The global demographic shift towards an ageing population has positioned dementia as a significant public health challenge. Characterised by progressive cognitive decline, dementia impacts memory, behaviour, and the ability to perform daily activities, leading to increased dependence and care needs. ¹ While the burden of dementia is universal, it is disproportionately felt in low- and middle-income countries, where healthcare systems are often less prepared to manage chronic, complex conditions. ²

Healthcare workers (HCWs), ³ including nurses, doctors, and community health workers, form the cornerstone of dementia care, from initial recognition and diagnosis to long-term management and end-of-life support. ³ Their ability to provide effective, person-centred care depends on a robust understanding of the disease and a strong sense of competence in managing its multifaceted manifestations. Inadequate knowledge and low perceived competence among HCWs can lead to delayed diagnosis, poor symptom management, increased caregiver burden, and suboptimal patient outcomes. ^{3, 4}

In the South African context, where cultural diversity, socio-economic disparities, and a strained public health system intersect, understanding the preparedness of the healthcare workforce to meet the demands of dementia care is critical. The existing literature on dementia in the region is sparse, and few studies have systematically evaluated HCWs’ knowledge and perceived clinical competence using validated tools. ⁵

This study, therefore, sought to address this gap by assessing dementia knowledge using the Dementia Knowledge Assessment Tool (DKAT-2) ⁷ and perceived competence using the Sense of Competence in Dementia Care Staff (SCIDS) ⁶ scale among a sample of HCWs in South Africa. Furthermore, it aimed to identify sociodemographic and professional factors associated with higher levels of perceived competence, providing crucial evidence to inform the development of targeted training and support interventions.

This study provides critical insights into healthcare workers’ dementia care capabilities in South Africa, revealing a complex picture of moderate foundational knowledge, significant gaps in clinical understanding, and a strong association between perceived competence and the practice environment. ¹¹ state that only about 49.5% of healthcare workers showed moderate to high knowledge of dementia. This means that while some knowledge exists, it is not enough to manage the dementia condition. The same study also found that 53.3% of participants had limited training and recognized gaps in their knowledge, pointing out problems in understanding dementia care. In a 2023 multi-centre study in Uganda, only 39.3% of healthcare workers had formal training in dementia. ¹² This highlights significant gaps in how HCWs are prepared, and the limited support they receive to render the services of managing dementia. Other evidence from Africa shows that 70% to 90% of people with dementia do not receive the care they need because there are not enough trained professionals to specialise in dementia.

The finding that most participants had moderate knowledge of dementia, with relatively few demonstrating high levels of understanding, aligns with previous research. Large studies show that while most healthcare workers have a moderate grasp of dementia, only a small number reach high levels of knowledge. ¹³ Although healthcare professionals usually know basic dementia concepts, such as risk factors and prevention, their expertise often does not extend to more complex areas, such as behavioural management, diagnostic assessment, and detailed care planning. ^{14 7} highlight that these gaps are often due to a lack of training and limited experience with specialised dementia care practices. This pattern was clearly reflected in the item-level analysis of the DKAT-2. While participants correctly identified core ideas like brain changes and visual perception problems, they struggled with the specific aetiology of dementia, differential diagnosis, and the management of late-stage symptoms. The pervasive misconceptions, such as the belief that confusion in older adults is invariably due to dementia or that sudden confusion is a hallmark of the disease, are particularly concerning. These misunderstandings could lead to diagnostic errors, mismanagement of delirium (a medical emergency often mistaken for dementia), and failure to address treatable conditions in older adults. ^{8, 15}

The results from the SCIDS scale further illuminate this issue. While over a third of HCWs reported high perceived competence, the majority reported only moderate competence. The item-level analysis on the SCIDS powerfully demonstrates that high overall competence is associated with confidence in the most challenging aspects of dementia care: managing difficult behaviours, making complex risk assessments, and engaging patients in meaningful, person-centred activities. These are precisely the skills that translate theoretical knowledge into effective clinical practice. ⁹ The data suggest that while many HCWs feel competent in maintaining a positive attitude and working in a team, they feel less equipped to handle the unpredictable and demanding behavioural and psychological symptoms of dementia (BPSD). ¹⁴

The most striking finding of this study is the significant association between perceived competence and the type of healthcare facility. HCWs in hospitals were substantially more likely to report high competence compared to their counterparts in clinics and community health centres. This disparity may be explained by several factors. Hospitals typically offer greater access to specialist colleagues (e.g., neurologists, geriatricians), more frequent exposure to complex cases, and potentially more opportunities for informal learning and skill development. ¹⁰ In contrast, HCWs in primary care and community settings often work in isolation with limited resources and fewer opportunities for continuous professional development focused on chronic, non-communicable diseases like dementia. ¹¹ This finding underscores the urgent need to decentralise dementia training and support, ensuring that HCWs on the front lines of community-based care are adequately equipped. A 2025 study on primary healthcare in South Africa points out resource shortages, staff constraints, and weak infrastructure. ¹⁶ A situational analysis in South Africa found that community-based dementia care remains underdeveloped. ¹⁷ Services depend a lot on underfunded NGOs and face challenges at the primary care level. ^{18 19} Highlight the evidence from other low- and middle-income countries shows that limited healthcare resources, poor diagnostic tools, and a lack of trained professionals hold back dementia care. These issues limit effective service delivery to dementia patients and caregivers in community settings. Even the HCWs are uncomfortable or frustrated with the matter of limited resources, because in the face of the community, the HCWs do not want to deliver the healthcare services. ^{18, 19}

The lack of a significant association between perceived competence and prior mental health training, years of experience, or professional qualification is noteworthy. It suggests that generic mental health training may not be sufficient to build specific competence in dementia care. A 2024 national survey found no significant link between years of experience and knowledge or attitudes about dementia among healthcare workers in healthcare facilities. ²⁰ A recent study highlights that competency-based dementia training greatly improves knowledge and self-confidence. ²¹ It shows that specific training on dementia, not just general background, drives competence. ²² concluded that structured, skills-based, and hands-on dementia training is needed to develop meaningful competencies of HCWs. In contrast, standard or passive training methods are less effective. Research on dementia training shows that competence is affected more by training transfer, organizational support, and learning context than by baseline qualifications alone. ²³

Furthermore, it implies that experience alone does not guarantee the development of effective dementia management skills, highlighting the necessity for structured, targeted educational interventions. Targeted dementia training interventions, such as interactive, team-based models, significantly improved healthcare workers’ knowledge, practice, and care quality, whereas routine exposure alone was not sufficient. ²⁴ It is important to provide structured, competency-based, and hands-on training to develop effective dementia care skills in the healthcare workforce. ^{25, 26 26, 27} emphasized that the experienced healthcare workers need extra education focused on dementia because skill gaps still exist. The borderline association with gender, in which a higher proportion of males reported high competence, warrants further investigation into potential gender-based differences in self-reporting or in the types of clinical roles and responsibilities they undertake. A consistent finding across studies is that men often report higher levels of self-confidence and self-perceived competence than women, even when their actual performance is similar. ²⁸ Research on the confidence gap shows that men are more likely to overestimate their abilities, while women tend to give more cautious or accurate self-assessments. ^{28, 29}

This study reveals a critical gap in the South African healthcare workforce’s readiness to meet the growing challenge of dementia care. While a moderate level of baseline knowledge exists, significant misconceptions and a lack of confidence in key clinical skills are prevalent. Studies consistently show that health systems in low- and middle-income countries are not ready for the rising dementia burden. This is due to limited training, low awareness, and not enough resources. Research across Sub-Saharan Africa shows that misunderstandings about dementia among HCWs, including cultural and supernatural explanations, are widespread. These misconceptions contribute to a poor understanding and management of the condition. The strong influence of the practice environment suggests that efforts to improve dementia care must extend beyond hospital settings and into the community. This current study suggests that to address these findings, the following recommendations are made: 1.

Develop Targeted, Multi-Level Training Programs: Training should move beyond basic facts to focus on practical skills, including differential diagnosis of delirium and depression, management of BPSD, and strategies for person-centred communication and care in late-stage dementia.

Ethical approval for this study was obtained from the Walter Sisulu University Health Sciences Ethics Committee under Ethics Approval Number WSU HREC 102/2025. All participants were informed about the study and provided written informed consent to sign before data collection. Anonymity and confidentiality were guaranteed.

The current study was presented to the Department of Public Health and the Faculty of Health Sciences for ethical review. The study was conducted in accordance with the Declaration of Helsinki and approved by the iYunivesithi Walter Sisulu Health Sciences Research Ethics Committee (Ethics Approval Number: WSU HREC 102/2025 on 12 June 2025) for studies involving humans.