Facilitators and barriers to mammogram screening uptake among Saudi women

ABSTRACT

Objectives:

To evaluate current mammogram screening rates and identify barriers and facilitators for mammogram uptake among Saudi women.

Methods:

This systematic review was conducted in accordance with the PRISMA framework, beginning with a database search performed by 2 researchers using PubMed, PsycINFO, CINAHL Plus, and Google Scholar for pertinent studies published between 2000 and 2024. Qualitative and quantitative studies were included if they: a) were conducted in Saudi Arabia among Saudi women, b) explored factors associated with mammogram uptake among Saudi women, and c) were peer-reviewed. The socioecological model was used to thematically synthesize the results.

Results:

A total of 39 studies were included in this review. Nine studies revealed low adherence to annual or biannual mammogram screenings among Saudi women. The socioecological model was utilized to categorize the factors that influenced Saudi women’s uptake of mammograms, divided into: a) individual factors, including breast cancer and mammogram knowledge, demographic characteristics, health beliefs, fear, pain, and embarrassment; b) interpersonal factors, including male family members, health care providers, and competing priorities; and c) social factors, including health behaviors related to secondary health screenings, and the health care system.

Conclusion:

To improve adherence to mammogram screening among Saudi women, it is recommended to design interventions that target factors at each level of the socioecological model. Understanding how each factor functions as a barrier or facilitator will enable more effective and tailored strategies that address these factors within their respective socioecological levels.

PROSPERO No. ID: CRD628485

Breast cancer (BrCa) is a significant global and national health issue due to its high morbidity and mortality rates among women.¹ In 2020, the Global Cancer Observatory reported 2.3 million new BrCa cases worldwide.² Breast cancer remains the second leading cause of cancer-related death in women.³ In Saudi Arabia, it is the most common cancer among women, with a rate of 27.3 per 100,000.⁴ Between 2004 and 2016, its incidence rose by 186%.⁴ The mortality rate in Saudi Arabia (12.8 per 100,000) is notably higher than in developed countries (7.5 per 100,000).^2-4

Regular mammogram screenings (MS) are the most effective strategy for early detection and reducing BrCa-related deaths.⁵ The Saudi Ministry of Health advises women aged 40-49 to undergo MS every one to 2 years.⁶ Nevertheless, adherence remains low among Saudi women (SaW).^7,8 This continues to hinder national efforts to combat BrCa.

Several studies have revealed low adherence to annual or biannual MS among SaW. The most recent reported rate showed only 6.5% of 2,786 women had obtained mammograms.⁸ In a Riyadh-based survey, only 30% of 3,776 women had undergone MS within the last year.⁹ Another survey of 3,245 SaW across multiple regions found that only 40% reported having had a mammogram at least once.¹⁰

Nonadherence to regular MS often results in late-stage BrCa diagnosis, linked to poor prognosis and higher mortality.^8,9 From 2007 to 2017, approximately 40% of non-metastatic BrCa cases were diagnosed at an advanced stage.¹¹ This delay has also increased the financial burden on the healthcare system.¹² One study found treatment costs were significantly higher at advanced stages (SAR305,585) compared to early stages (SAR53,432).¹²

Evaluating reasons for low MS uptake can help mitigate these consequences. Understanding factors that support or hinder SaW from obtaining mammograms may enhance utilization. Thus, this systematic review addresses the following Population, Intervention, Comparison, and Outcome (PICO) questions: 1) Among SaW, what barriers and facilitators are associated with MS uptake? 2) What are the reported MS rates among SaW according to existing studie

Methods

This systematic review was conducted in accordance with the PRISMA framework, which outlines a structured process encompassing the identification of the review objective, execution of the search process, screening of studies based on inclusion criteria, evaluation of study quality, data extraction, and data analysis. This review was registered with PROSPERO on 17 December 2024, under the registration number CRD628485.

Review objective

This review involved a systematic search for studies that explored MS rates among SaW. Additionally, the review covered studies that investigated factors, both barriers and facilitators, that impact mammogram uptake among SaW.

Conducting the search process

The search for studies was conducted by the review author, who holds a PhD degree in nursing. The search was performed from June 2023 to May 2024. The search process included PubMed, PsycINFO, CINAHL Plus, and Google Scholar for relevant articles published between 2000 and 2024. Boolean operators (AND, OR) were used with keywords such as: mammogram AND Saudi women, breast cancer screening AND Saudi women, breast cancer screening OR mammogram AND Saudi women, mammogram AND utilization AND Saudi women. Synonyms were also included, such as Saudi Arabia, and term such as utilization, knowledge, female, attitude, and behavior.

Screening for inclusion criteria

Studies were screened by the review author and a second researcher using the following inclusion criteria: qualitative and quantitative studies that a) were conducted in Saudi Arabia among SaW, b) explored factors associated with mammogram uptake among SaW, c) were peer-reviewed, d) were written in English, and e) were available in full text.

Evaluating the quality of studies

Each selected qualitative and quantitative study was thoroughly evaluated by both researchers. During the evaluation phase, the review authors used the appropriate tools from the Critical Appraisal Skills Programme (CASP),¹³ then validated by the second researcher.¹³ For the quantitative studies, the CASP cross-sectional studies appraisal checklist was used to assess the internal and external validity of the study methodologies, as well as potential bias due to study design, sampling or data analysis. For the qualitative studies, the CASP qualitative appraisal checklist was applied to evaluate the studies’ transferability and credibility in minimizing bias during data collection and interpretation. After the evaluation, the limitations of each study were documented in the table of evidence.

Extracting data

Tables of evidence were used to extract the data from each study. The tables included the study’s purpose, sample size and characteristics, study location, design, and results. The results section was further divided to identify barriers and facilitators of mammogram uptake among Saudi women. The tables also included comments on the limitations of each study, based on the appraisal checklist used during the evaluation phase. Data were extracted from all studies by the review author and then evaluated by the second researcher.

Analyzing the data

Data analysis was conducted in 2 phases. In the first phase, the review author analyzed and synthesized the factors associated with MS among SaW, based on the socioecological model.⁹ According to the model, different levels, including individual, interpersonal, and social factors, influence behaviors toward one’s health needs. Individual factors are defined as characteristics linked to individuals, such as educational level and age. Interpersonal factors arise from interactions of the individual with their direct social circle, such as family members. Finally, the social factors are the culture and the societal norms.⁹ The second phase of data analysis was conducted by the second researcher, which involved validating the results based on the study and the table of evidence.

Results

he systematic search yielded a total of 39 studies, which were included in this systematic review. A total of 2,573 records were identified through searches in PubMed, PsycINFO, CINAHL Plus, and Google Scholar. Following the removal of 919 records through advanced search filters, 69 duplicates, and 774 irrelevant records, 811 records remained for screening. Titles and abstracts were screened, and 767 records were excluded because they were not conducted on Saudi women. Of the 44 reports sought for retrieval, 2 could not be retrieved. Full texts of 42 reports were assessed, resulting in the exclusion of 3 studies that focused exclusively on breast self-examination or clinical breast examination (Figure 1). Ultimately, 39 studies met the eligibility criteria and were included to fulfill the objective of this review.

Figure 1.

- Flow diagram of literature search.

Mammogram screening rates in Table 1

Table 1.

- Mammogram screening rates among saudi women.

Location (City/Region)	Sample size	Mammogram screening rates		Study authors
		Obtained a mammogram at least once in lifetime	Have obtained mammogram within the previous one or two years
Riyadh/ Riyadh	3,788	29%	30%	[9]
All Regions	3,245	40%	Not reported	[10]
All Regions	2,786	6.5%	Not reported	[8]
Abha/Asir	421	11.6%	Not reported	[14]
Najran/ Najran	500	15%	Not reported	[15]
Jeddah/ Makkah	200	20%	Not reported	[17]
Makkah/ Makkah	400	51%	Not reported	[18]
Al-Ahsa/Eastren	816	16.2%	Not reported	[7]
Al-Madinah / Al-Madinah	465	22%	32%	[16]

Nine studies reported mammogram rates among SaW, revealing poor adherence overall.^7,11,14,17 Two national surveys (n=3,245 and n=2,786) showed that only 40% (n=1,298) and 6.5% (n=181), respectively had received a mammogram at least once in their lifetime.^8,10 Screening declined with age: 44% of women aged 41-50, 33% aged 51-60, and 24% of those over 60 had undergone MS at least once.⁸ In Riyadh (n=3,778), 29% had a mammogram at least once in their lifetime and 30% within the last 3 months.¹¹ In Abha (n=421), only 11.6% had undergone MS once in their lifetime, whereas 88.4% (n=372) had never had a mammogram.¹⁴ In Najran, 15% of 500 women had received MS.¹⁵ In Madinah, 22% of 465 women reported MS at least once in their lifetime, and 32% had received a mammogram within the previous 2 years.¹⁶ In Jeddah, only 11.6% of 200 had undergone MS once in their lifetime.¹⁷ In Makkah, 51% of 400 women had undergone MS at least once.¹⁸ In Al-Ahsa, 16.2% of 816 had received MS at least once in their lifetime.⁷

Factors associated with mammogram screening uptake

According to the socioecological model,¹⁹ the factors that influence SaW’s uptake of mammograms were categorized into 1) individual factors, including BrCa and mammogram knowledge, demographic characteristics, health beliefs, fear, pain, and embarrassment; 2) interpersonal factors, such as male family members, health care providers, and competing priorities; and 3) social factors, including health behaviors regarding MS and the health care system. Figure 2 describes the factors associated with MS explored in each study. To fulfill the aim of this systematic review, each factor was also classified as a facilitator or a barrier to obtaining a mammogram among SaW.

Figure 2.

- Facilitatiors and barriers of mammogram uptakes among Saudi women based on socioecological moder.

Individual factors. Knowledge about BrCa and mammograms:

Various tools and surveys assessed SaW’s knowledge of BrCa and MS, with most studies reporting unsatisfactory results. Poor to average knowledge was reported among 84% (26,058 of 31,022)^7-14 and 58% (1,882 of 3,245)²⁰ across Saudi regions. Region-specific findings included 69.3% (221 of 319) in Al-Ahsa,²¹ 67% (268 of 400) in Makkah,²² 71% (106 of 150) in Dammam,²³ 57% (300 of 400) in Qurayyat,²⁴ 39% (182 of 468) in Albaha,²⁰ and 90% (450 of 500) in Najran.²⁴ One study reported moderate education but limited understanding of BrCa treatment and screening effectiveness.²³ Poor knowledge was linked to delays in MS; significantly more women who never underwent screening reported poor knowledge.^16,24,25 Moreover, low knowledge was associated with perceived barriers to screening,²⁰ while higher knowledge predicted prior or intended MS uptake.¹⁰

Several studies also reported low awareness of BrCa risk factors^15,23,26-31 and general knowledge, with 62% (288 of 465) reporting poor understanding.¹⁶ Misconceptions were common, such as beliefs that BrCa is contagious or caused by the “evil eye” or tight bras.^30,31 Awareness of BrCa signs and symptoms, particularly nipple retraction, was also limited.^{7,14,18,26,27,29,30,32-35}

According to primary care providers, many SaW had limited knowledge of BrCa’s nature, signs, and treatment.^26,31 Lack of awareness of where to obtain MS was reported by 13% (126 of 973)²⁶ and 45% (180 of 400)³⁶ in 2 studies. Understanding of MS guidelines and recommended screening age was also low.^{10,22,29,32,35,36} In addition, limited awareness of MS procedures and effectiveness was observed.^15,37 A qualitative study in Makkah reported poor knowledge regarding the benefits of regular screening for early detection.³⁸ Knowledge levels were associated with demographics: higher knowledge was observed among women with higher education, employment, age ≥40, urban residence, multiparity, and family history of BrCa.^{7,13-15,17,22,25,34-36,38-41} Seven studies reported a positive correlation between middle to high household income and greater knowledge of BrCa and MS.^{8,10,15,24,25,36,39}

Demographic characteristics

Demographic factors significantly influenced MS rates among Saudi women. Higher education was consistently linked to greater MS uptake,^10,16,41 with those beyond high school more likely to undergo screening.^8,10 One study found that university-educated women were nearly 3 times more likely to have obtained a mammogram at least once in their lifetime.⁴¹ Higher household income also increased screening rates; women earning SAR15,000 were twice as likely to undergo MS as those earning SAR10,000 or less. Age played a role, with women over 50 showing higher rates of screening.^16,35,41 Marital status was another factor, married women were more likely to be screened than single or divorced counterparts.^10,16,41 Knowing someone with BrCa also influenced behavior; in one study, 27.7% underwent mammography and 38.5% performed breast self-exams for this reason.^16,42 Conversely, women without a family history of BrCa were 1.5 times less likely to be screened,¹⁰ and one study found this reason was reported by only a small proportion of participants.²⁴

Health beliefs

Champion’s Breast Cancer Health Belief Model was used in 3 studies to examine MS utilization among SaW.^10,18,34 In one study, 93% (372 of 400) acknowledged the importance of mammograms, yet this did not translate into higher MS uptake.¹⁸ Another study found that 31% (1,005 of 3,245) cited low perceived benefit as a major barrier.¹⁰ Perceived susceptibility was also assessed, with 20% (33 of 165) believing they were at risk; however, no link to MS behavior was reported.⁴³

Fear

Fear was one of the key psychological barriers to MS among SaW.^10,20 Most studies reported fear of BrCa diagnosis.^{10,14,15,21,23,25,35,42} In one qualitative study, primary care providers noted that fear of knowing mammogram results prevented some SaW from following up after screening,^20,23,42,44 particularly women aged 40-50 in Al-Hassa (n=1,315).⁴¹ Fear of radiation exposure also contributed to reduced MS uptake,^15,34,35 lowering screening by 48% among 223 of 465 women in one study.¹⁶ Additional fears, such as those related to BrCa treatment, hospitals, and healthcare providers,⁴¹ as well as BrCa stigma,^7,23,31 further discouraged adherence to screening.

Pain

Perceived pain during MS was a barrier for some SaW, discouraging both initial and regular screening due to fear of §discomfort or past negative experiences.^10,16,37 Ashkar et al³⁷ (2017) found that 67% (n=67) of SaW (N=100) anticipated pain before the procedure, and 74% reported it as painful afterward. Other studies showed that pain deterred 49% (207 of 423) and 15% (75 of 506) of women from regular screening.^25,35 SaW who viewed MS as painful were significantly less likely to undergo screening, with reduced rates of 56% in Al-Madinah (260 of 465), 33% in Al-Ahsa (269 of 816), and 11% nationally (357 of 3,245).^10,16,41

Embarrassment

Embarrassment about exposing private body parts during MS has been reported as a barrier to obtaining a mammogram.^{10,16,34-35,42} About 42% (177 of 423) of SaW reported this concern.³⁵ Similarly, 11% (1,066 of 9,691) and 18% (176 of 979) expressed embarrassment in other studies.^10,42 Additionally, 35% (162 of 465) considered the procedure shameful.¹⁶

Interpersonal factors. Male family members

Two studies reported an indirect impact of male family members on mammograms among SaW. Husbands with high levels of knowledge about BrCa facilitated their wives’ participation in MS at least once.⁴⁵ Positive attitudes toward MS among Saudi males were reported in the study by Al-Amoudi et al.⁴⁶ Approcimately 80% (n=659) of male participants (n=824) recommended mammograms to their mothers or sisters, 71% (n=585) provided psychological support to do so, and almost half of the sample were willing to personally accompany their female family members to obtain mammograms.⁴⁶

Being busy or having competing priorities

Busy schedules were a barrier to MS among SaW. In Abdel-Salam et al (2020), 63% (266 of 423) cited time constraints.³⁵ Similarly, 26% (75 of 290) in Al-Khamis et al,⁷ and 47% (149 of 319) and 33% (269 of 816) in Alanazi et al²⁰ reported being too busy. A qualitative study also noted that many female patients were in a hurry and lacked time to discuss MS and other screenings.⁴⁴

Health care providers

The relationship between SaW and healthcare providers played a dual role in influencing MS behaviors, acting as both a facilitator and a barrier.^34,35 Provider recommendations boosted MS uptake, with 32% (n=166) of 519 women reporting they underwent screening due to such advice.³⁴ In contrast, lack of recommendation was frequentlyreported as a barrier.^34,35 Preference for female physicians also supported screening engagement, as SaW felt more comfortable discussing BrCa screening options with them.^7,35,41 Conversely, the shortage of female physicians hindered access to MS services.^13,31,34,41 The knowledge of healthcare providers regarding BrCa and MS was another factor influencing women’s uptake of mammogram. Inadequate understanding of screening guidelines, benefits, and available resources negatively affected MS uptake.^22,31,44 Some providers lacked the expertise to perform or interpret mammograms, further impacting service quality.³⁴ In contrast, providers with better knowledge tended to promote MS more confidently and positively.^34,41 Additional barriers included previous negative experiences with providers, poor communication by mammogram technicians, and lack of trust between patients and healthcare professionals.^16,41,44

Social factors. General health behaviors for secondary health screenings

Routine visits to physicians for preventive screenings without presenting health complaints are uncommon in Saudi Arabia.⁴⁴ In the study by Al-Abdulkader et al,⁴² 35% (n=340) of the women (N=973) perceived mammograms as unnecessary. In another study conducted in Makkah, 93% (n=372) of SaW (N=400) reported that they would visit a physician only if experiencing breast problems. The lack of routine checkups, such as mammograms, contributes to an increased rate of advanced-stage BrCa diagnoses among SaW.⁴⁴ Abdel-Aziz et al⁴¹ (2009) reported that more than half of their sample underwent mammograms for diagnostic purposes, compared to only 32% (n=262) who had them for screening, out of a total sample of 816 participants. This behavior was attributed in several studies to ignorance, neglect, apathy, mistrust in mammograms, anxiety, low perceived benefit, or the absence of a perceived need for BrCa screening.^{7,22,24,28,44} Two studies, however, reported positive behaviors toward MS among SaW. In the Alnuwaysir et al²⁸ study, 85% (n=471) of SaW (N=555) were willing to adhere to MS even if they were in good health once they reached the recommended age for MS. Additionally, 63% expressed their intention to start screening even in the absences of symptoms.²⁸ In the Al-AbdulKader et al. (2023) study, 53% (n=252) of (N=476) of the women who received mammograms were interested in early BrCa detection even without having abnormal signs or symptoms.⁴²

Health care system

Several factors within the Saudi health care system were reported as barriers to obtaining mammograms or adhering to regular screening. Difficulties in scheduling appointments and long waiting times were cited as barriers in 2 studies.^7,31,34,35 Transportation related challenges were also reported in 4 studies as barriers to accessing mammogram services.^34,35,41,44 In terms of resources, Alzahrani et al⁴⁴ highlighted the shortage of specialized physicians in primary health care centers.⁴⁴ Additionally, Saudi physicians noted the lack of specialized clinics or mammograms services in primary health care centers.^41,44,47 These limitations add time constraints on primary health care physicians, reducing their ability to discuss BrCa screening or follow up with mammogram requests.^44,47 Collectively, these factors contributed to overcrowding in primary health care centers, where patients with acute conditions were prioritized over those seeking routine screenings like mammograms.^44,47

Discussion

This systematic literature review consists of 39 studies conducted in all provinces of Saudi Arabia (Table 2). The results demonstrate that SaW had low adherence to MS.^8-10,14-18 Factors contributing to MS uptake were classified according to the socioecological model at all 3 levels: (a) individual, (b) interpersonal, and (c) social.¹⁹ More importantly, this review provides a greater understanding of how each factor acts as a facilitator or a barrier to obtaining MS among SaW. Generally, SaW demonstrated moderate to poor levels of knowledge in most of the studies.^{7,14,15,20,23,26,29,32,33,35,39,40,48} These findings are aligned with those among Arab women in the United Arab Emirates, Qatar, and Palestine.^49,50-52 In this review, only 2 studies, Alnuwaysir et al (2018)²⁸ and Alghamdi et al, (2022)¹² reported an average level of knowledge, both of which included young participants (18 years and older). This age group may have been exposed to BrCa information by social media, which may have enhanced their level of knowledge of BrCa and its screenings. Additionally, Alnuwaysir et al’s (2018) study was conducted in the Eastern province in Saudi Arabia.²⁸ The prevalence of BrCa was found to be high in that province, which may have increased the chances of SaW being exposed to BrCa educational campaigns or having a family history of BrCa.⁵³

Table 2.

- Barriers to and facilitators of mammogram screening among saudi women classified according to the socioecological model.

Mammogram screening	Location (City/provinces)	Authors
Socioecological Model: Level 1
Individual factors
Barriers
Low level of knowledge about breast cancer and mammogram	Riyadh, Al-Ahsa, Al-Madinah, Jeddah, Makkah, Najran, Abha, Aljouf regions, Al-Qassim, Asir region, Dammam, Al-baha, and Jazan,	[7, 8, 10, 15- 18, 22-37, 39-41, 48]
Facilitators
High level of knowledge about breast cancer and mammograms	Five regions in Saudi North, South, East, West, and Central regions.	[10]
Demographic characteristics
Barriers
Low education level	Five regions in Saudi North, South, East, West, Central regions, Al-Madinah, Aljouf,	[8, 16, 35]
Facilitators
High education level	Five regions in Saudi North, South, East, West, Central regions, Alhasa, and Al-Madinah	[10, 16, 41]
Breast cancer history and knowing a friend with breast cancer	Five regions in Saudi North, South, East, West, Central region, Al-Madinah	[10, 24, 42]
Age	Five regions in Saudi North, South, East, West, Central regions, Alhasa, Al-Madinah, Alhasa, and Al-Qassim	[16, 24, 41]
Marital status (married)	Five regions in Saudi North, South, East, West, Central regions, and Al-Madinah	[10, 16, 41]
Health Beliefs
Barriers
Low level of perceived mammogram importance	Five regions in Saudi North, South, East, West, and Central regions.	[10]
Fear	Al-Ahsa, Aljouf region, Dammam, Makkah, Al-baha, and Riyadh.	[7, 10, 14, 15, 20, 21, 23, 25, 31, 35, 41, 42, 44]
Pain	Damam, Aljouf, Al-Madinah, Jeddah, Al-Ahsa	[10, 16, 35,37, 41]
Embarrassment	Five regions in Saudi North, South, East, West, Central regions, Aljouf, Al-Madinah, and Al Hassa	[10, 16, 34, 35, 41, 42]
Socioecological model: Level 2: interpersonal factors
Barriers
Being Busy or Having Competing Priorities	Abha, Aljouf, Riyadh, Makkah	[7, 20, 35, 41, 44]
Health Care Providers (Not receiving mammogram recommendation, low level of knowledge about breast cancer and mammograms, poor communication, lack of trust, lack of female physicians)	Makkah, Aljouf, Alhasa, and Al-baha, Jazan, and Al-Madinah, Riyadh	[16, 22, 23, 31, 34, 35, 41, 44]
Facilitators
Male Family Members	Jeddah, Abha	[45, 46]
Health Care Providers (availability of female physicians, qualified physicians)	Al-Qassim, Alhasa; Najran, Aljouf, and Dammam	[15, 24, 25, 34, 35, 41]
Socioecological Model: Level 3: Social Factors
Barriers
Negative Practices Toward Secondary Health Screenings	Five regions in Saudi North, South, East, West, Central regions, Makkah, Alhasa, and Riyadh.	[22, 41, 42, 44]
Facilitators
Health Care System (difficulties making appointments, transportation difficulties, shortage of specialized physicians and clinics, time limitations	Five regions in Saudi North, South, East, West, Central regions.	[28, 42]
Positive Practices Toward Secondary Health Screenings		[7, 31, 34, 35, 44]

Notably, most participants in Alnuwaysir et al’s (2018) study held bachelor’s degrees,²⁸ and several studies have reported a positive association between higher educational attainment and the level of BrCa knowledge among SaW.^{7,14,15,20,23,26,29,32,33,35,39,40,48} Several factors may help explain this finding. First, women with higher education levels often have greater access to health information, particularly through formal education and platforms such as social media, as highlighted by Al-Wassia et al (2017).¹⁰ Second, educated women are more inclined to adopt preventive health behaviors such as learning about BrCa, participating in awareness activities, and obtaining mammograms when advised as observed among Arab women.⁵¹ Thus, a national survey with a representative sample size is recommended to assess BrCa knowledge and its association with demographic factors.

Some factors associated with mammogram screening were deeply integrated with social norms and cultural beliefs in Saudi Arabia.³¹ For example, the stigma of BrCa was reported as a barrier to obtain a mammogram; it is a socially constructed factor within the context of Saudi culture. Nevertheless, understanding how these factors affect MS practices among SaW is still limited because they mainly have been explored using cross-sectional designs. Thus, to fully understand the impact of such factors on MS uptake among SaW, a qualitative research is recommended.

Behavior toward mammograms is another complex factor reported in the literature. As discussed, several subfactors contribute to this behavior. A common attitude toward secondary screening is that physician visits are unnecessary without symptoms.¹⁸ Perceived low benefits of mammograms may reinforce this belief.^22-24 The health-beliefs model may offer insight into SaW’s behaviors toward mammogram practices. It includes 6 core concepts: perceived BrCa seriousness, susceptibility, benefits, barriers, self-efficacy, and modifying factors.⁵⁴ Future research may apply this model to better understand SaW behaviors and develop interventions to reduce negative attitudes toward mammograms.

The role of male family members, especially husbands, was reported as a facilitator for MS among SaW.^45,46 Similar findings have been reported in other Arab countries.^55,56 In Lebanon, women who received their husbands’ encouragement to obtain mammograms were twice as likely to adhere to MS.⁵⁵ Additionally, among Muslim and Arab women in the United States, women who received their husbands’ support to obtain mammograms were more likely to adhere to MS.^57,58 Therefore, involving husbands in BrCa screening efforts should be considered to enhance MS adherence among SaW. Such family-centric intervention requires more understanding of the husbands’ role in mammogram adherence in Saudi Arabia. This gap in the knowledge could be filled by future research.

Using the socioecological model to improve mammogram uptake has shown promising outcomes in the United States.^59,60 Based on the reviewed evidence, it may be beneficial to consider designing an intervention that addresses all 3 socioecological levels-individual, interpersonal, and societal-as illustrated in Table 2, to potentially enhance mammogram screening adherence among Saudi women. Then, understanding how each factor affects MS, as a barrier or a facilitator, will help in designing targeted intervention.^59,60 To illustrate, fear of BrCa will be addressed in an intervention at the individual level. Then, fear will be classified as a barrier that negatively affects mammogram adherence, as reported in the literature.^{10,14,15,21,23,25,35,42} In the intervention program, women who have survived BrCa will share their experiences with fear while undergoing a mammogram. Similarly, the shortage of specialized physicians will be addressed at the social level.³⁴ Hence, establishing a national plan to provide family physicians with appropriate training for BrCa screenings is a crucial step. Additionally, emphasis will be placed on healthcare providers to recommend mammograms to women during clinical visits to enhance mammogram uptake among SaW at the interpersonal level.³⁴

Review limitations

This systematic review should be interpreted in light of several limitations. One notable limitation is the age heterogeneity present in several of the included studies. Some studies included participants as young as 18 years to assess BrCa knowledge and MS utilization; however, this younger age group may not accurately reflect the experiences of women aged 40 and above, who are the primary target of national screening guidelines in Saudi Arabia.⁶ The inclusion of wide-ranging age groups, particularly without appropriate stratification during data analysis, may have compromised the internal validity of some studies’ findings and limited their generalizability to the intended screening population-SaW. Additionally, most of the included studies employed cross-sectional designs, which restrict the ability to establish causal relationships between variables such as knowledge levels and age. Another limitation is that, although mammogram use among SaW is influenced by various factors, most studies (n=29) focused primarily on knowledge of BrCa and MS.^{7,14,15,20,23,26,29,32,33,35,39,40,48} Therefore, low MS uptake should also be examined through sociocultural and religious lenses to provide a more comprehensive understanding of the phenomenon. For instance, cultural beliefs such as the “evil eye” should be explored using qualitative research methods.

Recommendations

In view of the findings of this systematic review, several recommendations can be proposed. First, a national target for mammogram screening should be established to track progress among women in Saudi Arabia. For example, the target mammogram screening rate in the United States is 77.1% by 2030, which is used to evaluate adherence every 5 years.⁶¹ Second, MS rates among SaW should be monitored by the Ministry of Health in collaboration with the General Authority for Statistics. This collaboration could yield more accurate national estimates of MS adherence.Third, researchers in Saudi Arabia are encouraged to align with national research priorities. Cancer screening and early detection are among the top recommended fields of study.^62,63 In particular, BrCa is the most common cancer and the second leading cause of death among Saudi women.⁴ Therefore, research aimed at improving MS rates and health behaviors should be prioritized.

In conclusion, this review of 39 studies shows that Saudi women have low adherence to regular mammogram screening. Using the socioecological model, the factors influencing uptake were identified at the individual level (knowledge, demographics, health beliefs, fear, pain, embarrassment), the interpersonal level (family support, healthcare providers, competing priorities), and the social level (screening behaviors and healthcare system factors). To improve adherence, interventions should address all three levels, with tailored strategies that recognize whether each factor acts as a barrier or a facilitator.