**1. Introduction**

Breast cancer is one of the significant public health issues worldwide affecting women after puberty, as stated by the World Health Organization (WHO). In 2020, there were 2.3 million cases and 685,000 deaths worldwide due to breast cancer [1]. Several international surveys reported that breast cancer causes more disability-adjusted life years among women than any other cancer in the world [2,3]. Even though the etiology for breast cancer has not been completely understood, certain risk factors, including older age, genetic predisposition, family history, early menarche, late menopause, exogenous hormone usage, and obesity, play a significant role in the breast cancer development [4,5]. In the Kingdom

Alenezi, H.; Alanazi, M.F.; Alruwaili,A.S.; Alashjaee, R.H.; Alashjaee,Alrasheed, A.K.; Alshrari, B.D. Female Healthcare Workers' Knowledge, Attitude towards BreastCancer,andPerceivedBarriers

 A.; Wani, F.A.;

> F.H.;

**Citation:** Alenezi, A.M.;

Thirunavukkarasu,

 towards Mammogram Screening:A Multicenter Study in North SaudiArabia. *Curr. Oncol.* **2022**, *29*, 4300–4314. https://doi.org/ 10.3390/curroncol29060344

Received: 15 May 2022 Accepted: 14 June 2022 Published: 15 June 2022

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of Saudi Arabia (KSA), breast cancer ranks as the number one reported cancer (14.2%), and cancer-related deaths among women have an increasing annual incidence of 3.01% and a mortality of 0.93% [6,7].

Various screening methods are available for detecting breast cancer at an earlier stage, including breast self-examination, clinical breast examination, and ultrasound; however, mammography remains the primary screening modality used worldwide. In the KSA, the mammography screening technique is used for early detection of breast cancer, and it uses low-frequency X-rays to detect the features of microcalcification or mass in the breast [8,9]. As per the American Cancer Society's guidelines, breast cancer screening to be started at 40 years of age and annual screening to be done from 45 years of age. Considering the higher incidence of breast cancer in the KSA, the Ministry of Health has recommended breast cancer screening through mammogram for all women aged from 40 to 50 years for every two years and women aged 51 to 69 years should have regular mammograms for every one to two years [10]. In the KSA, Breast Cancer Early Detection (BCED) program aims to increase early-detected cases and reduce breast cancer mortality. As per the BCED, mammogram screening is available free of cost in hospitals, selected primary health centers, and mobile clinics for Saudi nationals and public sector workers. Women are enrolled in mammogram screening programs by raising awareness through different modalities [11].

Recent epidemiological studies reported that women with inadequate knowledge regarding risk factors and susceptibility to breast cancer were less likely to accept breast cancer screening methods. Other factors associated with the low uptake of mammogram screening programs were low income, low education, and lack of information regarding available screening methods [12,13].

Healthcare workers (HCWs) play a critical role in imparting knowledge regarding available health services improving access and screening services provided by the concerned authorities. They also help in changing the behavior of an individual, families, and communities through different health-promotion activities [14,15]. Hence, it is essential to improve the knowledge and skills of the HCWs. These factors can be achieved among the HCWs by continuously assessing the current awareness, perception, and barriers towards breast cancer screening programs.

Hence, the present study assessed the knowledge and attitude towards breast cancer among the female HCWs and identified the correlation between knowledge and attitude. This study also aimed to identify the barriers to breast cancer screening programs among them.

## **2. Materials and Methods**

#### *2.1. Study Design and Setting*

The current analytical cross-sectional survey was conducted in the Aljouf region from December 2021 to April 2022. This region is situated in the northern part of the KSA, with a total population of about 500,000. Healthcare in the Aljouf region is delivered by the ministry of health (MOH), private sectors, and other ministries through four levels: primary, secondary, specialty hospitals, and medical cities. There are 62 primary health centers, 13 general hospitals, and 2 specialty hospitals in this region under the MOH, KSA.

#### *2.2. Inclusion and Exclusion Criteria*

We included all the female HCW categories working in the MOH sector for a minimum duration of one year, namely doctors, nurses, pharmacists, lab technicians, and other categories. We excluded the HCWs on vacation, in different sectors (other than MOH), and those unwilling to give informed consent to participate in the present survey.

## *2.3. Sample Size Estimation*

By using Cochran's formula (n = z2 pq/e2), we estimated the minimum required female participants needed for this research. The following values were considered while calculating sample size, namely *n* = minimum size of the necessary sample, z = 1.96 at the confidence level of 95%, *p* = expected proportion (we took 50% as the *p*-value to ge<sup>t</sup> the maximum sample size), and *q* = 1 − *p* and e = margin of error at 5%. Considering all the above-specified values, the estimated minimum required sample size was 384. Finally, we adjusted the sample size to 480, with the expected 20% non-response rate.
