This randomized controlled trial (RCT) proposed to assess whether the practice, knowledge, and beliefs of teachers regarding BCS would improve following the implementation of an educational intervention. The study results suggest that the health educational intervention had a positive impact, as evidenced by significant improvements in the teachers’ BCS practices, knowledge, and beliefs after the intervention.

Breast self-examination

The results of this study display a significant improvement in BSE uptake among the intervention group compared to the control group over time. This improvement may be attributed to the simplicity of performing BSE and the effectiveness of the practical training session with the breast model, combined with the educational program. These findings suggest that practical, skill-based education can successfully increase both the implementation and frequency of BSE. These findings align with similar intervention studies that have shown improved BSE performance among those who received educational interventions compared to participants who did not [12, 23, 24, 41, 42]. The results are constant with studies by Akhtari-Zavare et al. [24], Masoudiyekta et al. [23], and Tuzcu et al. [12], which found that participants who practiced BSE on breast models with lumps demonstrated higher performance and frequency of BSE than those who learned through lectures, leaflets, videos, or other educational methods. Therefore, the educational intervention incorporating practical BSE training, along with the other components developed in this study, may be effective in increasing BSE practice and frequency in similar demographic groups.

Health belief model and BSE

Several intervention studies have supported the present findings, emphasizing the effectiveness of using the HBM as a theory-based approach to improving BSE behaviors [12, 23, 24, 28, 41]. A systematic review had supported the effectiveness of educational interventions on BSE globally, finding theory-based, hands-on approaches particularly effective for increasing screening behaviours [21]. Similarly, in a recent study conducted on female teachers in Iran, found significantly higher frequencies of BSE in the intervention group than in the control group six months post-HBM-based intervention, reinforcing the efficacy of educational initiatives grounded in HBM [43].

Recommendations and limitations for BSE

While BSE is no longer recommended as a primary screening method due to limited evidence of its effectiveness, it has been shown to empower women to notice any changes in their breasts. As a result, women are encouraged to become familiar with their breasts and promptly report any changes to physician. Experts suggest that self-awareness can be as efficient as regular BSE [44]. Additionally, the Malaysian Clinical Practice Guidelines recommend BSE not as a screening method, but as a tool for raising awareness [45].

Clinical breast examination

The findings of this study reveal a positive impact of the intervention on CBE performance. The results showed that CBE practice was significantly higher in the intervention group compared to the control group. These results are consistent with those from a RCT conducted by Elder et al. [46], which found a significant increase in CBE performance in the cancer screening condition from 47 to 63% compared to the control group. Similar findings were observed in studies conducted in Iran by Mirmoammadi et al. and Fathollahi-Dehkordi and Farajzadegan [28, 47], which also demonstrated the efficacy of educational interventions in promoting CBE practice.

There are notable similarities between the findings of this study and those reported by Tuzcu et al. [12], which found that after a 6-month follow-up, the rate of CBE practice was better in the intervention group compared to the control group (34.1% vs. 10.1%). The significant increase in CBE performance among participants in the intervention group of our study may be attributed to the distribution of printed materials on BCS methods and the motivational follow-up through telephone messages post-intervention. Likewise, studies by Akhtari-Zavare et al., Masoudiyekta et al., and Mirmoammadi et al. [23, 24, 28] identified motivational telephone messages and printed materials as effective strategies for rapidly improving BCS uptake.

A randomized controlled study supports these findings, reporting that the intervention group exhibited a notably higher frequency of CBE six months post-training [43]. Likewise, a systematic review emphasized that educational interventions are generally effective in promoting CBE and enhancing women’s knowledge and participation in screening practices worldwide [21]. The interesting finding of the current study is the relationship between age and CBE uptake. These findings are consistent with the study of Tuzcu et al. [12], who stated that CBE increased by 1.1 (CI: 1.03–1.16) with each additional year of age. This association is supported by other studies, indicating that older women are more likely to perform CBE [48], perhaps due to increased perception of risk. Nevertheless, a study by Andegiorgish et al. [49] reported no significant association between CBE practice and age (P = 0.961), suggesting that further study may be needed to investigate the impact of age on CBE uptake.

Mammography

The results of this study suggest that there were no significant differences in MMG uptake between or within the two groups. The low MMG practice rate in this study could be attributed to numerous factors: the small number of respondents over 40 years old (17%), lack of insurance coverage, short follow-up period, and absence of screening programs. These findings align with Wu & Lin [50], who stated similar challenges in improving screening level. In contrast to our findings, a study by Gondek et al. [51] assessing the efficacy of a health education program for immigrant women in the USA stated a significant increase in MMG screening post-intervention. However, the study reported that women from Middle Eastern backgrounds were less likely to contribute in screening compared to Thai and Burmese women. This lower rate was attributed to cultural factors, such as the family structure in Middle Eastern, where women often rely on male relatives for medical care decisions. This may also justify the low MMG rates in our study, as it similarly involved women from Middle Eastern nations.

In another contrast to the findings of this study, Lee-Lin et al. [30] reported significantly different findings among Chinese American immigrant females. The study reported six months’ post-intervention, the intervention group was 9 times more probable to practice MMG compared to the control group (OR = 9.10, 95% CI: 3.50-23.62). One possible explanation for the high education program effect is that research grant funding covered MMG costs for participants, reducing financial barriers. This financial support, unavailable to population in our study, could account for the lower MMG screening rates. Similarly, studies implemented in the USA [46, 52] and Turkey [11] found significantly higher MMG level in the intervention group compared to the control group. One possible explanation for these contradictory findings is that the HBM used in our intervention focuses primarily on intra-personal factors related to health behavior, such as disease perceptions and self-efficacy. However, the HBM provides limited insight into social, interpersonal, and economic barriers to health behaviour change [53].

In contrast, studies like those by Lee-Lin et al. and Taymoori et al. [30, 54] utilized a combination of health behavior models that address more multifaceted needs, leading to better screening level. The findings of our study suggest that Yemeni women in Malaysia encounter many challenges in accessing MMG screening facilities, involving limited healthcare services, language barriers, transportation difficulties, cultural norms, and high costs. Addressing these issues may require a long-term culturally tailored educational method that involves local culture sensitivities, includes family members, and explore ways to reduce screening costs. Such method may be essential to shift health practices and overcome traditional barriers.

Breast cancer screening knowledge

The results of the present research indicate that teachers in the intervention group showed a significant increase in BC knowledge following the intervention, compared to participants in the control group. This important improvement may be attributed to the information offered through the program. Moreover, the high level of education between the women in the study sample may have contributed to the success of the education program. The findings align with studies by Rabbani et al., Akhtari-Zavare et al., and Yılmaz et al. [13, 24, 55], as well as study by Khiyali et al. [41]. The current findings also consistent with the results of a quasi-experimental study in Iran [23].

Furthermore, a recent descriptive study on women in urban Lucknow, India, found a substantial increase in BC awareness post-intervention. This improvement suggests that targeted educational programs can significantly raise BC awareness, potentially aiding early detection among urban populations, especially where awareness levels may initially be low [56]. Moreover, a study among women in Egypt found a significant increase in BCS knowledge after the implementation of an educational intervention, highlighting the potential for parallel programs to increase knowledge in diverse populations [57].

However, some previous studies have stated that educational programs were not effective in improving BC knowledge across different groups. For example, Elder et al. [46] found no significant difference in BC knowledge scores between intervention group and control groups, proposing that intervention effectiveness may vary based on some factors such as delivery approach, content, and participant engagement. In this study, previous exposure to information about BCS was positively associated with improved BC knowledge. Women who had previously read or heard about BCS were more knowledgeable about BC. These results are consistent with previous study by Hussen et al. [58], who found that participants with prior information about BC were more possible to have greater knowledge than those without such information.

Beliefs about breast cancer screening

The findings of the current research indicate that, following the educational intervention, there was a significant progress in most health beliefs subscales in the intervention group. The notable improvement in knowledge and beliefs among participants underscores their readiness to acquire more health information and develop skills to promote healthy behaviors. However, the lack of significant differences in some belief subscales may be attributed to the homogeneity of the study sample concerning socio-demographic factors, which could explain the limited variation in respondents’ beliefs about BC.

These findings support Yılmaz et al. [13], who reported a significant improvement in post-test mean scores for benefits, barriers, health motivation, and self-efficacy. The findings of the current study also align with a RCT conducted in Iran, which found important differences between the study groups in perceived benefits of CBE, MMG, self-confidence, and health motivation. Nevertheless, no significant differences were detected for perceived susceptibility and severity [28]. Additionally, a similar study conducted in Egypt found a significant improvement in beliefs related to BSE after implementing an educational program based on the HBM [57]. Similarly, the present study’s findings are consistent with Khiyali et al. [41], which demonstrated significant improvements in the benefits of BSE, barriers to BSE, and self-efficacy in the intervention group. In line with these results, Akhtari-Zavare et al. [24] indicated significant differences between the study groups for the benefits of BSE, barriers to BSE, and confidence, though not in perceive seriousness or susceptibility.

In contrast to these findings, Kocaöz et al. [42] found no evidence of the efficacy of the intervention in the benefits of BSE. Similarly, Lee-Lin et al. and Tuzcu et al. [12, 59] found no significant difference in the benefits of MMG. Elder et al. [46] found that scores for barriers to MMG and CBE were significantly lower in the intervention group compared to the control group, which is inconsistent with the current study. The non-significant changes in MMG barriers detected here may be related to improvements in participants’ knowledge about the cost of MMG, fear of radiation, and the fact that a majority of the respondents were below the recommended age for MMG.

While the current study did not show significant improvement in perceived susceptibility, studies by Fathollahi-Dehkordi & Farajzadegan, Tuzcu et al., Yılmaz et al., and Htay et al. [12, 13, 47, 60] reported a significant increase in susceptibility scores post-interventions. This discrepancy may be justified by participants’ younger age, with younger women probably perceiving BC risk as mostly relevant to older women. Another factor could be that studies employing multiple health behavior models have been more effective in addressing women’s multi-dimensional needs by considering cultural, economic, and social impacts on health beliefs [47, 59]. In contrast, this study used only the HBM, which primarily focuses on individual health-related perceptions. Factors significantly associated with health beliefs in this study included age, prior exposure to BCS information, and family history of BC. These findings align with Yılmaz et al. [13], who reported a significant association between prior knowledge of BCS and susceptibility, benefits of BCS, and confidence. Similarly, Kissal et al. [61] reported an association between self-efficacy and family history of BC.

Cultural and logistical challenges in healthcare access

Although the education intervention positively influenced health beliefs in some areas, the effectiveness of BCS initiatives for Yemeni women in Malaysia is also shaped by substantial cultural and logistical challenges. Cultural beliefs and stigmas around BC can create fear or discomfort regarding BCS procedures, particularly among women who may lack familiarity with preventive healthcare practices. Additionally, younger women may view BC risk as more relevant to older women, limiting the effect of susceptibility-focused messages in the education intervention. Language barriers can also limit effective communication with healthcare providers, reducing women’s ability to navigate healthcare services confidently and understand screening recommendations.

Logistical limitations further complicate access to health care services. Many women may experience financial limitations, making it difficult to afford transportation or healthcare costs, and limited availability of culturally sensitive healthcare providers may impact their comfort and trust in seeking services. Additionally, traditional family roles and responsibilities may restrict women’s time and ability to prioritize personal healthcare, further hindering access.

Acknowledging these barriers provides a more comprehensive understanding of the context in which our intervention was implemented, highlighting potential limitations of the intervention’s effectiveness. Addressing these factors in future interventions could improve Yemeni women’s engagement with BCS initiative in Malaysia, strengthening the alignment of these interventions with the exclusive needs of this population.