Understanding breast cancer causes: insights from Jordanian women's awareness.

1.
Introduction
Breast cancer (BC) has become the most prevalent cancer among females worldwide, surpassing lung cancer and accounting for 11.7% of cases. It is followed by colorectal cancer (10.0%), prostate cancer (7.3%), and stomach cancer (5.6%) [1]. Although BC is the second most common cause of cancer-related deaths for women worldwide and the most commonly diagnosed cancer, there are notable differences in incidence and treatment across different countries [2]. Survival rates have been improved in developed countries by early detection, accessible diagnostics, and effective treatments. However, in less developed countries, BC is often detected at more advanced stages [2].
In Jordan, BC is the third leading cause of cancer-related deaths, following lung and colorectal cancers [3]. Jordanian women often lack sufficient knowledge about BC symptoms, diagnostic procedures, and management strategies [3]. Moreover, BC in Jordan is typically diagnosed at younger ages and more advanced stages compared to Western countries, with the median age of diagnosis in Arab countries being about ten years younger than in the West [4]. Significant regional variations in BC demographics and diagnostic trends are shown in the average age of BC presentation in Jordan and the surrounding Arab countries, which is 45.4 years, with the highest prevalence among women between the ages of 40 and 50 [5–9].
In Jordan, there are screening techniques available, although participation is still low. In October 2023, for instance, only 10,000 women used the free mammograms offered by the Jordan BC Program (JBCP), and 93.6% of Jordanian and Syrian refugee women aged 40 and over said they had never had a mammogram (Atrooz et al., 2023). These difficulties highlight the importance of increasing public awareness, advancing understanding of risk factors and early warning signs, and facilitating access to early detection techniques.
1.1.
BC causes
The adoption of specific behaviors and modifications in lifestyle can effectively reduce the likelihood of getting BC [10,11]. Various factors, including hormonal imbalances, lifestyle behaviors, and environmental exposures, can influence the etiology of BC [10,12–14]. The primary unmodifiable causes associated with the likelihood of developing BC include gender, older age, and the presence of inherited genetic mutations [15–17]. The incidence of BC is positively correlated with older age since most BC cases are detected in individuals aged 50 and beyond [15–17]. Individuals who possess the most widely recognized genes, namely BC gene 1 (BRCA1) and BC gene 2 (BRCA2), experience a notably increased susceptibility to the development of BC [18]. Among Jordanian females, 12.2% had pathogenic/likely pathogenic BRCA1 or BRCA2 mutations (Abdel-Razeq et al. 2021). Furthermore, it has been observed that women previously diagnosed with BC have a higher chance of experiencing a recurrence of the disease [15–17]. Certain benign breast conditions, such as atypical ductal hyperplasia or lobular carcinoma in situ, are correlated with increased susceptibility to developing BC [15–17]. Additionally, the risk of developing BC in women is elevated when they have a first-degree relative, such as a mother, sister, or daughter, diagnosed with breast or ovarian cancer [15–17]. The risk may also increase if there are many cases of breast or ovarian cancer among relatives on the family’s maternal and paternal sides [15–17,19].
Additional non-modifiable causes that associate with the risk of BC include the onset of menstrual periods before the age of 12 and the occurrence of menopause after the age of 55 [15–17]. Moreover, BC may be heightened by the initial occurrence of pregnancy after age 30, and women who undergo childbirth at an age younger than 24 experience a reduction in their overall risk of getting BC (Albrektsen et al. 2005; Russo et al. 2005). Further pregnancies have enhanced this protective effect (Albrektsen et al. 2005; Russo et al. 2005). On the other hand, there has been a recognized correlation between nulliparity and a heightened susceptibility to specific reproductive cancers, such as breast, ovarian, and uterine cancers (Gleicher 2013).
According to existing research, there is evidence to suggest that the use of oral contraceptives by women is associated with an increased probability of developing BC [20–22]. Nevertheless, the risk of BC diminishes upon oral contraceptive use discontinuation, and the women’s susceptibility to BC reverts to the baseline level after years of cessation [20,22]. Furthermore, the utilization of hormone replacement treatment (HRT) is correlated with a heightened susceptibility to the development of BC [23–25]. The prevalence of HRT usage among Jordanian women, based on a recent study, is 14.3% (Albeitawi et al. 2024). The duration of HRT use appears to determine the risk of developing BC; it is suggested that HRT use for less than one year does not increase BC risk [23–25]. However, for individuals who engage in HRT for over one year, the likelihood of developing BC is reportedly higher compared to women who have never utilized HRT [23–25].
Regarding the modifiable causes, a positive correlation exists between women’s lack of physical activity and increased susceptibility to developing BC [15–17,19]. According to existing research, there is an increased susceptibility to BC among older women who are classified as overweight or obese as compared to those who maintain a healthy weight [15–17,19]. In Jordan, there is a lack of studies specifically addressing the prevalence of physical activity among females. However, a national study found that only 12.5% of adults engage in regular physical activity, even though 55.9% are aware of the recommended exercise guidelines (Beni Yonis et al. 2020). On the other hand, according to existing research, it has been indicated that additional variables, including smoking and exposure to chemicals, may associate to the development of BC [26–28]. As of 2024, the most recent data on the prevalence of smoking among females in Jordan indicates a rate of around 13.4% in 2022. This number is projected to increase to 13.9% by 2025 and 15% by 2030. These estimates are based on trends observed in previous years. For instance, the prevalence of tobacco smoking among females in Jordan increased from 5.7% in 2007 to 10.8% in 2019 (Khader 2023). The consumption of alcohol also is continuously associated with an increased risk, even at levels below 10–15 grams per day [29]. Additionally, some evidence, albeit less robust, indicates a correlation between alcohol consumption and the development of benign breast disease as well as heightened breast density. These causes have the potential to function as early signs of susceptibility to BC [29].

2.
Methods
2.1.
Study design and data collection
A cross-sectional survey was conducted in Jordan between November 2022 and November 2023 via Google Forms to evaluate Jordanian women’s awareness and knowledge of BC, including its causes. The survey was disseminated online via Facebook and WhatsApp, using a snowball sampling method. Participants who completed the survey were encouraged to refer others to take part. At the start of the survey, participants were asked to confirm their willingness to participate. To minimize self-reporting bias, assurances were provided regarding the voluntary nature of participation and the anonymity and confidentiality of responses.
The introductory section of the questionnaire outlined the study’s objectives and methodology, emphasizing the commitment to protecting participants’ privacy. Only those who agreed to participate were granted access to the questionnaire, while those who declined were excluded. The survey was designed to be neutral, avoiding any biased or discriminatory questions. Since Arabic is the primary language spoken in Jordan, the survey was conducted in this native language. It featured a mix of closed-ended questions, including multiple-choice options such as “Yes,” “No,” or “Don’t know,” along with checkboxes allowing for multiple selections.

2.2.
Sample size
Using the Raosoft online calculator (http://www.raosoft.com/samplesize.html), the recommended minimum sample size was determined to be approximately 360 participants. This calculation ensures a 95% confidence level with a 5% margin of error. The survey was initially distributed to a target group of 800 Jordanian women, and ultimately, 381 participants were included to enhance the study’s relevance and applicability.

2.3.
Ethical consideration
The protocol of this study was approved by the Institutional Review Board (IRB) of the Hashemite University, Jordan (reference number: 20/9/2021/2022).

2.4.
Development of the survey questionnaire
The questionnaire included a 16-item section designed to assess participants’ knowledge of the causes of BC. These items were adapted from the Breast Cancer Awareness Measure (Breast CAM, Version 2), a validated tool developed by Cancer Research UK to assess awareness of breast cancer signs, risk factors, and related behaviors [30]. The original Breast CAM was developed through expert consultation, cognitive interviews, and psychometric testing, and has demonstrated good reliability and construct validity in population surveys. Although the instrument was originally designed in English, it has been successfully adapted and used in Arabic-speaking populations (e.g., Kuwait and Saudi Arabia) with similar cultural and linguistic contexts [31,32].
Content validation was conducted through expert review by eleven public health and oncology professionals. Although no formal pilot test was undertaken, minor wording adjustments were made based on expert input to improve comprehension and relevance. To evaluate internal consistency, Cronbach’s alpha was calculated for the 16-item knowledge scale, yielding a value of 0.788, indicating acceptable reliability.
The questionnaires were designed to collect descriptive data on participants’ demographic characteristics and health history, including age, education level, marital status, and a history of BC. Participants’ responses focused on the causes of BC, with a specific focus on their responses to Likert-scale items. Demographic information included variables such as gender, age, nationality, place of residence, whether the participant had children, and their primary occupation. Health history encompassed records of previous or current breast-related issues and familial medical history.
Another section of the questionnaire addressed the factors associated with the risk of developing BC. These factors included a positive family history, larger or denser breast tissue, early onset of menstruation, delayed menopause, oral contraceptive use, breastfeeding, hormone replacement therapy, exposure to radiation during early life, delayed pregnancy, regular self-examinations, and dietary habits such as high-fat food and alcohol consumption. The questionnaire was developed by carefully selecting and formulating interconnected questions based on a comprehensive scholarly literature review.

2.5.
Data analysis
All data were coded and entered into a tailored database created using IBM SPSS Statistics (V26.0, IBM, NY, USA) for statistical analysis. Descriptive statistics were used to summarize participant characteristics, such as age, educational level, and area of residence, as well as responses to various questionnaire items, including those measured on Likert scales. Responses to questionnaire items related to the “causes of BC” were analyzed.
Participants’ knowledge of BC causes was assessed using a 3-point Likert scale (Yes = 3, Don’t know = 2, No = 1). For negatively worded statements, reverse scoring was applied to ensure that higher scores consistently reflected correct knowledge. The total knowledge score ranged from 16 to 48, with higher scores indicating greater knowledge. This method preserves the gradation between incorrect, uncertain, and correct responses and aligns with previously published adaptations of the Breast CAM [31].
Using Bloom’s cutoff criteria, knowledge levels were classified as follows: “good knowledge” for scores between 80–100% (38.4–48 points), “neutral knowledge” for scores between 60–79% (28.8–38.3 points), and “poor knowledge” for scores below 60% (less than 28.8 points). Although not psychometrically validated, this approach is widely used in public health survey research to enable categorical comparisons of knowledge levels [33,34].
The Kolmogorov-Smirnov test was employed to evaluate the normality of variable distributions. Associations between participants’ demographic characteristics and their knowledge of the causes of BC were analyzed using Pearson’s Chi-square test or Fisher’s Exact test, as appropriate.
To examine the association between sociodemographic factors and participants’ level of knowledge about BC causes, an ordinal logistic regression model was applied, as the outcome variable (knowledge level) was measured on an ordered scale (e.g., poor, neutral, good). The model was assessed for overall significance using the likelihood ratio chi-square test comparing the final model to the intercept-only model. Model fit was evaluated using the deviance goodness-of-fit test, and the assumption of proportional odds was verified using the Test of Parallel Lines. The strength of association for each predictor was expressed as an odds ratio (OR) with a 95% confidence interval (CI), derived by exponentiating the regression coefficient (B). For all analysis, statistical significance was set at P < 0.05.

3.
Results
3.1.
Participants’ socio-demographic characteristics
A total of 381 female participants completed the questionnaire and were included in the study, yielding a response rate of 47.6%. The majority of participants, 61.4%, were aged between 20 and 30 years. This age group is predominant, reflecting the study’s emphasis on increasing BC awareness among younger populations, as early education plays a vital role in fostering lifelong health habits and reducing future disease risks. Regarding religious affiliation, 99.5% of participants identified as Muslim, with the remaining 0.5% as Christian. Among the participants, 28.6% were married, with three having no children. Of those married and with children, only 3.1% had five or more children. A smaller proportion, 21.3%, were employed, with 10.8% in non-governmental jobs, 9.2% in government positions, and 1.3% self-employed. Regarding education, 57.5% of participants held an undergraduate degree from public or private universities, while 6.3% pursued postgraduate education. About 70.6% of the participants reported a monthly income of less than one thousand dollars, as shown in Table 1.

3.2.
Participants’ health history characteristics
The majority of women in the study reported no current breast-related issues (91.6%) or any previous history of such concerns (85.5%). The study also found that 0.5% of participants had been diagnosed with breast, colon, or lung cancer, as well as other types of cancer. In contrast, approximately 23.6% of the women had been diagnosed with different forms of cancer. Many women reported cancer cases among their first or second-degree relatives (12.1% in first-degree relatives and 26.8% in second-degree relatives) and among their friends (15.8%). A large proportion of women (82.2%) indicated that no members of their family had been diagnosed with ovarian, breast, colon, lung, pancreatic, brain, or prostate cancers. According to Table 2, only 10% of the female participants reported having a family history of BC before the age of 50.

3.3.
Participants’ responses to statements in the questionnaire
Table 3 presents the participants’ responses to statements categorized into two main factors: the causes of BC. Notably, a large percentage of participants agreed with the statements “Regular breast examinations at consistent intervals improve the prognosis of BC” and “A positive family history of BC increases the likelihood of developing BC,” with agreement rates of 93.7% and 92.1%, respectively. The statement “Having contact with a person who has BC raises the risk of developing BC” garnered the lowest agreement, with only 7.6%. About 69.3% of participants believed that long-term use of hormonal replacement therapy is linked to a higher risk of BC. Similarly, 66.1% thought that having cancer in one breast lowers the chances of developing BC. The table also shows the level of agreement on five other factors potentially associated with an increased BC risk. These include current use of oral contraceptives (69.3%), consumption of fatty foods (61.7%), alcohol use (60.9%), lack of breastfeeding (57.5%), and null parity, or not having children (56.4%).

3.4.
The level of participants’ knowledge about the causes of BC
A higher mean score for each factor in the questionnaire reflects a strong level of knowledge among women about the causes of BC (36.8 ± 5.3). As shown in Table 4 below, nearly 40% (39.9%) of participants demonstrated a good understanding of the causes of BC. The majority were neutral about their knowledge of the causes (52.8%), while a small percentage (7.3%) had limited knowledge regarding the causes of BC.

3.5.
The sociodemographic determinants of participants’ knowledge about the causes of BC
Religion, education level, and family income did not have a statistically significant impact on participants’ knowledge about the causes of BC (P > 0.05). Table 5 presents the results of Pearson Chi-square or Fisher’s Exact test, highlighting statistically significant associations between various factors and participants’ knowledge about the causes of BC. Significant associations were found between the level of knowledge and participants’ marital status (P = 0.000), age (P = 0.035), place of residence (P = 0.015), presence of children (P = 0.000), number of children (P = 0.000), and specialty (P = 0.000). Participants with a better understanding of the causes of BC were more likely to be single, aged 20 to 30 years, reside in the central or western regions of Jordan, have no children, and have studied pharmacy (Table 5).
Almost all of the participants’ health history characteristics did not statistically affect their knowledge about the causes of BC (P > 0.05). Supplementary Table 3 presents the results of Pearson Chi-square or Fisher’s Exact test, highlighting the statistically significant associations between various factors and participants’ knowledge of the causes of BC. Significant associations were found between knowledge levels and the presence of a cancer diagnosis (P = 0.020) and whether a family member or close friend had been diagnosed with cancer (P = 0.035). Participants with better knowledge about the causes of BC were more likely to be free of malignant diseases and unaware of any family members or close friends diagnosed with cancer (Supplementary Table 3).

3.6.
Predictors associated with knowledge of BC causes among Jordanian women
An ordinal logistic regression was conducted to identify sociodemographic predictors of BC knowledge levels among Jordanian women. The model demonstrated a statistically significant improvement over the intercept-only model (χ2 = 49.75, df = 17, p < 0.001), indicating that the included predictors collectively explained a significant amount of variance in knowledge levels. Model adequacy was confirmed by the goodness-of-fit statistics: the deviance test was non-significant (χ2 = 153.72, df = 129, p = 0.068), suggesting a good fit to the data. The assumption of proportional odds was also met, as shown by the Test of Parallel Lines (χ2 = 20.65, df = 17, p = 0.242), supporting the use of a single set of coefficients across all thresholds of the outcome variable. The model’s explanatory power, reflected by the Nagelkerke pseudo R2, was 0.147, indicating that approximately 14.7% of the variability in BC knowledge level was explained by the included predictors.
Among the predictors, age and educational level were significantly associated with BC knowledge. Women aged 41–50 years were significantly more likely to have higher knowledge than those aged 51 or older (OR = 5.23, 95% CI: 1.05–26.1, p = 0.044). Regarding education, respondents with a diploma degree were significantly less likely to be in a higher knowledge category compared to those with postgraduate education (OR = 0.09, 95% CI: 0.02–0.47, p = 0.004).
Other predictors, including marital status, specialty, and most other age and education groups, were not statistically significant. For example, being single or married was not independently associated with knowledge levels after controlling for other variables (p = 0.181 and P = 0.585, respectively). Although women with only a high school education had lower odds of better knowledge (OR = 0.365), this finding approached but did not reach statistical significance (p = 0.054) (Supplementary Table 4).

4.
Discussion
The current study was undertaken among a cohort of Jordanian women to assess the prevailing knowledge and awareness of BC’s causes. This is crucial in facilitating the timely identification of cases and reducing mortality rates associated with the disease. The disease’s occurrence percentage can be ascribed to many circumstances, including insufficient levels of education, misconceptions, and delayed diagnosis [35].
The substantial percentage of pharmacy students (64.8%) in this survey significantly affected the overall knowledge results. The awareness levels of these participants, who have received formal medical education, do not fully reflect the baseline knowledge of the Jordanian population as a whole. Although the finding that nearly 40% of the sample possesses excellent knowledge appears favorable, this statistic likely overstates the level of awareness among non-medically trained women. This indicates that, outside of health-related academic settings, awareness of the causal aspects of BC is alarmingly deficient in the general population.
This study revealed a significant and somewhat unexpected finding: women without a personal or familial history of cancer demonstrated markedly higher knowledge on the etiology of BC (p = 0.035). Similarly, participants who reported not knowing whether close family members or friends had been diagnosed with cancer also exhibited higher knowledge scores (p = 0.035). While these results may initially appear counterintuitive, they are likely explained by underlying confounding factors, particularly age and educational background. Many of the participants in these categories were younger (aged 20–30) and enrolled in pharmacy programs, where formal academic training likely contributed to greater awareness. This suggests that academic health literacy may have a stronger influence on knowledge levels than experiential exposure to cancer. In contemporary Jordan, younger women studying health-related fields are more likely to access up-to-date information through university curricula and digital health resources. Thus, formal education appears to be a more reliable determinant of BC knowledge than personal or familial cancer experience in this context. These findings highlight the importance of adjusting for sociodemographic variables when interpreting bivariate associations and underscore the influential role of structured academic programs in promoting cancer awareness.
A significant theme arising from our findings is the divergence between overall knowledge scores and particular clinical misunderstandings. A notable percentage of participants (39.9%) were classified as possessing ‘excellent’ knowledge; yet, a considerable majority (66.1%) erroneously affirmed that having BC in one breast diminishes the probability of obtaining a new malignancy in the other. This discovery is very troubling, as it signifies a significant medical mistake that opposes known clinical information indicating the heightened risk of contralateral BC. The existence of a prevalent misconception—despite generally high awareness levels—indicates that Jordanian women may exhibit ‘superficial health literacy,’ recognizing basic terms while misinterpreting specific clinical risk profiles. This contradiction underscores a significant deficiency in public health education: elevated overall awareness ratings may unintentionally obscure perilous misconceptions that could foster a false sense of security and postpone care for the contralateral breast. Consequently, forthcoming health programs in Jordan must transition from broad awareness campaigns to an ‘educational recalibration’ that precisely addresses and dispels these high-risk clinical misconceptions.
The study revealed that somewhat fewer than two-fifths (39.9%) of them had a strong understanding of the causes of BC. This aligns with the results of a separate investigation conducted among women in Mwanza, Tanzania [36]. Comparable findings were observed in a study conducted in Iraq, focusing on an educated population, wherein approximately 50% of the sample exhibited a low level of awareness of BC [37]. Further research was undertaken to examine younger women and university students with advanced education in several countries to ascertain if they exhibited heightened levels of knowledge [38,39]. The outcomes yielded were unsatisfactory, and the limited awareness observed in different countries is a notable concern [38–40]. Our results are notably lower than the awareness levels reported by Martínez et al. (2017) and Zhai et al. (2019), suggesting that regional educational gaps remain a significant barrier [41,42].
While initial bivariate analysis suggested that unmarried women had greater awareness of BC causes compared to their married counterparts, this relationship did not persist after adjustment for confounding variables in the multivariate ordinal logistic regression model. Specifically, marital status was not a statistically significant predictor of knowledge levels once age, education, and specialty were accounted for. The apparent difference in awareness between married and unmarried women is therefore likely explained by underlying sociodemographic factors. In this study, married women tended to be older, less likely to be current students, and more often outside academic or professional health-related environments. Within the Jordanian socio-cultural context, they are also more likely to carry significant caregiving and household responsibilities, which may limit opportunities for proactive health engagement and access to current medical information. As such, marital status in this context may act as a proxy for factors like age-related information attrition, reduced educational exposure, and time constraints, rather than functioning as an independent predictor of low BC knowledge. These findings highlight the importance of interpreting demographic associations within a broader framework of education, age, and gendered social roles, and caution against attributing disparities in health knowledge to marital status alone.
In our study, a significant majority of the participants, precisely 94%, demonstrated awareness regarding the positive correlation between early detection and improved survival rates and the treatability of BC when detected in its early stages. The findings of research conducted in Pakistan [43] and Singapore [44] were consistent. Nevertheless, it is worth mentioning that the female participants in our study exhibit an understanding of the potential benefits of early radiation exposure in the development of BC (p < 0.05). This observation aligns with previous research findings that indicate a positive association between radiation exposure during the early stages of life and an increased incidence of BC [45,46].
When considering the factors that impact the probability of developing BC, it is seen that there is a correlation between larger breast density in women and an increased vulnerability to this disease [47]. The likelihood of developing BC increases in women with dense breasts, characterized by a higher ratio of fibrous and glandular tissues than adipose tissue [48,49]. The findings of our study indicate that a notable fraction of participants have little knowledge regarding the correlation between larger breast density (15.5% of participants’ responses) and dense breast tissue (38.6% of participants’ responses) and an increased vulnerability to BC development. On the other hand, the results showed that there is a variation of the awareness and knowledge among participants regarding early menarche (25.7%), late menopause (34.9%), use of oral contraceptive pills (69.3%), lack of breastfeeding (57.5%), nulliparity (56.4%), and delayed pregnancy (11.8%). As demonstrated by several studies, these factors do, however, significantly correlate with an elevated risk of BC [22,50–55]. Evidence indicates that a 12-month breastfeeding period is linked to a statistically significant 4.3% decrease in the incidence of BC, per a study done in the UK [52]. Additionally, studies have shown that women who have two children and breastfeed both of them are 8.6% less likely to be at risk for BC [55]. Additionally, previous studies have demonstrated that women who give birth to their first child after the age of 30 face an elevated risk in comparison to those who have at least one child before the age of 30 [56].
Accordingly, advocating for the recognition of the importance of early cancer diagnosis necessitates the incorporation of educational modules on breast health, BC, and breast screening into the curricula of primary and secondary schools, as well as institutions of higher education. Moreover, maintaining up-to-date campaign information is crucial to increase the likelihood of women reporting any suspected concerns regarding BC and to ensure their understanding of the warning signs. As a result, this occurrence leads to the quick identification of the problem and improved therapeutic outcomes.
This research underscores a pivotal convergence between health literacy and public health initiatives. Our findings reveal a reasonable understanding of BC causes; however, it is crucial to recognize the significant ‘knowledge-practice gap’ in the Jordanian setting. Increased information does not necessarily lead to proactive screening, such as mammogram. Despite the provision of complimentary screenings via the JBCP, participation is exceedingly poor, with more than 90% of eligible women never having undergone a mammogram [57]. This gap is frequently influenced by socio-cultural obstacles, such as the ‘social stigma’ linked to a cancer diagnosis, fatalistic attitudes, and a profound fear of clinical environments [3]. Thus, our findings underscore that although enhancing knowledge is a fundamental prerequisite, it constitutes only the preliminary step toward behavioral transformation. Future public health programs in Jordan must transcend ‘theoretical education’ and focus on dismantling the psychological and structural impediments that prevent health-literate women from accessing life-saving screening services.

5.
Conclusions and limitations
This study aimed to assess Jordanian women’s awareness and knowledge of the causes of BC. The findings suggest that married women in the Jordanian community demonstrated a restricted comprehension of the causative factors and warning signs associated with the disease. Insufficient knowledge can lead individuals to postpone seeking treatment, which is particularly concerning given the high incidence of BC in Jordan. While further national research is required, these results underscore the need for intensified, targeted efforts to enhance women’s knowledge at both regional and national levels.
This study has several limitations that should be acknowledged. First, although the questionnaire was adapted from the validated Breast CAM and demonstrated acceptable internal consistency (Cronbach’s alpha = 0.788), a full psychometric validation, such as exploratory or confirmatory factor analysis, was not conducted. While the instrument was informed by prior literature and reviewed by experts, the lack of full validation may limit the assessment of construct validity and the generalizability of the findings. Second, using online snowball sampling through social media may have caused selection bias, which means that younger, tech-savvy, and college-educated women were more likely to be included in the study. It is important to note that 61.4% of the people who took part were between the ages of 20 and 30. As a result, the findings may not be applicable to the wider Jordanian female population, especially older women, those residing in rural areas, or individuals with restricted access to digital technologies. Third, a substantial proportion of the sample (64.8%) consisted of pharmacy students, whose formal medical training likely contributed to higher knowledge scores. This introduces a potential health-literacy bias, as the results may overestimate the general population’s awareness of BC causes. Consequently, the findings primarily reflect the knowledge levels of a health-literate, university-educated subgroup, rather than those of the broader Jordanian female population.
Fourth, cultural sensitivity and societal stigma surrounding BC in Jordan may have influenced participation and response patterns. Reluctance to engage with the topic was observed among some women, potentially contributing to non-response bias. Fifth, this study assessed self-reported knowledge rather than actual screening behaviors. Therefore, the findings do not capture the extent to which awareness translates into preventive practices, highlighting a potential knowledge–practice gap. Future research should employ probability-based sampling methods, such as stratified random sampling, and target more demographically diverse populations to enhance representativeness and external validity.
Finally, several potentially important sociodemographic variables—such as place of residence, presence and number of children, description of main work, and family income—were not included in the final regression model. These variables may have influenced BC knowledge levels and could act as confounders in the relationships between age, marital status, and other predictors. Their exclusion, due to concerns about multicollinearity and the need for model parsimony, may have reduced the comprehensiveness of the analysis. Future studies should consider incorporating a broader set of covariates to better capture the complex, multifactorial determinants of health knowledge.

Supplementary Material

Supplementary_tables_causes_of_BC_Revised.docx