Breast cancer (BC) is a condition where aberrant breast cells proliferate uncontrollably and develop into tumors. Untreated tumors have the potential to spread throughout the body and become fatal. In 2022, breast cancer caused 670 000 deaths worldwide, and 2.3 million women received a diagnosis. Breast cancer occurs in every country and can affect women at any age after puberty, although it is more common later in life.1

Despite rigorous efforts in many countries to mitigate its incidence, breast cancer is the leading cause of cancer-related deaths among women worldwide, and its prevalence is rising. BC is expected to cause more than 3 million annual deaths by 2040 due to population growth and aging alone. This was predicted based on demographic projections and assuming that the rates remained stable from the baseline year of 2020 and was calculated by applying the 2020 rates to the predicted population data.2 In 2021, breast cancer accounted for 9.64% of all cancer deaths in the United Arab Emirates (UAE), making it one of the most common causes of cancer-related deaths. Of all malignant cases in 2021, 1139 cases of breast cancer were reported to the UAE National Cancer Registry, accounting for 20.3% of all cases.3

In the United States, the primary barrier to women in specific demographic groups adhering to or following up on cancer screening programs appears to be a lack of health insurance4, suggesting that financial constraints can act as a potential barrier even in other countries, in addition to cultural or knowledge-related barriers. Improved methods of informing women, particularly those in disadvantaged groups, are necessary to improve the outcomes of cancer screening programs. Health education is essential, especially for vulnerable populations, as it would help women adopt more positive attitudes and modify their behavior toward breast cancer screening.4,5 Language and cultural barriers, mobility constraints, psychological barriers, lack of time, and prioritizing other health conditions are additional challenges present in most of the studies being conducted.4-13

Barriers to breast cancer screening utilization can be broadly classified into many types, such as psychological, systemic, social, and cultural. Regarding culture-related barriers, one study reported that women’s uneasiness when receiving treatment or examinations from male physicians is a barrier.5,14-16 Similarly, a study conducted in Tanzania among 354 women reported that the primary barrier to breast cancer screening was the participants’ ignorance about breast cancer, which can be identified as a systemic barrier.17 Additionally, many psychological barriers have been identified by various studies. For instance, a systematic review of the barriers to breast cancer screening in Saudi Arabia revealed that the two most often mentioned barriers among those found were humiliation from breast-related tests and fear of finding cancer. Furthermore, fear of clinical examination discomfort came in second, followed by anxiety about not understanding the procedure. Additionally, fear of radiation exposure was identified as a common concern, in addition to ignorance about the issue. Concerns, including the idea that there is no cure for cancer and the perception that mammograms are not important, were significant barriers noted in some studies. Lack of time, financial or work limitations, and a shortage of female healthcare experts were somewhat less frequent but essential barriers.18,19

The existing literature has discussed various barriers that affect the utilization of breast cancer screening programs among women in different countries, including fear of receiving a cancer diagnosis, embarrassment, fear of pain, ignorance, and worries about radiation exposure. This shows how complex individual, cultural, and systemic factors interact to shape screening practices.4-13,20 Nevertheless, research on barriers to breast cancer screening in the UAE remains insufficient. While numerous studies have identified key barriers, few have investigated which demographic groups perceive them most strongly or how this perception impacts utilization rates. Therefore, the purpose of this study was to broaden our understanding of the potential barriers that could affect the utilization of breast cancer screening programs among women in the UAE, emphasize the necessity of focused measures, and encourage proactive health-seeking practices that could help in the early detection efforts and lessen the burden of breast cancer.

Among the 959 participants, the mean (SD) age was 34.27 (10.978) years. Most participants were younger than 40 years (498 [51.9%]), from the Eastern Mediterranean Region (EMR) (431 [44.9%]), had a high school education or less (411 [42.9%]), were married (633 [66.0%]), and were unemployed (643 [67.0%]).

Table 1 presents the association between perceived barriers and the utilization of breast cancer screening. Perceived barriers such as lack of knowledge, fear or anxiety regarding the procedure, cost or insurance coverage, and lack of physician recommendation were significantly associated with the utilization of breast cancer screening.

A higher proportion of participants who did not perceive barriers such as a lack of knowledge (169 [22.9%]), fear or anxiety regarding the procedure (175 [22.6%]), cost or insurance coverage (172 [23.2%]), and a lack of physician recommendation (178 [24.5%]) underwent breast cancer screening more frequently than those who perceived these barriers.

Table 2 presents the perceived barriers as predictors of breast cancer screening utilization. Significant associations were found between cost or insurance coverage, lack of a physician recommendation, and screening utilization.

Participants who did not perceive cost or insurance coverage (adjusted odds ratio [aOR], 1.808; 95% CI, 1.187–2.754; P = 0.006) and lack of physician recommendation (aOR, 2.625; 95% CI, 1.681–4.10; P < 0.001) as barriers were significantly more likely to undergo breast cancer screening compared with those who did perceive them as barriers.

Although participants who did not perceive fear or anxiety as a barrier had significantly higher odds of breast cancer screening utilization in the crude analysis (crude odds ratio [cOR], 1.546; 95% CI, 1.005–2.379; P = 0.047), this association was not statistically significant after adjustment (aOR, 1.267; 95% CI, 0.812–1.976; P = 0.30). Likewise, lack of knowledge was statistically significant in the crude analysis (cOR, 1.578; 95% CI, 1.058–2.354; P = 0.025) but lost its significance after adjustment (aOR, 1.506; 95% CI, 1.000–2.268; P = 0.050). Furthermore, accessibility to screening issues was not statistically significant in the adjusted analysis (aOR, 2.213; 95% CI, 0.656–7.471; P = 0.20).

Table 3 presents the association between sociodemographic characteristics and the barrier “lack of a physician recommendation.” The analysis revealed that age, education level, and employment status were statistically significant factors associated with this barrier, whereas nationality and marital status were not. A higher prevalence of this barrier was reported among participants younger than 40 years (142 [28.5%]), those with an undergraduate education (54 [28.9%]), and unemployed women (192 [29.9%]), compared with their older, more highly educated, and employed counterparts.

Table 4 shows the associations between sociodemographic characteristics and the “lack of knowledge” barrier. Education level and employment were statistically significant, whereas age, nationality, and marital status were not. Participants with an undergraduate education reported the highest percentage of facing this barrier (57 [30.5%]), while those with a high school (87 [21.2%]) or postgraduate education (77 [21.3%]) had lower percentages. Similarly, participants in the healthcare field were significantly less likely (13 [12.7%]) to report lack of knowledge as a barrier compared with individuals in non-healthcare fields (49 [22.9%]) and unemployed women (159 [24.7%]).

Among the sociodemographic characteristics examined, only age showed a statistically significant association with fear or anxiety regarding the procedure (P = 0.02), while no significant associations were found between sociodemographic characteristics and perceived barriers such as cost or insurance coverage and accessibility issues.

Table 5 shows the predictors of the perceived barrier “lack of a physician recommendation.” Unemployed women had significantly higher odds of perceiving a lack of physician recommendation as a barrier to breast cancer screening utilization (aOR, 4.339; 95% CI, 2.036–9.248; P < 0.001). However, other sociodemographic factors, such as age younger than 40 years and educational level (high school and undergraduate), lost their significance after adjustment.

An interaction variable between education and employment was included in the analysis; however, it was not statistically significant (P > 0.05) and did not meaningfully affect the significance of other variables. Therefore, this variable was excluded from the final analysis.

Table 6 shows the predictors of the perceived barrier “lack of knowledge.” Women younger than 40 years (aOR, 1.585; 95% CI, 1.108–2.267; P = 0.012) and married women (aOR, 1.588; 95% CI, 1.077–2.341; P = 0.019) were significantly more likely to perceive lack of knowledge as a barrier to breast cancer screening utilization.

In the crude analysis, an undergraduate education (cOR, 1.63; 95% CI, 1.10–2.41; P = 0.014), unemployment (cOR, 2.25; 95% CI, 1.22–4.14; P = 0.009), and employment in a non-healthcare field (cOR, 2.03; 95% CI, 1.05–3.95; P = 0.036) were significantly associated with perceiving a lack of knowledge as a barrier.

These associations were not sustained after adjustment. Additionally, an interaction term between education and employment was included in the analysis, where women with an undergraduate education who were unemployed had significantly higher odds of reporting lack of knowledge as a perceived barrier (aOR, 4.089; 95% CI, 1.132–14.767; P = 0.032).

Overall, this study found that perceived barriers such as cost or insurance coverage and lack of a physician recommendation had a significant impact on the utilization of breast cancer screening. Additionally, sociodemographic factors such as employment status significantly influenced the perception of a lack of physician recommendation as a barrier; likewise, age and marital status were significantly associated with perceiving a lack of knowledge as a barrier.

The results of the present study showed that women who did not report a lack of knowledge as a perceived barrier had about 1.5 times higher odds of utilizing breast cancer screening compared to those who did. This suggests that knowledge plays a significant role in screening uptake. However, a study conducted by Othman et al. in Yemen found that women with insufficient knowledge about breast cancer were 47% less likely to avoid screening, indicating a higher likelihood of participation despite limited knowledge.24 In contrast, in a study by Albadawi among women in Jordan, it was observed that women who recognized the benefits of screening were 2.44 times more likely to undergo it.22

Differences in these findings may be attributable to variations in healthcare system accessibility, age distribution of the study populations, and external factors, such as the influence of family and friends.

Likewise, a study by Abdulelah et al. found that insufficient knowledge about screening methods is a significant obstacle to breast cancer screening, suggesting that awareness of breast cancer risks and available screening techniques is crucial for encouraging participation.25

The present study also found that a lack of physician recommendations is one of the strongest predictors among all barriers. Similarly, in a study by Abdullah et al. among women attending an urban university primary care clinic, physician recommendation was the strongest predictor, with women being 7.61 times more likely to undergo a mammogram when advised by their physician. This shows the role physicians play when it comes to screening uptake, regardless of the time and place.26

In the current study, although the crude odds ratio indicated a significant association between fear or anxiety and reduced screening uptake, this association was no longer significant after adjustment, suggesting the influence of confounding factors. In contrast, research by Salama et al. on Egyptian women found that fear of embarrassment (aOR, 2.6; 95% CI, 1.4–5.1; P = 0.004) and fear of a positive result (aOR, 2.4; 95% CI, 1.3–4.7; P = 0.008) were significant barriers to breast cancer screening. These differences suggest that fear and anxiety may act as stronger deterrents in specific cultural or regional contexts.27 Studies have shown that fear can arise from either emotional responses or information gaps. For instance, one study reported that fear was due to concerns about dying, undergoing surgery, and threats such as divorce or infertility, reflecting both emotional and informational gaps.28 Another study reported that anxiety was due to pain during the procedure and side effects of radiation during mammography, indicating a link between anxiety and misconceptions about breast cancer screening.29 Therefore, proper education about breast cancer screening, along with support from family and friends, can help reduce the impact of fear as a barrier.

In the present study, women who did not report concerns related to cost or insurance were approximately 1.8 times more likely to undergo breast cancer screening compared with those who did. These findings underscore the importance of financial accessibility in promoting participation. Similarly, a study by Hughes et al. revealed that women with copay-focused insurance plans underwent 24 fewer diagnostic breast imaging procedures per 1000 women than those with coinsurance-focused plans (estimate, −0.024; 95% CI, −0.037 to −0.011). Women with deductible-based plans also received 16 fewer procedures per 1000 (estimate, −0.016; 95% CI, −0.028 to −0.005). Both results were statistically significant, suggesting that higher out-of-pocket expenses are linked to a notable decline in follow-up diagnostic imaging after initial mammograms.30

However, contradictory findings have been reported by Mottram et al., who found that although higher socioeconomic status and income were associated with higher screening attendance, the findings were not statistically significant compared with women of intermediate socioeconomic status.31 This suggests that nonfinancial factors, such as a woman’s perceived need and health literacy, may also play a role, as those who perceive themselves to be at lower risk may be less likely to seek care, regardless of income.

The present study found that unemployed women had 4.3 times higher odds of viewing the lack of a physician recommendation as a barrier to breast cancer screening. These findings align with research by Abdel-Salam et al. in Saudi Arabia, where women with a monthly income of less than 7000 SAR were significantly more likely to report higher perceived barriers to screening (B=−0.803, P = 0.037). Likewise, a study by Salama et al. involving Egyptian women found that unemployed women had a 3.5-fold higher probability of skipping mammography screening, underscoring the critical role economic stability plays in a woman’s decision to engage with breast cancer screening programs.18,32

The current study also found that while women with an undergraduate education, unemployed women, and women working in a non-healthcare field initially appeared to have higher odds of perceiving lack of knowledge as a barrier, this association was no longer statistically significant after adjustment. Similarly, neither age nor education level showed any significant association in the adjusted analysis for perceiving a lack of physician recommendation as a barrier. These results suggest that factors other than employment, educational level, and age may play a more important role in perceiving barriers to breast cancer screening. This aligns with the findings of a study by Joho et al. on women in Tanzania, where no statistically significant differences were observed based on age or educational attainment.17

However, a study by Anaba et al. found that women with no education were the least likely to participate in breast cancer screening. Conversely, higher education showed a strong positive association with screening uptake (cOR, 8.96; aOR, 6.17).33

Given the conflicting results in the literature, further research is needed to determine whether educational attainment is a significant barrier to screening uptake.

In the present study, women younger than 40 years were significantly more likely to perceive a lack of knowledge as a barrier to breast cancer screening. Consistent with this finding, another study on young Black women reported widespread knowledge gaps concerning breast cancer prevention.34 Similarly, a study involving mostly women aged 18 to 34 years found that inadequate knowledge about breast cancer was a commonly perceived barrier.17 Furthermore, a Saudi Arabia-based study demonstrated a significant association between age and lower awareness regarding mammograms.20 Collectively, these findings underscore the challenges of insufficient breast cancer knowledge among young women, representing a critical barrier to early diagnosis.

In addition, married women in the current study exhibited higher odds of perceiving a lack of knowledge as a barrier to breast cancer screening. This contrasts with findings from a study in the UAE, where married women had a higher level of breast cancer knowledge compared with unmarried women.35 Similarly, a study in Yemen reported that single women were less likely to be aware of breast cancer than married women.24 These divergent findings suggest that, although married women may have greater levels of knowledge, their awareness of their own knowledge gaps may contribute to the perception of lack of knowledge as a significant barrier.

This study identifies key barriers to breast cancer screening in the UAE, with insurance coverage and physician recommendations being significant predictors of participation. Additionally, significant predictors of perceived barriers, such as employment, age, and marital status, underscore the role of sociodemographic factors in shaping women’s perceptions of breast cancer screening. These findings emphasize the need for comprehensive strategies, such as community initiatives, awareness campaigns, and active engagement by healthcare professionals, to close the gaps hindering early detection. Future studies should explore these issues in more depth across diverse populations to tailor interventions accordingly.

This study identified cost or insurance issues and lack of physician recommendation as significant perceived barriers that influenced the utilization of breast cancer screening. Additionally, sociodemographic factors such as employment, age, and marital status were significantly associated with perceiving these barriers. Addressing these barriers by targeting specific sociodemographic groups and increasing awareness can promote early detection by improving screening rates. Future studies should explore a wider range of barriers and influencing factors to address existing gaps in the literature.