**4. Discussion**

In spite of the availability of these programs, a low-level mammogram screening uptake was prevalent in all sectors of the population living in all provinces of the KSA. A study conducted in the KSA reported that among 1135 women aged 50 years and above, 92% never had mammogram screening [21].

We conducted the current study among the 414 randomly selected different categories of HCWs. The present study found that a high proportion of the HCWs recognized family history and smoking as risk factors for developing breast cancer. In contrast, the lowest proportion of the participants reported early puberty, late menopause, and physical inactivity as risk factors. Similar to the current study findings, a study done by in Jordan found that female participants were highly aware of family history as a risk factor. However, only one-third recognized early puberty as a risk factor [12]. A recently conducted survey in the KSA found results in contrast to the present study. Another study done in 2020 found a lower proportion of their study participants was aware of these risk factors. The possible reason for this variation could be the difference in study settings and inclusion and exclusion criteria [16,22]. Our study revealed that nearly half of the female HCWs had low knowledge of breast cancer risk factors and symptoms regarding overall knowledge categories. A study conducted in the Riyadh region of KSA among the healthcare professionals from a tertiary care center and another study conducted in a Nigerian urban city also found similar findings [22,23].

The binomial logistic regression analysis of the current study found that knowledge scores were significantly associated with age group, nationality, level of education, and HCWs categories. Similar to the current study findings, a survey conducted among the female primary HCWs found a significant association between knowledge with the HCWs' profession and education status [24]. The present study results revealed that only 25.2% of the HCWs had a high attitude towards breast cancer, and the attitude score was lower among the Saudi nationals than the expatriates. We could not find any other sociodemographic characteristic that was significantly associated with the attitude. Interestingly, in a Vietnam study, a higher proportion of females had a positive attitude towards breast cancer and related procedures [17]. The dissimilarities between our study and the later study are attributed to the variations in study settings, cultural characteristics, and the applied survey tools. A qualitative survey conducted in Australia reported that most of the participants had a positive perception of personalized mammogram screening, and more than 90% of them had undergone mammogram screening. The contrasting results could be due to differences in the screening model. In the KSA, the breast cancer early-detection program aims to enhance the awareness of mammogram screening through a mass approach. There is no personalized screening model available, as explored by an Australian study [25]. Even though the latter study was done in Australia, a personalized breast cancer screening model could be implemented in the KSA, where a well-established healthcare system is available as per the international standards.

Healthcare services utilization, including mammogram screening utilization by the public, is influenced by numerous barriers [16,26–28]. Our study revealed that more than one-third of the HCWs working in the MOH were not aware of the MOH, Saudi Arabia's recommendation for mammogram screening for breast cancer. Moreover, the present study demonstrated that fear of discovering cancer, apprehension regarding radiation exposure, and embarrassment due to breast-related tests were the common barriers to mammogram screening uptake. Similar to the present study, some other studies conducted

in the KSA and other Arab countries also reported that embarrassment due to breast examination, fear of discovering cancer, and fear of radiation were the common barriers faced by the women [16,18]. In contrast, a survey conducted in 2022 among Spanish health professionals reported that workload and financial limitations were the common barriers they faced [29]. Another study reported that being busy and lack of perceived susceptibility were the significant barriers perceived by the female HCWs [27]. The possible differences in the results might be due to the conservative nature of societies in the KSA and other Arab countries. The current study found that the barriers to mammogram screening were significantly higher among Saudi nationals, divorced/widowers, diploma holders, and other HCWs categories such as pharmacists, lab technicians, and physiotherapists. Similar to our study findings, some other authors also found that lower education is one of the predictors of barriers to mammogram screening [16,30].

Health literacy is an individual's competence and knowledge to understand and make a proper decision on the health-related needs of them and others. A high level of health literacy and knowledge is critical for making a proper health-related decision [31,32]. The research team attempted to find the correlation between the knowledge and attitude of the HCWs to the barriers to uptake of mammogram screening. The present study results sugges<sup>t</sup> that HCWs' knowledge is negatively correlated with the barriers to uptake mammogram screening. The present study results are supported by a survey conducted in 2020 among Jordanian women [18]. In their study, more participants with a good knowledge of breast cancer reported having a mammogram than the participants with insufficient knowledge. In the KSA, the healthcare sciences curriculum is developed based on rapid change in the demography, pattern of disease, and health care needs. The healthcare students are taught about major public health problems relevant to global and local health needs. The traditional classroom learning is supplemented through additional programs such as community health activities and health promotion activities in the field. To keep up with the changing demands, the curriculum is constantly updated and incorporated into the healthcare sciences colleges' study plan [33]. Improvements to the current training program for the HCWs and curriculum that stresses the importance of the breast cancer prevention program might facilitate them to work with greater effectiveness and improve the uptake of screening mammography by the eligible women in the community [34,35].

The WHO Global Breast Cancer Initiatives is an essential collaboration formed in 2021 to empower women and reduce breast-cancer-related deaths by 2.5% and save 25 million lives by 2040. This aim can be achieved by raising awareness of breast cancer and the importance of early detection to the HCWs, as they play a central role in strengthening the existing healthcare system [36,37].

Based on the above-mentioned findings, it is recommended to develop evidence-based and target-oriented educational programs for the HCWs, which would empower them to educate the community regarding the risk factors of breast cancer and the importance of early detection. Additionally, concerned authorities may consider changing their strategies from a mass approach to a personalized risk assessment and screening method. Furthermore, a prospective study is warranted in other regions of the KSA to understand the region-specific training needs for the HCWs.

The research team conducted the current survey using the validated tool with an adequate sample size using the standard methodology. At the same time, certain constraints need to be considered during the interpretation of this survey's results. Firstly, this study design is cross-sectional and can find only the association, not the causation. Secondly, there is a possibility of bias due to self-reported studies present in this study. Thirdly, the present study assessed female HCWs' knowledge, attitude, and barriers, not the general population. Hence, the current study's findings may not be generalized to all sections of the KSA. Finally, we included only the HCWs working at the ministry of health, KSA. Nonetheless, the current research explored critical aspects of one of the significant global health issues to be addressed immediately.
