scale DCAS items was assessed using Cronbach’s alpha. The distribution of responses to DCAS statements was examined using a binomial test, and the relationship between knowledge or attitude and sample characteristics was assessed using Pearson’s chi-squared test or Fisher’s exact test.
Results
The overall validity (Cronbach’s alpha) for DCAS statements (0.88) was greater than 0.80, indicating good level of internal consistency. Out of 107 healthcare workers who completed the survey, 53.3% had unfavourable attitude towards dementia care, and 49.5% had a moderate-to-high knowledge level.
Conclusions
Our pilot survey revealed a lack of knowledge and attitudes about dementia among health professionals and urges high quality surveys to validate the results.
Supplementary Information
The online version contains supplementary material available at 10.1186/s13104-025-07446-2.
Keywords: Dementia, Alzheimer’s disease, Dementia care, Healthcare professionals, Knowledge, Attitudes, Republic of somaliland
Introduction
Dementia, also called major neurocognitive disorder, is one of the leading cause of death and disability, and dependency among the elderly population globally [1]. The disease is characterized by chronic progressive cognitive loss of function in the absence of fluctuating consciousness [2, 3]. Alzheimer’s disease (AD), vascular dementia, Lewy body dementia (LBD), and frontotemporal dementia are the major forms of dementia [3]. Alzheimer’s disease is the most prevalent and prototypical form of dementia, characterised by a gradual onset and progressive decline in cognitive functions like memory, reasoning, and language. Vascular dementia is the second most common type of dementia and often co-occurs with AD. LBDs encompass Parkinson’s disease dementia (PDD) and dementia with Lewy bodies (DLB), which have similar features, including cognitive decline, motor symptoms like parkinsonism, and neuropsychiatric symptoms like visual hallucinations. The primary distinction lies in the timing of symptom onset, with DLB typically showing cognitive and neuropsychiatric problems before or alongside parkinsonism, while PDD manifests with parkinsonism first, followed by cognitive decline. Frontotemporal dementias (FTDs) typically begin earlier than other dementia types, often between 40 and 65, and tend to progress more rapidly. A significant portion of FTD cases have a genetic component and can be inherited [3].
Dementia management is becoming an international concern due to the increasing ageing population and the increasing prevalence of dementia [1]. The proportion of the world’s population over 60 is expected to nearly double by 2050 [4]. There are over 55 million people worldwide who have dementia, with an annual incidence of 4.6 million new cases. The majority of these cases occur in low- and middle-income countries (LMICs), and it is predicted that the number of dementia cases will double every 20 years [5]. Dementia poses difficulties for carers in addition to expenses and service usage [6] and disproportionately affects older people over 65 and women [5]. A recent meta-analysis [7] found that among those 50 years of age and older, the pooled community prevalence for all types of dementia, Alzheimer’s disease, and vascular dementia was 7.0%, 3.2%, and 1.2%, respectively, and the prevalence was greater in women than in men (7.9% versus 5.6%) in the overall analysis.
Because dementia is a degenerative illness, those who have it need frequent contact with and care from a variety of healthcare workers (HCWs), primarily primary care physicians and community nurses [1, 8, 9]. The number of health professionals needed for dementia care varies considerably based on the stage of dementia, the care setting (home, assisted living, or nursing home), and individual factors like comorbidities. The ideal healthcare staff-to-resident ratio in dementia care homes generally falls between 1:5 and 1:6; i.e., for every 5 to 6 residents with dementia, there should be one healthcare professional [10]. One of the most significant factors affecting HCWs’ capacity to recognise and diagnose dementia patients was a lack of understanding about the disease [11, 12]. Moreover, a lower recognition rate of dementia was linked to health workers’ unfavourable views towards those who have the disease [13, 14]. Conversely, compared to those with low dementia knowledge and attitudes, health professionals with higher levels of knowledge and positive attitudes were more likely to identify and diagnose dementia early on and showed a greater propensity to use a person-centred dementia care approach [15, 16].
Studies have been conducted on the factors influencing the knowledge, attitudes, and approaches to dementia care of health professionals. The sociodemographic characteristics of health professionals, including older age, holding a bachelor’s degree, and having an interest in dementia care, were found to be positively associated with dementia knowledge in a cross-sectional study involving 387 hospital nurses in Taiwan [17]. The results were consistent with another study [23], which found that HCWs over the age of 60 had higher knowledge scores about dementia than their younger colleagues; however, no correlation was found between gender and attitudes or knowledge about dementia. Likewise, age, education, professional group, and care experience were associated with knowledge scores, whereas attitudes were influenced by age, professional group, gender, and care experience in a survey involving 380 participants in China [8]. Similar study found that a higher education level was a predictor of knowledge of dementia [18, 19]. In a similar vein, a favourable attitude regarding dementia care was linked to exposure to dementia training in a cross-sectional study conducted in Hong Kong [20]. A different study in Taiwan also found that nurses with dementia care training outperformed those without it in terms of dementia knowledge [17].
Finding evidence to support dementia care education and training requires first assessing health professionals’ knowledge, attitudes, and care styles. The majority of research on HCWs was carried out in high-income nations [8]; therefore, social and cultural variations may restrict the generalizability of the study’s findings in Somaliland and other LMICs. Moreover, the ways in which educational programmes are developed to meet the learning needs of health professionals may be impacted by the differences in health policies and systems among LMICs.
Dementia is the top 20 leading cause of death in Somalia, which accounted for 0.41% of total deaths in 2020 [21]. Despite a small body of research showing that dementia-related knowledge or attitude deficiencies exist and showing how advances in understanding can enhance clinical practice and patient outcomes in developed countries, no such study has been carried out in Somalia. Such research is necessary to pinpoint knowledge or attitude gaps and direct the development of targeted dementia education initiatives [6]. Dementia care is not yet covered in Somaliland’s bachelor’s degree programmes in medicine or nursing, but it is covered very briefly in the formal education curriculum for courses addressing various neurological illnesses. There is no cross-topic integrated learning materials or stand-alone topics in dementia care [22]. Hence, identifying evidence to inform dementia care education and training requires assessing health workers’ knowledge and attitudes concerning dementia and dementia care. The current pilot survey, the first of its type in the country, looked at health professionals’ attitudes and knowledge surrounding dementia in an effort to close this research gap and inform the creation of targeted dementia educational interventions.
Materials and methods
Study design and setting
Between June and July 2023, we undertook an online pilot survey with a convenient sample of 107 health professionals in Somaliland. The Republic of Somaliland is a self-declared young country in the Horn of Africa [23]. It is home to 5.7 million people, and older people over 65 years-old account for 4% of the total population [24, 25]. About 197 doctors, 1256 nurses, and 344 midwives serve the country’s population [26]. English is the official academic language used in higher education in the country.
Data collection tool development and measurement
We used an English questionnaire with Alzheimer’s Disease Knowledge Scale (ADKS) statements [27] and Dementia Care Attitude Scale (DCAS) statements [28] adapted from previous studies. We assessed the health professionals’ knowledge about Alzheimer’s disease and attitudes towards dementia with ADKS and DCAS, respectively. The ADKS is a single-factor scale that includes 30 true or false questions covering seven domains: life impact (3 items), assessment and diagnosis (4 items), symptoms (4 items), course of the disease (4 items), treatment and management (4 items), caregiving (5 items), and risk factors (6 items) [8]. We determined the total score by adding the correct responses for each item, resulting in a total score ranging from 0 to 30. A higher overall score implies better knowledge [28]. The mean ADKS score was used as a benchmark to determine the knowledge level of the participants. We regarded the knowledge level as high if the score was equal to or higher than the mean score; otherwise, we deemed it low.
The DCAS contains 10 items, with responses scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Four of the 10 items are negatively worded and are reversed in a definite order (e.g., a score of 5 becomes 1) when calculating the total score. The total score range was from 10 to 50; scores above the median attitude score were considered positive attitudes, and scores below the median score were considered negative attitudes.
Recruitment process
Directors and principals of health institutions were requested to circulate the survey link to healthcare workers in the Republic of Somaliland, who in turn were encouraged to further share the link with other participants in health facilities across the country.
Survey administration
Kobo Toolbox forms were administered (see also the supplementary file), and participation was voluntary, and no incentives were offered. We limited participation to a single response.
Data management and analysis
We exported and downloaded the Kobo Toolbox data in XLS forms and cleaned and coded it in Excel before imported to SPSS. We used Cronbach’s alpha coefficient [29] to assess the reliability of the attitude statements. We used the Kolmogorov-Smirnov test to assess the normality of all the scale variables.
We summarized baseline information (such as age, gender, and education level) and metrics of main outcome data (ADKS and DCAS) using descriptive statistics, such as frequency, percentage, and measures of central tendency (mean and median) and measures of dispersion (standard deviation and interquartile range).
The reliability knowledge and attitude items were assessed by Cronbach’s alpha coefficient, while the association of knowledge and attitudes with sample characteristics was analysed by Pearson’s chi-squared test or Fisher’s exact test. A binomial test was used to assess the distribution of responses to the attitude statements. All tests were performed using SPSS v. 20 (Armonk, NY, IBM, Corp.) [30], and the statistical significance was set at a two-tail p-value < 0.05.
Results
Baseline characteristics
Among the 107 healthcare professionals who responded to the online survey, almost all (> 90.0%) were aged between 18 and 39 years old and held a bachelor’s degree or above, and the sex ratio was 1:06 (Table 1).
Table 1.
Summary of participants’ baseline characteristics
| Characteristics | Frequency | Percentage |
|---|---|---|
| Age, median (IQR) | 28(25,31) | 25,31 |
| 18–39 | 103 | 97.2 |
| 40–59 | 2 | 1.9 |
| ≥ 60 | 1 | 0.9 |
| Gender | ||
| Male | 55 | 51.4 |
| Female | 52 | 48.6 |
| Education Level | ||
| Diploma | 8 | 8.2 |
| Bachelor or above | 90 | 91.8 |
Alzheimer’s disease knowledge scale (ADKS)
The Alzheimer’s Disease Knowledge Scale (ADKS) mean score was 18.7 (SD = 3.1) out of 30, and healthcare workers responded to 62% of the ADKS statements correctly (Tables 2 and 3).
Table 2.
Participants’ alzheimer’s disease knowledge disease scale (ADKS)
| ADKS Domains | Answered correctly N (%) | Mean ± SD |
|---|---|---|
| Life Impact | ||
| It is safe for people with Alzheimer’s disease (AD) to drive as long as they have a companion in the car at all times. (F) | 62 (57.9) | 0.58 ± 0.50 |
| Most people with AD live in nursing homes. (F) | 56 (52.3) | 0.52 ± 0.50 |
| Drivers in the early stages of AD have more auto accidents than other older drivers. (F) | 21 (19.6) | 0.20 ± 0.40 |
| Domain mean score ± SD | 1.30 ± 0.88 | |
| Assessment and Diagnosis | ||
| An evaluation of a person for AD typically includes information from a physical exam, memory tests, brain scans, and a history of the symptoms. (T) | 98 (91.6) | 0.92 ± 0.23 |
| AD is a normal part of aging, like gray hair or wrinkles. (F) | 60 (56.1) | 0.56 ± 0.50 |
| Currently, the best way to diagnose AD is with a blood test. (T) | 33 (30.8) | 0.31 ± 0.46 |
| A person suspected of having AD should be evaluated to rule out treatable disorders with similar symptoms. (T) | 94 (87.9) | 0.88 ± 0.33 |
| Domain mean score ± SD | 2.63 ± 0.97 | |
| Symptoms | ||
| AD progresses at the same speed as everyone else. (F) | 79 (73.8) | 0.74 ± 0.44 |
| In general, as people with AD get worse, they are likely to wander and get lost. (T) | 90 (84.1) | 0.84 ± 0.37 |
| Some people with AD cannot recognize their children when they see them. (T) | 89 (83.2) | 0.83 ± 0.38 |
| People with AD have more problems remembering things on some days than others. (T) | 87 (81.3) | 0.74 ± 0.39 |
| Domain mean score ± SD | 3.22 ± 0.90 | |
| The course of the disease | ||
| In rare cases, people have recovered from Alzheimer’s disease. (F) | 42 (39.3) | 0.39 ± 0.49 |
| Eventually, the person with AD will need 24-hour supervision. (T) | 87 (81.3) | 0.81 ± 0.39 |
| After symptoms of AD appear, the average life expectancy is 6–12 years. (T) | 62 (57.9) | 0.58 ± 0.50 |
| A person with AD becomes increasingly likely to fall as the disease gets worse. (T) | 87 (81.3) | 0.81 ± 0.40 |
| Domain mean score ± SD | 2.53 ± 1.01 | |
| Treatment and Management | ||
| AD cannot be cured. (T) | 80 (74.8) | 0.75 ± 0.44 |
| When a person has AD, using reminder notes is a crutch that contributes to decline. (F) | 40 (37.4) | 0.37 ± 0.49 |
| People whose AD is not severe can benefit from psychotherapy for depression and anxiety. (T) | 89 (83.2) | 0.83 ± 0.38 |
| Medications can permanently stop AD from getting worse. (F) | 50 (46.7) | 0.47 ± 0.50 |
| Domain mean score ± SD | 2.42 ± 1.00 | |
| Caregiving | ||
| People with AD do best with simple instructions given one step at a time. (T) | 83 (77.6) | 0.78 ± 0.42 |
| When people with AD repeat the same question or story several times, it is helpful to remind them that they are repeating themselves. (F) | 33 (30.8) | 0.31 ± 0.46 |
| If a person with AD becomes alert and agitated at night, a good strategy is to make sure that the person gets plenty of physical activity during the day. (T) | 79 (73.8) | 0.74 ± 0.44 |
| If a person with AD follows the caregiver all over the house, it is helpful to encourage the person with AD to stay in one room. (F) | 44 (41.1) | 0.41 ± 0.50 |
| People with AD do best when exposed to new experiences and environments as often as possible. (F) | 37 (34.6) | 0.35 ± 0.50 |
| Domain mean score ± SD | 2.58 ± 1.00 | |
| Risk factors | ||
| Genes can only partially account for the development of dementia. (T) | 72 (67.3) | 0.67 ± 0.47 |
| AD can be caused by eating food that is cooked in aluminum pots. (F) | 76 (71.0) | 0.71 ± 0.50 |
| More than 50% of people older than 85 have AD. (T) | 83 (77.6) | 0.78 ± 0.42 |
| The percentage of people older than 65 with AD exceeds 10%. (F) | 26 (24.3) | 0.24 ± 0.43 |
| Having a parent or sibling with AD increases the chance of developing it. (T) | 82 (76.6) | 0.77 ± 0.43 |
| It has been scientifically proven that mental exercise can prevent a person from getting AD. (T) | 80 (74.8) | 0.75 ± 0.44 |
| Domain mean score ± SD | 3.92 ± 1.07 | |
| Overall ADKS mean score ± SD | 18.70 ± 3.13 | |
AD: Alzheimer’s Disease; F: Wrong response; T: Correct response
Table 4.
Distribution participants’ responses to dementia care attitude scale (DCAS) statements
| DCAS statements | Strongly (agree) | Strongly (disagree) | p-value | |
|---|---|---|---|---|
| 1 | Much can be done to improve the quality of life of caregivers of people with dementia. (PW) | 64 (65.3%) | 34 (34.7%) | 0.003 |
| 2 | Families would rather be told about their relatives’ dementia as soon as possible. (PW) | 61 (63.5%) | 35 (36.5%) | 0.010 |
| 3 | Much can be done to improve the quality of life of people with dementia. (PW) | 66 (69.5%) | 29 (30.5%) | 0.000 |
| 4 | Providing a diagnosis is usually more helpful than harmful. (PW | 75 (76.5%) | 23 (23.5%) | 0.000 |
| 5 | Dementia is best diagnosed by specialist services. (PW) | 62 (66.0%) | 32 (34.0%) | 0.003 |
| 6 | Patients with dementia can be a drain on resources with few positive outcomes. (NW) | 35 (45.5%) | 42 (54.5%) | 0.494 |
| 7 | It is better to talk to the patient in euphemistic terms. (PW) | 46 (59.7%) | 31 (40.3%) | 0.110 |
| 8 | Managing dementia is more often frustrating than rewarding. (NW) | 39 (47.0%) | 44 (53.0) | 0.661 |
| 9 | There is little point in referring families to services as they do not want to use them. (NW) | 36 (47.4%) | 40 (52.6%) | 0.731 |
| 10 | The primary care team has very little role to play in the care of people with dementia. (NW) | 43 (45.7%) | 51 (54.3%) | 0.470 |
| Overall median (IQR) attitude score | 34 (25, 39) | |||
Items with the poorest responses included those related to life impact and caregiving, with 43% and 52% correct answers, respectively (Table 3). More than half of participants mistakenly thought that drivers in the early stages of AD have more auto accidents than other older drivers (80%, n = 86); when people with AD repeat the same question or story several times, it is helpful to remind them that they are repeating themselves (69%, n = 74); and people with AD do best when exposed to new experiences and environments as often as possible (65%, n = 70) (Table 2).
Table 3.
Summary of healthcare workers’ responses across the alzheimer’s disease knowledge scale (ADKS) domains
| ADKS domains | # of items | %Correct responses | Mean ± SD |
|---|---|---|---|
| Life impact | 3 | 43% | 1.30 ± 0.88 |
| Assessment and diagnosis | 4 | 66% | 2.63 ± 0.97 |
| Symptoms | 4 | 80% | 3.22 ± 0.90 |
| Course of the disease | 4 | 66% | 2.53 ± 1.01 |
| Treatment and management | 4 | 61% | 2.42 ± 1.00 |
| Caregiving | 5 | 52% | 2.58 ± 1.00 |
| Risk factors | 6 | 65% | 3.92 ± 1.07 |
| Overall | 30 | 62% | 18.70 ± 3.13 |
Furthermore, a 61% correct response rate was recorded about dementia treatment and management, and about 37% and 47% responded correctly that ‘when a person has AD, using reminder notes is a crutch that contributes to decline’ and ‘Medications can permanently stop AD from getting worse’, respectively (Table 2).
Out of the 107 participants, 49.5% scored greater or equal to the median ADKS score (i.e., 18.7), indicating a moderate-to-high level of knowledge, while 50.5% scored below the median score (Fig. 1).
Fig. 1.
Knowledge level of participants on Alzheimer’s disease
Factors related to alzheimer’s disease knowledge (ADKS)
The knowledge level was significantly associated with gender, and higher proportions of women had moderate-to-high knowledge than men (χ2 = 4.11, p-value = 0.043) (Fig. 2). However, ADKS was not related to the level of education (p > 0.05).
Fig. 2.
Knowledge level on Alzheimer disease by participants’ baseline characteristics
Dementia care attitude scale (DCAS)
The overall validity value (measured by Cronbach’s alpha) for attitude was 0.88, while the item values ranged from 0.86 to 0.89, indicating a good level of internal consistency.
The median (IQR) DCAS score was 34 (25, 39) (Table 3), and 46.7% of participants (50 of 107) had a positive attitude towards dementia care (DCAS score ≥ 34) (Fig. 3). Over three-quarters of healthcare workers mistakenly disapproved that providing diagnosis is usually more helpful than harmful (Table 3, Fig. 4). Likewise, over one-third of participants had a negative view that ‘managing dementia is more often frustrating than rewarding’, ‘there is little point in referring families to services as they do not want to use them’, ‘the primary care team has very little role to play in the care of people with dementia’, and ‘patients with dementia can be a drain on resources with little positive outcome’ (Table 4, Fig. 3).
Fig. 3.
Healthcare workers’ attitude towards dementia care, Somaliland, 2023
Fig. 4.
Distribution of healthcare workers’ response to Dementia Care Attitude Scale (DCAS) statements. A1: Much can be done to improve the quality of life of caregivers of people with dementia; A2: Families would rather be told about their relatives’ dementia as soon as possible; A3: Much can be done to improve the quality of life of people with dementia; A4: Providing a diagnosis is usually more helpful than harmful; A5: Dementia is best diagnosed by specialist services; A6: Patients with dementia can be a drain on resources with little positive outcomes; A7: It is better to talk to the patient in euphemistic terms; A8: Managing dementia is more often frustrating than rewarding; A9: There is little point in referring families to services as they do not want to use them; A10: The primary care team has very little role to play in the care of people with dementia
Factors associated with attitudes towards dementia attitude (DCAS)
Study participants’ attitudes toward dementia care were unrelated to their gender or educational level (p > 0.05) (Fig. 5).
Fig. 5.
Dementia attitude status by participants’ baseline characteristics
Relationship between ADKS scores and DCAS scores
No correlation was found between ADKS scores and DCAS scores (r = 0.171, p = 0.079).
Discussion
We report low mean Alzheimer’s’ Disease Knowledge Scale (ADKS) score, and half of the healthcare workers had a low dementia knowledge level. Studies from Uganda [31], China [8, 28], and Australia [32] have indicated high levels of dementia knowledge. The lowest-level knowledge in this study was related to dementia’s life impact, where four out of five participants gave the wrong answer to the statement “Drivers in the early stages of AD have more auto accidents than other older drivers.” This finding was discordant with those of a Chinese study [8], which indicated that the lowest percentage of health professionals correctly answered knowledge statements related to providing care. Accurate comparison of knowledge levels across these studies was not possible due to differences in measurement and scoring methods, study population, sample size, and sampling. In Somaliland, dementia receives less attention [22]; a lack of prior dementia training can significantly contribute to reduced awareness and understanding of dementia, impacting the quality of care provided [33].
In this study, less than half of the participants held positive attitudes toward dementia, and the median (IQR) attitude score was 34.0 (29, 39). A higher proportion of positive attitudes were reported in China [28]. The unfavourable attitudes may have resulted from a lack of enforcement of dementia policies [22].
Limitations
This is a pilot survey compounded by several limitations, such as the small sample size, the use of convenience sampling, and the potential for self-selection bias. Only healthcare workers with internet access and active participation completed the survey, which limited the generalisability of the results. As a result, a longitudinal study based on a large sample size and random sampling would be able to overcome the study limitations. Despite these limitations, the study provides baseline data on the knowledge and attitude towards dementia among the health professionals in Somaliland.
Conclusions
The pilot survey demonstrated that healthcare workers in Somaliland had low levels of knowledge and attitudes towards dementia. We recommend a high-quality, large-scale survey to confirm the results.
Electronic Supplementary Material
Below is the link to the electronic supplementary material.
Acknowledgements
The authors would like to thank everyone who participated in this survey.
Abbreviations
- AD
Alzheimer’s disease
- ADKS
Alzheimer’s disease knowledge scale
- DCAS
Dementia care attitude scale
- DLB
Dementia with lewy bodies
- IQR
Interquartile range
- LMICs
Low- and middle-income countries
- PDD
Parkinson’s disease dementia
Author contributions
MD and TG conceived, designed the study, and prepared the data collection tools. TG supervised the data collection, data analysis, and preparation of the first draft of the manuscript. Both authors read and approved the final manuscript.
Funding
No funding was received for conducting this survey.
Data availability
Data is provided within the manuscript or supplementary information files.
Declarations
Ethics approval and consent to participate
Ethical approval was obtained from the Bulhan Ethics Review Board (BRB-00000001). We collected no personally identifiable information. On the first page of the online questionnaire, all relevant information regarding the survey, data protection, and the statement of consent was presented. Participants provided informed consent before undertaking this survey, and permission was granted for publication of the results.
Consent publications
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
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