*2.5. Ethical Consideration*

After obtaining ethical clearance from the Aljouf regional research ethics committee, Qurayat health affairs, MOH (approval number 126), the data collectors began the survey. The following considerations were made to avoid ethical issues:


## *2.6. Data Collection Tool*

The present study used a standardized self-administered questionnaire prepared by a team of experts from general surgery, radiology, and public health departments based on existing pieces of literature [16–18]. The structured questionnaire was tested for required validity and reliability. The independent experts examined the face and content validity of the data collection tool. Furthermore, we conducted a pilot study among the 30 different HCWs categories to understand the cultural adaptability and reliability in the local settings. All the pilot study participants agreed that the data collection tool was simple and easy to understand, and there were no missing data found in the completed data collection forms. The pilot study's test score reliability coefficient (Cronbach's alpha) for knowledge, attitude, and barrier scores were 0.78, 0.81, and 0.83, respectively, which showed good reliability in the present form of the survey questionnaire. Hence, the research team collected the data with the same data collection tool. The survey tool consisted of four sections; the first part inquired about socio-demographic details of the HCWs, including age (years), nationality, marital status, highest education qualification, current working healthcare facility, work experience duration, and HCW category. The second part consisted of sixteen questions. Of the sixteen questions, the first ten questions are related to the common risk factors (such as early puberty, late menopause, and family history), and the following six questions were related to common breast cancer symptoms. The participants were asked to choose "yes", "no", or "do not know". We gave a score of one for correct answers (response as yes) and zero for wrong answers (response as no or do not know). The third part consisted of ten questions related to the attitude of the HCWs towards breast cancer and patients diagnosed with breast cancer. The participants responded on a 5-point Likert scale ranging from strongly agree to strongly disagree, and scores were given from 5 (strongly agreed) to 1 (strongly disagree). The final part included ten questions about the barriers to uptake of the mammogram screening program,

including fear of the procedure, embarrassment due to breast-related tests, apprehension regarding radiation exposure, and fear of discovering cancer. The presence of a barrier was scored as one, and the absence of a barrier was scored as zero. Furthermore, the research team categorized knowledge, attitude, and barriers into high (80% and above of total scores), medium (60–79% of total scores), and low (less than 60% of total scores). Our categorization is as per the original Bloom's cut-off point and is supported by previous studies conducted among the HCWs in the KSA and other parts of the world. In Saudi Arabia, the HCWs are expected to have high knowledge (≥80%) of common public health problems, as they play a crucial role in preventing diseases by health education and delivering healthcare services implemented by the concerned authorities [19,20]. Hence, we combined low and good scores as a single category for logistic regression analysis, and previously conducted surveys among the HCWs strongly support and justify our categorization.

## *2.7. Data Collection Procedure*

After necessary administrative approvals from the concerned healthcare facilities, the data collectors initiated the survey. We used an electronic shareable document (Google form) with the IRB-approved questionnaire for data collection. After briefing about the research rationale and objectives and obtaining informed consent, the selected HCWs were requested to fill the google form on the personal electronic device of the data collectors. For data security, the research team decided to give authorization only to the principal investigator to access, download, and export the survey's spreadsheet. In addition, the research team made three attempts in two weeks to communicate with the selected participants. The HCWs who were unwilling to participate and those who could not be communicated with despite three attempts were recorded as non-respondents.
