Attitudes and needs of brain health promotion for older adults in China: a qualitative study

Abstract

Background

With the deepening of population aging, the disease burden associated with brain health in older adults is increasingly severe. To develop targeted strategies for promoting brain health among older adults, it is essential to first understand their awareness of brain health as well as their motivations and barriers to health promotion. This study aims to explore older adults’ cognition and attitudes toward brain health, along with their needs and preferences regarding brain health promotion.

Methods

Individual, face-to-face and semi-structured interviews were conducted with 17 older adults from Zhengzhou, Henan Province. Questions, used in our study, focused perception of brain health, attitudes and beliefs toward brain health promotion, and needs and preferences regarding brain health promotion. Responses were analyzed using inductive qualitative content analysis.

Results

The following themes and sub-themes were identified: (1) Multidimensional yet compartmentalized brain health perceptions, including physiological function, disease association, psychological well-being, behavioral coordination; (2) Diverse attitudes toward brain health promotion, including proactive prevention, cognitive-behavioral dissonance, fatalistic neglect; (3) Intrinsic motivators for brain health promotion, including health awareness, quality of life, family responsibility, disease-related anxiety; (4) External support as a moderating factor in brain health promotion, including family support, peer support, community support; (5) Barriers to brain health promotion activities, including physical limitations, role conflict, cognitive misconceptions, information quality; (6)Needs and preferences for brain health promotion, including authoritative yet practical content, and diversified age-friendly formats.

Conclusions

Older adults have a compartmentalized understanding of brain health, often accompanied by misconceptions and tend to hold negative attitudes toward brain health promotion, highlighting an urgent need for professional guidance to provide correct education and direction. Our study reveals that effective brain health promotion requires enhancing internal motivation, building external support networks, and overcoming implementation barriers through integrated strategies, while crucially tailoring approaches to individual needs and preferences for maximum effectiveness.

Highlights

• Qualitative exploration of older adults’ perceptions, attitudes, and needs regarding brain health promotion in China.

• Reveals multifaceted perceptions of brain health among older adults, which are often fragmented and primarily associated with some disease rather than lifelong wellness

• Identifies diverse attitudes towards brain health promotion, including proactive prevention, cognitive-behavioral dissonance, fatalistic neglect.

Call for integrated, multi-level strategies that are precisely tailored to older adults, focusing on:

Content: Authoritative, clear messaging that brain health is preventable and manageable.

Formats: Community-based delivery through trusted channels, with flexible, accessible and age-friendly designs.

Motivation: Strengthen intrinsic drive via family, peer, and community support systems.

Background

According to the World Health Organization (WHO) [1], the global population aged 60 and above will surge from 1 billion in 2020 to 2.1 billion by 2050, with those over 80 reaching 426 million. WHO’s healthy aging strategy identifies “preventing brain aging and maintaining brain health” as a high-level goal [2] In 2022, WHO launched the Global Action Plan on Brain Health [3], defining brain health as “the state of brain functioning across cognitive, sensory, social-emotional, behavioural and motor domains, allowing a person to realize their full potential over the life course, irrespective of the presence or absence of disorders.”

However, as global aging intensifies, the burden of brain health-related diseases continues to rise [4]. Studies indicate that stroke and Alzheimer’s disease (AD)-related cognitive impairment are the two leading causes of compromised brain health in older adults [5]. Stroke remains the top global cause of death and the second-leading contributor to disability-adjusted life years (DALYs). Meanwhile, AD-related cognitive impairment has emerged as a top-ten cause of death, accounting for 1.95 million deaths worldwide in 2021. By 2050, its DALY burden is projected to rank eighth, with a 142% increase. Brain disorders progressively impair physical, cognitive, and social functioning in older adults, severely diminishing their quality of life while imposing heavy economic and care giving burdens on families and societies [6].

To address this, interventions must align with the “four-level prevention gap” framework for chronic diseases, shifting focus toward earlier risk factor management [7–9]. The Lancet [10] has updated its life-course model of dementia risk factors, emphasizing that modifying these 14 key modifiable risk factors could prevent or delay approximately 45% of dementia cases. Similarly, The BMJ’s Brain Health Series proposes six pillars for brain health maintenance: (1) physical activity, (2) cognitive training, (3) dietary nutrition, (4) social engagement, (5) sleep and stress management, and (6) vascular risk factor control [11, 12]. The 2024 Brain Health Summit further emphasized “risk factor control to promote brain health“ [13], advocating proactive brain health strategies for older adults.

Despite these advances, global studies report low awareness of brain health among older populations [14, 15]. Many perceive brain diseases as an inevitable consequence of aging, overlooking the link between healthy behaviors and brain health [4, 16, 17]. Currently, available assessment tools for brain health in older adults primarily focus on subjective questionnaires or objective clinical examinations of cognitive function levels. There is a significant lack of specialized instruments to evaluate their underlying attitudes, the reasons behind their behaviors, and their specific needs for brain health promotion. This gap is evident in the literature: while international research has explored perspectives of younger [18] and middle-aged adults [19], and Chinese studies have assessed lifestyle-related dementia risks in high-risk groups, few investigations focus specifically on older adults’ attitudes toward brain health or their motivations and barriers to engagement in brain health promotion. Given that this research topic, particularly concerning the “attitudes” and “needs” dimensions, is in its early stages of exploration among the Chinese older adult population, the relevant perceptions are likely complex and not well understood. Therefore, this study employed a descriptive qualitative research approach. The aim is to explore this phenomenon deeply without preconceived theoretical frameworks, openly capturing the rich, contextualized personal experiences, beliefs, and core demands directly from the perspectives of older participants. This approach is a necessary step to uncover the complexities of this under-researched area and to lay the crucial conceptual groundwork for the future development of targeted assessment tools and intervention strategies.

Methods

Study setting and participants

Our study employed descriptive qualitative research, adhering to the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist [20] (Appendix 1.). Data collection occurred from December 2024 to February 2025 in one zone of Zhengzhou, Henan Province. This district represents a distinctive “urban complex,” characterized by the presence of numerous universities and research institutes—home to a large population of retired older adults with high educational attainment and urban professional backgrounds (e.g., retired university professors). Concurrently, the area contains several “relocation communities” formed due to urban expansion, where older adults who were formerly farmers and have transitioned to urban citizenship reside. Participants met the following criteria: (a) aged over 60, (b) with normal vision and hearing, able to communicate clearly, and (c) without severe mental or physical conditions affecting participation. To comprehensively capture the diversity of perspectives within this social context, we employed maximum variation sampling. Participants were recruited through multiple avenues: from community senior activity centers (n = 9), which serve as key hubs for daily socialization; from a public senior care facility (n = 3), which caters to older adults requiring varying levels of care; by contacting a participant from prior studies (n = 1); and via snowball sampling (n = 4). This strategy ensured representation across varying ages, genders, and educational backgrounds. All participants provided informed consent and received a complimentary health moxa hammer(a traditional self-massage tool designed to relax tight muscles and promote local circulation through gentle percussion, available for about $2) as a token of appreciation, and this compensation was modest and non-coercive. The study followed ethical principles and was approved by Zhengzhou University’s Life Science Ethics Review Committee (ZZUIRB-2025-16).

Data collection

All the researchers systematically studied qualitative methods and interview techniques. The study employed face-to-face, semi-structured interviews, which were conducted by a team comprising the first and third authors (ZXJ and YPY), both Master’s-level researchers specializing in geriatric care. In this team-based approach, one researcher was primarily responsible for posing questions and guiding the conversation, while the other focused on documenting contextual observations and non-verbal cues. Specifically, the third author primarily led the questioning for interviews conducted in the senior care facility, while the first author acted as the primary questioner in all other settings. Interview locations were determined through mutual agreement with participants to ensure quiet and comfortable environments without the presence of any third parties. Before each interview, researchers explained the study purpose, ensured confidentiality through pseudonyms, and obtained written consent. Interviews were conducted in Mandarin or Henan dialect per participant preference, and had an average duration of 15 to 20 min. This focused interview length was feasible because the study was guided by a highly concentrated protocol targeting only three core domains, enabling efficient yet in-depth data collection. Concurrent analysis confirmed that data saturation was initially reached by the 15th participant, and two additional interviews were conducted to verify this, resulting in a final sample of 17.

The interview guide (Appendix 2) was developed through literature review, team discussions on three core domains (brain health perception, promotion attitudes, and needs/preferences), and pilot testing with two older participants. The interview guide served as a flexible framework, with researchers dynamically adjusting questioning strategies based on participant responses while encouraging interviewees to raise their own questions. The interview questions and the interviewer’s attitude were neutral to avoid bias against the participants. Critical information was verified through real-time probing, paraphrasing, and clarification techniques.

Data analysis

Data analysis was carried out in parallel with the data collection, with the interviewing process continuing through two additional participants after which no new themes emerged, ultimately resulting in a total of 17 interviewees. Following each interview, the first and third authors(ZXJ and YPY) promptly transcribed the recordings within 24 h. These transcripts were then cross-verified against the original audio by the fifth and seventh authors(XLJ and DSY) to ensure accuracy and consistency. Given the scarcity of qualitative studies on older adults’ attitudes and needs regarding brain health promotion in China, an inductive qualitative content analysis approach was adopted, allowing themes to emerge directly from the data without a pre-defined coding framework. The transcripts were imported into NVivo 11.0 for management and analysis, with each participant assigned a unique identifier (P1-P17) to ensure confidentiality. The first and fourth authors(ZXJ and ZMY) began by independently and repeatedly reading the transcripts to gain a comprehensive understanding, while simultaneously marking meaningful statements. They then broke down the data, performing line-by-line analysis to identify significant statements and assign initial codes. Through this process, recurring statements, events, and phenomena were systematically coded and categorized to generate preliminary themes. The relationships between these themes were then examined to form thematic clusters. To enhance the trustworthiness of the findings, investigator triangulation was primarily employed to ensure analytical rigor. The two coders subsequently met to review the coding scheme together, engaging in in-depth discussions to resolve discrepancies through consensus. Any unresolved differences were adjudicated by the fifth author(XLJ). The evolving coding structure developed throughout this process, see Table 1 for an example of the analytic process. The final thematic structure was presented and reviewed in a meeting with the entire research team, which included two doctoral-level, four master’s-level researchers, and one undergraduate research assistant, all experienced in qualitative methods. The goal of this team review was not to enforce a uniform interpretation but to acknowledge and explore emergent complexities and contradictions. All analysis was conducted on the Chinese transcripts. Subsequently, the results (including themes, categories, and illustrative quotes) were translated into English by an independent translator who was proficient in the local Henan dialect and had a background in gerontological nursing and expertise in qualitative data translation. Another researcher then verified this translation to ensure conceptual and contextual accuracy.

Table 1.

Example of the analytical process for brain health perceptions and attitudes

Quote	Code	Sub-theme	Theme
“Brain health means no blockages in the cerebrovascular system, ensuring adequate heart strength and blood supply to the brain, resulting in no dizziness or headaches, and the ability to think clearly.”	Linking health to blood flow and clear thought	Physiological Function	Multidimensional yet Compartmentalized Brain Health Perceptions
“Brain health… means not developing that ‘forgetting illness’.”	Fear of specific diseases	Disease Association
“Overthinking and depression harm brain health—I’ve experienced it. Obsessive thoughts make me dizzy.”	Personal experience of mind-body connection	Psychological Well-being
“Brain health means quick reflexes, being able to perform any desired movement smoothly, and maintaining coordination.”	Equating health with physical coordination	Behavioral Coordination

Results

Sample characteristics

The sample consisted of 17 older participants ranging in age from 60 to 86 years old(m = 72.59, sd = 7.39), with 47.1% having attained high school education or above. Eight participants identified as female and nine as male. Notably, only 4 participants had engaged in mental labor occupations prior to retirement (specifically as a teacher, doctor, and accountant respectively), while the majority had previously worked in physically demanding roles. Detailed characteristics of the study participants are presented in Tables 2 and 3.

Table 2.

Participant demographics

Participant (n = 17)
Characteristics				Means and Percentages
Age				72.59 years (SD = 7.39)
Gender				47.1% female (n = 8)
				52.9% male (n = 9)
Education				29.4% Primary school or below (n = 5)
				23.5% Junior high school (n = 4)
				35.3% Senior high school or Technical secondary school (n = 6)
				11.8% College (associate degree) or University (bachelor’s) (n = 2)
Marital Status				70.6% Married (n = 12)
				29.4% Widowed (n = 5)
Living Arrangement				17.6% Senior care facility (n = 3)
				35.3% Living with children (n = 6)
				11.8% Living with spouse (n = 2)
				35.3% Living with spouse & child (n = 6)
Previous Occupation				23.5% Mental labor (n = 4)
				76.5% Physical labor (n = 13)
Chronic illness status				88.2% Yes (n = 15)
				11.8% No (n = 2)

SD Standard Deviation

Table 3.

Characteristcs of each participant

No.	Gender	Age	Education	Previous Occupation	Chronic illness status
P1	female	84	senior high school	teacher	hypertension
P2	male	79	primary school	mechanical worker	none
P3	male	73	junior high school	logistics staff	hypertension
P4	male	86	senior high school	missile maintenance worker	chronic kidney disease
P5	female	65	senior high school	teacher	hypertension
P6	male	72	junior high school	farmer	hypertension & stroke
P7	female	68	primary school	textile worker	diabetes mellitus
P8	female	78	primary school	farmer	hypertension & diabetes mellitus
P9	female	63	university	doctor	hypertension
P10	male	71	college	accountant	coronary artery disease
P11	male	77	technical secondary school	steel factory worker	coronary artery disease & arthritis
P12	male	60	senior high school	driver	hypertension & stroke
P13	female	75	primary school	farmer	diabetes mellitus & coronary artery disease
P14	male	66	junior high school	farmer	diabetes mellitus
P15	male	80	junior high school	worker	hypertension
P16	female	67	senior high school	logistics staff	none
P17	female	70	primary school	farmer	stroke

Six themes were identified with 20 associated sub-themes (see Table 4).

Table 4.

Themes and sub-themes

Themes	Sub-themes
Multidimensional yet Compartmentalized Brain Health Perceptions	Physiological Function
	Disease Association
	Psychological Well-being
	Behavioral Coordination
Diverse Attitudes Toward Brain Health Promotion	Proactive Prevention
	Cognitive-Behavioral Dissonance
	Fatalistic Neglect
Intrinsic Motivators for Brain Health Promotion	Health Awareness
	Quality of Life
	Family Responsibility
	Disease-related Anxiety
External Support as a Moderating Factor in Brain Health Promotion	Family Support
	Peer Support
	Community Support
Barriers to Brain Health Promotion Activities	Physical Limitations
	Role Conflict
	Cognitive Misconceptions
	Information Quality
Needs and Preferences for Brain Health Promotion	Authoritative yet Practical Content
	Diversified Age-Friendly Formats

Theme 1: multidimensional yet compartmentalized brain health perceptions

Sub-theme 1: physiological function

Most older adults understand brain health based on their physical sensations and life experiences, primarily from physiological and brain function perspectives.

“Brain health means no blockages in the cerebrovascular system, ensuring adequate heart strength and blood supply to the brain, resulting in no dizziness or headaches, and the ability to think clearly.”(Participant 1)

“The brain should function normally, with clear thinking and quick reactions.” (Participant 5)

“It means the mind should be clear, able to remember things, and not confused.” (Participant 6)

“Brain health means not being confused.” (Participant 13)

“It’s related to cerebrovascular health.” (Participant 15)

Sub-theme 2: disease association

Most older adults associate brain health with related diseases, though some cannot specify which particular diseases, while others limit their understanding to conditions like stroke and dementia.

“It’s about not getting those brain diseases.” (Participant 8)

“Brain health… means not developing that ‘forgetting illness’.” (Participant 10)

“It’s about the brain not having problems! Like not getting cerebral infarction, and also that… what’s it called… Alzheimer’s.” (Participant 12)

“It’s mainly about avoiding cerebral infarction—after a brain infarction, you gradually develop dementia.” (Participant 16)

Sub-theme 3: psychological Well-being

Only four older interviewees recognized the connection between psychological states and brain function, acknowledging mental health as part of brain health.

“Overthinking and depression harm brain health—I’ve experienced it. Obsessive thoughts make me dizzy.” (Participant 1)

“Brain health requires emotional health.” (Participant 4)

“When feeling emotionally stifled, my brain ‘rusts shut’ too. That is not brain health.” (Participant 10)

Sub-theme 4: behavioral coordination

Only two older participants associated brain health with behavioral responsiveness and limb coordination.

“Brain health, I believe, mainly means good brain function—no memory decline, clear thinking, coordinated limbs, and no health issues.” (Participant 9)

“Brain health means quick reflexes, being able to perform any desired movement smoothly, and maintaining coordination.” (Participant 17)

Theme 2: diverse attitudes toward brain health promotion

Sub-theme 1: proactive prevention

Some older individuals recognize the importance of brain health and proactively adopt healthy behaviors to maintain it.

“Of course (it’s important)! If the brain stops working, is the person even okay?” (Participant 7)

“Extremely important! Prevention is always better than cure, so we must stay active.” (Participant 9)

“It’s absolutely (important)! See how we persist in (square dancing) all year round, never missing a day.” (Participant 17)

Sub-theme 2: cognitive-behavioral dissonance

Some older interviewees recognized the importance of brain health but failed to translate this awareness into healthy behaviors.

“How could it not be important? But with us watching grandchildren every day, getting by is enough.” (Participant 8)

“I know it’s important, but… (wry smile) at this age, why trouble the kids?” (Participant 11)

Sub-theme 3: fatalistic neglect

Some older adults hold a stereotypical belief that cognitive decline is an inevitable natural consequence of aging, lacking motivation to actively maintain brain health.

“When you’re old, nothing works right anymore! That’s just how aging goes.” (Participant 2)

“At my age, being forgetful is just how it is. Old folks are like ‘broken goods’—beyond repair.” (Participant 13)

Theme 3: intrinsic motivators for brain health promotion

Sub-theme 1: health awareness

Some older interviewees demonstrated strong health awareness, serving as a key driver for proactive brain health maintenance.

“I want to live healthily.” (Participant 1)

“This is about our own health—if we don’t care for it ourselves, who will?” (Participant 5)

“The body is one’s own responsibility, so persistence is essential.” (Participant 7)

“Our (square dancing) group prioritizes physical health above all.” (Participant 17)

Sub-theme 2: quality of life

Several interviewees identified the pursuit of quality of life in old age as a key motivator for their active engagement in brain health promotion.

“If your brain doesn’t function well, your quality of life will surely suffer. Plus, I’ve seen older friends whose cognitive decline made daily life difficult—that’s why we seniors should prioritize brain health.” (Participant 5)

“Life’s better now—my son moved us in with him. We want to keep our minds sharp to enjoy more good years together.” (Participant 6)

“Even one extra day of clear-mindedness beats being bedridden and spoon-fed.” (Participant 10)

Sub-theme 3: family responsibility

Several older participants emphasized maintaining brain health to avoid burdening their families.

“If we stay healthy, our children can focus on their own lives without worrying about us.” (Participant 4)

“That old guy next door—his brain (gestures)—doesn’t work well. His family won’t let him out and need someone watching him all the time, scared he’ll get lost. Everything’s inconvenient now.” (Participant 6)

Sub-theme 4: disease-related anxiety

Several older adults reported actively seeking preventive measures due to fear of brain-related illnesses, stemming from personal experiences or witnessing others’ suffering.

“I can’t afford to get sick again. Ten years ago, I was bedridden for a while… Ever since then, I haven’t been as sharp. Sometimes my mind just goes blank—that’s why I never miss my medications now.” (Participant 6)

“Prevention is non-negotiable! After caring for my mother during her illness and seeing her agony, I’m terrified. Our family medical history is like a time bomb. Now, if I hear about anything that might help prevent [brain decline], I’ll try it—better safe than sorry.” (Participant 10)

Theme 4: external support as a moderating factor in brain health promotion

Sub-theme 1: family support

Some older adults mentioned that the companionship, support, reminders, and supervision from their children and spouses serve as external motivation for actively participating in brain health promotion.

“My diabetes is well-controlled because my daughter buys my medicine for me. I don’t dare be careless—she always reminds me to take my meds, never missing a dose. And when it comes to meals, she’s very careful too, telling me not to eat this or that.” (Participant 5)

“My daughter sometimes comes over, bringing milk and stuff for me and my wife to drink.” (Participant 6)

“My spouse exercises with me, and we keep each other accountable, so it’s easier to stay consistent.” (Participant 9)

However, two interviewees noted that a lack of family support can hinder brain health promotion.

“They don’t study this stuff, and after working exhausting jobs all day, they don’t have the energy to talk about it. Sometimes when I don’t feel well, they just tell me to go to the pharmacy or, if it’s serious, to a big hospital.” (Participant 8)

“My kids tell me to socialize more, but my spouse passed away, and I don’t have much to talk about with others.” (Participant 11)

Sub-theme 2: peer support

Some older interviewees believed that the encouragement and influence of peers can motivate individuals to participate in brain health promotion activities.

“Every day, someone messages me on WeChat, and we arrange to exercise together.” (Participant 1)

“If people around me also prioritize brain health and we do it together, encouraging each other, it gives me more motivation. Otherwise, after a few days alone, I wouldn’t feel like continuing.” (Participant 5)

However, two respondents mentioned that without peer support, individuals may give up on related health behaviors.

“There’s no opportunity here… no equipment like microphones, and no one else shares this interest.” (Participant 2)

“It doesn’t work—they don’t like (playing the violin), and I’d just be disturbing them.” (Participant 3)

Sub-theme 3: community support

Some older participants mentioned that the community plays a crucial supportive role in encouraging their participation in health-promoting activities by providing diverse programs and venues.

“There’s a small park near us where people do group exercises every day—tapping here and there (referring to health-promoting movements).” (Participant 1)

“Our neighborhood has a ‘Healthcare Hub’ where we play the guzheng (Chinese zither), do crafts, play cards, or mahjong. They even offer incentives like redeemable points for goods, free eggs, health check-ups, or blood pressure and blood sugar tests. Everyone’s really enthusiastic about it.” (Participant 17)

Theme 5: barriers to brain health promotion activities

Sub-theme 1: physical limitations

Some older adults pointed out that physical mobility limitations and declining memory function are major obstacles to maintaining health-promoting behaviors.

“Getting older—my legs aren’t what they used to be. I can’t stand for long periods anymore.” (Participant 1)

“Health activities have to be manageable for seniors, otherwise we can’t stick with them!” (Participant 6)

“My memory’s failing me—I just saved some dietary recommendations, and now I can’t find them.” (Participant 10)

Sub-theme 2: role conflict

Some older participants mentioned that their family caregiving responsibilities leave them with little time or energy to engage in health-promoting activities.

“I watch the grandchildren during the day, and when my kids come home in the evening, I’m busy cooking and doing laundry—there’s no time left for anything else.” (Participant 8)

“No time at all, still have to look after the kids.” (Participant 4)

“If I had more free time, I’d definitely be willing to learn more (about health).” (Participant 16)

Sub-theme 3: cognitive misconceptions

Some older adults hold cognitive misconceptions that lead them to neglect health behaviors such as medical check-ups and non-pharmacological health promotion.

“If I don’t get check-ups, I won’t have any illnesses. But once I do, they’ll definitely find something wrong - then I’ll have to spend money on treatment. Might as well leave it alone.” (Participant 11)

“That won’t work…those are secondary measures…what really matters is taking medicine.” (Participant 12)

Sub-theme 4: information quality

Some older adults identified information overload and unreliable health information as major barriers to adopting healthy behaviors.

“Sometimes we can’t tell if the information is accurate, especially when it contradicts what we’ve always heard. We don’t dare follow advice when we’re unsure about its credibility.” (Participant 5)

“Online health information is overwhelming and disorganized. These flashy ‘new’ wellness methods keep popping up - it takes real effort to evaluate them. Those of us with some medical knowledge can sort through it better, but the information is so fragmented and inconsistent, never systematic enough.” (Participant 9)

“There’s too much conflicting advice online - some say walnuts are beneficial, others swear by fish. Who should we actually believe?” (Participant 10)

Theme 6: needs and preferences for brain health promotion

Sub-theme 1: authoritative yet practical content

The older interviewees emphasized that health education materials should be comprehensive and from authoritative sources.

“First and foremost, it must be authoritative—preferably materials from major hospitals or universities. And the content needs to be specific.” (Participant 9)

They also stressed that the knowledge should be practical and aligned with older cultural habits.

“But if you’re telling us not to eat congee (which goes against our daily habits)…that would be hard to adopt.” (Participant 7)

“Also, give us simple, easy-to-remember methods—like a few daily exercises or common ingredients to use. Don’t make it too complicated; I can’t retain that much.” (Participant 10)

“If it’s not troublesome and actually works, I’ll try it. But if it’s too complex, forget it—my brain can’t handle it…” (Participant 11)

“It can’t feel like a burden. If it does, we won’t stick with it.” (Participant 4)

Sub-theme 2: diversified age-friendly formats

The older adults expressed a desire for diversified formats in health education programs to cater to different preferences and needs:

“Combine pictures with text—make it vivid and interesting. Medium-length articles or short videos would work well.” (Participant 5)

“Smartphones are so convenient now—you can find anything with just a tap.” (Participant 8)

“For digital options, a reliable mini-program would be acceptable.” (Participant 9)

“Show us real success stories—concrete examples of good management cases.” (Participant 15)

“For articles, highlight the key points—that would help.” (Participant 1)

“Remember—many seniors have mobility issues, so make it doable.” (Participant 3)

“I hope for simple, easy-to-understand methods where I can immediately think—‘Ah, I can use this!’ “(Participant 5)

“Audio recordings work—I can listen repeatedly until I remember.” (Participant 6)

Discussion

The results of our study reveal that Chinese older adults’ understanding of brain health promotion is relatively limited and fragmented. Also, their attitudes can be categorized into three distinct types, while the translation of these attitudes into action is shaped by a combination of internal motivation, external support, and various practical barriers. These findings collectively emphasize that effective brain health interventions cannot be one-dimensional but must be comprehensive, multi-faceted strategies precisely tailored to this population’s specific cognitive, motivational, and contextual backgrounds.

Global studies consistently report low public awareness of brain health [14, 15]. Aligning with research on middle-aged Latinos [19], our findings show that older adults in China possess a basic awareness of brain health and interpret it through several dimensions. In our study, participants understood brain health through four key aspects: physiological function, disease association, psychological well-being, and behavioral coordination. A critical finding, however, is that their understanding tends to be compartmentalized, meaning that while individuals may recognize these distinct aspects, they often lack an integrated perspective on how these dimensions interact to constitute overall brain health. Specifically, participants primarily described physiological function through subjective experiences, such as “mental clarity” or the absence of headaches. While recognizing links to stroke and dementia, most couldn’t name specific diseases or understand connections to chronic conditions like hypertension [21, 22]. Furthermore, few associated psychological or behavioral factors with brain health, revealing particularly limited awareness of mental well-being’s role. These findings collectively demonstrate incomplete and superficial understanding of brain health among older adults.

The study reveals that three distinct attitudinal patterns emerged: proactive prevention, cognitive-behavioral dissonance, fatalistic neglect. Older adults with a proactive prevention attitude demonstrated a high degree of congruence between cognition and behavior. They not only deeply recognized the importance of brain health but also consistently translated the belief that “prevention is better than cure” into sustained health-promoting practices. Conversely, older adults with fatalistic attitudes often rigidly view cognitive decline as inevitable aging, leading to passive acceptance and low motivation for brain health maintenance-aligning with existing research findings [23–25]. These individuals frequently exhibit low self-efficacy, expressing resignation about their capacity to maintain brain health through behavior change [26]. Crucially, this study delineates a third, distinct group: those exhibiting a cognitive-behavioral dissonance attitude. They were characterized by a fundamental intention-action gap. Although they acknowledged the value of brain health at a conceptual level, their actions were constrained by a combination of practical and psychological barriers: on one hand, they depended on family support for implementing behaviors, while on the other hand, they suppressed help-seeking due to a strong reluctance to be a burden. More profoundly, they failed to recognize that current investment in health constitutes a proactive strategy to alleviate their children’s future care giving burden. Collectively, all these findings highlight the need for targeted education that caters to older adults with different attitudes.

Additionally, our study elucidated several key factors influencing older adults’ engagement in brain health promotion, which can be categorized into three primary dimensions: intrinsic motivators, external support, and practical barriers. Firstly, older adults’ emphasis on health, pursuit of quality of life, sense of family responsibility, and fear of disease serve as important internal drivers for participating in brain health promotion activities. Older adults with stronger health awareness, due to their better understanding of brain health, were more inclined to actively maintain brain health [27]. Some older adults believed that maintaining brain health could, on one hand, enable them to enjoy a higher quality of life in their later years and avoid inconveniences caused by cognitive decline [28]; on the other hand, it could also help maintain independence and reduce the care giving burden on their families [29]. Fear of disease is another important trigger for health behaviors among older adults [30]. Some older adults, having personally experienced or witnessed the suffering caused by brain diseases, developed fear and thus extensively sought preventive measures, though this sometimes led to blindly following trends without proper judgment [31]. Secondly, family, peer, and community support serve as vital external resources that significantly facilitate older adults’ adoption of brain health behaviors. Family serves as an important support system for older adults [32]. The companionship, reminders, and supervision from children and spouses can strengthen older adults’ motivation to participate in and adhere to health behaviors. Additionally, active involvement from family members provides emotional support, making older adults more willing to engage in health activities. Peer encouragement can motivate older adults to participate in brain health promotion activities, while mutual supervision and support among older adults help overcome inertia and sustain healthy behaviors [33]. The public spaces and organized activities within communities provide essential physical venues and structured services for older adults to engage in brain health promotion behaviors [34]. However, when such external support is lacking, older adults’ brain health promotion behaviors may be significantly affected, leading to reduced motivation and opportunities to participate in health activities [35].

Furthermore, older adults’ adoption of brain health behaviors faces multiple barriers including physical limitations, role conflicts, knowledge gaps, and unreliable information. The decline in physical functions, memory, or the impact of chronic illnesses makes it difficult for them to adhere to brain health activities that require sustained engagement or complex motor skills, often due to physical discomfort or a sense of inadequacy, thereby hindering the formation of a virtuous cycle of health behaviors. Some older adults, due to responsibilities such as providing inter-generational care, struggled to find the time and energy to engage in health promotion activities. One study [36] found that while inter-generational care and family tasks can be beneficial to older adults’ health when kept within an appropriate range, excessive demands can create psychological stress and negatively impact their well-being. At the same time, some older adults held cognitive misconceptions, leading them to neglect health behaviors such as medical check-ups and non-pharmacological interventions. Interviews revealed that in the information age, the overwhelming and often contradictory online information made it challenging for older adults to discern scientifically valid advice, causing hesitation and difficulty in sustaining health behaviors [37].

The Lancet [17] has highlighted that modifying unhealthy lifestyles and adopting health-promoting behaviors can enhance brain health. To ensure the effectiveness and sustainability of brain health promotion initiatives, they must align with older adults’ needs and preferences [38]. Our study reveals that older adults’ expectations for brain health promotion primarily manifest in two dimensions: content that is authoritative and practical, and delivery formats that are diversified and aging-friendly. Regarding content, older adults demonstrated higher trust in health information from reliable sources [39]. They showed greater behavioral adoption rates when the content possesses strong practicality, can be directly applied to daily life, and aligns with local cultural contexts. In terms of format, while seniors expressed interest in diverse activity types, these interventions require age-appropriate adaptations considering their physical conditions and functional capacities. These findings suggest that future research should more precisely identify older adults’ specific needs and preferences, with particular focus on developing concrete brain health promotion protocols that effectively address these requirements.

Finally, synthesizing the core findings of this study, we propose the following tailored strategies. Future brain health promotion initiatives should integrate content from multi-modal authoritative guidelines to convey the scientific message that “brain health is preventable and manageable“ [40, 41] using language and methods that are easily understandable and memorable for older adults, thereby fostering a proactive attitude towards brain health maintenance. These messages should be precisely disseminated through established community health education channels to reduce older adults’ burden of information discernment. Personalized approaches should be adopted for older adults with different attitudinal types. Real-life cases should be utilized to demonstrate how maintaining brain health is crucial for preserving independent living and reducing family care giving burdens, thereby strengthening their intrinsic motivation for brain health promotion. Furthermore, positive guidance regarding their perception of disease should be provided to alleviate fear and anxiety, helping them channel concerns into motivation for health actions. Additionally, intervention protocols should be culturally and habitually adapted to different regions and designed to be low-intensity, progressive, and actionable, considering the physiological characteristics of older adults. At the family level, intergenerational support systems should be established through multi-generational health education. This aims to enhance children’s awareness of brain health and enable them to provide knowledge updates, emotional support, and behavioral supervision for their older family members. At the community level, a supportive environment should be created by integrating resources from community health centers and older adult activity centers. This includes organizing peer support groups led by respected older “health leaders” and offering flexible programs with varying difficulty levels and schedules to ensure accessibility and benefits for older adults with different physical conditions. The development of temporary childcare services or the design of intergenerational activities involving grandparents and grandchildren is recommended to overcome participation barriers for those providing grandchild care.

Strengths and limitations

Our study provides a focused examination of brain health attitudes and education needs among older adults and emphasizes the importance of tailored interventions that account for individual preferences and situational barriers. The findings highlight key factors for effective promotion, including the need to strengthen motivation, broaden support systems, and overcome behavioral obstacles through multi-faceted collaboration. However, this study has several limitations. First, the relatively short interview duration (15–20 min), while sufficient for capturing core themes due to our highly focused guide, may have limited the exploration of more nuanced personal narratives. To ensure data quality, we employed real-time probing and paraphrasing to clarify and confirm key information. Second, the recruitment of participants from a single city in China, while providing rich contextual data, affects the generalizability of our findings to other socio-cultural settings. Future research should involve multicenter studies across diverse socioeconomic regions to explore geographical differences in brain health awareness. Third, conducting some interviews might have introduced social desirability bias, where participants provide answers they believe are expected. We sought to mitigate this by emphasizing confidentiality, using neutral questioning, and assuring participants that there were no right or wrong answers.

Finally, the exclusive reliance on qualitative methods, while a necessary first step to gain a deep, contextually grounded understanding of this under-studied area, presents inherent constraints on the replicability and generalizability of the results. Therefore, a vital future direction involves building directly upon these qualitative findings to develop and validate a standardized quantitative assessment tool. Such an instrument would allow for testing the distribution of the attitudes and needs identified here across larger and more diverse populations, enabling cross-cultural comparisons and informing more targeted public health strategies.

Conclusions

Our study reveals that older adults’ engagement in brain health behaviors is shaped by the interplay of attitudinal patterns, intrinsic motivators, external support, and perceived barriers. The identified typology—proactive prevention, cognitive-behavioral dissonance, and fatalistic neglect—provides a crucial framework for developing targeted interventions. Future efforts should adopt stratified intervention strategies based on individual differences, focusing on the integration of precise information dissemination, personalized planning, actionable protocols, and family-community support systems. The ultimate goal is to establish a brain health promotion ecosystem characterized by feasible interventions, comprehensible knowledge, and trustworthy information.

Appendix 1

Table 5.

Consolidated criteria for reporting qualitative studies (COREQ) 32-item checklist

No	Item		Guide questions/description	Response/page number
Domain 1: Research team and reflexivity
Personal Characteristics
1	Interviewer/ facilitator	Which author/s conducted the interview or focus group?		Page 6 (Data collection): Reported in Methods under Data collection section. The first and third authors (ZXJ and YPY), both Master’s-level researchers, conducted all interviews. They employed a paired team approach where one primarily guided the conversation while the other recorded observations, with the third author leading sessions in the senior care facility and the first author leading elsewhere.
2	Credentials	What were the researcher’s credentials? E.g. PhD, MD		Page 8 (Data analysis): The seven-member research team included two PhD, four master’s-level researchers, and one undergraduate research assistant.
3	Occupation	What was their occupation at the time of the study?		Page 6 (Data collection): They are all from nursing science.
4	Gender	Was the researcher male or female?		All research team members were female, with the exception of the undergraduate student.
5	Experience and training	What experience or training did the researcher have?		Page 8 (Data collection): Both interviewers were native to Henan Province, fluent in both Mandarin Chinese and the Henan dialect. Each had received qualitative research training and conducted qualitative interviews previously, possessing relevant fieldwork experience. And other researcher are all with experience in qualitative research.
Relationship with participants
6	Relationship established	Was a relationship established prior to study commencement?		The interviewers had no prior relationship with most research participants. (A single participant had been contacted due to prior participation in a related study within our research group.)
7	Participant knowledge of the interviewer	What did the participants know about the researcher? e.g. personal goals, reasons for doing the research		The older participants were explicitly informed of the researchers’ student status and study purpose during recruitment. Upon agreeing to the interview, they received detailed explanations about the research content.
8	Interviewer characteristics	What characteristics were reported about the interviewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic		The interviewers were researchers specializing in geriatric care. To mitigate potential bias, we employed neutral questioning techniques during data collection and implemented investigator triangulation with team reflexivity discussions during analysis, ensuring themes emerged naturally from the data rather than from presuppositions. Our primary interest in this topic stemmed from observing the scarcity of person-centered brain health promotion strategies in Chinese community settings.
Domain 2: study design
Theoretical framework
9	Methodological orientation and Theory	What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis		Page 7 (Data analysis): This study adopted the method of descriptive qualitative research and inductive qualitative content analysis was used to identify key themes.
Participant selection
10	Sampling	How were participants selected? e.g. purposive, convenience, consecutive, snowball		Page 5 (Study setting and Participants): We used maximum variation sampling and snowball sampling
11	Method of approach	How were participants approached? e.g. face-to-face, telephone, mail, email		Page 6 (Data collection): The study employed face-to-face, semi-structured interviews
12	Sample size	How many participants were in the study?		Page 5 (Study setting and Participants): 17 participants were interviewed.
13	Non-participation	How many people refused to participate or dropped out? Reasons?		One older participant withdrew from the interview due to the need to pick up her grandchild from school.
Setting
14	Setting of data collection	Where was the data collected? e.g. home, clinic, workplace		Page 5 (Study setting and Participants): The interviews were conducted in community senior activity centers or senior care facility.
15	Presence of non-participants	Was anyone else present besides the participants and researchers?		Not applicable- no third parties were present during the interview.
16	Description of sample	What are the important characteristics of the sample? e.g. demographic data, date		Page 10 (Participant demographics): Table 2
Data collection
17	Interview guide	Were questions, prompts, guides provided by the authors? Was it pilot tested?		Page 6 (Data collection): The final interview guide was systematically developed through an evidence-based process combining targeted literature review and collaborative research team deliberations. Interview guide is provied in Appendix 2.
18	Repeat interviews	Were repeat interviews carried out? If yes, how many?		Not applicable- interviews were only conducted once.
19	Audio/visual recording	Did the research use audio or visual recording to collect the data?		Page 6 (Data collection): Audio recordings were collected.
20	Field notes	Were field notes made during and/or after the interview or focus group?		Yes, during the interview, one researcher was responsible for taking field notes, which included documenting contextual observations and non-verbal cues.
21	Duration	What was the duration of the interviews or focus group?		Page 6 (Data collection): Interviews lasted 15–20 min. This focused interview length was feasible because the study was guided by a highly concentrated protocol targeting only three core domains, enabling efficient yet in-depth data collection.
22	Data saturation	Was data saturation discussed?		Page 7 (Data analysis): Data saturation was confirmed by conducting two additional interviews after no new themes emerged, reaching a final sample of 17 participants.
23	Transcripts returned	Were transcripts returned to participants for comment and/or correction?		Page 7 (Data analysis): While we did not return transcribed texts to participants for member checking, we ensured data accuracy through multiple rigorous approaches: (a) real-time verification during interviews using probing questions, paraphrasing and clarification techniques; (b) post-interview cross-validation by research team members systematically comparing transcripts against original recordings and field notes.
Domain 3: analysis and findings
Data analysis
24	Number of data coders	How many data coders coded the data?		Page 7 (Data analysis & results): The coding was conducted independently by the first and fourth authors(ZXJ and ZMY), resulting in the identification of 6 major themes and 20 sub-themes.
25	Description of the coding tree	Did authors provide a description of the coding tree?		Page 9 (Results): The authors provided an illustrative example of the coding tree through Table 1
26	Derivation of themes	Were themes identified in advance or derived from the data?		Page 7 (Data analysis): Themes were derived from the data.
27	Software	What software, if applicable, was used to manage the data?		Page 7 (Data analysis): Interviews were analyzed in NVivo 11.0.
28	Participant checking	Did participants provide feedback on the findings?		Not applicable-older participants did not provide feedback on the findings.
Reporting
29	Quotations presented	Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g. participant number		Page 9 (Results): Illustrative quotations were presented in the Results, along with participants numbers and characteristics.
30	Data and findings consistent	Was there consistency between the data presented and the findings?		Page 9 (Results): Research findings presented represent the data.
31	Clarity of major themes	Were major themes clearly presented in the findings?		Page 9 (Results): Major themes are presented in our study results.
32	Clarity of minor themes	Is there a description of diverse cases or discussion of minor themes?		Page 9 (Results): We discuss a diversity of responses within each theme.

Appendix 2. Interview Guide - English version

Interview Guide.

1. Perception of Brain Health.

What do you know about brain health?

Could you share your thoughts and feelings about brain health?

What factors do you believe keep your brain healthy?

What factors do you believe make your brain unhealthy?

How did you gain these knowledge?

• 2.Attitudes and Beliefs Toward Brain Health Promotion.

• What are your views on brain health promotion?

• What are behaviors you think you can do to keep your brain healthy?

• Do you think the following behaviors can improve brain health? (e.g., physical exercise, cognitive training, balanced nutrition, social activities, sleep and stress management, controlling vascular risk factors)

• What do you perceive as the facilitators and barriers to maintaining these healthy behaviors for brain health?

• 3.Needs and Preferences for Brain Health Promotion.

Would you like to learn more about brain health?

If a professional institution provided scientifically validated brain health information, what kind of support or advice would you prefer?

Through which channels would you like to receive brain health knowledge? What format (e.g., text, video, workshops) would be most engaging/memorable for you?

Would you apply this knowledge in your daily life after learning it?

Why do you want to follow it?

Is there anything else you would like to add, or anything you feel you did not get a chance to say?

Authors’ contributions

Zhang XJ: Conceptualization, Project administration, Data curation, Writing-original draft, review & editing. Zhang Y : Conceptualization, Resources, Methodology, Writing - review & editing. Yuan PY : Data collection, Writing - review & editing. Zhao MY : Data analysis, Writing - review & editing. Xing LJ : Data analysis, Writing - review & editing. Tian YT: Conceptualization, Writing - review & editing. Dong SY: Writing - review & editing.

Funding

This research was supported by the University-Industry Collaborative Education Program (Smart Care and Human Factor Engineering Joint Laboratory) under Grant No. 230905329045253 and the Zhengzhou University Graduate Independent Innovation Project (Grant No. 20250413). The content presented herein represents solely the views of the authors and does not necessarily reflect the official position of the Ministry of Education and Zhengzhou University.

Data availability

To safeguard the confidentiality and anonymity of participants, the transcripts and coding analyzed in this study cannot be publicly shared. Individual requests for data access will be reviewed. For further information, please contact Zhang XJ at zxj101395@163.com.

Declarations

Ethics approval and consent to participate

The study followed ethical principles and was approved by Zhengzhou University’s Life Science Ethics Review Committee (approval reference: ZZUIRB-2025-16). Before each interview, researchers explained the study purpose, ensured confidentiality through pseudonyms, and obtained written informed consent from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.