Abstract
Background
Breast cancer is the most prevalent malignancy among women in Bahrain, with the highest age-standardized incidence rate in the Gulf Cooperation Council (GCC) region. Despite mammography being the gold standard for early detection, screening uptake remains suboptimal. This study aimed to evaluate knowledge, attitudes, and practices regarding mammography screening among Bahraini women and identify barriers and facilitators to its utilization in primary care.
Methods
A cross-sectional analytical study was conducted among 400 Bahraini women aged ≥ 40 years attending five randomly selected primary healthcare centers across Bahrain. Data were collected via face-to-face interviews using a semi-structured questionnaire covering socio-demographics, medical history, knowledge, attitudes, practices, and barriers. Chi-square tests and binary logistic regression were used to identify predictors of screening uptake.
Results
Participants had a mean age of 54.4 ± 8.8 years. Knowledge was predominantly average (47.3%) to good (34.5%). While 70.3% held a positive attitude toward mammography and 68% had been screened at least once, only 43.8% adhered to recommended periodic intervals. The leading enabler was physician recommendation (66.9%). Key barriers included absence of physical symptoms (41.7%), lack of time (41%), and fear of pain or cancer diagnosis (38.9%). Factors significantly associated with higher uptake included older age (p < 0.001), higher knowledge (p = 0.003), positive family history (p < 0.001), history of benign breast disease (p = 0.022), and unemployed or retired status (p = 0.001). Binary logistic regression confirmed independent predictors: age > 60 years (AOR = 5.84, 95% CI: 2.84–12.01, p < 0.001), family history (AOR = 2.39, 95% CI: 1.36–4.20, p = 0.002), benign breast disease (AOR = 2.89, 95% CI: 1.26–6.63, p = 0.012), and good knowledge level (AOR = 3.23, 95% CI: 1.49–6.97, p = 0.003).
Conclusions
Bahraini women demonstrate fair knowledge and positive attitudes toward mammography, yet a significant gap persists between initial screening and periodic adherence. Primary care interventions must move beyond general awareness to address symptom-driven misconceptions and psychological fears. Strengthening physician-led recommendations and implementing electronic reminder systems for high-risk groups are essential to improving national screening program effectiveness.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12875-026-03367-6.
Keywords: Breast cancer, Mammography, Screening, Bahrain, Primary Health Care, Barriers, Facilitators
Background
Breast cancer is the most prevalent malignancy among women globally, accounting for more than one in ten new cancer diagnoses annually [1]. Over the past decade, worldwide incidence has increased by over 20%, accompanied by a 14% rise in mortality [2]. In 2020 alone, the disease was responsible for 2.3 million cases and 685,000 deaths globally [3]. This burden is particularly acute in Bahrain, where breast cancer is the most common malignancy among women. Notably, Bahrain reports an age-standardized incidence rate (ASIR) of 52.3 per 100,000—the highest among all Gulf Cooperation Council (GCC) states [4].
While therapeutic advancements have improved survival rates, early diagnosis remains the most effective strategy for mortality reduction and improved prognosis. Although screening can be performed via breast self-examination (BSE), clinical examination, or ultrasound [5], mammography is recognized as the gold standard for its efficacy in reducing mortality and treatment-related morbidity [6]. Despite its proven benefits, a significantly low proportion of breast cancer cases in Bahrain are detected through screening, highlighting a critical need to investigate the knowledge levels and barriers associated with this modality [7].
In response to the evidence favoring mammography, the Bahrain Cancer Society, in collaboration with the Ministry of Health, launched the National Campaign for the Detection of Breast Cancer in 2005. For over two decades, these organizations have worked to educate the public on the necessity of early diagnosis. Current national guidelines recommend that women of average risk undergo mammography screening every two years starting at age 40 [8].
However, previous research suggests significant gaps in public awareness. A 2011 study involving 286 women at Bahraini primary healthcare centers revealed low general knowledge, with only 5.6% of participants answering more than half of the knowledge-based questions correctly. While higher education was associated with better awareness, healthcare providers were cited as the least common source of information (29.7%) [9]. By 2018, another study in Bahrain found improved awareness regarding the starting age for screening (82.3%) and the safety of the procedure (91.0%); however, only 13.7% of women correctly identified mammography as the most effective detection tool [10].
Similar trends of inadequate knowledge are observed across the region. In Najran, Saudi Arabia, 90.4% of women lacked knowledge regarding mammograms [11], while nearly half of the participants in a Mashhad, Iran, study demonstrated inadequate awareness [12]. Conversely, a Qatari study reported good knowledge of warning signs (69%), though recognition of specific risk factors like early menarche remained low [13]. In the United Arab Emirates (UAE), specifically Ras Al Khaimah, only 4% of participants knew the correct age to begin screening [14], whereas research in India showed higher knowledge levels regarding both the disease and mammography (62.99% and 78.67%, respectively) [15].
Attitudes and practices also vary significantly. In the Eastern Province of Saudi Arabia, only 12.4% of women had undergone mammography, with 75.2% reporting that their physicians played no role in their education regarding screening [16]. In Jordan, while 76% of women were aware of the disease’s prevalence, education level remained the primary predictor of screening knowledge [17]. Regarding attitudes, Bahraini-specific data is currently lacking, but neighboring regions show mixed results. A 2022 Saudi study found that 16.1% of women held poor attitudes toward screening [18], and only 7.9% of Iranian participants reported positive attitudes [12]. In contrast, attitudes in the UAE were generally positive [19], and while Indian women also displayed positive attitudes, their actual screening uptake remained low [15].
Actual screening practice in the region is consistently insufficient. In Bahrain, it is estimated that only 12.7% of cases are detected via mammography [7]. Uptake rates are similarly low in Qatar (16%) [13] and the UAE, where lifetime mammography rates range from 11.7% [20] to 14.7% [14]. Across various Saudi Arabian cohorts, practice rates fluctuate between 12.4% and 28.3%, though one study among university staff reported a higher uptake of 51.5% [11, 16, 18, 21]. Regional rates are even lower in Jordan (6.7% lifetime) [22] and Iran (5.4% annual uptake) [12]. Even in Singapore, participation in routine screening remains below 40% [23].
The barriers preventing women from seeking screening are multifaceted. In Saudi Arabia, the predominant deterrents are fear of a cancer diagnosis (57.2%) and concerns regarding radiation exposure (57%) [18]. In Qatar, logistical issues such as difficulty in securing appointments were identified [13], while UAE participants cited pain and lack of physician recommendations [14]. Iraqi Kurdish women reported a lack of perceived symptoms and time constraints [24], and Jordanian women highlighted the cost of testing and religious beliefs [25]. Internationally, Swedish women cited structural conditions and time estimation [26], while Malaysian women noted a lack of understanding regarding where to access the exam [27].
Participation in screening is influenced by several clinical and demographic factors. Positive correlations have been established between screening uptake and the level of knowledge regarding risk factors and symptoms [17]. Additionally, women over age 40 or those with poorer health status are more likely to undergo mammography [14]. Iranian research confirmed that screening behaviors correlate significantly with both knowledge and attitude scores [12]. Finally, international data from Singapore indicates that lower income, lack of social proximity to cancer patients, and the perception of mammography as “embarrassing” are significant predictors of non-attendance [23].
Despite the high incidence of breast cancer in Bahrain, there is a lack of contemporary research exploring why screening uptake remains low. This study aims to evaluate the knowledge, attitudes, and practices of mammography screening among Bahraini women aged 40 and above attending primary healthcare centers. Specifically, the objectives are to: (1) assess the level of knowledge regarding breast cancer risk factors and screening guidelines; (2) determine the prevailing attitudes toward mammography; (3) measure the actual uptake and frequency of screening; and (4) identify the specific personal and structural barriers that prevent women from utilizing these services. By identifying these factors, this study seeks to provide evidence-based recommendations for primary care interventions to improve early detection rates in the Kingdom of Bahrain.
Methods
Study design and setting
A cross-sectional analytical study was conducted among Bahraini women attending primary healthcare centers across the Kingdom of Bahrain. The Gulf Cooperation Council (GCC) is a political and economic alliance of six Arab states: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. These countries share broadly similar sociocultural characteristics, healthcare systems, and epidemiological profiles, making regional comparisons contextually meaningful. Bahrain’s primary healthcare system is structured across five health regions (governorates) and comprises 27 government-operated centers staffed by family physicians and allied health professionals. These centers serve as the first point of contact for preventive and chronic disease services, including national cancer screening programs, and are accessible free of charge to all Bahraini citizens. To ensure geographic representation, a multistage sampling approach was used. First, one primary healthcare center was randomly selected from each of the five health regions using a simple random selection method. The selected centers were: National Bank of Bahrain HC (Muharraq), Sabah Al Salem HC and Yousef Engineer HC (Capital), Hamed Kanoo HC (Northern), and Zallaq HC (Southern).
Participants and sampling
The target population consisted of Bahraini women aged 40 years and older. Inclusion criteria were Bahraini nationality, age 40 years or older, and no prior diagnosis of breast cancer. Women with a personal history of breast cancer were excluded, as they would be under active surveillance or treatment rather than primary screening. Additionally, women who had undergone prophylactic bilateral mastectomy were excluded, as this procedure eliminates the anatomical basis for mammographic screening. Women who were unfamiliar with mammography completed the demographic and knowledge sections of the questionnaire but were excluded from the attitude and practice analyses, as those items presupposed basic familiarity with the procedure. The number of women in this category is reported in the Results.
Participants were recruited from the waiting areas of the selected health centers using a convenience sampling technique. The sample size was calculated based on the total population of Bahraini females in this age group (N = 87,656). Using a 95% confidence level, a 5% margin of error, and an assumed 50% standard deviation, the minimum required sample size was determined to be 383. To account for potential incomplete responses, the final sample was rounded to 400 participants, distributed proportionally across the five centers based on the population size each center serves.
Study instrument
Data were collected using a semi-structured, six-part questionnaire administered via face-to-face interviews to ensure clarity and response accuracy. The questionnaire was available in both Arabic and English.
Part 1: Demographics: Included age, occupation, educational level, marital status, and presence of children.
Part 2: Medical History: Assessed family history of breast cancer (including degree of kinship) and personal history of benign breast diseases.
Part 3: Knowledge: Contained 15 items evaluating awareness of breast cancer signs, symptoms, risk factors, and mammography guidelines.
Part 4: Attitude: Assessed using a 7-item Likert scale (from “Strongly Disagree” to “Strongly Agree”) regarding the perceived benefits and safety of mammography.
Part 5: Practice: Evaluated whether participants had ever heard of or undergone a mammogram, including the frequency and motivators for screening.
Part 6: Barriers: A list of potential deterrents related to procedures, cancer-related fears, and logistical issues (e.g., time).
Validity and reliability
The questionnaire was newly developed by the research team, informed by validated instruments from comparable regional KAP studies. Content validity was established through expert review by three Family Medicine and Public Health faculty members, who assessed item relevance, clarity, and domain coverage prior to piloting. Face validity was confirmed during the pilot phase. A pilot study was conducted with 10 participants to assess the questionnaire’s clarity and reliability. The instrument demonstrated excellent overall internal consistency (Cronbach’s alpha = 0.90 for the full instrument). Domain-level internal consistency was also adequate: Knowledge subscale (α = 0.82), Attitude subscale (α = 0.87), and Barriers subscale (α = 0.79).
Statistical analysis
Data collected via Google Forms were exported to Microsoft Excel and analyzed using IBM SPSS Statistics version 23.0.
Knowledge scoring
Correct answers were assigned 1 point, while “no” or “I don’t know” answers received 0. Scores were categorized as poor (< 8), average (8–11), or good (> 11) based on the mean (10 ± 3).
Attitude scoring
Responses were coded as 1 (disagree), 2 (neutral), or 3 (agree). Participants scoring > 19 (the mean) were classified as having a “good” attitude.
Statistical tests
Descriptive statistics (frequencies, percentages, means, and standard deviations) were used for demographic data. The relationships between knowledge, attitude, practices, and socio-demographic variables were analyzed using the Chi-square test. Binary logistic regression analysis was conducted with mammography practice (ever screened vs. never screened) as the dependent variable. All variables reaching significance at p < 0.05 in bivariate analysis were entered simultaneously as covariates to generate adjusted odds ratios (AOR) with 95% confidence intervals, controlling for potential confounders. Model adequacy was assessed using the Hosmer–Lemeshow goodness-of-fit test. A p-value of < 0.05 was considered statistically significant.
Results
A total of 400 Bahraini women participated in the study, with a mean age of 54.4 ± 8.8 years. The demographic distribution (Table 1) shows that the largest age group was 50–60 years (36.0%). Most participants were married (78.3%), and 45.3% were unemployed. Educational attainment varied, with 29.8% holding a bachelor’s degree or higher. Regarding clinical history, 32.8% of women reported a family history of breast cancer, while 13.8% had a personal history of benign breast disease.
Table 1.
Socio-demographic characteristics and medical history of participants (N = 400)
| Variables | N (%) |
|---|---|
| Age group | |
| Less than 50 years | 137 (34.3) |
| 50–60 years | 144 (36) |
| More than 60 years | 119 (29.8) |
| Occupation | |
| Employed | 73 (18.3) |
| Un-employed | 181 (45.3) |
| Retired | 146 (36.5) |
| Educational level | |
| Less than high school | 61 (15.3) |
| High school | 164 (41) |
| Diploma | 56 (14) |
| Bachelor’s degree and above | 119 (29.8) |
| Marital status | |
| Single | 28 (7) |
| Married | 313 (78.3) |
| Widowed | 31 (7.8) |
| Divorced | 28 (7) |
| Presence of children | |
| Yes | 343 (92.2) |
| No | 29 (7.8) |
| Family history of breast cancer | |
| Yes | 131 (32.8) |
| No | 269 (67.3) |
| History of benign breast diseases | |
| Yes | 55 (13.8) |
| No | 345 (86.3) |
The overall knowledge levels were categorized as average for nearly half the sample (47.3%). While awareness of specific signs like breast lumps was high (73.8%), knowledge regarding hormonal risk factors, such as late-age childbearing, was notably lower (33.0%). Most participants (77.5%) correctly identified mammography as the most effective screening.
Table 2 reveals that Many of them considered screening mammography to be worthwhile, willing to do it if offered to them, and safe (90.5%, 77.5%, and 68.3%, respectively). As for the calculated overall attitude scoring, the majority of the participants (70.3%) revealed good attitude towards mammography screening.
Table 2.
Attitude of participants toward screening mammography
| Statement | Agree N (%) |
Neutral N (%) |
Disagree N (%) |
|---|---|---|---|
| Opinion on the following statements regarding mammography screening | |||
| 1. Screening for breast cancer is worthwhile | 362 (90.5) | 29 (7.2) | 9 (2.3) |
| 2. A mammogram detects cancer early, which makes treatment more effective | 355 (88.8) | 32 (8) | 13 (3.3) |
| 3. A mammogram helps find breast lumps easily | 334 (83.5) | 50 (12.5) | 16 (4) |
| 4. A mammogram helps decrease the number of women who die of breast cancer | 318 (79.5) | 44 (11) | 38 (9.5) |
| 5. I will do mammography when it is offered to me | 310 (77.5) | 47 (11.8) | 43 (10.8) |
| 6. A normal mammogram result is a reassurance that no cancer is present | 274 (68.5) | 64 (16) | 62 (15.5) |
| 7. Mammography is considered safe to perform | 273 (68.3) | 93 (23.3) | 34 (8.5) |
Figure 1 demonstrates that a large proportion of the participants had done screening mammography before (68%). Of those who did screening mammography, only 43.8% of them did it periodically as per the guidelines recommendations while 56.2% did it once or twice.
Fig. 1.
Practicing screening mammogram among participants
The most frequently cited barriers to mammography included the absence of physical symptoms (41.7%), lack of time (41.0%), and fear of pain or a cancer diagnosis (38.9%) as demonstrated in Table 3.
Table 3.
Barriers toward screening mammography among participants
| Statement | Yes N (%) |
No N (%) |
|---|---|---|
| F1: Barriers related to the mammography screening procedure | ||
| 1. I am afraid of the pain related to the procedure | 56 (38.9) | 88 (61.1) |
| 2. I am apprehensive regarding radiation exposure | 39 (27.1) | 105 (72.9) |
| 3. I am afraid of not knowing the procedure | 34 (23.6) | 110 (76.4) |
| 4. I feel embarrassed due to a breast-related test | 21 (14.6) | 123 (85.4) |
| F2: Barriers related to the thought of not needing the mammogram | ||
| 1. I do not have problems with my breast | 60 (41.7) | 84 (58.3) |
| 2. I do not have a family history of breast cancer | 36 (25) | 108 (75) |
| 3. I am not old enough to be diagnosed with cancer | 10 (6.9) | 134 (93.1) |
| F3: Barriers related to cancer diagnosis | ||
| 1. I am afraid of discovering cancer | 56 (38.9) | 88 (61.1) |
| 2. I believe that cancer has no cure | 12 (8.3) | 132 (91.7) |
| F4: Barriers related to time | ||
| 1. I do not have time to undergo a screening mammogram | 59 (41) | 85 (59) |
| 2. I have other priorities to take care of | 51 (35.4) | 93 (64.6) |
Based on the data from Fig. 2, the graph illustrates that Physician Recommendation is the most powerful enabler, with 66.9% of women identifying it as their primary motivator. This is followed by Breast Cancer Awareness Campaigns (31.8%) and the influence of Family or Friends (23.4%). Information gathered from the Internet and Social Media (14.6%) and direct outreach via Phone calls or SMS from Health Centers (12.4%) were found to be the least frequent drivers for uptake. These results emphasize the critical role of primary care physicians in directly influencing screening behavior compared to passive media or automated notification systems.
Fig. 2.
Motivation/reason for doing mammography screening
Statistical analysis of the factors associated with mammography uptake (Table 4) revealed several significant clinical and demographic predictors. Age played a critical role (p < 0.001), with women over 60 years old being significantly more likely to have undergone screening (85.0%) compared to those under 50 (47.4%). Clinical history was also a powerful driver of behavior, as women with a family history of breast cancer (p < 0.001) or a personal history of benign breast disease (p = 0.022) demonstrated significantly higher participation rates. Furthermore, knowledge levels were directly linked to practice (p = 0.003), with those scoring in the “Good” category showing higher uptake than those with “Poor” knowledge. Occupational status also showed a significant association (p = 0.001), likely reflecting differences in time availability between retired and employed women. Conversely, educational level (p = 0.580) and marital status (p = 0.479) did not significantly influence screening participation, suggesting that in the Bahraini primary care context, clinical risk perception and age-related outreach are more influential than general socio-economic status.
Table 4.
Factors associated with participation in mammography screening
| Factors | Uptake of mammography screening | P value | |||
|---|---|---|---|---|---|
| Yes N (%) |
No N (%) |
||||
| Socio-demographic characteristics | Age group | < 50 years | 55 (47.4) | 61 (52.6) | < 0.001* |
| 50–60 years | 96 (72.2) | 37 (27.8) | |||
| > 60 years | 91 (85) | 16 (15) | |||
| Occupation | Employed | 33 (49.3) | 34 (50.7) | < 0.001* | |
| Unemployed | 105 (69.5) | 46 (30.5) | |||
| Retired | 104 (75.4) | 34 (24.6) | |||
| Educational level | < high school | 35 (74.5) | 12 (25.5) | 0.580 | |
| High school | 100 (68.5) | 46 (31.5) | |||
| Diploma | 35 (70) | 15 (30) | |||
| Bachelor’s | 72 (63.7) | 41 (36.3) | |||
| Marital status | Single | 15 (57.7) | 11 (42.3) | 0.479 | |
| Married | 188 (67.6) | 90 (32.4) | |||
| Widowed | 20 (74.1) | 7 (25.9) | |||
| Divorced | 19 (76) | 6 (24) | |||
| Family history of breast cancer | Yes | 99 (79.8) | 25 (20.2) | < 0.001* | |
| Medical History | No | 143 (61.6) | 89 (38.4) | ||
| History of benign breast diseases | Yes | 41 (82) | 9 (18) | 0.022* | |
| No | 201 (65.7) | 105 (34.3) | |||
| Level of knowledge | Poor | 23 (9.5) | 26 (22.8) | 0.003* | |
| Average | 121 (50) | 49 (43) | |||
| Good | 98 (40.5) | 39 (34.2) | |||
| Attitude | Poor | 60 (60.6) | 39 (39.4) | 0.064 | |
| Good | 182 (70.8) | 75 (29.2) | |||
The binary logistic regression analysis identified several significant predictors for the uptake of mammography screening among Bahraini women (Table 5). The results revealed that age was a strong predictor: women aged 50–60 years were three times more likely to undergo mammography compared to those under 50 (AOR = 3.006, p < 0.001), while women above 60 years were nearly six times more likely (AOR = 5.841; p < 0.001). Regarding socio-economic factors, unemployed women were twice as likely to be screened compared to employed women (AOR = 2.060; p = 0.042), whereas retired women showed a non-significant trend (AOR = 1.752; p = 0.127). A family history of breast cancer significantly increased the likelihood of screening (AOR = 2.390; p = 0.002), as did a history of benign breast disease (AOR = 2.886; p = 0.012). Finally, knowledge level was a powerful predictor: women with average knowledge were 3.5 times more likely to undergo screening compared to those with poor knowledge (AOR = 3.535; p < 0.001), and those with good knowledge were similarly more likely (AOR = 3.227; p = 0.003).
Table 5.
Factors associated with mammography screening uptake among Bahraini women aged 40 years and above: results of binary logistic regression analysis
| Factors | Categorical | Adjusted Odds Ratio | 95% CI (Lower, Upper) |
P. value |
|---|---|---|---|---|
| Age | < 50 years | Ref. | ||
| 50–60 years | 3.006 | 1.665, 5.427 | < 0.001 | |
| > 60 years | 5.841 | 2.841, 12.009 | < 0.001 | |
| Occupation | Employed | Ref. | ||
| Unemployed | 2.060 | 1.025, 4.138 | 0.042 | |
| Retired | 1.752 | 0.852, 3.601 | 0.127 | |
| Family history of breast cancer | No | Ref. | ||
| Yes | 2.390 | 1.360, 4.200 | 0.002 | |
| History of benign breast diseases | No | Ref. | ||
| Yes | 2.886 | 1.257, 6.626 | 0.012 | |
| Level of knowledge | Poor | Ref. | ||
| Average | 3.535 | 1.696, 7.368 | < 0.001 | |
| Good | 3.227 | 1.494, 6.969 | 0.003 |
Discussion
Breast cancer remains a formidable challenge for women’s health in Bahrain, yet our findings offer a nuanced picture of progress and persistent gaps. The study revealed that most Bahraini women possess a baseline knowledge level ranging from average to good (47.3% and 35.0%, respectively), suggesting that decades of public health messaging have successfully socialized the concept of breast cancer. Like their peers in Qatar, the UAE, Jordan, Iraq, and Hungary, our participants were most adept at recognizing overt symptoms, such as breast lumps or axillary lymphadenopathy [13, 14, 17, 24, 26]. However, this “symptom-based” literacy creates a dangerous paradox: while women know how to spot the disease once it appears, many remain unaware of the silent, hormonal risk factors—such as nulliparity or hormonal replacement therapy—that dictate the need for preventive screening before symptoms arise [13, 17, 24, 28].
When we compare our findings to previous Bahraini data, a shift in risk perception is evident. While Fikree and Hamadeh (2011) and Verhagen et al. (2018) noted family history and smoking as primary concerns, our participants placed even greater emphasis on these factors (88.5% and 71.8%) [9, 10]. This heightened awareness of heredity is particularly vital in the GCC context, where familial ties are strong and genetic risk is high [29].
The psychological landscape of screening in Bahrain appears overwhelmingly positive, with 70.3% of participants maintaining a favorable attitude toward mammography. This mirrors results from Jordan and India but stands in stark contrast to the higher levels of apprehension seen in Saudi Arabia, Iran, and Qatar [11–13, 15, 17].
Furthermore, 77.5% of our sample recognized mammography as the gold standard for early detection, a sharp increase from the 13.7% reported by Verhagen et al. just six years ago [10]. This surge likely reflects the expansion of primary care outreach and the clinical community’s efforts to destigmatize the procedure. However, a “knowledge-practice gap” persists. Although 68% of our participants had undergone a mammogram—a figure significantly higher than that reported among healthcare workers in Saudi Arabia or the general public in the UAE—only 43.8% adhered to the recommended biennial frequency [14, 18, 21]. This suggests that while Bahraini women are willing to initiate screening, they struggle to maintain it as a lifelong habit. The drivers of this behavior have shifted. In 2011,
Bahraini women relied heavily on traditional media (TV and radio) for information [9]. Today, our study identifies Physician Recommendation (66.9%) as the primary motivator, a trend also noted in recent regional studies [21, 29]. This highlights the immense trust Bahraini women place in their primary care providers. Conversely, the most significant barrier was the “illusion of health”—41.7% of women skipped screening simply because they “had no breast problems.” This perceptual barrier, also seen in Singapore and Iraq, underscores a critical misconception: that mammography is a diagnostic tool for the sick rather than a preventive shield for the healthy [23, 24]. Unlike women in Jordan or earlier cohorts in Saudi Arabia, our participants did not cite cost as a barrier, reflecting the success of Bahrain’s free-of-charge screening policy [11, 17].
Statistically, our study clarifies the profile of the “non-screener.” We found that knowledge level is a powerful predictor of practice (p = 0.003), as informed women are better equipped to navigate their own health risks [17, 23]. Interestingly, attitude alone did not guarantee action (p = 0.064), suggesting that even a woman with a positive outlook may be deterred by logistical or psychological hurdles. Age (p < 0.001) and family history (p < 0.001) were the strongest predictors of uptake, as older women and those with affected relatives often feel a greater sense of “perceived vulnerability” [14, 21, 23, 29]. Perhaps the most surprising finding was that unemployed and retired women were more likely to be screened than their employed counterparts (p = 0.001). This contradicts Jordanian data where employment favored screening [17]. In Bahrain, this suggests that time—or rather, the lack of it—is a structural barrier. When screening services are primarily offered during morning working hours, employed women face a “time tax” that retirees do not. Finally, the lack of association between education level and screening practice (p = 0.580) is a departure from UAE and Hungarian findings [14, 28]. It suggests that in Bahrain, the primary care system has effectively leveled the playing field, making screening accessible regardless of a woman’s academic background, provided she receives the right recommendation from her doctor.
Multivariate regression analysis further refines this picture. After adjusting for confounders, age remained the most powerful demographic predictor, with women above 60 years nearly six times more likely to be screened than those under 50 (AOR = 5.84), a magnitude consistent with findings from Malaysia and Oman [30, 31]. The independent contribution of family history (AOR = 2.39) aligns with evidence from Jordan and the broader literature establishing hereditary risk perception as a durable motivator across cultural contexts [31, 32]. Notably, a history of benign breast disease independently predicted uptake (AOR = 2.89), reflecting what Castells et al. termed a “disease experience” pathway to screening — prior contact with the healthcare system for breast-related concerns elevates perceived susceptibility and facilitates adherence [33]. The role of knowledge remained significant in the adjusted model (average-knowledge AOR = 3.54; good-knowledge AOR = 3.23), corroborating Egyptian and Arab immigrant data linking mammography-specific knowledge — not merely general health literacy — to screening behavior [30, 34]. Occupational status lost independent significance for retired women (AOR = 1.75, p = 0.127), while unemployed women retained a twofold odds advantage (AOR = 2.06, p = 0.042), suggesting that time availability, not retirement status per se, is the operative structural factor.
Implications for Primary Care Practice. The findings of this study carry direct and significant implications for primary care in Bahrain and the broader GCC region. The family physician emerges as the single most influential actor in the mammography screening pathway, with 66.9% of women citing physician recommendation as their primary motivator for screening [30, 35]. This finding is not merely a statistic — it reflects the deep trust that Bahraini women place in their primary care providers and the unique gatekeeping role that family physicians occupy in the preventive healthcare system. Yet, despite this influence, a substantial proportion of women who have never been screened have also never received a recommendation to do so. This gap suggests a systemic failure at the level of opportunistic preventive counseling during routine primary care consultations [36]. Potential reasons include high patient flow, a predominantly reactive (symptom-driven) consultation model, and the absence of structured prompts within electronic health records to flag overdue screening [37]. There is also a mismatch in operating hours: since screening services are predominantly offered during morning working hours, employed women — who represent an estimated 18% of this study’s sample — face a structural time barrier that retired and unemployed women do not. These findings together make a compelling case for embedding brief, standardized mammography counseling prompts into primary care workflows, extending screening service hours or implementing mobile outreach, and establishing a proactive recall system that targets women who have exceeded recommended screening intervals [38]. The primary care center is not simply a point of referral — it is the most promising lever for population-level change in mammography uptake in Bahrain.
Limitations
Several limitations should be acknowledged when interpreting these findings. First, convenience sampling from waiting areas may have introduced selection bias, as women who regularly attend primary care centers may be more health-seeking than the general population, potentially overestimating knowledge and screening uptake. Second, while the intended sample size was achieved, the data collection period did not permit extension to additional centers or seasonal variation in attendance, which may limit representativeness. Third, the barriers domain did not comprehensively capture all potential deterrents; items relating to religious beliefs, screening accessibility, waiting times, and procedural anxiety were not formally included and should be addressed in future studies. Fourth, a subset of participants reported being unfamiliar with mammography and were therefore unable to complete the attitude and practice sections. These women contributed to the knowledge and demographic analyses but were excluded from attitude and practice assessments. Their profile — typically older age and lower educational attainment — suggests their exclusion may underestimate the burden of low awareness in this subgroup; this has implications for data completeness and the validity of attitude and practice estimates. Fifth, findings are limited to Bahraini women attending public primary healthcare centers and cannot be generalized to non-Bahraini residents, private-sector patients, or those who do not regularly access primary care.
Conclusion and recommendations
Bahraini females had an average to good level of knowledge about breast cancer; however, they were unaware of some key risk factors such as prolonged use of oral contraceptives or hormonal replacement therapy, being pregnant at an advanced age, or not getting pregnant. They were aware of screening mammography, and had a positive attitude toward screening mammography, but they did not practice it on a regular basis, and 20% of the women who did not practice screening mammography regularly had a positive family history of breast cancer. This high-risk group requires additional attention and regular yearly screening workup by keeping an alerting sign in the electronic system to remind health workers to carefully follow their screening schedule, as well as to send messages by phone and track defaulters. In our study, physicians were the primary motivators for screening mammograms, followed by awareness campaigns. We believe that increasing practice can be improved by social media, reminder texts, or phone calls. The most common reasons for not participating in mammography screenings were a lack of breast complaints, a lack of time, a fear of pain, and a fear of discovering cancer. We recommend that the community learn more about risk factors and regular screening, as well as understand that screening is for asymptomatic people who do not have complaints, and that early detection will reduce morbidity and mortality through social media, posters, leaflets, and videos for people who have had breast cancer discovered by screening mammography to raise awareness. Further research is needed to understand the attitudes and practices of healthcare professionals towards patient screening mammography. From a primary care perspective, these findings underscore the central and largely underutilized role of the family physician in driving mammography adherence. The fact that physician recommendation is the strongest facilitator, yet a meaningful proportion of never-screened women have never received one, reveals a gap that is both preventable and actionable. Primary care interventions must move beyond general public awareness campaigns and instead target the clinical encounter itself: equipping family physicians with brief, structured counseling prompts; leveraging electronic health record alerts for overdue screening; extending clinic hours or implementing community-based outreach to reduce the time burden on employed women; and establishing systematic defaulter-tracking for high-risk groups. Addressing the “symptom-driven” barrier — the misconception that screening is only necessary when symptoms are present — should be a core message in all primary care-based health education, as it was the leading deterrent in this study. These recommendations are directly relevant not only to Bahrain but to the wider GCC region, where primary care systems share comparable structural features and where mammography uptake remains consistently suboptimal.
Supplementary Information
Acknowledgements
The authors would like to acknowledge the directors of primary healthcare centers for enabling the data collection process. We would like also to thank Dr. Amer Almarabheh from the Family and Community Medicine Department as the Arabian Gulf University for his guidance and assistance in the statistical analysis of the results.
Authors’ contributions
Jenan Al-Hashimi: Conceived Idea / Study design / Data collection / Data Analysis / manuscript writing. Zainab Ahmadi: Conceived Idea / Study design / Data collection / Data Analysis / manuscript writing. Muna A. Almutawa: Study design / Data collection, literature review / Data Analysis. Noor Hamada: Study design / Data collection, literature review. Shamma Alfadhel: Study design / Data collection, Questionnaire design. Fatema Shareeda: Study design / Data collection, Questionnaire design. Nayla Aldoseri: Study design / Data collection, literature review. Amna Aljunaid: Study design / Data collection, Questionnaire design. Noora Mukhtar: Conceived Idea / Study design / Data collection. Muneera Almahmeed: Study design / Data collection. Maha AlTajer: Conceived Idea / Study design / Data Analysis / Revision and Supervision. Mohamed Hany Shehata: Data Analysis / Manuscript writing, Revision and Supervision.
Funding
The work was self-funded by the researchers.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval from the Arabian gulf university Research and Ethics Committee was obtained (E3-PI-4-23) as well as administrative approvals from the health centers in Bahrain. Informed consent was obtained from participants for their acceptance to participate in the study.
The study adhered to the Declaration of Helsinki regarding dealing with human data.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.