This study aimed to investigate the mediating role of knowledge on the relationship between preventive behaviors and the practice of breast self-examination (BSE) among student nurses in Saudi Arabia. The participants' average knowledge score disclosed in the study's findings suggests that this group of students exhibits a moderate to high understanding, but with syntax variability. This agrees with earlier works which had pointed out the effect of confidence regarding knowledge as a determinant of performance. For example, research on Norwegian medical students established that level of knowledge confidence relates positively to academic performance, since reliable moderate confidence knowledge tended to outscore less confident students [30]. This cognitive judgment regarding one’s subjective knowledge to scoring high in preparation. Moreover, nursing students revealed that knowledge and literacy levels of nursing students went hand in hand, that is high knowledge levels were nurtured by good educational results [31]. Considering the practical skills, the average practice depicts that the students are generally low to moderate in self-examination skills experience, although, there still exist differences in performance. This variability is important because it indicates that while most of the students are capable, a portion of the cohort might need more time and resources than is available. Regarding breast self-examination practices among nursing students, the authors concluded the need for training in education on self-examination practiced, especially in low-skilled groups [31]. In the same vein, stressed that the barriers to practice should first be addressed as they provide direction for designing practical health education for the students to enhance self-examination behaviors [32].
Conversely, the average behavior prevention measures indicate that nursing students have high tendencies to perform preventive behaviors. Also, it implies that most of the students have good preventive practices but some need more assistance and education. This observation conforms to literature which posits that preventive health behaviors among nursing students improves with targeted educational programs. For example, Elmonaem et al. [33] reported that knowledge and attitude held by nursing students are influential indicators of their preventive health behaviors concerning COVID-19. They further stressed that nursing students needs to be well grounded in prevention so as to become effective in health promotion and patient education as caregivers [34]. Otherwise, it was found that knowledge, anxiety and past experience are examples of factors that made nursing students to follow preventive measures during the COVID-19 pandemic for the first time imposing difficulties in treatments for Jung and Kim [34]. This creates the need for educational strategies that provide knowledge as well as help to mitigate psychological aspects that could hinder good preventive practice.
Numerous factors account for the heterogeneity in prevention behaviors in nursing students. For instance, it was reported that nursing students lack sufficient information on certain health problems such as osteoporosis, which makes it difficult for them to adopt the appropriate preventive measures effectively [35]. While the nursing students have good preventive behaviors on breast cancer, the study shows that improvement on their knowledge and practice is still needed through focused education. However, should the nursing students address such knowledge gaps and the psychological barriers that may prevent them from performing such preventive measures, they would be able to assist better in the prevention of breast cancer and educating the patients on the disease."
The results which reveal a considerable level of association between knowledge and practice among the participants and knowledge and prevention behavior towards breast self-examination (BSE) affirms the importance of knowledge in affecting both practical skills and preventive actions particularly among the nursing students. Such has been the case with much of the existing literature whereby understanding in a particular subject area has been shown to correlate well with the application of that knowledge in practice. For instance, it has been pointed out that students on healthcare courses are likely to gain knowledge and adhere to standard precaution and hand hygiene techniques through the use of enhanced educational and training programs [36]. Their study noted that practical sessions even if there are conventional lectures improves the retention and application of knowledge on the nursing students [36].
Additionally, consonant with the findings of Elmonaem et al. [33], the current study highlights the importance of knowledge and attitude in nursing students’ preventive health practices. Their research emphasizes skilled and educated future health care specialists, as these factors have an impact on the level of clinical care provided. In addition, the study by Bani and associates [37] also goes in line with this where in older nursing students’ larger amount of educational content and clinical practice affects better health behaviors. This appears to validate the idea that with furthering of studies there is assimilation of knowledge that augers well with encouraging constructive changes in attitudes towards more preventive practices. The research undertaken by Anh et al. [38] supports the argument that education programmes can bring the adequate understanding of the prevention and maintenance practices among nursing students and translate this knowledge into action. According to their research results, teaching based on the medical sector, in particular case-based medical learning increases the knowledge, attitude and practice of universal precautions among student nurses [38]. This indeed corresponds to the findings of the present study which establishes the evidence for practice after provision of theoretical knowledge. Conversely, some studies suggest that despite possessing adequate knowledge, nursing students may still encounter challenges in translating this knowledge into practice. Cognitive factors, such as limited problem-solving skills or decision-making abilities, and gaps in course content may contribute to these discrepancies. For instance, previous research mentioned that the explanation is obviating in the medical sector, where the workers have knowledge over infection control measures but practice is typically where the most difficulty lies [39]. This further stresses the fact that it is not enough to only provide students with information but that students must be offered the appropriate training for the effective application of the knowledge in real practice.
The exploration of the relationships among breast cancer preventive behaviors, knowledge, and breast self-examination (BSE) practice using structural equation modeling (SEM) provides valuable insights into the factors influencing BSE among nurses in Saudi Arabia. The findings indicate significant positive correlations between knowledge and both practice and prevention behaviors, as well as a notable correlation between knowledge and BSE practice. These results are consistent with existing literature that underscores the critical role of knowledge in shaping health behaviors, particularly in the context of breast cancer prevention. Study on breast cancer awareness among Saudi females corroborates these findings, indicating that increased knowledge about breast cancer significantly influences the practices of BSE among women [40]. The study highlights that awareness and knowledge are essential components in promoting preventive behaviors, aligning with the current study's results that demonstrate knowledge as a key factor influencing BSE practices. Similarly, found that educational interventions significantly enhanced the knowledge and attitudes of nursing students regarding BSE, leading to improved practice rates [11]. This suggests that educational strategies focusing on knowledge enhancement can effectively motivate nursing students to engage in regular BSE.
The analysis of direct effects in the study reveals significant associations between breast cancer preventive behaviors, knowledge, and breast self-examination (BSE) practice among nurses in Saudi Arabia. Specifically, the findings indicate that breast cancer preventive behaviors positively influence knowledge and BSE practice while knowledge has a substantial positive impact on BSE practice. These results suggest that preventive behaviors not only directly enhance knowledge but also indirectly influence BSE practice through this knowledge. The relationship between preventive behaviors and knowledge is well established in the literature. For example, Zhang and associates [41] found that greater knowledge about breast cancer greatly increased BSE behavior among female college students in China Their study, argued this position by reporting improved practice of prevention behaviors through education targeting knowledge gaps like in the current study where the mediator role of knowledge in the relationship between preventive behaviors and the practice of BSE [41]. In addition, Nguyen and Tran (2021) found that midwifery students who viewed BSE as a worthwhile practice were more aggressive in performing BSE, noting the situated socio-cognitive factors on health behaviors [42]. This withering opposition supposes that once group members understand the meaning and the necessity of preventive actions, such acts like BSE are sooner or later going to become a common practice. On the other hand, the suppressive effect that engaging in preventive behaviors has on the practice of BSE deserves special attention. This finding may suggest that even though these practices are regarded as useful in providing education, they do not necessarily promote an appropriate behavior in practical situations. For instance, mentioned some of the psychological variables such as stress that could hinder engagement in the preventive practices affecting women suffering from breast cancer practicing BSE [43]. This portrays that external factors such as psychological or even emotional factors may hinder individuals from turning acquired knowledge into a practical application.
There was support that knowledge plays a mediating role between breast cancer preventive behaviors and BSE practice. It was clear that the total effects included the framing of breast cancer preventive behaviors as positively impacting BSE practice. These results further support the case for knowledge as a mediator for the interrelationship between breast cancer preventive behaviors and BSE practice among nurses in Saudi Arabia, thereby calling for specific evidence-based strategies to improve both behaviors and knowledge in practice. The mediating role of personal knowledge, as far as changing health behavior is concerned appears to be widely observed in the other studies. In fact, it was highlighted that positive health beliefs and positive knowledge are positively related to the pursuit of preventative procedures such as mammography which means knowledge is vital in pushing women whether to perform BSE or not [44]. Their findings indicated that greater health motivation and knowledge were associated with a higher probability of performing preventive actions [44]. The above appears to support the former of the current study whereby it concluded that knowledge is a significant mediator of the relationship between preventive behavior and BSE practice as it is an empowering tool to individuals to be more proactive with their health. Furthermore, it has been established that this fear of breast cancer possessed by surgical nurses affected their practices of protecting themselves, thus demonstrating that aside from knowledge, emotional factors also influence practice [45]. This shows that health-related behaviors are complex in nature – knowledge without other aspects is not enough; other additional factors such as emotional and psychosocial factors need to be put into consideration as well. The present study therefore points out that knowledge although a significant mediator, cannot be overemphasized especially in implementing these interpersonal emotions in changing practices toward BSE. In other terms, some authors state that theory-practice relation may not be direct. For instance, knowledge regarding actions aimed at the prevention of breast cancer was correlated with such actions, however, there were differences between perceived barriers, self-efficacy and engaging in wife beating [46]. This implies that approaches that are made to enhance interventional knowledge only may not be effective in promoting health behaviors that work; rather more of these other factors are required for health behaviors that will promote discharge.
Study implications
This study has revealed that the improvements in nursing education and practice are very much needed so as to increase the preventive measures against breast cancer. While integrating breast cancer knowledge and self-breast examination into the existing nursing education including developing of specific interventions/educational strategies, and treating psychological aspects, the students of nursing can be trained in better ways to help them advocate breast cancer prevention. Furthermore, nurses are important in teaching patient’s self-examination and eliminating barriers to practice as well as promoting early diagnosis. A self-sustaining and effective approach in regard to breast cancer demands both evolution in nursing training and the practice.
Study limitations
The design of the present study was cross sectional in nature which although was advantageous in determining the association of variables rather limited in establishing the cause and effect relationship between the variables. Moreover, because of the nature of the subjects comprising of only female nursing students and not including Bridging pathway students, the sample population was biased which has implications on the findings of the study. Furthermore, owing to the nature of the data that was collected, there was the possibility of social desirability bias since the information was mainly self-reported and this was a problem since it was possible that the knowledge, practice, and prevention behaviors that were expected to be addressed are too broad to be captured by the tools that were used. Last, the researcher's geographical focus on Saudi Arabia restricts the research implications to one country. Making these suggestions in future research might help in understanding the factors affecting breast cancer knowledge, practice and prevention behaviors among nursing students to develop better strategies.