Awareness, facilitators, barriers, and behaviours surrounding brain health: a large-scale cross-sectional survey of adults across UK and Ireland | BMC Public Health

This study collected cross-sectional data on behaviours and awareness surrounding brain health, and the facilitators and barriers to future behaviour change, among ≥ 6800 respondents aged ≥ 40 years across the UK and Ireland. Although the sample was majority female (79%), white (99%), and highly educated, there was good representation across geographical regions and age groups.

Awareness of modifiable factors among the sample was mixed. Some protective factors (physical activity, healthy diet, and cognitive stimulation) were well-acknowledged, similar to previous research conducted both nationally and internationally [6, 16, 30, 31]. However, recognition of other risk factors (i.e., hearing loss, air pollution, hypertension, and obesity) was limited, similar to previous studies conducted among young Scottish adults [15] and Irish adults [19]. Global evidence has also suggested a limited understanding of the role of cardiometabolic risk factors (such as hypertension and obesity) in dementia risk reduction [6, 10, 31, 32] and reinforces a crucial need to improve awareness of these factors and provide individuals with the knowledge and tools to address them. Future work should also explore where individuals acquire this knowledge, to help guide the design of more targeted and effective public health messaging.

Awareness differed significantly between demographic groups for each modifiable factor. Generally, lower awareness was identified among younger adults and those with lower educational attainment, consistent with previous international research [30]. Future interventions aiming to improve awareness of dementia risk reduction, should therefore be tailored to the characteristics and needs of specific groups. Notably, these demographic differences also varied geographically, with the England/Wales group including a greater proportion of older and more highly educated respondents than the Republic of Ireland, which likely contributed to observed regional variation in awareness and behaviours. Beyond demographic composition, contextual factors such as national public health policy priorities, infrastructure, and exposure to dementia prevention messaging may also influence regional variation. These findings underscore the importance of designing brain health initiatives which are both demographically sensitive and contextually appropriate across regions. While many of the observed differences between groups were small in magnitude, effect sizes were calculated and included for key comparisons, and even modest differences can provide valuable insights for refining intervention design. At a population level, small shifts in awareness or behaviour across subgroups may translate into meaningful public health benefits. Future studies should consider adjusting for demographic variables to more clearly isolate country effects. Moreover, researchers should actively consider health equity during intervention design, to ensure that existing disparities, particularly among groups disproportionately affected by broader determinants of health, are not inadvertently reinforced [33, 34]. This includes addressing affordability-related barriers, which were more frequently reported among individuals with lower educational attainment in this sample. Such findings highlight the need for brain health initiatives and public health campaigns to consider socioeconomic constraints and reduce financial barriers, to support equitable access to brain health-promoting behaviours. Ultimately, these findings support co-designed approaches to brain health promotion. Whilst not analysed within this manuscript, free-text responses identifying potential actions to support brain health may offer valuable insights to inform future, contextually grounded intervention development.

Considering these findings, multi-level approaches which combines evidence-based subgroup- or individual-level strategies (e.g., health education) with low-agency population-level initiatives may be more effective in reaching diverse groups. Findings align with previous results from mass-media educational campaigns which aimed to raise awareness surrounding brain health in the Netherlands [35], Belgium [36] and Denmark [32]. Although one campaign identified an improvement in awareness among individuals with lower educational attainment [35], another [36], reported no change in awareness pre-post campaign among individuals with lower educational attainment. One solution to this, may be to run mass-media campaigns alongside smaller, targeted campaigns which have been co-produced with individuals from the target group and relevant stakeholders, such as public health bodies and media representatives [32, 34, 37]. These smaller campaigns could leverage non-traditional methods, such as dissemination of health information via messaging platforms (e.g., WhatsApp, Instagram) [38], and social media campaigns, which may include the use of social media influencers [38,39,40], alongside in-person group-based information sessions.

The provision of information (psychological capability) surrounding the promotion of brain health was also identified as a substantial barrier (lack of information) and a facilitator (provision of information) for behaviour change, similar to previous research [17, 36, 41]. Psychological capability refers to the mental processes required to engage in a behaviour, such as knowledge, comprehension, memory, and reasoning. In this context, a lack of psychological capability was reflected in respondents reporting limited awareness or understanding of what actions to take to support brain health. In relation to this, respondents also expressed uncertainty surrounding the benefits of behaviour change (beliefs about capability). Acknowledging the role of social influence as a facilitator, delivery of information from sources deemed trustworthy and legitimate by the target population, may help to improve both psychological capability and/or beliefs about capabilities. This could help to alleviate doubts about the credibility of information and in turn, potentially minimise sharing of misinformation [13, 42]. Consideration should also be given to the positive framing of information, using terms involving the promotion of brain health, and shifting away from focusing on the prevention of dementia [31, 43, 44].

Although psychological capability (which may be targeted via health education) was frequently reported as a barrier and facilitator for future behaviour change to promote brain health, behavioural drivers often act synergistically and should be considered in combination. Other prevalent facilitators were linked to social opportunity/social influences. Similarly, data from this study also suggested that both fear, and self-identity, were linked to brain health. For instance, a substantial proportion of respondents who self-identified as overweight still rated their general health positively, suggesting that perceived risk may not always align with the presence of modifiable factors. Combined, such findings align with previous research which suggest individuals are most likely to take preventive action when they believe they are susceptible to developing the condition and external cues are provided [17, 25, 41, 43, 45]. Noticing early cognitive changes was a more prevalent facilitator than receiving a formal diagnosis, suggesting that early subjective concerns may preserve a sense of agency, while diagnosis could, for some, trigger fatalism. This also suggests that for many, the cue to taking preventative action occurs at/or following the presentation of cognitive symptoms. This may be detrimental, as at this time point, it may be too late to prevent or delay dementia [44, 46]. Future work should therefore explore how best to provide appropriate cues to action early, to encourage the adoption of preventative behaviours. Although, this also highlights the potential for future campaigns to screen and identify individuals at-risk and to motivate their adoption of brain health promoting behaviours, in the pre-clinical/prodromal phase, prior to occurrence of tangible cognitive decline.

Other barriers to behaviour change identified were related to emotion (needing to engage in activities they did not enjoy) and optimism (lack of self-motivation). Yet a lack of self-motivation as a barrier to behaviour change was reported less frequently by respondents in this study compared to results from the Global Brain Health Survey (33% vs. 22%) [17]. Acknowledging the role of automatic motivation, this study contributes to evidence which emphasises the importance of using co-design principles within future behaviour change interventions, to nourish enjoyment, and improve efficacy [41].

Consumption of a healthy, balanced diet could contribute towards better brain health [47]. Regarding current behaviours, most respondents stated they had a healthy diet. The mean MIND score within this survey was higher compared to other study populations both in the UK [48], and internationally [26, 49, 50], which have generally ranged between 6 and 7 out of 15. This may be due to both the use of convenience sampling within this study (resulting in a highly educated, white and majority female population), and the use of a dietary screener, rather than a more granular dietary assessment tool (e.g., FFQ or 24-hr dietary recall). A previous qualitative study among Northern Irish adults which explored the facilitators and barriers to the MIND diet, did however, report similarly low intakes of wholegrains (44% less than twice p/w), fish (72% less than twice p/w), and beans/legumes (76% less than twice per week). Such components (e.g., fish and wholegrains) are often found in diets associated with potentially neuroprotective effects (e.g., MIND diet, Mediterranean diet). In addition to dietary behaviour, the BHLS also captured participants’ beliefs about what constitutes a healthy diet, which may inform future research on dietary knowledge and its relationship with brain health behaviours. Further investigation is needed to understand the barriers and facilitators to increasing consumption of specific food components, particularly among UK and Irish populations, to better support brain health.

Over half of all respondents stated they engaged in regular exercise, but only 27% were categorised as active according to GP-PAQ. However, categorisation for the GP-PAQ derives from time spent engaging in both structured physical exercise and occupational exercise [28]. Thus, a potential explanation for such findings may involve the high proportion of retired respondents in this sample. Although, additional analyses were performed to stratify the sample and remove respondents with no occupational activity level (e.g., retired, unemployed, other). Results showed the percentage of respondents deemed physically active according to GP-PAQ remained relatively low, at 35%. Ultimately, this reflects previous research which has suggested many UK and Irish adults fail to meet national recommended physical activity guidelines [51, 52]. It may also highlight a reduction in social desirability/conformity bias when physical activity is assessed using a formal assessment tool, versus a simple question which asks about perceived physical activity levels. A third of the sample reported regular consumption of alcohol and a further 5% suggested their consumption was excessive. Incorporating the link between heavy alcohol consumption and dementia risk within future public health campaigns may increase perceived susceptibility among the public, which was acknowledged as a facilitator for lifestyle change [53,54,55].

This study has several strengths. The design of the BHLS was evidence-based, developed with PPI representatives, and underpinned by behaviour change frameworks. Data was captured to explore awareness, beliefs, and behaviours surrounding brain health, across a large sample size. However, of the 9,127 individuals who accessed the survey, 2,226 did not complete consent and were excluded (24% attrition). This level of drop-out was expected due to absence of incentives. A key limitation was the use of convenience sampling which led to a sample predominantly composed of white, female, and well-educated respondents. This also resulted in variations in demographic characteristics (e.g., age, gender, and educational attainment) across countries, meaning observed differences may reflect demographic composition rather than true country effects. Future research should adjust for these factors to better isolate country-specific influences, as well as to improve sample diversity to enhance the generalisability of findings to the wider UK and Irish population. Secondly, the BHLS was completed online, which may have limited access by those living in data poverty and/or those with poor digital literacy. Future research may consider re-administration of the BHLS using both an online and paper format, to under-represented groups to improve representation and comparability. Additionally, awareness was assessed using recognition-based items, a common approach in dementia literacy research. However, this method cannot confirm whether responses reflected true knowledge. Future research could incorporate open-ended items to assess awareness more robustly. In addition, the order in which survey questions were presented, with questions assessing behaviour, preceding those which examined awareness, may have introduced bias, although this was intended to reduce priming and reflect natural response flow. Data collection for this study also occurred during the global COVID-19 pandemic, which may have influenced participants’ responses and behaviours. This context should be considered when interpreting study results. Additionally, sub-group comparisons were not adjusted for potential confounding variables. As such, observed differences between countries or demographic groups may reflect underlying disparities in age, education, or other characteristics, rather than true effects. Future research should employ multivariable analytical approaches to more accurately isolate the influence of specific factors.