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WHAT IS ALREADY KNOWN ON THIS TOPIC Breast cancer is widely known by name, but many women still lack clear information about its real risk factors, early warning signs and ways to prevent or detect it early, especially in low-income and middle-income countries. Previous studies suggest that age, education, income and personal contact with the disease may influence awareness, but most of this evidence comes from smaller or more limited samples.WHAT THIS STUDY ADDS In this large survey of 5435 women, almost everyone had heard of breast cancer, yet fewer than half reached a good level of overall awareness, and more than half had poor awareness of breast self-examination (BSE). Women were better informed about family history and obvious symptoms like a breast lump, but knew much less about reproductive and lifestyle risk factors and subtler signs such as nipple or skin changes. The study also shows that the factors linked to overall awareness are not the same as those linked to BSE awareness, and that information sources do not all have the same impact.HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY These results underline the need to go beyond simply ‘raising awareness’ and to focus on improving both accurate knowledge and practical skills such as BSE. They can help policymakers and health professionals to target specific groups of women and to use the most effective channels (healthcare providers, media, campaigns) to correct misconceptions and strengthen early detection efforts in breast-cancer control programmes.Introduction Breast cancer is the most diagnosed cancer in women, accounting for 25% of all female cancer cases and 15% of cancer-related deaths. 1 In 2022, it was estimated to have resulted in 670 000 deaths and 2.3 million new cases and represented 6.9% of all cancer-related deaths and 11.6% of the global cancer burden.2In the Middle East and North Africa (MENA) region, breast cancer continues to be the most frequently diagnosed cancer among women and is the leading cause of cancer-related deaths. According to a study by Zahwe et al, there were about 118 200 new breast cancer cases and 41 000 deaths in MENA, accounting for 25% of female cancer cases and almost 20% of cancer-related deaths. Interestingly, the incidence and mortality rates of breast cancer vary widely across the region, with Algeria and Iraq having the highest incidence, while Saudi Arabia and Yemen have the lowest. Although the incidence rates in the region are comparatively low compared with global averages, the mortality rates are disproportionately high, second only to sub-Saharan Africa. The worrying factor is the projected increase in the number of cases and deaths by 2050, with an estimated 219 000 cases and 88 900 deaths, representing an 86% and 117% increase, respectively.3 Factors contributing to this rise include shifts in reproductive behaviours, increasing life expectancy and lifestyle changes. Despite advances in healthcare infrastructure in some countries within the region, many challenges remain regarding public health awareness, timely diagnosis and access to treatment. These issues are further exacerbated by cultural and societal factors that can delay the presentation of symptoms and hinder participation in screening programmes.4One of the most pressing challenges in reducing breast cancer mortality is the lack of awareness surrounding the disease, particularly concerning its risk factors and early symptoms. While global studies have shown that 84% of women are generally aware of breast cancer, a much smaller percentage (51%) are knowledgeable about the specific symptoms and risk factors.5 In the MENA region, studies indicate even lower levels of awareness. For example, research conducted in Saudi Arabia revealed that only 33.7% of women were knowledgeable about the signs and symptoms of breast cancer, with 66.3% displaying a lack of awareness.6 This deficiency in knowledge often leads to delayed presentation, later-stage diagnoses and ultimately poorer treatment outcomes. Cultural stigma and misconceptions surrounding breast cancer further complicate efforts to promote early detection in the MENA region. In many communities, discussing breast health or cancer remains taboo, with fear of social stigma discouraging women from seeking medical advice or undergoing screenings.7 In addition, misconceptions about the disease, including fatalistic beliefs or misinformation about its treatment, can deter women from recognising the importance of early intervention. These cultural barriers, combined with socioeconomic factors such as limited healthcare access and lower education levels, contribute to delayed diagnoses and increased mortality rates.8Moreover, research indicates that regular breast self-examination (BSE) practice enables women to become familiar with the normal consistency of their breast tissue, allowing them to detect abnormalities such as lumps or changes in texture at an earlier stage.9 Although BSE is a basic and affordable approach to early detection, BSE is not commonly practised in the MENA region.10 11 The inadequacy of the practice is often attributed to limited knowledge, inadequate training and a failure to recognise its importance. Studies suggest that teaching women to build on education and develop skills for BSE can increase early detection, which can improve clinical outcomes.12 A recent knowledge, attitude, and practice study on Arab women in the MENA region found that misconceptions, fear of diagnosis and cultural stigma were among the major barriers to early breast examination and screening.13 While valuable, that study was limited in scale and geographic scope. To address these gaps, the present study adopts a multinational, cross-sectional design with a large sample size across several MENA countries. It aims to comprehensively assess women’s awareness of breast cancer and their knowledge, attitudes and practices related to BSE. By including diverse cultural and socioeconomic contexts, this study provides a broader perspective and highlights region-specific barriers that can inform tailored health education and intervention strategies.Methods and analysis Study design and participants We conducted an observational, cross-sectional, questionnaire-based study across multiple (MENA) countries between March and August 2024 to assess breast cancer awareness and BSE knowledge among women. Participants were recruited via non-probability convenience sampling. The survey (Google Forms) was disseminated through social media platforms (eg, WhatsApp, Facebook, X/Twitter), university mailing lists and community groups to maximise reach. Countries were included based on the availability of local collaborators and feasibility of distribution.Eligible participants were: (1) women aged ≥18 years; (2) of MENA origin and (3) able and willing to provide electronic informed consent. A total of 6193 responses were received; after quality checks (see Data Management and Quality Control), 5435 valid responses remained for analysis.Sample size Based on an estimated 244.9 million women in the MENA region, 14 we conservatively set p=0.50, a 95% confidence level (Z=1.96), and a 5% margin of error (d=0.05). A value of 0.50 was used for the sample size calculation because no pooled regional estimate was available for the primary endpoint, namely the proportion of women with good breast cancer awareness. This choice maximises variability and yields the most conservative estimate of the required sample size. Given the multicountry design and anticipated within-cluster homogeneity, we applied a design effect (DEFF)=3. Using the single-proportion formula n0=[DEFF×Zˆ2×p(1−p)]/dˆ2, the minimum analytical sample size was n0≈1153. The finite population correction was negligible. Allowing for 20% non-response, the recruitment target was ⌈1153/0.80⌉=1441. Calculations were verified with OpenEpi (‘Sample Size for a Proportion’). To ensure adequate power and buffer unforeseen losses, our operational objective was to recruit a sample exceeding 1441. The achieved sample (5435) surpassed this target.Questionnaire and measures The self-administered questionnaire was available in Arabic and English; respondents selected their preferred language at entry. The instrument covered four sections:Sociodemographic characteristics (age, residence, income, marital status, occupation, education and parental education).Breast cancer awareness (symptoms and risk factors; response options ‘Yes/No/I don’t know’).BSE knowledge (timing and method, especially in relation to the menstrual cycle).Screening, treatment and prevention (knowledge of available options).We assessed breast cancer awareness with a 23-item tool covering Q18a–d (statements), Q19a–j (symptoms), and Q20a–m (risk factors). Each item was scored 1 for a correct answer and 0 for an incorrect/’don’t know’ response (total 0–23; higher scores indicate greater awareness). Correct answers were ‘Yes’ for all statements, symptoms and risk-factor rows except the two protective factors—breastfeeding and having many children (multiparity)—which were reverse-scored (‘No’=correct). Following a consensus among the members of the research team, scores ≥13 were classified as good awareness. BSE awareness was measured with six items (Q21, Q23–Q26, Q29) using the same coding (total 0–6); correct responses were ‘Yes’ for knowledge/practice items and ‘At the end of the cycle (days 7–10 after period starts)’ for timing, with scores ≥3 indicating good BSE awareness.Content was adapted to the MENA context from previously used items and reviewed by two public-health experts for content validity. We pilot-tested with 20 participants to assess clarity and cultural appropriateness, leading to minor wording refinement.Data management and quality control Responses with >20% missing data were excluded. Isolated missing items were left blank. Additional exclusions covered contradictory or illogical responses in key variables. Of 6193 initial responses, 758 were excluded, yielding 5435 valid observations. We screened potential duplicate entries (eg, identical timestamps/IP patterns and metadata anomalies) and retained the first complete instance when duplication was suspected. The final analytic dataset reflects complete case analysis for each model.Statistical analysis Analyses were conducted in R V.4.4.1. We summarised sociodemographic variables using descriptive statistics (frequencies/percentages). Primary outcomes were good versus poor breast cancer awareness and good versus poor BSE awareness, defined as above. Multivariable modelling, we fitted univariates and multivariate logistic regression models to estimate ORs and 95% CIs for factors associated with breast cancer awareness and then with BSE awareness. Covariates were selected a priori and retained regardless of statistical significance to reduce residual confounding. For categorical predictors with >2 levels, we report the p-global for overall association. Statistical significance, two-sided p<0.05 was considered statistically significant.Results Demographic characteristics Of the 5435 women who participated in this study, 47% were between the ages of 20 and 30. 71% of women lived in cities, 39% made an average monthly salary, 75% had a bachelor’s degree and 49% were never married or not in a formal union. Table 1 illustrates the detailed demographic characteristics of the study sample.Table 1Demographic characteristics of the study sample (n=5435)Demographic characteristicsFrequency (percentage)Age (n=5435) <20 years590 (11%) 20–30 years2559 (47%) 31–40 years1081 (20%) 41–50 years856 (16%) >50 years349 (6.4%)Marital status Married2475 (46%) Divorced191 (3.5%) Widowed87 (1.6%) Single2682 (49%)Country Algeria24 (0.4%) Bahrain804 (15%) Comoros3 (<0.1%) Egypt635 (12%) Iran1 (<0.1%) Iraq24 (0.4) Jordan489 (9%) Kuwait290 (5.3%) Lebanon7 (0.1%) Libya347 (6.4%) Morocco343 (6.3%) Oman31 (0.6%) Palestine473 (8.7%) Qatar120 (2.2%) Saudi Arabia1013 (19%) Sudan69 (1.3%) Syria34 (0.6%) Tunisia486 (8.9%) UAE237 (4.4%) Yemen5 (<0.1%)Place of Residence Urban (city)3853 (71%) Rural (village)1386 (26%) Other196 (3.6%)Monthly Income High income201 (3.7%) Average income2111 (39%) Low income1062 (20%) No income2061 (38%)Educational level Elementary school49 (0.9%) Middle school134 (2.5%) High school883 (16%) Bachelor4051 (75%) Masters/PhD274 (5.0%) Uneducated44 (0.8%)Paternal Educational level Elementary school462 (8.5%) Middle school561 (10%) High school1414 (26%) Bachelor2146 (39%) Masters/PhD345 (6.3%) Uneducated507 (9.3%)Maternal educational level Elementary school527 (9.7%) Middle school505 (9.3%) High school1422 (26%) Bachelor’s1987 (37%) Masters/PhD169 (3.1%) Uneducated825 (15%)Occupation Office work1861 (34%) Manual work (craftsman)472 (8.7%) Unemployed3102 (57%)Are you aware of the disease known as breast cancer? Yes5233 (96%) No202 (4%)Have you ever experienced a benign (non-serious) breast injury? Yes571 (11%) No4864 (89%)Are you acquainted with someone who has breast cancer? Yes3737 (69%) No1698 (31%)From which sources did you acquire your knowledge about breast cancer? Awareness campaigns1190 (21.8%) Healthcare professionals538 (10%) Broadcast media and social media platforms.1624 (29.86) Family and friends.1297 (23.8) University647 (11.9%) Others124 (2.3%) Don’t know this disease16 (<0.3%)Awareness of breast cancer As table 1 shows, we found that 96% of participants were aware of breast cancer. Moreover, 69% of participants reported having contact with someone with breast cancer, which may explain the increased level of awareness. Around 29.86%, 23.8% and 21.8% of respondents used broadcast media and social media platforms, family and friends, and awareness campaigns, respectively, as sources of information. Meanwhile, only 10% stated that healthcare professionals acted as their information source, highlighting a minor role of professional-driven awareness efforts. Table 2 depicts data related to breast cancer epidemiology, risk factors, symptoms, management and prevention. Of the overall participants, 74% agreed that breast cancer is the most prevalent type of cancer among women in both the world and the Arab world. However, 66% believed breast cancer could affect girls early in life, and only 54% thought it could affect men.Table 2Participant’s responses about breast cancer’s epidemiology risk factors as well as signs of the diseaseItemsYesNoDon’t knowBreast cancer epidemiology Breast cancer is the most common type of cancer among women worldwide4004 (74%)195 (3.6%)1236 (23%) Breast cancer is the most prevalent form of cancer among women in the Arab world.4046 (74%)111 (2.0%)1278 (24%) Can breast cancer affect men?2915 (54%)836 (15%)1684 (31%) Can breast cancer affect girls at an early age?3588 (66%)413 (7.6%)1434 (26%)Risk factors Family history of breast cancer4683 (86%)198 (3.6%)554 (10%) Contraceptives2564 (47%)710 (13%)2161 (40%) Menopausal hormone replacement therapy2797 (51%)465 (8.6%)2173 (40%) Obesity2027 (37%)1141 (21%)2267 (42%) Having a parent diagnosed with breast cancer3724 (69%)725 (13%)986 (18%) Delayed childbirth or nulliparity1921 (35%)1171 (22%)2343 (43%) Early onset of menstruation before the age of 11 or 121495 (28%)1344 (25%)2596 (48%) Delayed menopause1459 (27%)1259 (23%)2717 (50%) Insufficient physical activity2304 (42%)996 (18%)2135 (39%) Breastfeeding584 (11%)3430 (63%)1421 (26%) Exposure to radiation2958 (54%)730 (13%)1747 (32%) Having many children579 (11%)2619 (48%)2237 (41%) Alcohol consumption2378 (44%)719 (13%)2338 (43%)Signs and symptoms Breast/armpit pain4080 (75%)704 (13%)651 (12%) Breast lump5030 (93%)113 (2.1%)292 (5.4%) Nipple discharge3417 (63%)408 (7.5%)1610 (30%) Nipple rash2939 (54%)627 (12%)1869 (34%) Breast size change4046 (74%)374 (6.9%)1015 (19%) Breast shape change4088 (75%)316 (5.8%)1031 (19%) Breast skin dimpling or puckering3154 (58%)457 (8.4%)1824 (34%) Breast skin redness2970 (55%)615 (11%)1850 (34%) Nipple position change3187 (59%)453 (8.3%)1795 (33%) Nipple inward pulling2795 (51%)484 (8.9%)2156 (40%)We found a high prevalent awareness in the following risk factors: having a family history of breast cancer (86%), having a parent diagnosed with breast cancer (69%), exposure to radiation (54%) and menopausal hormone replacement therapy (51%). Less prevalent awareness was associated with delayed menopause (27%), delayed childbirth and nulliparity (35%) and insufficient physical activity (42%). Concerning breast cancer symptoms, respondents were well-aligned with breast lump (93%), breast/armpit pain (75%), and breast size and shape change (74%, 75%). However, they were less acquainted with nipple inward pulling (51%), breast skin redness (55%), breast skin dimpling (58%) and nipple position change (59%). In the management domain, 88% and 87% of participants believed surgery and chemotherapy, respectively, were treatment options. In the prevention domain, a large portion of participants was aware of the possible modalities, including having a healthy diet (82%), abstaining from the non-medical use of hormones (79%) and engaging in physical activity (77%) (table 2).Among 5435 participants, overall breast cancer awareness was good in 2128 women (39.2%, 95% CI 37.9% to 40.5%) and poor in 3307 women (60.8%, 95% CI 59.5% to 62.1%) (online supplemental Table S1). Thus, roughly three in five participants fell below the good-awareness threshold.SP210.1136/bmjonc-2025-000869.supp2Supplementary dataAccording to multivariate logistic analysis in online supplemental Table S3, several factors were statistically significantly associated with good breast cancer awareness after adjustment. Compared with women ≤20 years, awareness was significantly higher at 20–30 (adjusted OR, AOR 1.85, 95% CI 1.49 to 2.30), 31–40 (AOR 1.61, 95% CI 1.24 to 2.10) and 41–50 (AOR 1.45, 95% CI 1.10 to 1.92), while >50 was not significantly associated. Relative to rural residence, suburban residence was significantly associated with lower odds (AOR 0.54, 95% CI 0.38 to 0.76), whereas urban residence was not significantly associated. For income, high income showed a significant positive association (AOR 1.96, 95% CI 1.42 to 2.73) and low (AOR 1.03, 95% CI 0.87 to 1.22). Compared with single women, married (AOR 0.63, 95% CI 0.54 to 0.74) and divorced (AOR 0.60, 95% CI 0.43 to 0.85) women had significantly lower odds, while widowed was not significant (AOR 0.86, 95% CI 0.52 to 1.40) versus the unemployed, manual workers had significantly higher odds (AOR 1.71, 95% CI 1.38 to 2.12), whereas office workers were not significant (AOR 1.10, 95% CI 0.95 to 1.27). An education gradient was evident: compared with Bachelor’s, uneducated (AOR 0.36, 0.16–0.76), middle school (AOR 0.54, 95% CI 0.35 to 0.81) and high school (AOR 0.61, 95% CI 0.51 to 0.73) were significantly lower; elementary was not significant (AOR 0.90, 95% CI 0.48 to 1.65); Masters/PhD was significantly higher (AOR 1.51, 95% CI 1.16 to 1.97). Experiential factors were also important: prior benign breast injury (AOR 1.59, 95% CI 1.32 to 1.92) and knowing someone with breast cancer (AOR 1.42, 95% CI 1.25 to 1.62) were significantly associated with higher awareness. Using healthcare professionals as the reference, broadcast/social media was significantly associated with lower awareness (AOR 0.53, 95% CI 0.43 to 0.65), awareness campaigns were modestly but significantly lower (AOR 0.79, 95% CI 0.64 to 0.98).Breast self-examination Regarding BSE, figure 1 and figure 2 show that broadcast media and social media platforms (42%), discussions with friends (20%) and healthcare doctors (20%) were the major sources of information related to BSE. In addition, 42.2% and 24.8% of women had never and rarely performed BSE, respectively. Figure 3 illustrates the reasons for not performing BSE, including inadequate knowledge (28.2%), lack of necessity (13%), concerns about a positive test result (10.1%) and other non-mentioned reasons (38.8%).Figure 1The figure titled ‘Sources of Knowledge about Breast Self-Examination’ illustrates various sources from which individuals acquire knowledge about breast self-examination. The most significant source is media and social media, accounting for 42% of responses. Doctors are the second most cited source, with 20%. Discussions with friends also represent 20% of the knowledge sources. Additionally, 9.1% of respondents indicated that they do not know about breast self-examination (BSE), while discussions with mothers accounted for 8.6%.Figure 2The figure titled ‘Frequency of Breast Self-Examination’ shows how often people do breast self-examinations. A large number, 42.2%, said they never do them. Next, 24.8% mentioned that they do it rarely. Some, 13.4%, check themselves at least once a month, while 10.6% do it every 6 months. Fewer people examine themselves at least once a year (5.6%), just once a year (2.9%) and only a tiny 0.5% do it once.Figure 3The figure titled ‘Reasons for Doing Breast Self-Examination’ highlights the motivations behind why people perform self-examinations. The most common reason, cited by 38.8% of respondents, is ‘others’, indicating they are influenced by external factors. Following this, 28.2% of individuals said they ‘don’t know’ their reasons for doing it. Additionally, 13% are motivated by concerns about a possible health issue, while 4.4% find the process embarrassing. Lastly, 2.9% mention being sensitive about the topic, and 2.7% have personal reasons.In summary, among 5435 participants, BSE awareness was good in 2340 women (43.05%, 95% CI 41.73% to 44.38%) and poor in 3095 women (56.95%, 95% CI 55.62% to 58.27%). In other words, over half of participants did not meet the good-awareness threshold, underscoring the need for strengthened BSE education and skills reinforcement (online supplemental Table S1).According to online supplemental Table S5, age showed a strong, statistically significant pattern in which all groups older than ≤20 had lower odds of good BSE awareness, for example 20–30 years AOR 0.47 (95% CI 0.37 to 0.59) and >50 years AOR 0.29 (95% CI 0.20 to 0.40). Income also mattered, as average AOR 0.78 (95% CI 0.66 to 0.91) and high AOR 0.63 (95% CI 0.46 to 0.88) were lower than no income, while low income was not significant. Married women had higher odds AOR 1.25 (95% CI 1.07 to 1.46), manual workers had lower odds AOR 0.75 (95% CI 0.60 to 0.93), and education showed a mixed pattern with elementary AOR 2.34 (95% CI 1.23 to 4.55) and uneducated AOR 2.18 (95% CI 1.10 to 4.38) higher, but Masters or PhD lower AOR 0.56 (95% CI 0.42 to 0.73). Prior benign breast injury AOR 0.43 (95% CI 0.36 to 0.52) and knowing someone with the disease AOR 0.49 (95% CI 0.43 to 0.56) were associated with lower awareness, and broadcast or social media was associated with higher awareness AOR 1.33 (95% CI 1.08 to 1.65) compared with healthcare professionals, while residence showed no significant association.Discussion Breast cancer is an important global health problem. Timely identification can markedly enhance survival rates, highlighting the necessity of understanding the disease and its screening techniques. 4 According to our knowledge, this study provides the first extensive analysis of breast cancer awareness and BSE behaviours among women in several countries within the MENA area. We aimed to achieve an extensive understanding of women’s awareness of breast cancer and BSE in this varied location.Our research reveals that the predominant sources of breast cancer information for participants were social and broadcast media (29.86%), followed by family and friends (23.8%) and awareness initiatives (21.8%). This pattern aligns with research reported in the UAE, Jordan, Saudi Arabia and Egypt.15–18 Nevertheless, 10% of individuals identified healthcare providers as their principal source of knowledge. This stands in contradiction to studies from Jordan, where 51.8% of female students indicated that they acquired breast cancer information from friends, family and healthcare providers, with analogous trends observed in the UAE highlighting the role of healthcare professionals. The results underscore the need to increase the involvement of healthcare providers in awareness campaigns, while simultaneously using the broad influence of social and mass media as instructional instruments.A substantial proportion of participants (74%) correctly recognised breast cancer as the most common cancer affecting women worldwide. However, this still leaves more than one in four women without this fundamental knowledge, underscoring the need for broader awareness efforts. Misconceptions about the at-risk population were also evident; 46% were unaware that men can develop breast cancer, and 66% believed it may affect girls of any age. Such misconceptions may stem from cultural beliefs that breast cancer is exclusively a women’s disease, limited visibility of male breast cancer in public discourse and insufficient emphasis on age-related risks in awareness campaigns. These findings are consistent with research by Al Bashir et al19 and a study in Pakistan, which indicated that only 15% were alert to age-related dangers.20 The existing gaps highlight the pressing necessity for focused public health education to clarify misunderstandings about breast cancer.Concerning risk variables, awareness of family history was significantly elevated, with 86% of participants acknowledging its significance, and 69% comprehending that a parent’s breast cancer diagnosis heightens risk. These findings correspond with studies from Jordan, where family history was identified as the predominant risk factor (75.4%).21 Nevertheless, the understanding of additional significant risk variables remained less comprehensive. For example, 43% were oblivious to the fact that delayed childbirth and nulliparity increase breast cancer risk, while 48% failed to acknowledge the hazards linked to early menarche and late menopause. This deficiency in awareness aligns with the findings of Al-Mousa et al21 and Ben El-Fakir et al,22 highlighting the necessity for awareness initiatives to address these lesser-known risk factors. Furthermore, awareness of lifestyle-related risk factors, including contraceptive use (47%), hormone replacement treatment (51%), alcohol intake (44%) and physical inactivity (42%), was moderate. Promoting knowledge of good lifestyle choices as preventive strategies against breast cancer is essential.Participants demonstrated substantial awareness of prevalent breast cancer symptoms. These results align with research conducted in Saudi Arabia and the UAE.23 However, there was only a moderate level of knowledge of less common but crucial symptoms, such as changes in nipple position (59%), skin redness (55%), nipple inward pulling (51%) and skin dimpling (58%). The existence of these knowledge gaps is troubling, as the identification of a wider array of symptoms is crucial for early detection and improved health outcomes. Only 39.2% of participants achieved good breast cancer awareness. Compared with a regional systematic review (30% high, 45% moderate, 25% low awareness across 25 studies), our estimate lies at the moderate–high boundary, but differences in definitions limit direct comparison. The bottom line is clear: fewer than two in five women reached the good-awareness threshold, highlighting the need for targeted, context-specific education.24 Our study identified several factors associated with breast-cancer awareness; notably, holding a Master’s/PhD (vs Bachelor’s) was significantly linked to higher awareness (AOR 1.51; 95% CI 1.16 to 1.97). A systematic review25 of 92 studies reported similar findings, highlighting education level as the most consistent determinant of awareness, with higher education consistently associated with greater knowledge across diverse settings. The systematic review25 also emphasised age and marital status as key correlates of breast-cancer awareness, though findings were mixed; some studies reported greater awareness among younger women, while others found higher knowledge among older women. Similarly, several studies observed lower awareness among married women, whereas a few suggested prioritising divorced or single women for education. In our data, awareness peaked in mid-life, compared with ≤20 years, women aged 20–30 had higher odds (AOR 1.85, 95% CI 1.49 to 2.30), as did those aged 31–40 (1.61, 95% CI 1.24 to 2.10) and 41–50 (1.45, 95% CI 1.10 to 1.92). For marital status (vs single), married (0.63, 95% CI 0.54 to 0.74) and divorced (0.60, 95% CI 0.43 to 0.85) women had significantly lower odds of good awareness. Together, these results align with the review25 in identifying age and marital status as important determinants, while clarifying that in our setting, awareness was highest in mid-life and lower among married and divorced women.Although 43.05% of participants were aware of BSE, its practice remained significantly low, with only 42.2% performing it regularly and 24.8% doing so infrequently. These findings are consistent with those reported by Jobran et al and Ahmad et al, highlighting the gap between knowledge and implementation.16 26 Primary obstacles to doing BSE comprised insufficient information regarding the procedure (28.2%), a perceived lack of necessity (13%) and apprehension over uncovering a positive diagnosis (10.1%). Other factors, like embarrassment and apprehensions regarding sensitivity, were also seen. These obstacles have been recorded in research from Saudi Arabia, Algeria, Syria and Palestine.16 23 26 27 Importantly, the large proportion of women identified as having ‘poor’ BSE practice points to a more significant challenge in behaviour than in general awareness. While 39.2% of participants had poor breast cancer awareness, more than 57% either did not perform BSE at all or performed it incorrectly. This disparity shows that BSE is not a behaviour that improves knowledge alone, it also depends on feeling comfortable with one’s body, knowing the correct technique and receiving consistent guidance over time. These findings suggest that future programmes should move beyond simply providing information about BSE and focus on building practical skills through demonstrations, culturally sensitive educational materials and community-based approaches that support women in performing BSE correctly and regularly.Mitigating these obstacles by extensive teaching on the significance of BSE and offering specific guidance on its techniques is essential for enhancing practice rates. Along with individual barriers, cultural issues also significantly influence women’s perceptions and practices towards breast cancer screening. In most MENA cultures, cultural taboos regarding discussion of female anatomy and modesty may be responsible for hesitation in conducting BSE or seeking clinical examination. Religious beliefs and social norms regarding privacy can further entrench embarrassment and hesitation, causing under-reporting of symptoms or delayed care-seeking by women. Fatalistic attitudes towards cancer as a predetermined or incurable disease may also discourage active screening activities. Such cultural effects have been seen across comparable environments, indicating that breast health promotion programmes must be culturally sensitive and adapted to social and religious milieus to enhance awareness, acceptance and uptake of BSE and other screening activities.24 In interpreting the observed ‘poor levels’ of breast cancer awareness and BSE practice, it is crucial to understand that these categories reflect not only individual gaps in knowledge or behaviour but also broader sociocultural, structural and educational limitations across the MENA region. A classification of ‘poor awareness’ often reflects limited access to structured health education, dependence on informal information sources and insufficient integration of breast health topics into school and community programmes. Likewise, ‘poor BSE practice’ must be interpreted within cultural contexts where modesty norms, stigma surrounding breast-related discussions and concern about social judgement discourage women from examining their bodies or seeking help. These contextual factors provide essential insight into why knowledge may fail to translate into preventive action and highlight the need for culturally adapted, community-driven interventions.This study provides a detailed evaluation of breast cancer awareness across the MENA region, supported by a large and diverse sample of 5435 participants. The inclusion of women from various cultural, social and economic backgrounds allows for a nuanced understanding of awareness disparities across different populations and healthcare systems. The comprehensive questionnaire design effectively highlights knowledge gaps related to risk factors, symptoms, screening methods and preventative strategies, offering valuable insights to guide targeted educational initiatives. Moreover, the study adheres to rigorous ethical standards, ensuring participant consent and privacy.Despite its strengths, the study has notable limitations. The use of convenience sampling may introduce selection bias, as individuals with internet access or a specific interest in health topics may be over-represented, limiting the findings’ generalisability. The cross-sectional design captures awareness at a single point in time, preventing the assessment of causality or temporal changes. Self-reported data poses risks of recall and social desirability biases, potentially leading to overestimation of knowledge and screening behaviours. Non-response bias may further impact the representativeness of the results. Additionally, while the questionnaire addresses key aspects of breast cancer awareness, it does not explore complex issues such as cultural beliefs, healthcare access and psychological factors in depth. The absence of longitudinal data precludes tracking changes over time, and the exclusion of male participants limits insights into their awareness and perspectives, despite the occurrence of breast cancer in men.Conclusions This study aimed to evaluate women’s awareness of breast cancer and the frequency of BSE in the MENA region. While general awareness of breast cancer is relatively high, significant gaps persist in knowledge regarding specific risk factors and symptoms. Notably, healthcare professionals play a limited role in disseminating information, with most participants relying on social and broadcast media as their primary sources. This finding underscores the need for more structured and evidence-based educational initiatives. Despite an awareness of the importance of BSE, adherence remains low due to inadequate knowledge and a perceived lack of necessity. These findings highlight the critical need for targeted educational programmes that not only enhance awareness of breast cancer and its associated risk factors but also provide practical guidance on BSE. Strengthening educational efforts and increasing the involvement of healthcare professionals are essential for improving awareness and fostering preventive health behaviours, ultimately contributing to early detection and improved outcomes in the MENA region.SP110.1136/bmjonc-2025-000869.supp1Supplementary data