Factors associated with breast self-examination practice among female medical students in selected universities in Borama, Somaliland

Introduction

Breast cancer is a global health crisis characterized by the uncontrolled proliferation of abnormal cells, having recently surpassed lung cancer as the most diagnosed malignancy worldwide with 2.3 million cases and 670,000 deaths in 2022 (1, 2). Projections suggest that by 2050, annual incidence will reach 3.2 million cases (3). While breast self-examination (BSE)—a screening method involving visual inspection and palpation to detect lumps or changes—was promoted as early as 1947 by Dr. A.M. Popma, its consistent practice remains a challenge (4). However, current evidence from systematic reviews and major health organizations, including the WHO, does not support BSE as an effective population-based screening method due to lack of demonstrated mortality benefit and increased risk of false positives and unnecessary biopsies. Early detection of breast cancer therefore relies on evidence-based approaches such as clinical breast examination and mammography, combined with increased awareness of warning signs (5–7).

In sub-Saharan Africa, the burden of breast cancer is severe; it is the leading cause of cancer death in Rwanda and Nigeria, where late-stage presentation is common due to limited treatment options (8, 9). Similar trends are observed in Uganda and Ethiopia, where rural women often prioritize traditional treatments over formal healthcare (10, 11). Although BSE is the most cost-effective screening tool for low-resource settings (12), practice rates across the continent remain low (13, 14). Even among healthcare professionals, who are expected to lead by example, consistency is lacking: practice rates vary from 75.5% in Eritrea to only 56.3% in Ethiopia (15, 16). In Somaliland, while 89% of healthcare professionals demonstrate strong knowledge of the disease, only a small percentage perform BSE correctly and at the proper time (17, 18).

The Health Belief Model (HBM) serves as the theoretical framework for this study, suggesting that individuals are more likely to engage in preventive behaviors like BSE if they perceive a significant health threat and believe the action will effectively reduce that threat (19). In this study, BSE practice is defined as a self-conducted, three-step screening method—visual inspection, palpation while lying down, and palpation while bathing—assessed by frequency, timing, and technique (20–22). Previous research in Ethiopia and Rwanda identifies socio-demographic factors, knowledge, and attitude as the primary drivers of BSE behavior (23–25). Consequently, this study operationalizes these variables to investigate the specific barriers and facilitators among female medical students in Borama.

Literature indicates that socio-demographic factors such as higher family income and older age significantly increase the likelihood of practicing BSE due to better resource access and cumulative medical education (26–28). However, knowledge gaps persist; while many women have “heard” of breast cancer through media, fewer understand the specific timing—such as 3–5 days post-menses—or the correct monthly frequency (23, 29). Furthermore, a good understanding of risk factors like family history or alcohol consumption is strongly correlated with regular practice (28). Getu and colleagues found that students who recognized that early detection improves survival were more likely to perform screenings, yet awareness of the methods themselves remained moderate at 54.1% (29).

Finally, attitude serves as a pivotal predictor of BSE performance. Students with a positive attitude toward BSE are up to 4.6 times more likely to practice it than those with poor attitudes (25). A favorable attitude encourages women to seek further health information, creating a positive feedback loop between knowledge and practice (24, 29). In Borama, Somaliland, there is a total absence of recorded data regarding BSE practice in the Ministry of Health's HIMS office. Preliminary researcher data suggests that while 58% of local female medical students practice BSE, 42% do not, despite their medical training. This study addresses this gap by investigating the factors associated with BSE practice among these students, aiming to reduce breast cancer morbidity and mortality in the region.

Conceptual framework of BSE practice and its associated factors

The conceptual framework in Figure 1 for Breast Self-Examination (BSE) practice explains the relationship between a set of independent variables and the dependent outcome of BSE behavior. The framework identifies sociodemographic factors, specifically family income level and age, as foundational influences that may shape a woman's health-seeking behaviors and access to resources. These factors interact with a second category of independent variables: knowledge on BSE and breast cancer. This domain includes the information women have received about BSE and breast cancer, their awareness of the importance of early detection methods (particularly BSE), and their familiarity with breast cancer risk factors. Such knowledge, however, is posited to be insufficient in isolation; it is further mediated by attitude, which includes the perceived importance of BSE, self-efficacy in promoting BSE (the confidence to perform the examination correctly), and an individual's perceived control over her own health. Collectively, these independent variables—sociodemographic background, knowledge base, and attitudinal disposition—are theorized to directly influence the dependent variable, which is Breast Self-Examination practice (Figure 1).

Materials and methods

Study setting and design

A cross-sectional survey research approach was used in this study to investigate the factors associated with breast self-examination practice. Given the resource constraints inherent in student-led research, this approach provided a time- and cost-efficient strategy for capturing a snapshot of current decision-making processes. This methodology allowed for the investigation of relationships between multiple variables without altering the study environment, providing critical insights into the behaviors of this specific population.

Study population and study area

The study population of this study was female students attending medical departments of Amoud and Adal universities in Borama for investigating factors associated with breast self-examination practice. The target population of this study was 506 female students attending medical departments of Amoud and Adal universities in Borama. This study was conducted in medical universities in Borama. It is the capital and the largest city of the northwestern Awdal region of Somaliland. Borama is located 117.3 km west of Hargeisa. Borama has a total population of 640,000 as reported by the Ministry of Health and Development. Borama, a city renowned for its educational achievements, stands out as a hub of learning in Somaliland, boasting the highest primary school net enrollment ratio at 46.9% and secondary school net enrollment ratio at 23.4%, reflecting its commitment to education (30). Beyond its academic excellence, the city thrives economically through vibrant businesses, including retail, trade, and small-scale enterprises, which play a pivotal role in its economic development. However, despite its educational prominence, challenges remain in health practices, as demonstrated by the fact that only 58% of medical students in Borama practice breast self-examination in the preliminary phase of this study, even though they possess adequate knowledge on the subject. This gap underscores the need for this study in Borama universities.

Sample and sampling techniques

This study utilized convenience sampling with proportional quotas to ensure institutional representation. The target population comprised 506 female medical students (326 from Amoud University and 180 from Adal University). The sample size was calculated using the Schwartz formula with a 95% confidence interval, a 5% margin of error, and an expected BSE practice proportion of 50% (from preliminary data). This calculation yielded a minimum required sample of 196. Accounting for a 10% non-response rate, the target sample size was set at 217. Based on this target, quotas were set at 64.4% for Amoud University (proportionate to 326/506) and 35.6% for Adal University (proportionate to 180/506). Out of the 217 students approached, 202 provided complete and usable data, yielding a high response rate of 93.1%. The 15 non-responses (6.9%) were primarily due to incomplete survey forms (n = 9) and time constraints during clinical rotations (n = 6). Because the non-respondents shared similar demographic and academic profiles with the final participants, the risk of significant non-response bias is considered minimal.

Research hypotheses

Based on the literature review, the following hypotheses were formulated:

• (H01a): There is no statistically significant association between age and the practice of breast self-examination among female medical students in selected universities in Borama, Somaliland.
• (H01b): There is no statistically significant association between family monthly income and the practice of breast self-examination among female medical students in selected universities in Borama, Somaliland.
• (H02): There is no statistically significant association between knowledge of breast self-examination and breast cancer and the practice of breast self-examination among female medical students in selected universities in Borama, Somaliland.
• (H03): There is no statistically significant association between attitude towards breast self-examination and the practice of breast self-examination among female medical students in selected universities in Borama, Somaliland.

Data collection methods and instruments

The main data collection method of this study was the questionnaire survey method. Since a structured questionnaire is a document that comprises a series of standardized questions with a predetermined scheme that sets the exact wording and sequence of the questions, it used to collect data from respondents. Higher levels of response and more accurate data result from this. Data collection occurred between April and May 2024.

Quality control: piloting, validity, and reliability

Piloting

The instrument was piloted in the department of health science students at Amoud University. The piloting helped the researcher to identify and correct anomalies in the tool before the main study. Therefore, it is expected to provide a correct reflection of the level of knowledge about breast self-examination practice and breast cancer risk factors. These groups share similar characteristics with the target population. The preliminary data came from an informal needs assessment conducted by the research team prior to the main study (n = 30, conducted in March 2024).

Validity of instruments

Validity was determined on content validity index (CVI) from items rated 3 and 4 by both judges as CVI = n3/4/N, where n3/4 are the items rated 3 or 4 by both judges, and N is the total items in the instrument (Oso, 2016); CVI = 19/22 = 0.86. A validity index of 0.86 was reported. Hence, the tools were valid since the validity index (0.86) was greater that the base validity index of 0.70 (70%) recommended in social science research (31). Therefore, the instruments produced adequate information needed to answer the research questions.

Reliability of instruments

The reliability of the instrument was assessed using Cronbach's Alpha, which yielded a coefficient of 0.850. This indicates good internal consistency and suggests that the instrument can be reliably used in similar research settings, meeting the benchmark of 0.7 for reliability (32, 33). This result confirms the reliability of the HBM-validated instrument and is consistent with findings from similar regional studies (16, 24).

Ethical considerations

This study involved human participants. Ethical approval was obtained from Amoud University School of Postgraduate Studies and Borama Regional Hospital (Reference No. BRH 55/2024). All participants provided written informed consent. The study was conducted in accordance with the Declaration of Helsinki.

Data analysis

The unprocessed data were transformed into an appropriate format for analysis and interpretation through a sequence of tasks including editing, coding, data entry, and tabulation. Data were analyzed using SPSS version 20. Descriptive statistics, including frequencies and percentages, were used to summarize the respondents' background characteristics and responses to key variables. Inferential statistics were performed to assess associations between independent variables (such as age, income, knowledge, and attitude) and the practice of breast self-examination. Logistic regression (simple and multiple) was applied to identify independent predictors of breast self-examination practice while controlling for potential confounders. Multicollinearity among independent variables was assessed using variance inflation factor (VIF), with mean VIF values below 2.0, indicating no significant multicollinearity. Variable selection was theory-driven based on the Health Belief Model and prior literature; all prespecified variables (age, income, knowledge, attitude) were entered into the multivariable model simultaneously. Results were presented in tables for clarity.

Results

Background information of respondents

The sociodemographic factors of the students in Table 1 shows that the study surveyed 202 female medical students, the majority of whom resided in Sheikh Ali (43.1%, n = 87), followed by Sheikh Makahil (23.3%), Sheikh Ahmed-Salan (18.8%), and Sheikh Osman (14.9%), a distribution likely influenced by local socioeconomic status and resource availability. Regarding marital status, 90.6% (n = 183) of participants were single, while 8.4% were married and 1.0% were divorced; the high proportion of single students suggests fewer domestic responsibilities, potentially facilitating a greater focus on preventive health behaviors compared to married counterparts. Institutional representation showed that 66.3% (n = 134) were enrolled at Amoud University and 33.7% (n = 68) at Adal University. Academically, the sample was dominated by students in their middle-to-senior years, with the highest participation from Year 4 (28.7%, n = 58) and Year 3 (25.2%), followed by Year 2 (19.8%), Year 5 (14.4%), and Year 1 (11.9%).

Table 1. Sociodemographic factor of the students.

Measurement of study variables (descriptive analysis)

The sociodemographic data reveals that the majority of respondents (82.7%) were between the ages of 20 and 24, while a smaller proportion (17.3%) fell within the 25–34 age group, indicating a predominantly young respondent population. In terms of family average monthly income, 43.6% reported a high income (above $500), 39.1% fell within the medium income range ($200–$500), and only 17.3% had a low income (below $200).

Knowledge was assessed using 7 multiple-choice items Table 2 Each correct answer was scored as 1, incorrect as 0, yielding a total score range of 0–7. Scores ≥6 (85.7%) were categorized as “high knowledge” for descriptive purposes, while the continuous score was used in regression.

Table 2. Knowledge of students about breast self-examination and breast cancer.

Multiple responses were permitted; percentages are based on total responses (n = 292).

Most respondents exhibited high breast cancer and BSE awareness (97.0%), primarily informed by university education (54.5%) and social media (24.3%). While 63.4% correctly identified the recommended starting age of 20–25 years, a near-unanimous 98.5% recognized that early detection improves survival. Despite a low reported family history (10.9%), a majority correctly identified all major risk factors (70.8%) and comprehensive BSE benefits (52.0%). These findings indicate robust institutional health promotion, though minor variations in knowledge suggest a need for more targeted education on specific risk factors. Attitude was assessed using four items (importance, feelings, confidence, and control). An overall positive attitude was defined as responding “agree/strongly agree” to the importance, confidence, and control questions, and “normal/comfortable” to the feelings question. The composite proportion of respondents with a positive attitude on all four items was 80.2% (162/202).

In Table 3 respondents demonstrated a universally positive attitude toward BSE importance (100% agreement), with 57.9% viewing it as routine and 23.8% feeling comfortable. Conversely, Only The 18.3% who reported discomfort may reflect cultural or psychological barriers; however, this was not directly measured. Further qualitative research is needed to explore these factors. Advocacy confidence was absolute (100%), while 99.5% believed BSE empowers women with health control. These results highlight a health-conscious cohort poised for peer-led advocacy despite minor cultural or educational barriers.

Table 3. Student's attitude towards breast self-examination practice.

Response scale for all items was a 4-point Likert scale (Strongly Agree, Agree, Disagree, Strongly Disagree; no neutral option). The 0% negative responses for the importance question accurately reflect unanimous participant agreement.

Table 4 demonstrates a total of 46.5% (n = 94) of respondents reported ever performing the examination. Among the subset of participants who practiced BSE, adherence to guidelines was high regarding timing but moderate regarding regularity: 87.2% (n = 82) correctly timed the examination post-menstruation, while 51.1% (n = 48) followed the recommended monthly frequency. Among those who had ever performed BSE (n = 94), 87.2% reported correct timing and 73.8% reported confidence in their technique.

Table 4. Students' breast self-examination practice level.

Measurement of study variables (inferential analysis)

Independent variables (knowledge, attitude, age, and income) were used in binary logistic regression (simple and multiple) identified significant predictive factors. Findings were quantified using odds ratios (ORs) and 95% confidence intervals to determine the primary drivers of preventive behavior. This dual-method approach provided a robust evaluation of factors influencing clinical adherence among female medical students.

Logistic regression identified age as a significant predictor of BSE practice (OR = 5.012, 95% CI: 1.978–12.705, p < 0.001), whereas income level showed no statistical significance (OR = 1.011, p = 0.957). While a unit increase in age category (20–24 was used as reference group) significantly raised the log odds of engagement (B = 1.612, Wald = 11.538), economic status remained non-influential. Age was identified as a significant predictor of BSE practice (OR = 5.012, 95% CI: 1.978–12.705, p < 0.001), whereas income level showed no statistical significance (OR = 1.011, p = 0.957). Thus, the null hypothesis was rejected for age but retained for income.

Logistic regression identified knowledge as a significant predictor of BSE practice (β = 0.149, Wald = 10.895, p < 0.001), with each unit increase in knowledge score is associated with a 16.1% increase in the odds of practicing BSE (OR = 1.161, 95% CI: 1.063–1.269). The significant constant (–2.764, p < 0.002) underscores the low likelihood of practice when knowledge levels are minimal. Consequently, the null hypothesis was rejected, establishing that medical awareness is a primary driver of clinical adherence. These findings suggest that targeted educational interventions are essential to bridge the gap between theory and self-care behavior.

Logistic regression identified attitude as a highly significant predictor of BSE practice (β = 1.179, Wald = 36.186, p < 0.001), with positive attitudes increasing the odds of engagement by 3.25 times (OR = 3.251, 95% CI: 2.214–4.774). The significant constant (–15.817, p < 0.05) underscores the low probability of performance among those with baseline negative attitudes. Consequently, the null hypothesis was rejected, establishing attitude as a primary driver of preventive health behavior. These findings suggest that fostering positive perceptions is essential for translating clinical awareness into consistent self-care practice.

Multicollinearity testing (VIF)

Prior to regression analysis, multicollinearity among independent variables was assessed using variance inflation factor (VIF) as shown in Table 8, with mean VIF values below 2.0, indicating no significant multicollinearity. According to the logistic regression results in Table 5, family monthly income had a coefficient (B) of 0.011 and a p-value of 0.957. Since the p-value was significantly greater than 0.05, the null hypothesis failed to be rejected for this variable, implying that within this study, family income level did not significantly influence the practice of BSE. This suggests that a unit increase in family income would not result in a notable change in the likelihood of a student performing the examination. Conversely, age was found to be a highly significant predictor, yielding a coefficient (B) of 1.612 and a p-value of 0.001. Since the p-value was less than 0.05, the null hypothesis was rejected for age, indicating a statistically significant association with BSE practice. The findings reveal that age is a strong determinant (OR = 5.012), implying that students in older age categories are over five times more likely to perform BSE compared to their younger counterparts. This likely reflects a scenario where increased academic maturity and cumulative clinical exposure lead to a higher adoption of preventive health behaviors.

• (H01): There is no statistically significant association between sociodemographic factors and the practice of breast self-examination among female medical students in selected universities in Borama, Somaliland.

• (H02): There is no statistically significant association between knowledge on breast self-examination and breast cancer and the practice of breast self-examination among female medical students in selected universities in Borama, Somaliland.

Table 5. Multiple logistic regression model of sociodemographic characteristics.

Significant at p < 0.05.

According to the results in Table 6, knowledge had a coefficient (B) of 0.149 and a p-value of 0.001. Since the p-value was less than 0.05, the null hypothesis was rejected, indicating that knowledge significantly influences the practice of BSE among the respondents. The findings reveal an odds ratio (OR) of 1.161 (95% CI: 1.063–1.269), implying that for every unit increase in a student's knowledge score, the likelihood of practicing BSE increases by 16.1%. While knowledge is established as a statistically significant driver of clinical adherence, the relatively low odds ratio suggests that while awareness is essential, it may not be sufficient on its own to ensure consistent practice without the support of other influential factors.

• (H03): There is no statistically significant association between attitude towards breast self-examination and the practice of breast self-examination among female medical students in selected universities in Borama, Somaliland.

Table 6. Binary logistic regression model of knowledge on BSE and BSE practice.

Significant at p < 0.05.

According to the results in Table 7, attitude had a coefficient (B) of 1.179 and a p-value of 0.000 (p < 0.001). Since the p-value was less than 0.05, the null hypothesis was rejected, establishing that attitude is a highly significant predictor of BSE practice. The findings reveal an odds ratio (OR) of 3.251 (95% CI: 2.214–4.774), indicating that students with a positive attitude toward the examination are over three times more likely to perform it than those with a poor or neutral attitude. These results imply that fostering positive perceptions and self-efficacy is the most critical factor for translating medical awareness into consistent health behavior, proving more influential than knowledge or sociodemographic variables alone.

Table 7. Binary logistic regression model of attitude towards BSE and BSE practice.

Significant at p < 0.05.

Table 8. Multicollinearity.

VIF of 1.64, indicating no serious multicollinearity among predictors.

Discussion

This study investigated the factors associated with breast self-examination (BSE) practice among female medical students in Borama, Somaliland, providing a vital baseline for health policy in a region currently lacking a centralized National Health Information Management System (HIMS) for breast cancer. As medical students represent the future frontline of the healthcare system, their engagement serves as a litmus test for the country's capacity to pivot toward preventive oncology. Among the sociodemographic factors examined, age was identified as a potent predictor, with older students being five times more likely to practice BSE than their younger counterparts (OR = 5.012, p < 0.001). This trend aligns with research by (28) suggesting that BSE adherence increases with academic maturity and cumulative clinical exposure, which reinforces “perceived susceptibility” under the Health Belief Model (HBM). Interestingly, family income showed no significant association with BSE practice (p = 0.957), diverging from general population studies (26, 27). This may suggest that the university environment is associated with a reduction in socioeconomic disparities, where shared access to a specialized curriculum could reduce the economic barriers typically encountered by the public, potentially indicating that educational immersion is more strongly associated with behavior than financial resources.

Despite the socioeconomic equalization provided by medical education, a significant “know-do gap” was observed among respondents. While 97% had received prior information and 77.7% demonstrated high knowledge levels, only 46.5% engaged in consistent practice. Notably, among those who practiced BSE (n = 94), 30.8% reported weekly practice, exceeding the recommended monthly frequency. While this indicates proactive behavior, it may also reflect misunderstanding of guidelines or health anxiety, warranting further investigation. Although logistic regression confirmed that increased knowledge significantly raised the odds of practice (OR = 1.161, p < 0.001; as shown in Table 6), theoretical awareness clearly was not consistently associated with behavioral action. This discrepancy supports observations by (23, 29) and mirrors findings from Rwanda (24), where healthcare professionals exhibited high theoretical knowledge but lacked proficiency in practical application. These results emphasize that information dissemination through academic channels is merely a precursor; without practical, hands-on training to address the nuances of timing and technique, abstract knowledge fails to translate into a sustained health habit.

The study found that attitude was the factor most strongly associated with BSE practice (as shown in Table 6). which aligns with the Health Belief Model (HBM) constructs of perceived benefits and perceived barriers. While 77.7% of students possess high knowledge, the “know-do” gap suggests that knowledge alone does not serve as a sufficient cue to action.

Furthermore, the 18.3% of respondents reporting discomfort during the exam represents a significant perceived barrier that outweighs their perceived susceptibility. This suggests that even if a student knows she is at risk (susceptibility), the psychological barrier of cultural discomfort or fear of finding a lump (barriers) is associated with lower likelihood of transitioning to practice in this sample. This suggests that despite high medical literacy, cultural modesty acts as a significant “Perceived Barrier” that requires targeted desensitization through clinical simulation. Our finding that age/seniority is a predictor (OR = 5.012) is consistent with the HBM; it could indicate that as students progress through clinical years, witnessing the severity of late-stage cancer cases may be associated with heightened perceived severity, which in turn may be related to overcoming barriers to practice. However, longitudinal research would be needed to confirm this pathway. Therefore, interventions must move beyond “cues to action” like posters and lectures, and instead focus on increasing self-efficacy through hands-on simulation to reduce the “perceived barrier” of technique-related anxiety.

Our findings can be compared with the two previous studies from Somalia and Somaliland. In a cross-sectional KAP study among healthcare professionals and students in Mogadishu (17), 89% demonstrated good knowledge of breast cancer, and 73% for cervical cancer, but only 46% knew that an HPV vaccine exists—closely mirroring our observation of limited awareness of vaccination availability. Similarly, the first cancer burden report from Somaliland's Needle Hospital (34) identified breast cancer as the most common malignancy (15.9%), with most patients presenting at stage III or IV, which aligns with our finding of advanced-stage predominance and reinforces that late diagnosis remains a critical challenge across both Somali regions. Unlike our study, however, Hagos et al. reported esophageal cancer as the second most common cancer (8.2%), whereas our cohort showed a lower proportion, possibly due to differences in referral patterns, diagnostic capacity, or geographic variation in dietary and environmental exposures. Taken together, these comparisons highlight consistent gaps in early detection and prevention infrastructure across Somalia and Somaliland, while also revealing region-specific variations in cancer epidemiology that warrant further investigation.

In conclusion, the overall practice rate of 46.5% among female medical students in Borama mirrors suboptimal trends observed in Ethiopia and Nigeria (20, 28) indicating that high cognitive understanding is consistently insufficient to drive screening across the region. The persistence of this “know-do gap” underscores the need for medical faculties in Somaliland to shift away from traditional, lecture-heavy approaches. To ensure the next generation of healthcare providers can lead by example in breast cancer early detection, educational strategies must prioritize practical simulations, peer-led advocacy, and interventions designed to enhance student self-efficacy. By focusing on attitude transformation and hands-on skill acquisition, universities can successfully translate theoretical awareness into the consistent clinical practice required to combat late-stage breast cancer diagnosis.

While this study applied the Health Belief Model (HBM) as a theoretical lens, it is important to note that the analysis was exploratory and did not employ fully validated HBM scales. Our operationalization focused primarily on perceived benefits and perceived barriers as components of attitude. Other core HBM constructs—specifically perceived susceptibility (the student's subjective perception of personal breast cancer risk), perceived severity (beliefs about the seriousness of the disease), and cues to action (triggers prompting BSE behavior)—were not directly measured using validated psychometric instruments. Consequently, our interpretation of attitude as the strongest predictor should be viewed within this exploratory framework. Nevertheless, our findings align with HBM predictions that perceived barriers (e.g., reported discomfort by 18.3% of respondents) may inhibit action, while perceived benefits (e.g., 99.5% believing BSE provides health control) promote engagement. Future studies in Somaliland should employ validated HBM questionnaires to quantitatively assess the relative contribution of all constructs, including susceptibility and severity, to BSE practice.

Policy implications

To bridge the identified “know-do gap” and translate high awareness into sustained practice, Somaliland's medical faculties must transition from theoretical instruction to competency-based frameworks. This requires: (1) Institutionalizing practical clinical simulations using breast models to standardize hands-on skills and build student self-efficacy; and (2) Integrating behavioral frameworks such as the Health Belief Model (HBM) into the curriculum. By moving beyond didactic lectures to address psychological constructs like “perceived susceptibility” and “perceived barriers,” educational policies can prioritize attitude transformation and confidence-building over simple information dissemination, fostering more proactive health behaviors among future healthcare providers.

Furthermore, strategic and national policy shifts are necessary to ensure long-term adherence and the normalization of screening behaviors. These include: (3) Prioritizing early-entry cohorts by mandating BSE training for first- and second-year students to establish self-examination habits before high-stress clinical years; (4) Establishing peer-led advocacy frameworks within universities to reduce cultural stigma and leverage peer-to-peer influence; and (5) Shifting national health communication policies from general awareness to action-oriented empowerment. At the governmental level, the Ministry of Health should collaborate with academic institutions and NGOs to develop materials that specifically address behavioral barriers, framing BSE as a proactive, empowering tool for self-care rather than a response to disease.

Limitations of the study

Study design and causal inference

A primary limitation of this research is its cross-sectional design. Because data on both predictors and breast self-examination (BSE) practice were collected simultaneously, it is not possible to establish a definitive temporal sequence or causal relationship. While strong associations were found between factors such as attitude and age with BSE practice, these results describe correlations at a single point in time rather than proving that one factor directly caused the change in behavior. Additionally, BSE practice was self-reported and not clinically verified. Participants may have overestimated the correctness of their technique, as no objective assessment was conducted.

Sampling and generalizability

The study utilized convenience sampling with proportional quotas, which may affect the representativeness of the findings. Since the participants were drawn from specific universities in Borama, the results may not be fully generalizable to all female medical students across Somaliland or to young women in the general population who do not have a medical background. Furthermore, the reliance on students from urban academic centers may overlook the unique barriers faced by women in more remote or less academic environments.

Data accuracy and response bias

The reliance on self-reported data introduces the potential for both recall and social desirability bias. Participants were asked to remember the frequency and timing of their past BSE practices, which can lead to inaccuracies. Additionally, because the respondents are medical students, they may have over-reported their level of practice to align with perceived professional expectations or “correct” health behaviors, potentially inflating the reported prevalence of BSE.

Scope of variables and theoretical framework

Finally, while this study focused on sociodemographic, knowledge, and attitude factors, it did not exhaustively account for all potential influences on BSE practice. Factors such as specific clinical training experiences, family history of breast cancer, or cultural modesty and taboos were not deeply explored. Furthermore, this study operationalized only perceived benefits and perceived barriers from the Health Belief Model (HBM). Other key HBM constructs—such as perceived susceptibility, perceived severity, and cues to action—were not directly measured using validated scales. This limits our ability to fully explain variance in BSE practice using the HBM framework and means that some of our theoretical interpretations remain exploratory. Incorporating these qualitative or more nuanced clinical variables, along with validated HBM instruments, in future research could provide a more holistic understanding of the barriers to early breast cancer detection in this context.

Directions for further research

To build upon the findings of this study, several avenues for future research are proposed:

Qualitative Exploration of Barriers: Future research should utilize focus groups and in-depth interviews to investigate the specific cultural, emotional, and psychological factors underlying negative attitudes and the reported discomfort associated with BSE.

Comparative and Longitudinal Designs: Comparative studies involving non-medical female students are needed to determine if these trends are unique to healthcare disciplines. Additionally, longitudinal designs tracking students from their first year through graduation would provide critical data on how clinical exposure and academic progression influence the long-term sustainability of BSE practice.

Experimental and Interventional Studies: Rigorous interventional research is warranted to evaluate the efficacy of practical, hands-on workshops compared to traditional didactic health education. This would provide empirical evidence on the most effective methods for bridging the “know-do” gap and enhancing behavioral adherence among the youth in Somaliland.

Conclusion

This study establishes that BSE practice among female medical students in Borama remains suboptimal (46.5%) despite high levels of knowledge and positive attitudes, with attitude being the factor most strongly associated with adherence (OR = 3.251). In this sample, family income showed no statistically significant association with BSE practice; however, this does not constitute evidence of no effect in the broader population. These findings reveal a persistent “know-do gap,” indicating that academic medical training alone is insufficient to guarantee behavioral action. The central challenge in this population is not a lack of awareness, but the translation of that awareness into consistent clinical practice. To improve early detection rates, institutional interventions must shift from purely theoretical dissemination toward experiential, skills-based training and psychological empowerment. Bridging the divide between medical knowledge and sustained health behavior is essential for reducing late-stage breast cancer diagnosis in Somaliland.

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Footnotes

Edited by: Moulay Abdelmonaim El Hidan, Université Ibn Zohr, Morocco

Reviewed by: Kamal Smimih, Université Sultan Moulay Slimane, Morocco

Mohamed Echchakery, Hassan Premier University, Morocco