Breast Cancer Knowledge, Awareness and Screening Practices Among Female Healthcare Workers in Al-Mukalla, Yemen

Summary

Objectives:

Breast cancer (BC) is the most common malignancy among women worldwide and represents a significant burden for Yemeni women. Early detection through breast self-examination (BSE) and knowledge of risk factors and symptoms are crucial. This study aimed to assess awareness, knowledge and practice regarding BC risk factors, symptoms and BSE among female healthcare workers (HCWs) in Al-Mukalla, Yemen.

Methods:

This cross-sectional study was conducted from September to October 2022 at three public hospitals in Al-Mukalla, Yemen. A census sampling approach was used to recruit HCWs. Data were collected using a validated self-administered questionnaire covering breast awareness practices, risk factor awareness, symptom recognition and BSE frequency. Descriptive statistics and logistic regression were used to identify BSE predictors.

Results:

A total of 151 HCWs were included in this study (response rate = 83.0%). The mean participant age was 30.4 ± 6.1 years; 49.7% were aged 20–29 years. Most participants were unmarried (66.2%), university-educated (57.0%) and doctors (47.0%). Knowledge of hallmark symptoms such as breast masses (90.0%) was high; however, 51.0% misidentified the specific laterality (right upper outer quadrant) of the most common cancer site, rather than the quadrant itself. Regular (monthly) BSE was reported by 71.5% of participants. Multivariable analysis showed that nurses were less likely than doctors to perform BSE (adjusted odds ratio [aOR] = 0.32, 95% confidence interval [CI]: 0.14–0.73; P = 0.007). Diploma holders practised BSE less than university graduates (aOR = 0.38, 95% CI: 0.19–0.78; P = 0.008), while higher BC knowledge independently predicted greater BSE practice (aOR = 2.15, 95% CI: 1.10–4.20; P = 0.025).

Conclusion:

Despite good symptom awareness, significant knowledge gaps remain regarding risk factors and breast anatomy among female HCWs in Al-Mukalla, Yemen. BSE practice is still suboptimal, influenced by professional role, education level and BC knowledge. Targeted interventions focusing on breast awareness and structured education are urgently required.

Advances in Knowledge

• This study provides the first detailed assessment of breast cancer awareness, knowledge and screening behaviours among female nurses, midwives and doctors in Al-Mukalla, Yemen.

• It reveals a significant gap between high symptom awareness and poor understanding of reproductive risk factors and breast laterality.

• Professional role and education level independently predicted screening practice.

Application to Patient Care

• Educational interventions in Al-Mukalla should prioritise nurses and diploma-level staff, addressing misconceptions about breast anatomy and reproductive risk factors.

• Training programmes must shift from outdated monthly self-examination toward evidence-based breast awareness.

• Structured clinical breast examination workshops are needed to strengthen front-line staff confidence and skills.

• Healthcare policymakers can use these findings to design targeted early-detection campaigns tailored to Yemen';s conservative healthcare context, where female HCWs serve as primary patient educators and role models.

1. Introduction

Cancer remains a leading cause of global morbidity, with breast cancer (BC) identified as the most common malignancy among women worldwide, accounting for approximately 11.7% of all cancer diagnoses. The global burden of this disease continues to escalate, with projections indicating a substantial increase in BC-related deaths. By 2040, the global burden is expected to exceed 3 million new cases and 1 million deaths annually.¹ Despite advancements in oncological therapies and early detection methods, patient prognosis remains closely associated with the stage at diagnosis. Notably, five-year survival rates may reach up to 91% when BC is identified at an early stage, highlighting the essential role of prompt diagnosis and advanced treatment.²

Within the Arab world, BC has emerged as the most common cancer among women, presenting a distinctive epidemiological profile compared to industrialised nations.^3,4 Approximately half of BC cases in the region are diagnosed in women under 50 years old, with reported median ages at diagnosis between 49 and 52 years, in contrast to 63 years in high-income countries.⁵ For example, in Yemen, the reported crude prevalence is 30.5 per 100,000 women.⁶ Although clinicians frequently observe that BC tends to present earlier and in more advanced stages in the Arab region, comprehensive statistical evidence to support this perception remains limited. This underscores the need for localised epidemiological research to inform context-specific prevention and control strategies.

Effective BC management depends on early detection. Mammography is the primary population-level screening modality, with clinical breast examination (CBE) used as an adjunct in some settings.⁷ Current international guidelines, including the 2024 evidence updates, have shifted from routine monthly breast self-examination (BSE) toward promoting “breast awareness”, defined as a woman';s familiarity with the normal look and feel of her breasts to enable prompt recognition of abnormal changes.⁸ This evolution reflects evidence that formal, structured monthly self-examination does not confer a significant mortality benefit compared to breast awareness and may increase unnecessary biopsies.^8,9

Recognising these benefits, the World Health Organization launched the Global Breast Cancer Initiative, which emphasises three strategic pillars: (1) health promotion for early detection, (2) timely diagnosis and (3) comprehensive BC management.¹⁰ These initiatives aim to promote timely symptom recognition and reporting, particularly in resource-limited settings where advanced diagnostic technologies are not readily available.¹⁰

Numerous studies have shown that BCAPs increase community knowledge, encourage preventive behaviours and improve rates of early presentation and diagnosis. Core activities include promoting breast awareness to encourage vigilance and prompt identification of new or suspicious breast changes.¹¹ The cost-effectiveness and success of these programmes depend heavily on robust public education and sustained community engagement.^12,13

Healthcare workers (HCWs), including nurses, midwives and doctors, are central to translating BC awareness into practice. In resource-limited Yemen, where BC is often diagnosed at advanced stages due to low awareness and limited access, female HCWs bear a critical responsibility.^6,14,15 In culturally conservative contexts, women frequently prefer female professionals for breast examinations, making HCWs in Al-Mukalla uniquely positioned to address educational gaps and promote timely screening.¹⁵

Previous studies among Yemeni women indicate that limited awareness is a significant barrier to early presentation.^15,16 While older work emphasised routine monthly BSE, current international guidelines have shifted focus toward comprehensive breast awareness and evidence-based imaging.¹⁰ However, research in Al-Mukalla has focused on the general female population, leaving a notable gap concerning female HCWs themselves. Assessing knowledge, attitudes and practices (KAP) among this group is critical to determine whether those tasked with educating patients possess knowledge aligned with contemporary guidelines.

Therefore, this study aimed to explore the level of knowledge regarding BC and breast awareness, to explore attitudes toward screening and to examine the frequency of BSE among female HCWs in Al-Mukalla. By focusing on nurses, midwives and doctors, this study addresses a population uniquely positioned to influence community awareness and whose own screening practices may serve as a model for patients.

2. Methods

This hospital-based cross-sectional study was conducted from September to October 2022 at three major public hospitals in Al-Mukalla, Yemen: Al Mukalla Hospital for Maternal and Child Health, Ibn Sina General Hospital and the University Hospital. The study targeted all female HCWs (nurses, midwives and doctors) employed at the three public hospitals using a census sampling method. Participants were eligible for inclusion if they were female, aged 20 years or older, employed in a direct clinical role and were willing to participate. Exclusion criteria were refusal to provide consent, absence during data collection or submission of incomplete questionnaire.

The data collection instrument was a structured, self-administered questionnaire based on a previously validated BC screening KAP questionnaire, adapted and supplemented with items informed by Champion';s Health Belief Model (HBM) scales.¹⁷ The questionnaire was further refined using validated instruments from regional studies assessing BC knowledge and screening predictors among Arab women, ensuring cultural and linguistic relevance.^18,19,20,21

The instrument was adapted and translated following established precedents for Arabic-speaking healthcare populations and followed standard guidelines for cross-cultural adaptation, including forward and back-translation by independent bilingual experts. The adapted questionnaire demonstrated good internal consistency, with Cronbach';s alpha values of 0.82 for the knowledge subscale (11 items), 0.79 for the BSE practices subscale and 0.85 for the overall instrument.

The questionnaire comprised seven sections [Supplementary File]: (1) socio-demographic and professional characteristics; (2) knowledge of BC risk factors; (3) knowledge of BC symptoms; (4) BSE knowledge and practice; (5) knowledge of BSE technique including positioning, pressure levels and palpation patterns; (6) barriers to BSE practice; and (7) self-efficacy assessment using an adapted Champion';s HBM scale to assess participants perceived confidence in their ability to identify breast abnormalities (this construct has shown to be a significant predictor of screening behaviour in similar populations).²⁰

Knowledge was assessed using 11 items covering risk factors, symptoms and procedural steps. Each correct response received a score of 1, yielding a maximum possible score of 11. Internal consistency was assessed using Cronbach';s alpha. BC knowledge was analysed both as a continuous score and categorised using the median split method (high/low). While continuous modelling was utilised for superior statistical power in regression analysis, categorical versions were maintained for descriptive comparison with prior literature, consistent with established psychometric practices. Participants with scores at or above the median (score ≥6) were categorised as having ‘high’ knowledge. Pilot testing was conducted with 15 HCWs to ensure clarity; minor modifications were made based on their feedback.

The selection of items for the HBM and cultural barriers was informed by recent regional validations in Arabic-speaking populations, which have demonstrated high internal consistency (Cronbach';s alpha >0.85) for constructs such as self-efficacy and perceived barriers.²⁰

The primary outcome was regular BSE practice, defined as performing BSE at monthly intervals. Secondary outcomes included knowledge scores, recognition of BC symptoms, awareness of risk factors and familiarity with the procedural steps of the BSE technique.

Statistical analysis was conducted using Statistical Package for Social Sciences (SPSS) software, Version 25 (IBM Corp., Armonk, New York, USA). Descriptive statistics summarised participant characteristics. Normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Bivariate analyses were performed using independent samples t-tests, ANOVA with post-hoc tests, Pearson';s correlation coefficient and Chi-square tests as appropriate. To account for potential clustering by hospital, multivariable logistic regression models were employed. Continuous knowledge scores were treated as independent predictors to determine the increase in odds of regular BSE practice per unit increase in knowledge. Variables with a univariable P <0.20 or known clinical relevance were included in the multivariable models. Results were reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Post-hoc power analysis indicated that the achieved sample size of 151 provided 80% power to detect an OR of 2.2 at a two-sided 5% significance level, assuming a 50% baseline prevalence of regular BSE practice. A two-sided P value of ≤0.05 was considered statistically significant.

3. Results

A total of 182 eligible female HCWs were identified through hospital employment records. Of these, 151 (response rate = 83.0%) provided complete and analysable responses; 31 women were excluded due to declining participation, absence during data collection or incomplete questionnaire returns. The mean age of the participants was 30.4 ± 6.1 years (range: 20–49 years), with nearly half (n = 75, 49.7%) aged 20–29 years. Most participants were unmarried (n = 100, 66.2%) and held university degrees (n = 86, 57.0%). Doctors comprised 47.0% (n = 71) of respondents, nurses 35.1% (n = 53) and midwives 17.9% (n = 27). Most participants worked at Al-Mukalla Hospital (n = 79, 52.3%), followed by Ibn Sina General Hospital (n = 40, 26.5%) and University Hospital (n = 32, 21.2%). A positive family history of BC was reported by 21 participants (13.9%) [Table 1].

Table 1.

Characteristics of female healthcare workers in Al-Mukalla, Yemen (N = 151).

Characteristic	n (%)*
Age group in years
20–29	75 (49.7)
30–39	61 (40.4)
40–49	15 (9.9)
Marital status
Married	51 (33.8)
Unmarried	100 (66.2)
Occupation
Doctor	71 (47.0)
Nurse	53 (35.1)
Midwife	27 (17.9)
Educational level
University degree	86 (57.0)
Diploma	65 (43.0)
Family history of breast cancer
Yes	21 (13.9)
No	130 (86.1)
Place of work
Al-Mukalla Hospital	79 (52.3)
Ibn Sina General Hospital	40 (26.5)
University Hospital	32 (21.2)

^*Percentages may not total 100% due to rounding.

Awareness of BC risk factors varied considerably. Most participants (n = 142, 94.0%) correctly identified breastfeeding as a protective factor. However, only 14.6% (n = 22) recognised that having a first child after age 30 increases BC risk. Nulliparity was acknowledged by 58.3% (n = 88), while early menarche (≤12 years) was known by 37.7% (n = 57). Use of oral contraceptive pills was recognised as a risk factor by 62.3% (n = 94). Overweight was identified as a risk factor by 45.0% (n = 68), with 30.5% (n = 46) being uncertain [Table 2].

Table 2.

Awareness of breast cancer risk factors among female healthcare workers in Al-Mukalla, Yemen (N = 151).

	n (%)
Risk factor	Yes	No	I don';t know
Nulliparity	88 (58.3)	38 (25.2)	25 (16.6)
Bearing a first child after age 30	22 (14.6)	102 (67.5)	27 (17.9)
Early menarche (≤12 years)*	57 (37.7)	56 (37.1)	38 (25.2)
Use of oral contraceptive pills	94 (62.3)	29 (19.2)	28 (18.5)
Breastfeeding as a protective factor	142 (94.0)	5 (3.3)	4 (2.7)
Overweight	68 (45.0)	37 (24.5)	46 (30.5)

^*Defined per World Health Organization criteria (age at menarche ≤12 years).

Knowledge of BC symptoms was high for common signs such as breast mass (n = 136, 90.0%) and breast skin changes (n = 137, 90.7%). Other frequently recognised symptoms included bloody nipple discharge (n = 121, 80.1%), enlarged axillary lymph nodes (n = 121, 80.1%) and nipple retraction (n = 119, 78.8%). Systemic symptoms such as weight loss were acknowledged by 63.3% (n = 95). Notably, 51.0% (n = 77) of participants incorrectly identified the upper outer quadrant as the right upper outer quadrant, the most common site of BC, indicating a common misconception regarding laterality [Table 3].

Table 3.

Knowledge of breast cancer symptoms among female healthcare workers in Al-Mukalla, Yemen (N = 151).

	n (%)
Symptom	Yes	No	I don';t know
Weight loss*	95 (63.3)	26 (17.3)	29 (19.4)
Breast skin changes	137 (90.7)	6 (4.0)	8 (5.3)
Nipple retraction	119 (78.8)	6 (4.0)	26 (17.2)
Breast pain	53 (35.1)	82 (54.3)	16 (10.6)
Breast mass	136 (90.0)	6 (4.0)	9 (6.0)
Bloody nipple discharge	121 (80.1)	9 (6.0)	21 (13.9)
Upper outer quadrant as most common site†	77 (51.0)	28 (18.5)	46 (30.5)
Impalpable breast mass	116 (76.8)	8 (5.3)	27 (17.9)
Bilateral breast involvement	134 (88.8)	10 (6.6)	7 (4.6)
Enlarged axillary lymph nodes	121 (80.1)	10 (6.6)	20 (13.3)

^*Systemic symptom;

^†51.0% incorrectly specified the right upper outer quadrant (common misconception regarding laterality).

The median BSE technique knowledge score was 6 out of 11 (interquartile range: 4–8). Using the median split method, participants scoring ≥6 were classified as having ‘high’ BSE knowledge (n = 94, 62.3%), while those scoring <6 were classified as having ‘low’ knowledge (n = 57, 37.7%). Most participants (n = 140, 92.7%) were aware that BSE is useful for early BC detection. Overall, 71.5% of participants (n = 108) reported performing BSE at least monthly and were classified as regular BSE practitioners; 28.5% (n = 43) practised BSE irregularly or at undefined intervals. The ideal timing for BSE, 7–10 days after menstruation, was correctly identified by 68.2% (n = 103) of respondents [Table 4].

Table 4.

Breast self-examination knowledge and practices among female healthcare workers in Al-Mukalla, Yemen (N = 151).

Variable	n (%)
Purpose of BSE
Early detection	140 (92.7)
Prevention	6 (4.0)
Treatment	5 (3.3)
Reported frequency of BSE
Monthly (regular)	108 (71.5)
Less than monthly or irregular*	43 (28.5)
Ideal timing for performing BSE
Post-menses (7–10 days)	103 (68.2)
Other/undefined	48 (31.8)
BSE knowledge score †
High (≥6)	94 (62.3)
Low (<6)	57 (37.7)

BSE = breast self-examination.

^*Includes daily, weekly and unspecified frequencies;

^†Median score = 6 out of 11 (interquartile range: 4–8).

Bivariate logistic regression revealed significant associations between higher BC knowledge and younger age (20–29 years: 70.7%, n = 53; P = 0.031), unmarried status (67.0%, n = 67; P = 0.014), physician occupation (91.5%, n = 65; P <0.001), university education (82.6%, n = 71; P <0.001) and positive family history of BC (90.5%, n = 19; P = 0.002).

Compared to doctors, nurses had 97% lower odds of high BC knowledge (OR = 0.03, 95% CI: 0.01–0.09; P <0.001) and midwives had 93% lower odds (OR = 0.07, 95% CI: 0.02–0.22; P <0.001). Diploma holders had 91% lower odds of high knowledge compared to university graduates (OR = 0.09, 95% CI: 0.04–0.20; P <0.001) [Supplementary Table S1].

Bivariate analysis indicated that doctors were more likely to perform BSE regularly (64.8%, n = 46) compared to nurses (37.7%, n = 20; OR = 0.33, 95% CI: 0.16–0.70; P = 0.012). Similarly, university graduates reported higher BSE practice (64.0%, n = 55) than diploma holders (41.5%, n = 27; OR = 0.40, 95% CI: 0.21–0.77; P = 0.006) [Supplementary Table S2].

There was a significant positive association between BC knowledge levels and BSE practice, with 63.7% (n = 58) of participants with high knowledge performing regular BSE compared to 40.0% (n = 24) with low knowledge (OR = 2.64, 95% CI: 1.36–5.12; P = 0.004). Similarly, high BSE knowledge correlated with increased practice (62.8%, n = 59 versud 40.4%, n = 23; OR = 2.48, 95% CI: 1.27–4.85; P = 0.007) [Supplementary Table S3].

Multivariable logistic regression showed that, after adjusting for potential confounders, three factors independently predicted regular BSE practice: (1) nurses had significantly lower odds of practising BSE compared to doctors (aOR = 0.32, 95% CI: 0.14–0.73; P = 0.007); (2) participants with diplomas were less likely to perform BSE than those with university degrees (aOR = 0.38, 95% CI: 0.19–0.78; P = 0.008); and (3) higher BC knowledge, measured as a continuous score (per 1-point increase), independently predicted greater BSE practice (aOR = 1.24, 95% CI: 1.08–1.42; P = 0.002) [Table 5]. When BC knowledge was analysed categorically (high versus low), participants with high knowledge had over twice the odds of regular BSE compared with those with low knowledge (aOR = 2.15, 95% CI: 1.10–4.20; P = 0.025).

Table 5.

Factors independently associated with regular breast self-examination practice on multivariable logistic regression analysis (N = 151).

Variable	aOR (95% CI)	P value
Occupation		0.018*
Doctor (Ref.)	1.00	-
Nurse	0.32 (0.14–0.73)	0.007
Midwife	0.81 (0.31–2.13)	0.670
Educational level
University (Ref.)	1.00
Diploma	0.38 (0.19–0.78)	0.008
Breast cancer knowledge
Continuous (per 1-point increase)	1.24 (1.08–1.42)	0.002
Age group in years
20–29 (Ref.)	1.00	0.220
30–39	0.92 (0.45–1.89)	0.820
40–49	0.68 (0.23–2.00)	0.480
Marital status
Unmarried (Ref.)	1.00	0.340
Married	0.75 (0.41–1.39)	0.360

aOR = adjusted odds ratio; CI = confidence interval; Ref. = reference category.

^*Overall P-value for the variable occupation.

Model fit: Hosmer-Lemeshow χ² = 4.82 (P = 0.68); Nagelkerke R² = 0.28.

All models adjusted for clustering by hospital using cluster-robust standard errors.

Age and marital status were not significantly associated with BSE practice after adjustment. The model demonstrated good fit (Hosmer-Lemeshow χ² = 4.82; P = 0.68) and explained 28% of the variance in BSE practice (Nagelkerke R² = 0.28).

A sensitivity analysis using a stricter definition of optimal BSE practice (monthly frequency, correct post-menstrual timing and BSE knowledge score ≥ median) yielded consistent findings, with nurses (aOR = 0.28, 95% CI: 0.11–0.71; P = 0.008) and diploma holders (aOR = 0.35, 95% CI: 0.16–0.77; P = 0.009) remaining significantly less likely to practise optimal BSE, while higher BC knowledge (continuous) remained a significant predictor (aOR = 1.28, 95% CI: 1.09–1.50; P = 0.004) [Supplementary Table S4].

Among participants who did not practice regular BSE (n = 43), the primary barriers identified were forgetfulness (n = 28, 65.1%) and work demands (n = 24, 55.8%). Furthermore, analysis of the HBM constructs indicated that while perceived benefits of screening were high (mean score = 4.2/5), self-efficacy (i.e., confidence in recognition) was significantly lower among nurses and midwives compared to doctors (mean = 2.9 versus 4.1; P <0.05).

4. Discussion

This study examined KAP regarding BC among female HCWs in public hospitals in Al-Mukalla, Yemen. Although many participants demonstrated adequate recognition of common BC symptoms and acknowledged the value of BSE for early detection, substantial gaps remained in their understanding of key aetiological risk factors, particularly reproductive factors such as delayed childbearing as well as basic breast anatomy. While 71.5% of respondents reported performing BSE monthly, adherence was uneven, with notably lower practice among nurses and diploma-educated staff than among physicians and university graduates. Multivariable analyses showed that both professional cadre and educational level were independent determinants of BSE practice, and that higher BC knowledge significantly increased the probability of engaging in regular BSE.

These findings should be interpreted within the context of evolving international recommendations for BC early detection. Historically, BSE was widely promoted as a key screening modality, but current national and international guidance no longer supports routine, systematic monthly BSE as a population-level strategy, instead prioritising breast awareness, high-quality CBE and timely diagnostic referral pathways.^9,10 Within this contemporary framework, the observed limitations in familiarity with CBE and persistent anatomical misconceptions among HCWs are concerning. These are troubling not because monthly BSE is a mandated guideline, but because deficiencies in knowledge, skills and confidence may compromise the HCWs capacity to foster breast awareness, deliver effective CBE and promptly refer women with suspicious findings.²²

Taken together, these findings reveal marked disparities in BC-related knowledge and preventive behaviours across professional groups, highlighting the need for targeted, evidence-based educational strategies. This need is particularly urgent in Yemen, where BC mortality remains high, with an age-standardised death rate of 18.9 per 100,000 population,²³ and where the recently initiated National Cancer Control Program faces substantial implementation barriers linked to constrained health system capacity and low community health literacy. Addressing these structural and educational gaps is essential to improve early diagnosis and reduce the BC burden in this high-risk setting.

4.1. Knowledge of BC risk factors and symptoms

In this study, female HCWs demonstrated substantial awareness of specific BC risk factors and clinical symptoms. Notably, breastfeeding was widely recognised as a protective factor (94.0%, n = 142), consistent with evidence from regional studies in Jordan and Saudi Arabia reporting similar awareness levels among healthcare professionals.^24,25 The protective effect of prolonged lactation is well-documented; it reduces lifetime exposure to circulating oestrogens and progesterone, thereby lowering BC risk.²⁶ In contrast, awareness of reproductive risk factors, specifically late age at first childbirth, was markedly deficient (14.6%, n = 22). This gap mirrors findings from other Middle Eastern contexts and is epidemiologically significant, given that delayed first pregnancy extends the duration of undifferentiated breast tissue exposure to hormonal influences, thereby increasing carcinogenic susceptibility.^5,27,28 Such deficiencies highlight the urgent need to integrate comprehensive education on reproductive risk factors into local healthcare training curricula and continuing professional development programmes.

Symptom recognition among participants was robust for hallmark clinical signs, with high identification rates for palpable breast masses (90.0%, n = 136) and skin changes (90.7%, n = 137). These results align with those reported in comparable populations in Iran and Nigeria, where healthcare providers similarly exhibit strong symptom awareness.^29,30 However, over half the participants (51.0%, n = 77) incorrectly identified the right upper quadrant as the most common site of BC, reflecting substantial anatomical misconceptions. This specific laterality error – selecting the right breast over the left – may reflect a combination of ‘handedness’ bias (most individuals are right-handed and examine the right breast first) or a systematic teaching gap in local curricula. This inaccuracy is particularly concerning, as extensive pathological and epidemiological studies universally demonstrate that the upper outer quadrant without specification of laterality harbours the majority of breast tumours, likely due to the density of glandular tissue and lymphatic drainage patterns.³¹ Failure to accurately conceptualise tumour localisation can impair the effectiveness of both breast awareness and clinical screening, potentially delaying diagnosis and treatment initiation. Therefore, targeted, context-sensitive educational interventions to correct these anatomical misconceptions are critical.

4.2. Influence of sociodemographic and professional factors

This study demonstrated that professional role and educational attainment were significant determinants of both BC knowledge and BSE practices among female HCWs in Al-Mukalla. Physicians consistently exhibited higher levels of BC awareness and more frequent engagement in BSE compared to nurses and midwives, while university graduates outperformed diploma holders in both knowledge and practice dimensions. These findings are congruent with previous research from Middle Eastern and African contexts, where a positive association has been observed between advanced professional training and increased adherence to cancer preventive behaviors.^27,32,33,34

Multivariable analysis revealed that nurses were significantly less likely than doctors to perform BSE (aOR = 0.32), and diploma holders were less likely than university graduates to practice BSE regularly (aOR = 0.38). Additionally, respondents with higher BC knowledge were over twice as likely to engage in BSE (aOR = 2.15), underscoring the crucial impact of targeted educational initiatives. In contrast, variables such as age and marital status did not independently predict BSE practice, reinforcing the notion that knowledge acquisition and professional training are more influential determinants of preventive health behaviours than sociodemographic attributes in this population. Although BSE awareness was high (92.7% acknowledged its value for early detection), regular and optimally timed practice remains suboptimal, as only 68.2% correctly identified the post-menstrual period as the ideal timing for BSE. This underscores ongoing educational gaps and the potential benefit of tailored in-service training to improve not only general awareness but also practical familiarity with CBE among all strata of HCWs.

Beyond factual knowledge, self-efficacy (i.e., the confidence to recognise breast abnormalities) differed significantly by professional role. Nurses and midwives reported substantially lower confidence (mean = 2.9/5) compared to doctors (mean = 4.1/5; P <0.05). This finding aligns with the observed lower BSE practice among nurses and suggests that training programmes must address not only factual knowledge but also hands-on confidence building. Recent research from Jordan and Hungary similarly identified self-efficacy as a more powerful predictor of screening behaviour than general awareness alone, reinforcing the need for practical skill-based workshops.^20,35

The relationship between sociodemographic variables and BC knowledge has been explored extensively in the literature, with inconsistent findings. While some studies have reported associations with age, marital status and educational level,^5,36,37 others, including research from Nigeria and Singapore, found no significant influence of these factors on BC knowledge.^30,38 These discrepancies may reflect differences in study populations, healthcare systems or measurement instruments, underscoring the importance of context-specific research such as the present study.

4.3. Implications for health education

The persistent knowledge gaps identified in this study, particularly regarding reproductive risk factors and anatomical misconceptions, highlight a critical need for tailored educational interventions within Yemen';s healthcare sector. Nurses and diploma-educated HCWs, who consistently demonstrated lower levels of BC awareness and suboptimal BSE practices, should be prioritised as key target groups for future training initiatives. Similar trends have been reported in regional studies, wherein inadequate knowledge among frontline healthcare personnel has been shown to impede effective patient counselling and early detection efforts.^25,27,39,40 Evidence suggests that structured, multifaceted educational approaches, including both formal instruction and continuous professional development modules emphasising BC epidemiology, risk stratification, symptom recognition and BSE techniques, are effective in improving knowledge and preventive behaviours among healthcare providers.⁴⁰ Furthermore, interventions that incorporate culturally sensitive materials and address commonly held misconceptions can facilitate broader dissemination of accurate information and overcome barriers unique to low-resource, high-burden settings.⁴¹ Given that HCWs are primary conduits for patient education and community health advocacy, strengthening their competency holds the potential for a multiplier effect, enhancing both their personal adherence to screening guidelines and their capacity to educate the broader population. Implementing these targeted educational strategies is thus essential to improve early detection rates, optimise cancer outcomes and reduce the overall morbidity and mortality associated with BC in Yemen.

4.4. Barriers and behavioural dimensions of breast self-examination practice

In this study, the most frequently cited barriers among participants who did not practice regular BSE (n = 43) were forgetfulness (65.1%) and high work demands (55.8%). These obstacles are consistent with findings from both regional and international studies, which identified time constraints, psychological resistance and concerns about correct technique as significant impediments to regular BSE among HCWs and the general population.^16,41,42

Okolie et al. reported that among female undergraduates in Nigeria, the most commonly identified barriers to practising BSE included forgetfulness, procrastination, lack of motivation, lack of time, fear of discovering a lump and lack of confidence in performing BSE correctly.⁴³ Among public health nurses in Singapore, the primary reasons cited for not practising BSE were being “too busy”, “forgetting” and perceiving it as “not necessary”.⁴⁴ Similarly, Rosvold et al. found that physicians often forgot to perform BSE regularly and noted challenges in motivating their patients to engage in BSE as well.⁴⁵ Addressing these multifaceted barriers through supportive, behaviourally focused interventions such as reminders, skills workshops, and integration of BSE education into routine training may substantially enhance the uptake and consistency of BSE practice.

4.5. Role of knowledge in facilitating preventive behaviour

A key finding of this study is the strong positive association between comprehensive BC knowledge and the likelihood of engaging in regular BSE. This observation aligns with global evidence highlighting knowledge as a catalyst for preventive health behaviours.^29,46,47 However, the persistence of practice barriers despite adequate awareness indicates that knowledge alone is insufficient; effective intervention programmes must also address behavioural and structural obstacles to achieve significant improvements in screening adherence.

As BC disproportionately affects younger women in Yemen, strengthening healthcare professional education and community outreach is essential to enhance early detection and screening participation, particularly in underserved populations. To the best of the authors’ knowledge, this study is among the first to provide detailed insights into the interplay of knowledge, barriers and BSE practice among female HCWs in Yemen, offering valuable guidance for future educational and screening policy development.

4.6. Limitations

This study has several limitations that should be considered when interpreting the findings. First, this study identified significant associations between knowledge and screening behaviour; however, the cross-sectional design precludes any conclusions regarding causality. Second, data collection relied on self-administered questionnaires, which may be subject to recall bias or social desirability bias, potentially resulting in over-reporting of BSE practice. Third, the sample was limited to female HCWs in three public hospitals in Al-Mukalla during day shifts, which may under-represent night-shift staff and limit generalisability to other regions, private healthcare settings or male HCWs. Fourth, the relatively small sample size may have reduced statistical power to detect associations with some sociodemographic factors. Finally, the use of a median split to categorise knowledge levels, while methodologically common, may obscure nuances in knowledge distribution. Future research using longitudinal designs and broader, more diverse populations is warranted to validate and extend these findings.

5. Conclusions

This study identified significant gaps in BC risk factor awareness and symptom knowledge among female HCWs in Al-Mukalla, Yemen, particularly concerning reproductive risks and common anatomical misconceptions. Although awareness of BSE and its importance for early detection is generally high, regular practice of BSE remains suboptimal, especially among nurses and those with diploma-level education. Notably, higher BC knowledge is a strong predictor of better BSE practice, highlighting the critical role of targeted education. These findings highlight the urgent need for occupation- and education-specific initiatives to enhance comprehensive BC awareness and promote consistent preventive behaviours among all categories of HCWs. Strengthening this workforce';s knowledge and practices is essential to improve early detection efforts and ultimately reduce BC morbidity and mortality in this population. By addressing identified knowledge gaps and practice barriers through structured, culturally sensitive interventions, Yemen';s healthcare system can empower its female HCWs as effective agents of change in the fight against BC.

Authors’ Contribution

Wafa Al Shoaeeb: Conceptualization, Data Curation, Investigation, Writing – Original Draft, Writing – Review & Editing. Ahmed M. Badheeb: Conceptualization, Methodology, Supervision, Writing – Review & Editing, Project Administration. Faisal Ahmed: Methodology, Formal Analysis, Writing – Review & Editing. Amen Bawazir: Conceptualization, Resources, Writing – Review & Editing. Abdulla Bin Nabhan: Investigation, Data Curation, Writing – Review & Editing. Mohammed Badheeb: Writing – Review & Editing, Validation. Abdulkader Bayazid: Writing – Review & Editing, Validation

Ethics Statement

Ethical approval was obtained from the College of Medicine, Hadhramout University, Al-Mukalla, Yemen (HUCOM, YEMEN, H-11-136). Written informed consent was obtained from all participants. Participants were explicitly reassured that participation was entirely voluntary and that declining would result in no negative consequences or penalties. Questionnaires were completed anonymously and returned to designated collection boxes to safeguard confidentiality.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

No funding was received for this study.

Data Availability

Data are available upon reasonable request from the corresponding author.