The effect of simulation-based breast health education on breast cancer awareness and breast self-examination skills of Afghan refugee women: a randomized controlled trial

Abstract

Objectives

The aim of this study was to examine the effects of simulation-based breast health education on Afghan women's awareness of breast cancer, including knowledge of its risk factors, signs, and symptoms, as well as to improve their breast self-examination skills.

Study design

This study was a pre-test, post-test, parallel-arm randomized controlled trial.

Methods

The study sample consisted of 46 Afghan women, with 23 participants assigned to each of the intervention and control groups using block randomization. This study was conducted at the Social Development and Aid Mobilization (SGDD-ASAM) in Ankara, Türkiye. The intervention group received simulation-based breast health training. Each session of breast health education was 180 min. The simulation used a one-to-one show-and-do technique, which took approximately 120 min. Data were collected using the Breast Cancer Awareness Measure and the Breast Self-Examination Skill Assessment Form. The data were analyzed with the IBM SPSS 26 program. Descriptive statistics were used to evaluate the study data, including mean, standard deviation, percentage, and frequency distribution. The Shapiro–Wilk normality test was applied for further analysis. The Chi-Square (X²) Test was used to compare outcomes between groups. The significance level of p < 0.05 was considered.

Results

After the simulation-based training, there was a significant increase in confidence, skills, and behavior awareness among participants in the intervention group compared to the control group (p < 0.001). While there was no change in the control group, awareness of breast cancer, knowledge, and skills in the intervention group were predominantly rated as sufficient.

Conclusions

The simulation-based breast health education intervention for Afghan refugee women was found to be a practical and innovative approach to raising breast cancer awareness and providing breast self-examination skills. This intervention may play a significant role in identifying at-risk individuals and raising their awareness. If sustained, this could potentially increase future screening participation and early detection, ultimately contributing to improved patient outcomes. It is recommended that policymakers and health professionals prioritize the integration of simulation-based health education into prevention and health promotion strategies targeting disadvantaged populations, such as refugees and migrants, to improve early diagnosis and advance health equity.

Trial registration

Clinical Trials Number is NCT06051331. Registration date is 22.11.2023.

Introduction

Breast cancer is the most common type of cancer among women worldwide [7]. The World Health Organization estimates that, by 2050, there will be more than 3 million cases of breast cancer and 1 million deaths worldwide each year [4]. According to the Cancer Statistics Report published in Türkiye in 2020, breast cancer is the most common type of cancer in women, with one in every four cancer diagnoses among women being breast cancer [32]. Although the Turkish Health Statistics Yearbook includes no data on breast cancer in refugee women, the disease is also common in this population [13, 14].

Türkiye hosts the largest number of refugees worldwide, with over 4 million. After Syrian refugees, Afghans make up the second-largest refugee group in the country. As of April 2025, there were 12,549 registered Afghan refugees and 106,241 Afghan asylum-seekers in Türkiye [36]. According to the Global Cancer Observatory, there were 3,545 new cases of breast cancer in Afghanistan in 2022, accounting for 14.6 percent of all cancers in both sexes and 27.2 percent of all cancers in women [14]. However, it has been stated that the actual incidence and mortality rates of breast cancer are likely significantly higher [20].

Even when Afghans migrate to different countries, their health levels do not change in the desired way. In fact, most diseases are even more widespread than in their country of origin [13, 28]. This situation is often associated with the low education level of Afghan refugees, language barriers, cultural differences, economic problems, family structure, and differentiation of health service provision [18, 35]. Previous studies reported that refugee women living in Türkiye had low cancer awareness and knowledge levels as well as low participation in early diagnosis and screening programs ([29, 30]). A study examining the breast cancer awareness of Afghan women in Northern California found that these women had low levels of breast cancer knowledge and awareness, and their participation in early diagnosis and screenings was also low [33]. Failure to diagnose breast cancer in women at early stages is often due to low levels of knowledge about breast cancer, lack of awareness about the importance of self-examination, not knowing how to perform breast self-examination (BSE), or simply not caring about it, as well as social poverty and the late onset of breast cancer signs and symptoms [27, 33]. In the first and only study analyzing breast cancer awareness among Afghan refugees living in Türkiye, it was found that Afghan women had significantly low breast cancer awareness an urgent need for targeted and culturally appropriate interventions to increase awareness and promote screening and early diagnosis [23].

A systematic review examining cancer screening among refugee women from Muslim-majority countries found that social and cultural influences, family context, stigma, gender roles, and religious beliefs significantly shaped cancer screening behaviors. Due to cultural perceptions and structural barriers, these women are reported to be less than adequately served by preventive services such as mammograms, Pap smears, and colonoscopy screenings [34]. The study found that community-based approaches and culturally and linguistically appropriate health education increased awareness among refugee women. The study suggests that interventions should aim to maximize partnerships between health systems and community- and faith-based organizations already serving refugee communities [34]. In line with recommendations emphasizing the importance of community- and faith-based partnerships in refugee health interventions, this study was conducted with Afghan refugee women registered with a well-established community-based organization serving refugees in Ankara.

Studies indicate that Afghan women's health behaviors related to early diagnosis and prevention of breast cancer are insufficient and that educational programs are needed to raise awareness and increase the implementation of regular screening behaviors [1, 22]. The interventions used to increase breast cancer awareness among migrant women are quite limited, and the traditional education model (e.g., lectures or brochures) has been frequently used in studies [19, 31]. In this study, culturally adapted training is combined with simulation-based method. This is an innovative method that allows hands-on learning that can increase understanding and retention of information about breast cancer awareness and self-examination skills.

The use of simulation with a trained facilitator has a positive impact on learner outcomes in health care [11, 24]. It allows participants to apply their theoretical knowledge in practice, while providing active participation based on learning in a realistic environment [16, 26]. This increases the retention of knowledge and skill development. Furthermore, simulation training allows participants to learn from mistakes and deal with situations they may encounter in real life, making them more confident and competent [15, 16, 21]. Simulation-based training is recognized as an effective tool not only for health professionals but also for enhancing health behaviors and practical skills, particularly among patients and populations with low health literacy [6, 37]. Therefore, the aim of this study was to examine the effects of simulation-based breast health education on Afghan women's awareness of breast cancer, including knowledge of its risk factors, signs, and symptoms, as well as to improve their BSE skills.

Research hypothesis

Simulation-based breast health education was expected to improve Afghan women's awareness of breast cancer, including knowledge of its risk factors, signs, and symptoms, as well as enhance their BSE skills.

Methods

Study design

This study was a pre-test, post-test, parallel-arm randomized controlled trial. The project’s Clinical Trials Number is NCT06051331. The study adheres to the CONSORT guidelines.

Participants

This study was conducted with Afghan refugee women registered with the Social Development and Aid Mobilization (SGDD-ASAM) in Ankara, Türkiye's capital SGDD-ASAM was established in Ankara in 1995 as an independent, impartial and non-profit organization. SGDD-ASAM's vision is to contribute to ensuring that all asylum seekers and refugees have access to fundamental rights and services and live in social cohesion and solidarity with the local community (https://sgdd.org.tr/en/). The recruitment process was carried out in cooperation with local SGDD-ASAM. However, some challenges were encountered in terms of increasing the number of participants. There were challenges related to refugee women's specific concerns about participating in the training program (such as their husbands not allowing them to participate, some cultural myths, etc.) and timing (such as the training program overlapping with the time of sending or picking up their children from school). Nevertheless, women were invited on a regular basis to raise basic public health awareness for both groups.

A priori power analysis was performed using G*Power 3.1, based on data reported by Alizadeh Sabeg et al. [5]. Assuming an effect size of d = 1.21, α = 0.05, and power (1–β) = 0.95, the required total sample size was calculated to be 38 (19 per group). To account for potential participant loss, 20% more women were included, resulting in 23 women in each group. A total of 54 women were evaluated for eligibility. Five women did not meet the inclusion criteria, and three women declined to participate in the study (Fig. 1). The study was completed with 46 women (23 intervention and 23 control group) with no drop out. The inclusion criteria were (1) being 20 years or older, (2) being able to read, write, and speak Persian or Turkish, and (3) volunteering to participate in the study. Exclusion criteria were (1) already participating in breast cancer health education, (2) diagnosis with breast cancer. In addition, all the participants in both groups were women who had no previous breast health education.

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Pilot test

The pilot study was conducted with five Afghan women who met the inclusion criteria. The women who participated in the pilot test were not included in this research study. After the pre-test, simulation-based breast health education was provided. The post-test was given at the end of the training. Interpreter support was needed during the training, and additional time was allowed to answer questions. Therefore, interpreter support was obtained, and each training session's planned duration was 180 min. The simulation used a one-to-one show-and-do technique, which took approximately 120 min. This included a collective tabletop demonstration, a demonstration on the model, and the women performing BSE on their bodies. According to the results of the pilot study, the duration of the training and the content of the materials were reviewed, and some minor adjustments were made. To make the learning process of the participants more effective, the duration of the training was slightly extended, and the content of the visual materials was made more comprehensive. Feedback from the pilot study, as well as meaningful comments from the participants on the training materials, allowed further strengthening of the modular training structure. Participants requested more practice opportunities, particularly in palpation techniques and tumor detection. This feedback was reflected in the training implemented in the original intervention with the addition of more hands-on training sessions.

Randomization and blinding

Block randomization was used to assign 46 participants who met the inclusion criteria to the intervention and control groups. The 46 participants received from the association were numbered and assigned to the groups using the Random Sequence Generator (https://www.random.org).

In this study, it was not possible not to inform the participants about the group assignments since only the intervention group was trained. However, to maintain impartiality in the evaluation processes, the data collecting researcher was assigned to be unaware of the study groups (assessor-blind). Some main strategies were applied to maintain blindness: Firstly, the researchers (1st researcher-NKA and 4th researcher-ZZ) responsible for delivering the modular training to participants requested the participants in writing and verbally not to share any information about the group assignments. Secondly, the data collector (3rd researcher-OA) who was unaware of which participants were in the intervention or control groups reminded the participants not to share any information about their group assignments before each data collection process. She coded and processed the data as Group 1 and Group 2. The 2nd researcher (AAD) analyzed and reported the statistical analyses without knowing which participants were in the intervention or control groups. These precautions prevented the data collector from being influenced by group information and maintained observer blindness. Thus, with these measures, researchers collecting and analyzing data were prevented from being influenced by group information and blinding in randomization, data collection and recording, statistical analysis, and reporting was tried to ensure.

Intervention procedures

The breast examination simulator used in the study was designed for breast examination and palpation practice. It simulates the breasts of an adult woman and offers realistic clinical and training applications. The model allows for BSE and external examination in both vertical and horizontal positions. Tumors of different sizes, shapes, and densities can be implanted (Fig. 2). Afghan women in the intervention group received simulation-based breast health training in two stages. In the first stage, breast health education was provided. The breast health education developed by the researchers included four modules using active learning methods: Breast Anatomy, Etiology, Risk Factors, Signs and Symptoms of Breast Cancer, Early Diagnosis and Screening Methods, and Breast Self-Examination. In the second stage, information was given about BSE and potential changes that may occur in the breast using a breast model.

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Intervention group training

Training on breast health for women in the intervention group was implemented in two stages: a theoretical training on breast health and simulation-based skill training focused on BSE.

Theoretical education

The theoretical sessions were conducted face-to-face by the researchers in the meeting room of SGDD-ASAM Ankara branch. The language of the training was Turkish and simultaneously translated into the native language of the participants through a sworn translator. Prior to the training process, the sworn interpreter was informed about the research modules and familiarized with the subject matter. The theoretical education consisted of four modules and each module lasted 60 min, one day a week. Active learning methods (question–answer, group discussions, use of visual materials, etc.) were used to increase participant interaction.

The modules and their contents in the theoretical training are as follows:

1. 1.

Module 1: Breast anatomy

2. 2.

Module 2: Breast cancer

*

◦ Etiology

*

◦ Risk factors

*

◦ Signs and symptoms

3. 3.

Module 3: Early detection and screening methods for breast cancer

4. 4.

Module 4: Breast self-examination (BSE)

Simulation-based skill training

Following the theoretical sessions, Afghan refugee women participated in simulation-based BSE training. They were divided into small groups of four participants and attended one-hour practical sessions. During the skill training, the researchers introduced participants to breast examination simulators and wearable breast models. Each participant was given the opportunity to practice BSE techniques using realistic simulation tools, under the supervision and guidance of the researchers. During the training, participants were taught palpation techniques of breast masses in detail. In addition to the simulation model used for breast cancer screening, participants were also taught the skill of recognizing different tumor types. Different tumor types are available in the breast simulator used in the training.

Participants in the intervention group who completed the theoretical training were divided into groups of 4 (5 groups consisted of 4 participants and 1 group consisted of 3 participants) and received simulation-based skills training, each lasting approximately 60 min. In these sessions, breast examination simulators and wearable breast models were introduced by the researchers. Participants were given the opportunity to perform the BSE one-on-one with realistic materials and were individually guided and supported during the practices. In the training, continuous feedback was provided, and the practices were evaluated by observer trainers for the participants to apply this skill correctly. The palpation skills of the participants were monitored by observations at every stage of the training process and the performance of each participant was evaluated individually.

Usual services for control group

The Refugee Support Association provides refugees and asylum seekers with access to rights and services, legal protection, women’s empowerment programs, livelihood opportunities, and activities that promote social cohesion with host communities. The women in the control group continued to receive routine services but did not participate in any breast health education. In line with ethical rules, the same simulation-based training content was provided to the participants in the control group by the research team after the study was completed.

Measures

Data were collected using a Personal Information Form to determine the participants' sociodemographic characteristics, the Breast Cancer Awareness Measure to assess awareness of breast cancer risk factors, signs, and symptoms, and the BSE Skill Assessment Form to evaluate BSE skills. BSE Skill Assessment Form was filled out the researcher, who was unaware of which participants were in the intervention or control groups.

Personal information form

Personal Information Form consisted of descriptive questions including age, marital status, education level, health insurance status, employment status, refugee status [5, 19]. These variables were used to describe the characteristics of the study population.

Breast cancer awareness measure

The Breast Cancer Awareness Measure (BCAM) was developed by the Cancer Research UK group at King’s College London in 2009 [25]. BCAM is a questionnaire that assesses seven domains of breast cancer awareness: a) knowledge of breast cancer symptoms, b) breast self-examination, c) confidence in noticing changes in the breasts, d) age and lifetime risk of breast cancer, e) urgency if breast changes are noticed, f) breast cancer risk factors, and g) breast cancer screening. Each of these seven domains captures a unique aspect of breast cancer awareness assessed in this study:

*

Symptom Awareness: Knowledge of common signs and symptoms of breast cancer.

*

Self-Examination Behavior: Frequency and consistency of BSE practices.

*

Confidence in Detection: Self-reported confidence in identifying changes in the breast.

*

Risk Perception: Understanding of age-related and lifetime breast cancer risk.

*

Response to Symptoms: Likelihood of seeking immediate medical attention upon noticing a change.

*

Risk Factor Knowledge: Awareness of modifiable and non-modifiable risk factors.

*

Screening Awareness: Knowledge of screening tools such as mammography and clinical breast exams.

The questionnaire can be administered face-to-face or by telephone. BCAM is highly readable for patients and has good test–retest reliability and construct validity [25]. The validity and reliability of BCAM have been confirmed in Muslim and Middle Eastern populations. In a study published in The Lancet, the scale was applied to a group of Afghan women and translated by a sworn translator [23]. The BCAM was rendered into Pashto and Dari by a certified translator specifically for the purposes of this study. Permission was obtained from the researchers to use BCAM in this study.

Breast self-examination skills assessment form

Practical BSE skills were assessed using a structured BSE Skill Assessment Form, developed by the researchers based on existing literature. The form includes 15 items that evaluate key elements of BSE performance, including inspection techniques, palpation coverage, positioning, and systematic approach. This assessment helped objectively evaluate the participants’ actual ability to perform BSE, rather than relying solely on their self-reported behaviors (e.g., frequency of BSE) or perceived confidence in performing it.

Davis's technique was used to determine the content validity of the evaluation form. For the content validity, expert opinions were obtained from seven academicians in internal medicine nursing, surgical diseases nursing, public health nursing, and obstetrics and gynecology nursing. Expert opinions were graded as follows:'the item represents the feature,''needs some correction,''needs many corrections,'and'the item does not represent the feature.'After evaluating each expert’s response, the content validity index was calculated by dividing the sum of the answers indicating that the item represents the feature and needed some correction by the number of experts. If the result was greater than 0.80, the item was considered valid in terms of content [10].

To apply the form reliably, all researchers using the form were given comprehensive training by the primary investigator before the assessment. Within the scope of this training, how to score each item in the form, what to pay attention to during the evaluation and how to prevent possible interpretation differences were discussed. To test inter-rater consistency, at the end of the training, all raters independently assessed the BSE of the same five women from the pilot study. The data obtained were analyzed using the weighted Cohen's Kappa coefficient and κ = 0.86. This result indicates a high level of agreement between the assessors and supports the reliability of the assessment process.

Data analysis

The data obtained from the study were analyzed using IBM SPSS (Statistical Package for the Social Sciences) Statistics 26 program for analysis. Descriptive statistics were used to evaluate the study data, including mean, standard deviation, percentage, and frequency distribution. The Shapiro–Wilk normality test was applied for further analysis. It was found that the data did not meet the normality assumptions, so non-parametric tests were used for comparison. To assess the differences between the intervention and control groups regarding breast cancer awareness and BSE skills before and after the training, the Chi-Square (X2) test was applied. This non-parametric test is suitable for comparing categorical variables between two independent groups. The significance level of p < 0.05 was considered.

Results

The sociodemographic characteristics of the intervention and control groups are summarized in Table 1. The mean age of the participants in the intervention group was 32.08 ± 6.39 years, while the mean age in the control group was 31.43 ± 7.43 years. In the intervention group, 87.0% were legally married, 60.9% were illiterate, 78.3% were unemployed, 52.2% had no social security, and 65.2% were living in Türkiye under temporary protection status. In the control group, 91.3% were legally married, 47.8% were illiterate, 100.0% were unemployed, 73.9% had no social security, and 52.2% lived in Türkiye under conditional refugee status. The intervention group was similar to the control group (p > 0.05) in terms of descriptive characteristics.

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Awareness of the 11 warning signs of breast cancer (lump/thickening in the breast, lump/thickening in the armpit, bleeding or discharge from the nipple, nipple retraction, change in nipple position, redness in/around the nipple, redness of the breast skin, size change in the breast/mammary gland, shape change in the breast/mammary gland, pain in the breast/armpit, dimpling of the breast skin) was assessed at baseline and after simulation training in both groups. At baseline, 61–87% of participants in the intervention group and 39–57% in the control group answered"do not know"regarding whether these signs were warning signs of breast cancer. After the simulation training, awareness of breast cancer warning signs increased significantly in the intervention group compared to the control group (p < 0.001). All participants in the intervention group (100%) correctly identified the warning signs of breast cancer (Table 2).

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Participants'confidence, skills, and behaviors related to breast cancer were evaluated at baseline and after the simulation training. At baseline, 34.8% of participants in the intervention group and 47.8% in the control group stated that they rarely or never performed BSE. In the intervention group, 52.2% reported being confident in noticing changes in their breasts, compared to 73.9% in the control group. Furthermore, 39.1% of the intervention group and 21.7% of the control group had never visited a doctor because of a change in their breasts. Additionally, 78.3% of participants in both groups could not determine the risk of breast cancer based on age. After the simulation training, there was a significant increase in confidence, skills, and behavioral awareness among participants in the intervention group compared to the control group (p < 0.001). All participants in the intervention group reported that they would perform monthly BSEs, felt somewhat or very confident about noticing changes in their breasts, and 56.5% correctly identified the associated risk (Table 3).

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Data on participants'awareness of breast cancer risk factors are shown in Table 4. Awareness of nine breast cancer risk factors (personal history of breast cancer, use of hormone replacement therapy, consumption of more than one unit of alcohol per day, being overweight, having a relative with breast cancer, late or no childbearing, early menarche, and late menopause, and low physical activity) was assessed at baseline and after simulation training. At baseline, 44–83% of participants in the intervention group and 26–78% in the control group answered"not sure"regarding whether these factors were risk factors for breast cancer. After the simulation training, awareness of breast cancer risk factors significantly increased in the intervention group compared to the control group (p < 0.001). More than 50% of participants agreed or strongly agreed with all risk factors except hormone replacement therapy.

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The comparison of findings regarding participants'BSE skills is presented in Table 5. There was no difference in BSE skills between the intervention and control groups before the training. In the pre-training skill evaluation, all items, except for the first item (explaining the purpose of breast examination), were answered as"inadequate"by 100% of participants. After the training, a significant difference was found between the intervention and control groups regarding BSE skills (p < 0.001). While no improvement was noted in the control group, the majority of participants in the intervention group demonstrated adequate performance in most BSE skill items following the training. However, item 3 on the BSE skills checklist, 61% of the participants in the intervention group continued to be rated as inadequate skill even after the training.

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Discussion and conclusions

Discussion

The present study concluded that simulation-based breast health education increased breast cancer awareness among Afghan refugee women and provided them with the ability to perform BSE.

In the current study, a significant majority of the women in both groups were not aware that 11 clinical symptoms could be related to breast cancer, while after the simulation-based training, all women in the intervention group (100%) correctly identified that these symptoms could be signs of breast cancer. In a study conducted outside the Afghan refugee population, a significant difference in breast cancer awareness was observed after an educational intervention on breast and cervical cancer for Syrian refugee women in Türkiye. The post-test means scores of the experimental group increased significantly from 11.76 to 64.36 after the education [12]. In another study involving a breast cancer telehealth education intervention for Afghan refugee women in Türkiye, 82–90% of women did not know the warning signs of breast cancer before the intervention, whereas 77–90% correctly identified the warning signs six months after the intervention. In another study comparing awareness of female cancers between Syrian refugees in Lebanon and Lebanese citizens, Syrian refugees had lower awareness of breast and cervical cancer screening programs [1]. A meta-analysis on cancer awareness and attitudes of refugees revealed that refugees had less knowledge and awareness about cancer. When refugees were compared to non-refugee immigrants and ethnic minorities, the refugee group had lower knowledge and awareness [34]. In a study by Idrees et al. [17] comparing the effectiveness of animation video and simulation techniques for BSE, animation videos and simulation were reported as useful tools by women to learn about their own BSE and to disseminate this knowledge to their relatives. In fact, they emphasized that simulation models can provide the necessary tactile input, as animated videos lack tactile sensation and the feeling of pathological breast masses by women may be important for the success of BSE in the long term. In parallel with previous studies, considering the remarkable change that emerged especially after the intervention in this study, the active participation provided by simulation in the learning process can be associated with the narrative and structured application opportunities supported by visual materials in modular education.

Breast self-examination is a cost-free, simple, reliable, and effective method for early detection of breast cancer [9]. Women need to be familiar with their breasts and detect changes at an early stage [3]. Therefore, encouraging women to acquire BSE skills is vital. In this study, both groups of women reported rarely or never performing BSE. While half of the women in the intervention group and most women in the control group expressed high confidence in their ability to notice changes in their breasts, a significant portion (39.1%) in the intervention group and 21.7% in the control group indicated that they had never sought medical attention for any changes in their breast tissue. Furthermore, most women in the intervention group, along with all participants in the control group, were unable to assess their risk of breast cancer based on age. However, more than half of the women in both groups were able to recognize changes in their breasts, reflecting a basic awareness of breast health. These findings revealed that Afghan refugee women had insufficient knowledge, confidence, skills, and behavioral awareness regarding breast cancer. Therefore, interventions are needed to improve breast cancer knowledge and awareness among vulnerable groups such as refugee women [12, 22]. Another study examining the effect of a self-care training program on lifestyle changes and BSE skills among migrant Afghan women in Shiraz found a significant increase in BSE skills in the intervention group after the training [19]. In our study, simulation-based breast health education not only increased awareness but also positively impacted BSE skills. After the training, the intervention group showed a significant increase in BSE skills compared to the control group. During the training, the participants learnt the correct BSE techniques by performing individual practices on breast models and reinforced their knowledge and skills by receiving instant feedback from the trainers. Although most BSE skills were adequately acquired in the intervention group, it is noteworthy that some visual assessment skills, such as evaluating breast shape, size, nipple retraction, and cupping, remained inadequate in a substantial proportion of participants. This suggests that simulation-based methods should be further enhanced, particularly through the inclusion of detailed visual materials and real-life examples, to effectively teach more complex observational skills.

The interactive and applied nature of the simulation process increased the permanence of the learned information and facilitated its transformation into behavior. In the literature, it is stated that simulation-based training is more effective than traditional methods, especially in gaining psychomotor skills, and increases learning motivation thanks to its applied structure [2, 8]. In addition, this method can offer significant advantages in terms of increasing the comprehensibility and recall of health information in individuals with low health literacy. Therefore, the results obtained in this study reveal that simulation-based education can be used effectively in disadvantaged communities such as refugee women and can significantly increase the level of knowledge and skills on breast health.

Nowadays, training only aimed at increasing knowledge and awareness are insufficient to develop behavioral change in individuals. Therefore, in this study, a simulation-based training model designed to increase knowledge and awareness and promote behavioral change was used.

Limitations and strengths

This randomized controlled trial had several limitations. First, the study involved a relatively small sample size of 46 Afghan refugee women in Ankara, with only 23 in each group. This limited number may affect the generalization of the findings to a broader population and refugee women of other nationalities. A larger sample size could provide more robust data and strengthen the conclusions drawn from the study. Second, this study is that, due to budgetary constraints and difficulties in reaching the sample population, no long-term follow-up was conducted to assess the sustainability of improvements in breast cancer awareness and self-examination skills. In this context, it is of great importance to identify follow-up strategies in future studies. For example, organizing repetitive training programs at regular intervals may enable participants to keep the information they have learned fresh and reinforce their skills. In addition, using digital tools can provide easy access to training materials, and women can replicate skills such as BSE through digital platforms. In addition, establishing community-based programs can encourage these women to disseminate their knowledge in their local communities and support each other. Third, in our study, randomization and blinding methods were used to control for bias, and we also attempted to minimize baseline differences between groups through pretest and posttest assessments. Although these methods greatly reduced the influence of external factors, it is not possible to claim that variables such as cultural beliefs and prior knowledge were eliminated. Therefore, these potentially confounding influences should be considered when interpreting the results of our study. One of the data collection tools used in this study is the assessment of breast examination skills based on the researcher's observation, while the other is a self-report form in which the participants express their level of knowledge with their own answers. Biases such as social desirability bias or recall difficulties may occur in self-report data. Participants may tend to overestimate their level of knowledge. To minimize this possibility, the questionnaires were filled in anonymously and participants were asked to give honest answers. In addition, the fact that breast examination skills were evaluated based on direct observation contributed to obtaining this data more objectively.

However, the strengths of this study include its status as the first randomized controlled trial in which simulation-based breast health education increased Afghan women's breast cancer awareness and enabled them to acquire the skills for breast self-examination. Another key strength of this study was that women were allowed to perform BSE on both a breast model and their own breasts. The breast simulation model provided Afghan refugee women with the opportunity to recognize breast-related changes. As a result of this study, Afghan refugee women's breast cancer awareness was enhanced, and they gained the skills to perform breast self-examination.

Conclusion

The simulation-based breast health education intervention for Afghan refugee women was found to be a practical and innovative approach to raising breast cancer awareness and providing BSE skills. This intervention may play a significant role in identifying at-risk individuals and raising their awareness. If sustained, this could potentially increase future screening participation and early detection, ultimately contributing to improved patient outcomes. It is recommended that health professionals incorporate simulation-based training models into breast cancer awareness programs, as these models effectively enhance both knowledge and practical skills. Given the cultural context, allowing women to practice on models can provide an opportunity to build confidence and competence.

At the policy level, such evidence-based and practical training models can be integrated into government policies aimed at improving refugee health services, community-based health programs run by NGOs, and migrant health centers within primary health care. Furthermore, the fact that simulation-based health-protective and health-promoting training can be structured in a way that can be easily implemented by nurses, who are the primary implementers of health education, makes it possible to include the use of this training model in large-scale groups. By examining the long-term effects of simulation-based training in different cultural contexts and on larger samples, future studies can provide comprehensive data that can inform refugee health policies for the international arena.

Data availability

Available from the corresponding author on reasonable request.

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