Community perceptions and barriers to brain health and dementia care in rural communities in Cameroon: a qualitative study

Abstract

Introduction

Community perceptions of brain health and dementia can significantly influence health-seeking behaviors. Context-specific data on community perceptions of dementia and brain health in rural communities in Cameroon is vital for the development of context-relevant interventions and policies to promote brain health and reduce the burden of dementia. This study aimed to explore community perceptions of dementia and brain health, as well as the barriers to optimal brain health and dementia care in some rural communities in Cameroon.

Methodology

We conducted a qualitative study using semi-structured interviews with healthcare workers, participants with dementia and their caregivers, and individuals without dementia from three rural communities in Cameroon. Data analysis was done thematically based on grounded theory.

Results

The study included seven healthcare workers, five participants with dementia and their caregivers, and 10 persons without dementia. Emerging themes in community perceptions of dementia were spiritual/supernatural, bewitchment, generational curse, infection, madness, and normal aging. For community perceptions of brain health, emerging themes included mental sharpness, healthy mind, the absence of brain disease, an intact brain, the importance of brain health, lifestyle, environment, systemic conditions, and socioeconomic and cultural factors. Barriers to dementia care were stigma, lack of public awareness, lack of specialist services, insufficient healthcare worker training, cultural practices, limited therapeutic options, lack of diagnostic tools, lack of social support, and financial constraints. Barriers to brain health were substance abuse, unhealthy lifestyles, economic constraints, low public awareness, cultural practices, and low access to health facilities.

Conclusion

Community misperceptions about dementia and brain health are common, and multiple barriers to brain health and dementia care exist in rural communities. A multipronged intervention is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-025-04609-3.

Introduction

Brain health, a continuous and lifelong state of optimal brain function across cognitive, sensory, socioemotional, behavioral, and motor domains, is an essential requirement for individuals to realize their full potential throughout their life course [1, 2]. Optimal brain health reduces the risk of brain-related diseases such as dementia [2, 3]. The demographic transition to an aging population and the rising rates of hypertension, diabetes, and lifestyle-related factors have resulted in declining brain health and a growing burden of dementia in Sub-Saharan Africa (SSA) [3, 4]. The lack of access to dementia care compounds the declining brain health and growing burden of dementia in SSA. Dementia care in SSA is hindered by the lack of essential diagnostics and therapeutics, a high rate of stigma, and a lack of culturally sensitive research and diagnostic tools [4, 5]. Worst still, public awareness of brain health and dementia remains critically low in SSA, often resulting in misconceptions and myths which negatively influence health-seeking behaviors and community attitudes towards people living with dementia [6].

In Cameroon, dementia is a growing public health problem [7]. A recent study found a prevalence of 7.0% and 28.3% of dementia and cognitive impairment, respectively [7]. A low level of awareness among healthcare workers often results in underdiagnosis or misdiagnosis. Insufficient training of health workers leads to suboptimal quality of dementia care [8]. Also, dementia-related stigma is common due to several misconceptions and myths [9, 10]. Dementia symptoms are often misattributed to witchcraft, which further delays appropriate help‑seeking behaviors.

Rural communities in Cameroon are characterized by an economy heavily reliant on agriculture, high poverty rates, and limited access to healthcare [11, 12]. The healthcare system in rural Cameroon faces numerous challenges, including inadequate infrastructure and a critical shortage of healthcare professionals [13]. Moreover, health literacy is low in rural communities and is significantly influenced by culture. Rural communities in Cameroon are often deeply rooted in their culture, with a strong respect for traditions, a reliance on traditional or herbal medicines, and specific norms and rituals that define community life [14]. Consequently, spiritual and traditional healers are often the first point of contact for patients seeking healthcare [14, 15]. Such practices are reinforced by limited public awareness. In these settings, understanding the community perceptions and barriers to brain health and dementia care is absolutely critical. Data on community perceptions and barriers to brain health and dementia care in rural communities will allow for the development and implementation of effective and sustainable solutions to reduce the burden of dementia and optimize brain health. This study aimed to explore community perceptions of dementia and brain health, as well as the barriers to optimal brain health and dementia care in some rural communities in Cameroon.

Methodology

Study design

We conducted a qualitative study in three rural communities in Cameroon, using semi-structured, face-to-face interviews with individuals without dementia, caregivers, individuals with dementia, and healthcare workers (HCWs).

Study settings

Participants were selected from three rural districts in the Northwest, West, and Adamaoua regions of Cameroon to capture diverse contexts. Cameroon is a lower‑middle‑income country in SSA with a growing burden of brain-related diseases, such as dementia, but limited availability of dementia care services [7]. Cameroon has over 230 ethnic groups with diverse community practices [16]. The rural healthcare system in Cameroon is characterized by limited specialist services, uneven distribution of primary‑care facilities, and a heavy reliance on primary healthcare nurses and community health workers to deliver frontline outreach and support [14, 15]. These primary healthcare nurses and community health workers do not always have the necessary skills and knowledge to effectively manage diseases such as dementia, leading to significant gaps in dementia screening, diagnosis, and ongoing care. The Adamaoua region of Cameroon is the country’s third-largest region, characterized by sparsely populated land [17]. The Muslim Fulbe (Fulani) constitute the major ethnic group, and the region’s cultural roots have been shaped by its position within the Sudano-Sahelian people. A Lamido leads a strong traditional authority structure in Lamidat, and the economy is based on agriculture, trade, and livestock breeding [17]. This region is medically underserved, with limited healthcare facilities and a shortage of specialists.

The North West region of Cameroon is one of the two English-speaking regions in the country, characterized by a diverse ethnic mix [18]. Traditional authorities, such as chiefs or Fons, are recognized as the heads of villages and may have greater influence over the local population than local administrative authorities [19]. There is a firm reliance on traditional medicine in rural areas, and community practices in the region often influence health-seeking behavior. Access to specialist care remains low. Over the last nine years, an ongoing sociopolitical crisis in this region has led to the destruction of local healthcare facilities and significantly disrupted healthcare delivery [20, 21].

The West region is home to the Bamileke and Bamoun, two of the largest ethnic groups in Cameroon. The area is deeply rooted in cultural traditions with powerful chieftaincies that influence community practices. Poor health-seeking behaviors, such as reliance on herbal concoctions, are common, and cultural beliefs about diseases and health often influence the adoption of modern healthcare.

Sampling

We purposively chose the three regions to increase representation of Cameroon’s diverse cultural backgrounds. The North West region to represent Anglophone Cameroon, the West region to represent French Cameroon, and the Adamawa region to represent the Northern part of Cameroon. The communities were randomly selected from a list of all communities in these regions where we have been conducting community outreach activities. From this list, we divided the communities by (a) population size ≥ 5,000 inhabitants and (b) presence of at least one primary health centre or hospital. We then randomly selected two communities per region from the top‑ranked list, yielding a total of six communities. This approach ensured that the selected villages were both logistically feasible and representative of the rural setting. Participants were recruited during community outreach activities using purposive sampling. Purposive sampling is a nonprobability sampling method in which researchers deliberately select participants based on specific characteristics to meet the study objectives. Using this method ensured the inclusion of participants with diverse sociocultural and economic backgrounds, who could provide rich data relevant to the research objective. Within each selected community, a community entry meeting was held with the village chief and village health committee. After obtaining permission, community health activities were organized in the communities. During these activities, participants were approached sequentially. Eligible individuals were invited to participate, and written informed consent (or proxy-assent) was obtained before any study procedures. We also visited randomly selected households to invite participants to participate in the study. We recruited health professionals who were actively providing clinical care in the selected communities based on the aforementioned eligibility criteria. We obtained a list of eligible staff, from which we invited individuals and obtained written consent. Participants were approached during these outreach activities, and the study details were presented to them. Next, informed consent was obtained from the participants and/or caregivers. Only participants who gave informed consent were included in the study. A diagnosis of dementia was made based on the National Institute of Aging and the Alzheimer’s Association (NIA-AA) clinical criteria for all cause dementia [22].

Inclusion criteria

Participants with probable dementia.

1. Must meet the NIA-AA criteria for all-cause dementia.

2. Has been residing in the rural area at the time of diagnosis.

3. Ability to provide informed consent (or assent with a proxy),

4. Able to understand and respond to interview questions.

Participants without dementia.

1. Has been residing in the rural area for most of their lives.

2. Has given informed consent to participate.

3. Able to understand and respond to interview questions.

Healthcare workers

1. Qualification as a medical doctor, nurse, or clinical officer.

2. Has been working in the rural area for at least 24 months.

3. Has seen and managed at least one case of probable dementia.

4. Ability to provide informed consent.

Participants were excluded if they did not meet the inclusion criteria. Additionally, participants with probable dementia were excluded if they,

• (i)Had a history of major psychiatric illness.
• (ii)Presented with an acute medical illness that could confound cognitive testing.
• (iii) Were unable to communicate verbally or in writing (e.g., severe hearing loss.

Data collection

Data were collected through semi-structured face-to-face interviews. All interviews were conducted by the principal investigator (MNN), who has a background in community health and prior experience in qualitative research. Field notes documenting nonverbal cues and environmental context were also taken during each interview to provide greater depth and understanding of the data. Interviews were conducted to understand participants’ perceptions of brain health, dementia, motivation in maintaining brain health, and barriers to optimal brain health and dementia care. We pilot-tested the semi-structured interviews and pre-tested the semi-structured interview guide. A copy of the interview guide has been included as a supplementary file. These allowed us to identify ambiguous or irrelevant questions, revise them, practice conversational flow to ensure it was engaging, and assess the overall structure and sequence of questions for logical progression. Additionally, the pilot testing allowed us to anticipate and prepare for potential ethical challenges and to reflect critically on our role and biases. The interview guide included a set of core questions, posed verbatim to each participant to ensure comparability. The interviewer could adapt wording or sequence for cultural relevance and use the guide as a thematic checklist. The interviewer used spontaneous probes to clarify or expand on participants’ responses, ensuring they remained aligned with the study objectives. Interviews were conducted in participants’ primary language at primary healthcare centers where outreach activities were conducted, and each lasted 30–45 min. Local translators were used when participants were unable to understand either French or English. Data collection continued until no new information emerged or until themes repeated. Interviews were audio‑recorded and transcribed verbatim.

Data analysis

Data analysis was done thematically following a grounded theory approach. Thematic coding was conducted iteratively, allowing emergent concepts to be refined through researcher triangulation, thereby reducing individual researcher bias and enhancing the credibility of the findings. The data analytical framework combined open coding with constant comparison to identify initial concepts, themes, and categories, exploring relationships between them. The emerging themes were then interpreted in light of the study’s objective. Additionally, participant validation was used to verify if themes and interpretations align with their knowledge and realities.

Results

A total of 27 semi-structured interviews were conducted with seven primary healthcare workers, five participants with probable dementia, five caregivers, and 10 persons without dementia. Table 1 shows the sociodemographic characteristics of the participants.

Table 1.

Sociodemographic characteristics of participants

Participant type	Sex	Occupation	Level of education	Language of the interview
HCW 1	Female	Nurse	Secondary	English
HCW 2	Female	General practitioner	Tertiary	English
HCW 3	Female	Nurse	Tertiary	French
HCW 4	Male	General practitioner	Tertiary	English
HCW 5	Male	Nurse	Secondary	English
HCW 6	Male	Nurse	Tertiary	English
HCW 7	Male	Nurse	Tertiary	English
PwD 1	Male	Farmer	Primary	Pidgin
PwD 2	Female	Trader	Secondary	Pidgin
PwD 3	Female	Housewife	Primary	Fulfulde
PwD 4	Male	Cattle rearing	None	French
PwD 5	Male	Farmer	Primary	Pidgin
Caregiver PwD1	Female	Housewife	Secondary	Pidgin
Caregiver PwD2	Female	Farmer	Secondary	Pidgin
Caregiver PwD3	Male	Trader	None	Fulfulde
Caregiver PwD4	Female	Teacher	Tertiary	Pidgin
Caregiver PwD5	Male	Farmer	Primary	Pidgin
PwoD 1	Female	Farmer	None	Pidgin
PwoD 2	Male	Trader	Primary	Pidgin
PwoD 3	Female	Farmer	Secondary	French
Pw0D 4	Male	Builder	None	French
PwoD5	Male	Trader	Primary	French
PwoD6	Female	Housewife	Secondary	Fulfulde
PwoD7	Male	Teacher	Tertiary	English
PwoD8	Female	Handicrafts	Primary	Fulfulde
PwoD9	Female	Tailor	Secondary	French
PwoD10	Male	Carpenter	Primary	Pidgin

HCW Healthcare worker, PwD Person with dementia, PwoD Persons without dementia

Emerging themes

Table 2 summarizes the key themes that emerged during data analysis. The themes have been arranged in a hierarchical order based on how often they occurred.

Table 2.

Key emerging themes

Main theme	Sub-themes
Community perceptions of dementia	1. Spiritual/supernatural 2. Bewitchment 3. Generational curse 4. Normal aging 5. Madness 6. Infection
Community perceptions of brain health	1. Mental sharpness 2. Absence of brain disease 3. Healthy mind 4. Intact brain 5. Lifestyle 6. Importance of brain health 7. Environment 8. Systemic conditions 9. Socioeconomic and cultural factors
Barriers to dementia care	1. Lack of public awareness 2. Lack of specialist services 3. Insufficient HCW training 4. Limited therapeutic options 5. Stigma 6. Cultural practices 7. Lack of diagnostic tools 8. Financial constraints 9. Lack of social support
Barriers to brain health	1. Low public awareness 2. Unhealthy lifestyles 3. Substance abuse 4. Financial constraints 5. Cultural practices 6. Low access to health facilities 7. Social events

Community perceptions of dementia

Spiritual/Supernatural

Symptoms of dementia were often perceived as supernatural or spiritual, and consequently, the first resort to care was traditional healers before pursuing clinical evaluation. This led to delayed presentation in more advanced disease stages at the time of formal assessment.

“I don’t believe that my memory problem is natural; there is a supernatural force behind this.” (PwD3, female).

“When people are sick with a medical disease, you will usually see the symptoms on their bodies. My husband’s concern is that his memory is failing, and he forgets things. This is spiritual. Maybe somebody wants him to forget his properties so that they can take them.” (Caregiver PwD4, female).

Bewitchment

Some participants further attributed dementia to bewitchment.

“I know that we can sometimes forget things or names, but if someone who was very fine before starts forgetting things to the point where they cannot even remember the road to their houses or function normally, then it must be witchcraft. Someone must have thrown something evil on the person.” (PwoD2, male).

“My father’s symptoms started just around the time when he bought a piece of land. Someone must have envied him to the point of bewitching him.” (Caregiver PwD2, Female).

Generational curse

For some participants, dementia was a generational curse transmitted across generations.

“My paternal grandmother had similar symptoms, and I was told that my great-grandmother also had the same symptoms at the time of her death. This must be a generational curse from our ancestors.” (PwD1, male).

Infection

Others described dementia as resulting from an infection.

“I think that my husband has an infection in his head that is eating his brain and causing him to forget things quickly. Perhaps the infection originated from the bad water we drink in this community. They need to scan his head.” (Caregiver PwD1, female).

Madness

Dementia was also perceived as a form of madness, which was probably the result of bewitchment.

“I see my mother’s condition as the beginning of madness. Someone somewhere has manipulated my mother’s brain and wants her to run mad.” (Caregiver PwD3, Female).

Normal aging

For many participants, symptoms of dementia were perceived as a natural part of aging rather than a pathological condition.

“Old people usually have memory problems, and they can sometimes behave abnormally. As they grow older, the symptoms can become worse, but it is normal.” (PwoD3, female).

“When you grow old, your memory can become very bad and you may even forget things you used to do or behave as if your head is not alright. This is normal, and I don’t think medical attention is required.” (PwoD9, female).

“Poor memory is part of age. I myself sometimes have memory loss, and it has been getting worse over the years, but I believe it is because age has caught up with my brain.” (PwoD7, male).

Community perceptions of brain health

Participants generally accepted that brain health was essential and were interested in maintaining it. Still, their perceptions and understanding of the meaning of brain health and factors influencing it were poor.

Community perceptions of the meaning and importance of brain health

Mental sharpness

One participant described brain health as the ability to be mentally sharp.

“To me, brain health means you are mentally sharp and you can understand things quickly. Our brains need to be healthy because we need to use them every day.” (Caregiver PwD2, Female).

Healthy Mind

Another participant attributed brain health to having a healthy mind, which could be achieved through prayer, stress avoidance, reducing overthinking, and consuming certain herbs, traditional herbal concoctions believed to cleanse the mind.

“Brain health is having a healthy mind, which allows you to reason well. To have it, you should not overthink; instead, reduce stress and pray more, as prayer clears your mind. There are also some herbs that you can chew to fortify your brain.” (PwoD10, Male).

Absence of brain disease

For some participants, brain health meant the absence of any brain disease.

“If they say your body is healthy when there is no disease, it means the brain is also healthy when there is no disease in it.” (PwoD5, Male).

“A brain that is healthy means it has no disease that can prevent it from working normally.” (Caregiver 5, Female).

Intact brain

One participant perceived brain health as a state in which the brain and its functions are fully intact daily.

“A healthy brain is intact and works well every day without any problem. It is good to keep your brain healthy because it is the brain that helps us to read, calculate, and remember things.” (PwoD9, Female).

Perceptions of factors influencing brain health

Lifestyle

Lifestyle factors, such as a healthy diet, adequate sleep, and moderate alcohol consumption, were perceived as important factors influencing brain health.

“What you eat or drink can affect your brain. Also, when you don’t sleep well, it can affect your brain.” (PwoD4, Male).

“I think lack of sleep affects how your healthy brain is because when I don’t sleep, I can feel that my brain is not normal.” (Caregiver PwD2, Female).

“Alcohol and drugs like marijuana can make the brain unhealthy. We can even see the effect on young people who consume them in excess; their brains can never be healthy.” (PwoD10, Male).

Systemic conditions

There was a poor understanding of how systemic health conditions like diabetes, hypertension, and cardiovascular diseases affect brain health.

“High blood pressure and diabetes can cause stroke, which can damage the brain. Apart from that, I don’t know any other way that these conditions can affect the health of the brain.” (PwoD1, Female).

“High blood pressure and sugar are in the blood. I don’t know if they can cross to the brain and make it unhealthy.” (Caregiver PwD5, Male).

Environment

Participants also had a poor understanding of the effect of the environment on brain health.

“I don’t see how our environment can affect the health of our brains.” (PwD4, Male).

“I know that environmental pollution can affect your lungs, but I don’t know how it affects the brain.” (PwoD7, male).

Socioeconomic and cultural factors

There was a general lack of comprehensive understanding regarding specific socioeconomic factors that are relevant to their brain health.

“When you are poor, you overthink and stress a lot. This can affect the health of your brain.” (PwoD8, Female).

“When you have a good relationship with your family members and people in the community, it can help you to live in peace, grow and progress, but I don’t know if this can help your brain to stay healthy.” (PwD1, male).

“Education can help you to have a healthy brain because going to school allows you to learn things that can keep your brain healthy.” (PwoD3, female).

“Culture does not affect the health of our brains.” (Caregiver PwD5, male).

Barriers to dementia care

Lack of public awareness

One of the most frequently cited barriers to dementia care was the lack of awareness in the community. This often resulted in delayed healthcare-seeking and late presentations.

“There is a very low level of awareness about dementia in this village. People don’t know what dementia is, and so when the symptoms start, they don’t come to the health facility. Some will stay at home while others will go to traditional healers for treatment.” (HCW1, female).

“Community inhabitants do not believe that dementia is a medical condition that can be managed in a health facility. They attribute it to witchcraft, and even when you educate some of them, there is little improvement, as only a few seek medical care, and the rest go for herbal medicines.” (HCW5, male).

Lack of specialist services

The lack of specialists or dementia-trained HCW further widened the diagnostic and treatment gap.

“There are no specialists in this community, and even in the nearest hospital. When we refer patients to the nearest hospital, some return disappointed because no specialist is available. This is not good because it will push patients to visit traditional healers.” (HCW2, Female).

Insufficient HCW knowledge and skills

Substantial gaps in HCWs’ knowledge and skills hindered accurate diagnosis, treatment, and timely referral of suspected cases of dementia.

“I didn’t receive any training on dementia assessment and care. It is complicated for me to distinguish between normal aging and dementia.” (HCW4, Male).

“I have not yet received formal training on the assessment and management of patients with memory problems or dementia. When I receive a patient with complaints of memory loss or a suspected case of dementia, I usually search the net and read. This is not always possible because we are in a rural community and the network is not the best.” (HCW6, Male).

“It’s very challenging to assess properly and manage patients when you don’t have the skills and knowledge. When I have a suspected case of dementia, I will contact a medical doctor through WhatsApp and present the case and ask for guidance on how to manage the patient. To do this, I need to walk to a place with a network connection. I might even advise the patient to go home and return later once I receive feedback from the doctor. There are times when the doctor will want to do an audio or video call to question the patient further, but the network will be bad, or I might have left the spot where there’s a network.” (HCW3, Female).

“I had some training on dementia during my training, but it is not often sufficient. I do my best to read from time to time to fill the gaps in skills and knowledge.” (HCW4, Male).

Cultural practices

Culturally embedded practices that prioritize traditional healing rituals posed a significant challenge to formal healthcare-seeking.

“Unhealthy cultural practices really affect care-seeking and management of dementia negatively. Some of the patients have abandoned treatment due to cultural practices. Some don’t even start treatment due to cultural beliefs.” (HCW2, Female).

“These people believe too much in traditional healing rituals, even if they do not see any benefit. They see health facilities as the last hope when they have tried all kinds of traditional healing rituals.” (HCW7, Male).

Limited therapeutic options

The unavailability of essential medicines for dementia management resulted in poor compliance with medical treatment.

“Patients often feel discouraged when I tell them that there are currently no medications to cure the disease. Some will prefer to go back home instead of going for a referral, or they may visit another health facility to get a second opinion.” (HCW4, Male).

“Some patients were diagnosed and placed on treatment in urban hospitals, but subsequently relocated to this place, and we don’t have the medications here. It makes it difficult for them to take their treatment continuously.” (HCW7, Male).

Lack of diagnostic tools

The lack of access to diagnostic tools, such as cognitive screening tests and basic laboratory tests, delayed the recognition and diagnosis of dementia.

“We don’t even have access to screening tools. With screening tools, I can effectively screen patients who present with memory complaints and know which patients are actual cases of dementia. Even basic tests like full blood count and serum electrolytes are not available in this health center.” (HCW6, Male).

Financial constraints

Financial limitations often prevented patients from traveling to distant healthcare facilities to see specialists or afford healthcare services.

“We spent a lot of money to travel from this village to the town to see a specialist. When we arrived, we had only a small amount of money left to do the requested tests, and it was not enough. We had to come back without doing some of the tests.” (Caregiver, PwD5).

Geographic barriers

The remoteness of some villages further impedes access to dementia diagnosis and care.

“We were asked to go and scan my father’s head, but the nearest hospital where you can do a brain imaging is hundreds of kilometers away, and to get there is very difficult due to bad roads.” (Caregiver PwD2, Female).

“I was asked to go and see a specialist in town, but I didn’t go because it is very far. I can’t leave my cattle because there is no one to take care of them when I travel.” (wPD4, Male).

Stigma

Enacted stigma from the community dissuaded patients and their caregivers from seeking healthcare and reinforced reliance on traditional medicines.

“People in the community stigmatize those with symptoms of dementia because they believe that those affected are witches or wizards. This makes patients stay home and avoid coming to a health facility to seek care for fear of how people will treat them.” (HCW2, Female).

“I prefer keeping my mother indoors because when people see her, they run away and call her all sorts of names.” (Caregiver PwD3, Female).

Barriers to brain health

Substance abuse

Excessive consumption of illicit drugs, alcohol, and locally brewed stimulants was perceived as a barrier to brain health, especially among youths in the community.

“Young people in this community consume too much alcohol, and this affects their brains. They also smoke strong substances, which can cause their brains to malfunction at times. This is really becoming a big problem here.” (PwoD4, Male).

“The use of marijuana and locally-made illegal substances is growing in this community. Some of my students, who were once very intelligent, have been greatly affected by this. These substances have destroyed their brains.” (PwoD7, Male).

Unhealthy lifestyles

Unhealthy lifestyle choices, including an unhealthy diet, smoking, and alcohol, made it difficult for community members to maintain their brain health.

“The way people eat salt, sugar, and oil can make their brains unhealthy. If something is not too sweet, some of them will not eat it. Too much sugar can cause diabetes, which can damage the brain and cause a stroke.” (PwoD5, Male).

“The way people live their lives can also damage their brains. When I was growing up, it was difficult to see people who smoked cigarettes in this village, but today many people smoke and drink too much alcohol, especially palm wine, which affects their brains. I know people in this village who are now behaving like mad people because of the effect of too much palm wine on their brains.” (PwoD1, Female).

Similarly, the lack of healthy options such as fruits and vegetables led some participants to opt for unhealthy foods.

“When you go to the hospital, they tell you to eat fruits and vegetables, but it’s not easy to find those in this community. We eat what is available even though it may be bad for our brains.” (PwoD9, Female).

Financial constraints

Limited income often prompted participants to prioritize immediate subsistence over preventive health measures, thereby reducing adherence to brain-health-promoting lifestyles.

“The doctor told me that eating healthy foods is good for my body, but I don’t have money to buy them because they are expensive.” (PwD4, Male).

“I have high blood pressure, but I don’t take medications regularly because of money problems. Sometimes I can feel that my blood pressure is high and is affecting my brain because I will be experiencing headaches or dizziness, but I don’t consult because I won’t have the money to pay for the services.” (PwoD7, Female).

Low public awareness

Limited health literacy and paucity of community education on brain health further hindered the maintenance of brain health.

“I don’t even know what brain health means or how to have it.” (PwoD8, Female).

“People here don’t even know what the brain is, not to mention brain health. This is because no sensitization is being done, and partly because of no specific training of healthcare workers on brain health.” (HCW2, Female).

“I know that I have to keep my brain healthy, but I don’t know what I have to do to keep it healthy.” (PwoD6, Female).

Cultural practices

Harmful cultural practices, fueled by limited health literacy and cultural misconceptions, further discouraged engagement in preventive brain-health lifestyles.

“Cultural practices such as not giving certain foods that are suitable for brain development in children are standard here. Some pregnant women avoid eggs and certain fruits and vegetables due to cultural beliefs that they will affect the baby. This type of practice can lead to malnutrition, which can affect the development of the baby’s brain. I have managed cases like this.” (HCW4, Male).

Low access to health facilities

The lack of health facilities with specialized services was a barrier to regular health‑seeking behavior and follow‑up care for participants in these remote villages.

“All the big hospitals with specialists are in town. There are no hospitals in this village; we only have a health centre with a nurse who told me that he is not an expert on my condition. I don’t go for regular check-ups because there are no hospitals with specialists for my condition near me.” (PwD5, Male).

“It is good to do regular check-ups so that you can know if you have conditions that can harm your brain or if your brain already has a problem, but the only time we can do a check-up is when doctors come to this village to do general consultations, like you are doing now. Hospitals are very far away from here.” (PwoD4, Male).

Limited access to healthy choices

Limited access to healthy choices, stemming from geographic distance, unreliable transportation, and fewer grocery stores, hindered access to preventative care.

“To buy fruits, you have to travel long distances to find a place where they sell them, or you will only buy them when you travel to town. Sometimes, you can spend an entire year without traveling to town.” (PwoD9, Female).

“Most of the food we have here is starchy food such as maize and cassava. People only occasionally consume protein-rich foods and fruits. For example, people only consume mangoes or avocados when they’re in season.” (HCW3, Female).

Lack of social support

The lack of or inadequate social support from both family and the community was also mentioned as a barrier.

“I know my children and wife are doing their best to help me, but I sometimes feel that the support is not enough. They are the ones to take me to see the doctor for appointments; I cannot go on my own because I might forget the road, but sometimes, they prefer to go to the farms or village markets instead of taking me to the hospital. Sometimes they will get annoyed when I keep asking the same questions or when I ask them to take me to the hospital.” (PwD1, male).

“We don’t receive any support from the community. Instead, people laugh at my father when he starts acting confused. Some will even take advantage of his poor memory.” (Caregiver PwD2, female).

Discussion

We found several community misperceptions about brain health and dementia, as well as multiple barriers to dementia care and optimal brain health. Our study revealed that dementia is mostly interpreted through a mixture of spiritual, cultural, and age-related lenses, with spiritual/supernatural, bewitchment, and generational curse attributions, and the view of memory loss as “normal aging” emerging as the dominant explanatory model. In many of the interviews, the onset of cognitive decline was attributed to witchcraft, suggesting a belief that is externally imposed rather than biomedical. Such beliefs can delay help-seeking behaviors as families may opt for traditional healers or witch doctors. At the same time, the notion of “curse passed down through generations” reflects a communal sense of fatalism and collective responsibility for the disease. Fatalism can hinder self-efficacy, making it difficult for families to adopt preventive measures for dementia [23]. Many respondents saw dementia as a supernatural or spiritual thing, emphasizing prayer and ritual healing. This suggests that religious leaders may be key allies in health talks that bridge the gap between spiritual and medical care. The “poor memory is part of normal aging” narrative is well documented across settings worldwide and may delay health-seeking [24].

The communities’ explanatory models create a cultural lens that both shapes and hinders health-seeking behavior. These beliefs may result from long-standing traditions and provide psychological comfort, but they may also delay diagnosis and lead to underutilization of formal services. These findings underscore the need for interventions that respect cultural worldviews while introducing evidence-based information [24].

Concerning perceptions of brain health, most participants framed it in terms of mental sharpness, a healthy mind, and the absence of brain disease. These lay definitions both overlap and diverge from biomedical concepts of cognitive health, shaping how community members recognize, value, and act on brain-related concerns. Participants linked brain health to the ability to think quickly and solve everyday problems. This “performance-oriented” view may make people believe that cognitive decline is a personal failure rather than a medical condition. Consequently, subtle changes (e.g., occasional forgetfulness) may be dismissed as normal aging rather than a warning sign. This may fuel a “wait and see” attitude, which interacts with structural barriers. For a sizable minority, brain health meant not having a brain disease. This negative definition of what a positive state of brain health looks like, beyond the absence of pathology, may be demotivating, as community members may lack a motivational target for preventive behaviours such as lifestyle changes.

Similar to our results, the Global Brain Health Survey, a multilingual survey on people’s perceptions of brain health involving 27,590 participants from 81 countries, showed that participants recognized the impact of lifestyle factors on brain health but were less aware of the role of socioeconomic factors [25]. Participants in the survey were more likely to associate mental health disorders with the brain than neurological disorders. A systematic review of what people know about brain health, including 101 studies, found that participants in developed countries are generally well-informed about measures to maintain brain health. However, those with lower levels of education and income had less knowledge about brain health, and minority ethnic participants had less knowledge about brain health [26]. Notably, many existing studies on public perceptions of brain health originate from developing countries. There is a dearth of data on public perceptions of brain health in SSA.

These community misconceptions about dementia and brain health could be attributed to several factors. Firstly, the lack of scientific knowledge and understanding of the brain, its functions, and manifestations of brain disorders stems from the scarcity of awareness-raising initiatives that focus on raising awareness of the brain and brain-related disorders, such as dementia. In the absence of scientific understanding, people may interpret symptoms of dementia, especially personality changes, confusion, and forgetfulness, as signs of evil spirits or demonic possessions. Additionally, similarity or overlap in symptoms of dementia and manifestations associated with demonic possessions may contribute to these community misperceptions. Furthermore, the limited access to information sources, such as radios, TV, newspapers, and social media, through which these misperceptions could be addressed, is common in rural communities and may also contribute to the persistence of these community misperceptions. Moreover, traditional healers, who often capitalize on public ignorance and offer alternative explanations for medical conditions, are frequently present and readily accessible in many rural communities in Cameroon [27]. They may be a source of misinformation propagation, which fuels community misperceptions. The lack of health facilities where community members could get accurate information on brain health and dementia, as well as a low level of awareness of dementia and brain health among healthcare professionals in rural settings, may also play a crucial role in the persistence of community misperceptions.

The most common barriers to dementia care were a lack of public awareness, a lack of specialist services, and insufficient HCW training. Knowledge gaps on dementia shape healthcare-seeking behavior. When a community does not recognize dementia as a medical condition, they may attribute signs and symptoms to “normal aging” or witchcraft, leading to late presentations in health facilities [28]. Public health messages must translate biomedical concepts into everyday language, emphasizing, for example, that forgetting the route to a familiar place is not just a sign of getting old [24]. Even when families recognize a warning sign, the nearest neurologist or specialist clinic is often more than a day’s travel away, and the cost may be prohibitive. The lack of specialized services compounds the awareness gap, as the perceived effort required to access care outweighs the uncertain benefit. Consequently, most people with suspected dementia never receive a formal diagnosis, and those who do often present at a late stage when caregiver burden is already high. Primary healthcare workers in the communities reported insufficient training on the assessment and management/referral of dementia. This knowledge and skills gap suggests that even when people do seek care, their concerns may be missed, further decreasing the community’s trust in the health system. This vicious cycle may sustain the burden of dementia in rural communities. These findings echo those reported in similar studies conducted in Africa and other parts of the World, which reported pervasive misconceptions about dementia, low levels of awareness, lack of diagnostic tools, and limited therapeutic options [5, 6, 29–32]. Although medical understanding has advanced significantly, beliefs that attribute dementia to supernatural causes persist in many parts of SSA. Community misperceptions about dementia and other neurodegenerative diseases have been identified as major contributors to delayed healthcare-seeking and poor outcomes for these conditions in SSA [6].

A systematic review of studies from Tanzania and South Africa reported poor knowledge of dementia, poor community support for caregivers and patients with dementia in the community, as well as poor health-seeking behaviors of and for people with dementia [23]. Another systematic review of evidence from SSA showed that supernatural beliefs substantially influenced people’s perception of dementia and that these perceptions fueled stigmatizing attitudes towards people with dementia [33]. The review also revealed that more highly educated people were less likely to hold stigmatizing attitudes towards people living with dementia. Again, the review showed that even healthcare professionals believed that dementia had supernatural causes and tended to stigmatize those affected.

A low level of public awareness, unhealthy lifestyles, and substance abuse were the most common barriers to brain health. If a community is not aware of what brain health is, its importance, and how to maintain it, early warning signs of poor brain health or brain disease may be normalized or attributed to aging, leading to delayed healthcare-seeking and missed opportunities for prevention. Research from Sub-Saharan Africa has shown a changing pattern in lifestyles among rural populations with increasing adoption of unhealthy lifestyles, which may contribute to higher rates of hypertension, diabetes, and cardiovascular disease, which are well-established vascular risk factors for cognitive decline [34, 35]. Chronic use of substances such as alcohol and illicit drugs has been linked with an earlier onset of cognitive impairment [36, 37]. These substances exacerbate neuro-vascular damage and increase the risk for traumatic brain injury. Harm reduction strategies that respect cultural norms, such as community-led interventions, provision of low-cost cessation aids, and the integration of substance-use screening into routine health visits, are essential.

Recommendations and future directions

Implementing a multipronged awareness-raising initiative at multiple levels, involving multiple stakeholders, could help ensure these community misperceptions are addressed [4]. Such an initiative should include the development and dissemination of culturally-tailored messages through community social groups, community markets, schools, and churches. Integrating community‑based education that clearly differentiates dementia from normal ageing and aligns with local cultural narratives is essential for promoting timely diagnosis and access to care [38]. A study examining the impact of an interactive visual art exhibition on adults’ motivation for reducing their risk of dementia found a significant increase in motivation for brain-healthy lifestyles immediately after the exhibit, particularly in response to positive cues to action [39]. Moreover, a longer time spent engaging in the exhibit was associated with increased motivational change. Based on these findings, interactive visual art exhibitions should be regarded as for awareness-raising activities on dementia and brain health in rural communities, especially given the low educational attainment among rural-dwelling individuals in Cameroon, which may hinder comprehension of these messages. Offering positive cues to action can reinforce and promote brain-healthy lifestyles. It is also crucial to involve communities in the development and implementation of awareness-raising initiatives to foster ownership, thereby increasing commitment and making them more sustainable in the long term [40]. Given that traditional and spiritual healers are trusted cultural figures who are often deeply integrated into their communities, possess valuable local knowledge, and hold significant influence and trust among the local populations in rural areas, engaging them during community awareness-raising activities ensures that these activities are culturally relevant and enhances community engagement [27, 41]. Their knowledge of local beliefs and practices will allow for better communication and understanding, fostering a stronger connection between the community and awareness-raising initiatives.

To effectively address the barriers to dementia care and optimize brain health in rural communities, collective efforts to improve awareness, care, support, and resource allocation would be absolutely critical. These collective efforts will require the training of rural primary health workers, enhancing local access to specialists, implementing community-based support programs, and raising awareness. Equipping rural primary healthcare workers with context-validated screening tools and knowledge will enable effective screening, timely diagnosis, and referral of dementia cases [42]. Training programs for rural primary dementia care should be based on context‑specific modules that are relevant to the roles and experiences of rural healthcare workers, involve active face-to-face participation, underpin experiential learning, be delivered by an experienced facilitator who knows local needs, support application of knowledge in practice, and provide context-informed guidelines to guide care practice [43]. With the critical shortage of dementia specialists in rural communities, task-shifting dementia care to non-physician healthcare workers, such as nurses, can reduce the diagnostic and treatment gap for dementia in rural communities. Such strategies have been previously shown to practice change and promote the timely diagnosis and management of dementia in general practice [42, 44]. A pilot program for lay health workers in rural Uganda demonstrated that with a 5-day culturally adapted training to enhance capacity, lay health workers may be able to support community-based case management for dementia [45]. Implementing a similar culturally adapted training for rural community health volunteers could improve early detection and strengthen care delivery networks. Additionally, the use of telemedicine can improve access to dementia specialists and support for rural healthcare workers [46]. Telemedicine can be used to administer cognitive screenings, review and initiate medications, follow up on therapy, assess changes in symptoms, and provide support and education to care partners. These telemedicine models can be community-based or located within a rural healthcare facility. Previous studies have shown that the use of telemedicine in dementia can improve patient and care partner satisfaction, improve cognitive assessment and diagnosis compared to in-person visits, and improve outcome measures following rehabilitation [46]. Where real-time communication is challenging due to poor network conditions, the use of an asynchronous (store-and-forward) model, where data such as images and patient histories are collected and shared later for specialist review, may be more feasible in rural communities. WhatsApp is a free and accessible platform that uses internet data and can be leveraged for telemedicine [47]. It is an affordable, efficient, and readily available alternative to phone calls and SMS. Patients can easily connect with healthcare providers using WhatsApp, while healthcare providers can send health-related messages. Additionally, specialists can offer quick advice, consultations, and follow-up care to patients in rural communities via WhatsApp. However, potential issues with patient confidentiality, data security, and inadequate medical record documentation need to be identified and addressed. A sizable body of evidence from the literature suggests that WhatsApp is an effective adjunctive telemedicine tool when used as a means of communication between healthcare professionals, as a channel of communication between healthcare professionals and the general public, or as a learning tool for providing healthcare information to professionals or the general population [47–49].

Improving care coordination through enhanced communication and the establishment of robust referral pathways between urban and rural healthcare facilities and healthcare professionals will ensure seamless care for individuals with dementia in rural communities. Moreover, embedding faith-based and cultural norms and involving traditional and spiritual leaders within rural dementia care outreach programs, while still upholding scientific principles, may improve community engagement and uptake of dementia services and brain-healthy lifestyles among highly religious and culturally diverse individuals [5].

Mobile clinics staffed with dementia specialists and support staff can provide essential, direct dementia care and brain health services in rural areas by overcoming geographical barriers [50, 51]. These clinics can offer a broad range of services, including cognitive screening, consultations, follow-up care, and medication initiation. Innovative models of mobile clinics, such as intelligent mobile clinics that combine on-site services with telemedicine and artificial intelligence, can further improve accessibility, ensure continuity of care, and improve outcomes for people living with dementia in rural communities.

Community-based public health campaigns that use context-relevant messages to promote brain-healthy lifestyles, such as social engagement, cognitive activity, and physical activity, should be regularly conducted to normalize discussions about brain health and related disorders [40, 52]. Local activities such as spending time outdoors, gardening or farming, walking in nature, engaging in traditional dance, learning new skills (e.g., learning how to use a local musical instrument), participating in community events, storytelling and drama, and arts and crafts programs, should be encouraged to foster social connections and build cognitive reserves [52]. Additionally, it is crucial to harness the inherent cohesiveness and community spirit in rural areas to develop and sustain social support systems that are accessible and tailored to local needs. Addressing misconceptions about brain health through culturally tailored education could improve early recognition and reduce stigma associated with brain-related conditions, thereby enhancing access to appropriate care [38]. Furthermore, integrating brain health services into rural primary care and partnering with local schools to implement school-based programs on brain health are feasible strategies to promote brain health. Conducting advocacy from local to national levels will further increase education and awareness, improve community engagement, foster policy and systemic changes, and improve health services for brain health and dementia [53, 54]. Implementing and evaluating the effectiveness of these models through longitudinal mixed‑methods studies will generate actionable evidence for scaling culturally responsive dementia care across rural Cameroon.

Aligning these community-driven interventions with national dementia-care frameworks can further strengthen dementia care and brain health in rural Cameroon. Policymakers should prioritize systematic needs assessments to refine rural healthcare and outreach programs.

Conclusion

This qualitative study highlights the profound impact of community perceptions on dementia and brain health in rural Cameroonian communities, revealing intricate social dynamics and beliefs that shape understanding and care practices. The findings underscore a critical need for culturally sensitive interventions that bridge traditional beliefs with biomedical understandings to enhance dementia care pathways. Based on the findings of this study, we suggest that initiatives aimed at improving brain health and dementia care in rural Cameroon should prioritize awareness-raising, healthcare workers training, and improvement in the quality of diagnostics and therapeutics available for both curative and preventive neurology. Specifically, interventions must address the prevailing misconceptions associated with dementia, which often lead to delayed diagnosis and inadequate support for persons living with dementia and their caregivers.

Study strengths and limitations

We used a qualitative design, which allowed an in-depth exploration of nuanced community perspectives; however, its localized scope limits direct generalizability across all rural settings. Future quantitative and interventional studies are crucial for statistically validating the prevalence of these beliefs and assessing the effectiveness of proposed interventions.

Abbreviations

HCW

Healthcare Worker

PwD

Person with dementia

PwoD

Person without dementia

SSA

Sub-Saharan Africa

Biographies

Mundih Noelar Njohjam

is a final-year neurology resident in the department of neurology, Cheikh Anta Diop University, Dakar, Senegal. She also holds an MSc in Global Health from Liverpool School of Tropical Medicine, UK.

Emmanuelle Mylene Tonga

is a consultant neurologist in the Department of Neurology at Laquintinie Hospital, Douala, Cameroon.

Tiffany Falonne Niakam

is a consultant neurologist in the department of neurology, Cheikh Anta Diop University, Dakar, Senegal.

Mark Olivier Ngoule

is a stroke fellow in the department of neurology, University Hospital Center, Montreal, Canada.

Alex cyrille mondomobe

is an epilepsy fellow in the department of neurology, University Hospital Center, Montreal, Canada. He also holds a master’s in epidemiology.

Authors’ contributions

MNN designed the study, collected and analyzed data and prepared the manuscript for publication. EMT, TFN, MON, and ACM proofread and provided constructive feedback during study design, analysis, and write-up. All authors read and approved the final paper.

Funding

Not applicable.

Data availability

The original dataset for this study is not publicly available to maintain the privacy of the individuals interviewed. De-identified data can be made available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was part of a larger investigation to assess the burden of neurological disorders and barriers to care in Cameroon, which received ethical approval from the Ethics Review Committee for Human Health Research in the Center Region of Cameroon. All participants provided written informed consent and had the option to withdraw at any time without consequence. Where a participant with probable dementia could not provide informed consent, the participant’s legal guardian or an appropriate representative provided informed consent on the participant’s behalf. All interview data were securely stored on encrypted servers and de‑identified to protect participant privacy. This study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.