2.1. Systematic Review Methodology

The present systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed to identify studies relevant to barriers and facilitators to engagement with the breast screening programme in Malta. The protocol for the systematic review was registered with PROSPERO (Registration ID: CRD42024580313) to ensure transparency and adherence to predefined methodologies.

2.2. Inclusion/Exclusion Criteria

Articles that met the following criteria were included in the present systematic review: (i) published in a peer-reviewed journal, ensuring the studies have undergone a rigorous evaluation process to maintain scientific quality; (ii) included a sample of women aged 50–69 eligible for breast screening as part of the Maltese NBSP, as this age group is the target population for the programme; (iii) focused on breast screening behaviour or participation among women in Malta, aligning with the present systematic review’s objective to investigate factors influencing engagement with the Maltese NBSP; (iv) written in English or with an available English translation, to ensure accessibility and consistency in the presentation of the reported data; (v) published between 2011 and 2024, capturing the most recent studies reflecting current practices, policies and societal attitudes in Malta; (vi) original research articles with full-text availability, ensuring that the studies provided adequate study information and transparency and (vii) study designs being quantitative, qualitative, or mixed-methods, allowing for a broad range of perspectives and methods to be included in the present review to enhance the richness and applicability of the findings.

Studies were excluded if (i) they were not published in a peer-reviewed journal; (ii) they did not include participants within the specified age range (50–69); (iii) they were not focused on breast screening behaviour/participation among women in the NBSP in Malta; (iv) they were nonoriginal research articles including book excerpts, reviews, editorials and postgraduate theses; (v) they were not published in the aforementioned specified timeframe (2011–2024); (vi) there was lack of full-text availability and (vii) they did not include the aforementioned study designs.

2.3. Search Strategy

Articles were identified via searches of the following databases: PsycINFO, PsychArticles, MEDLINE and Google Scholar in June 2024. Reference lists of relevant articles were also investigated. Search terms were generated by examining the terminology used in a previous review examining breast screening (e.g., [27]). Search terms included ‘breast cancer screening’ OR ‘mammogra ^∗’ OR ‘breast imag ^∗’ OR ‘breast exam ^∗’ OR ‘breast check-up’ OR ‘cancer screening uptake’ OR ‘cancer examination uptake’ OR ‘screening behav ^∗’ OR ‘screening participation’ AND ‘Malta’ OR ‘Maltese wom?n’ OR ‘Maltese adult ^∗’ OR ‘Maltese female ^∗’ AND ‘factor ^∗’ OR ‘uptake’ OR ‘influence ^∗’ OR ‘reason ^∗’ OR ‘determinant ^∗’ OR ‘barrier ^∗’ OR ‘obstacle ^∗’ OR ‘challeng ^∗’ OR ‘constraint ^∗’ OR ‘facilitat ^∗’ OR ‘enabl ^∗’ OR ‘adoption’ OR ‘acceptance’ OR ‘engagement’ OR ‘utili?ation’ OR ‘non-acceptance’ OR ‘non-engagement’ OR ‘non-attendance’ OR ‘avoidance’ OR ‘rejection’. Proximity operators, such as NEAR/3 and ADJ/2, were used to refine the search.

2.4. Search Results

The initial search yielded 48 records. After removing six duplicates, 42 records were screened, and 29 were excluded based on the inclusion/exclusion criteria. Of the 13 full-text articles assessed, exclusions were made for the following reasons: PhD thesis (n = 2), book excerpt (n = 1), psychometric scale development (n = 1), breast compression techniques (n = 1), qualitative study focused on interviews with radiologists and radiographers from multiple countries, including Malta (n = 1), audit of the Maltese NBSP (n = 1) and non-peer-reviewed articles (n = 2). Journal titles were cross-checked with the Directory of Open Access Journals and the Committee on Publication Ethics; articles from journals on the Critical Appraisal Skills Programme watchlist were excluded. One additional record was found through citation searches (Google Scholar). The present systematic review included a total of five full-text papers (Figure 1, PRISMA flow diagram; Table 1, study characteristics).

2.5. Data Extraction

Data extraction followed a modified Cochrane Collaboration template [28]. The corresponding author (Daniel Gaffiero) extracted data from two studies, while the second author (Brian Fenech) extracted data from the remaining three. Both authors then reviewed the data to ensure consistency across all studies. Extracted data included study aims, methods, participant demographics, inclusion/exclusion criteria, withdrawals, subgroup information, sample sizes, outcomes related to barriers and facilitators, statistical data, and key conclusions.

2.6. Quality Assessment of Studies A–E

In this review, the quality of included studies was assessed using the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies [29]. Authors Brian Fenech and Daniel Gaffiero independently evaluated each study, awarding 2, 1 and 0 points for fully met, partially met and unmet criteria, respectively, resulting in a total score range of 0–16. Studies were classified into three quality levels based on their total score: low (score range, 0–8), moderate (score range, 9–12), and high (score range, 13–16). To assess the risk of bias, each study’s total score was converted into a percentage, with the following risk classifications; high risk, ≤49%; moderate risk, 50%–69%; and low risk, >70%. A detailed breakdown of the quality assessment is provided in Table 2.

Points were deducted for methodological and analytical shortcomings in the studies. Studies A and E used unvalidated methods for measuring exposure, with study A lacking information on the validation of its modified questionnaire and study E using an unvalidated questionnaire. All studies except study B inadequately addressed confounding factors, with studies A, C, D and E failing to employ rigorous multivariate analysis, weakening their findings. Study E also misclassified the non-parametric tests used as parametric. After quality assessments, authors resolved six discrepancies with 100% agreement. Studies B, C and D were rated as being high quality, while studies A and E were rated as being moderate. Although studies A and E provide valuable insights, their methodological limitations warrant cautious interpretation.

3.1. Demographic Information of Participants in the Included Studies

The current review included five studies with a total of 911 women (mean age range, 54.6–58 years; studies B, C and D used the same participant cohort). It should be noted that although the same participant cohort was used across studies B, C and D, each study addressed different research questions, which led to the presentation of distinct aspects of the barriers and facilitators influencing engagement in the NBSP. While the cohort remained the same, the studies provided complementary and nuanced insights, with each study contributing new information relevant to the present systematic review (Table 1 for differing outcome measures). The inclusion of these studies was based on their ability to present unique perspectives or findings within the context of the overall research question. All studies were from Malta, with study B also including participants from Gozo. Studies A and B specifically recruited women in Malta, while study E did not specify ethnicity. The most common occupations included (i) housewives (77%) and (ii) employed but not in healthcare (24.4%). In study B, most women were married (86.9%), had a below-average income (<16,114€), owned a car (83.7%) but could not drive (56.2%), had a family physician (93.3%), were generally healthy (54.2%) and visited their physician only in emergencies (88.6%).

3.2. Study Designs Employed by the Authors of the Included Studies

Four studies used a cross-sectional questionnaire design, while study A employed a mixed-methods approach, combining cross-sectional questionnaires with thematic analysis, a form of qualitative analysis. Study A collected retrospective data via telephone from women who had participated in the Maltese NBSP, presenting statistical data under five themes (accessibility, efficiency, perception, supportive care and acceptability) without detailing the analytical approach or epistemological stance.

Studies B, C and D also used retrospective data via a telephone questionnaire. Study B categorised women as ‘attendees’ (n = 243) and ‘non-attendees’ (n = 161) based on their response to NBSP invitations. Study C focused on women who had received their first screening invitation, distinguishing between those screened within (‘adherent’, n = 324) or beyond (’non-adherent’, n = 80) the 3-year interval between invitations. Study D compared women who had previously attended a mammogram as part of the NBSP (‘lifetime attendees’, n = 348) with women who had not (‘non-lifetime attendees’, n = 56). Study E gathered data through intermediaries distributing the survey focusing on women attending a mammogram as part of the NBSP (n = 127).

3.3. Study Aims of the Included Studies

Study A aimed to evaluate women’s satisfaction with the NBSP during its prevalent call. Study B investigated the knowledge, health beliefs and illness perceptions about BC and screening in women in Malta, identified reasons for non-attendance of their screening appointment as part of the NBSP, and determined the socio-demographic, health status and other predictors associated with the uptake of the first invitation to breast screening. Study C explored the predictors for women in Malta screened within or exceeding the recommended 3-year frequency in organised (i.e., NBSP) or private screening in Malta. Study D sought to understand the determinants of attendance for mammography screening and examine the predictors of lifetime mammography use and non-use. Finally, study E aimed to assess knowledge and awareness of breast density among women in Malta attending a mammogram as part of the NBSP.

3.4. Barriers and Facilitators Affecting Uptake of NBSP

Barriers and facilitators influencing engagement with the NBSP were analysed across three primary levels (see Table 3 for an overview). At the psychological level, factors included knowledge, fear and anxiety, health beliefs and illness perceptions. The social level encompassed the influence of educational level, occupation, income and marital status. Lastly, factors at the healthcare level encompassed the infrastructure and services of the healthcare system, including accessibility, quality of care and effective communication with healthcare providers. These categories offer a structured framework for comprehensively examining and addressing the barriers and facilitators affecting engagement with the Maltese NBSP.

4.1. Knowledge

The studies showed marked variability in knowledge about BC and screening. Study B revealed uncertainty about screening frequency, with 46.3% of women stating mammograms are annual and 43.3% stating mammograms take place every 2–3 years. Additionally, 38.7% and 47.5% of women mistakenly considered BC was caused by a ‘germ or virus’ or ‘accidents or injuries’, respectively. Study D linked knowledge of mammography frequency to lifetime screening participation, while study E highlighted limited awareness of the role of breast density in BC risk. These findings suggest that inconsistent knowledge and misconceptions about BC and screening frequency could affect both initial and ongoing participation in the NBSP.

4.2. Fear and Anxiety

Fear and anxiety about BC are prevalent among women in Malta. Study A found higher anxiety in older women (63.1% of women aged 59–61 vs. 50.2% of women aged 56–58), primarily due to fears about results and their impact. Study B reported widespread anxiety, with numerous participants concerned about the severe life consequences of BC and its influence on the progression of the disease. In that study, 41% of ‘non-attendees’ cited fear as a major reason for not participating, including fear about results (25%), pain (10%), unknown procedures (6.2%), radiation (3.7%) and embarrassment (8.1%). These findings indicate that fear and anxiety are marked barriers to NBSP uptake, especially regarding screening outcomes and procedures.

4.3. Health Beliefs

Three studies (B, C and D) assessed constructs of the Health Belief Model (HBM) influencing breast screening attendance. Perceived benefits were linked to higher first and lifetime screening attendance (studies B and D), while ‘non-attendees’ perceived fewer benefits, including reduced belief in early detection through screening (study B). Perceived barriers were the strongest HBM predictor of non-attendance (studies B, C and D). Barriers included fear of male mammographers, results, unknown procedures and mammography discomfort. The logistic regression in study D confirmed perceived barriers as the strongest predictor of non-attendance. Cues to action were important across most of the included studies (B, C, D and E). Attendance increased with healthcare provider advice or having a relative/friend diagnosed with BC, while advice from friends and family was less impactful. Media coverage, text/letter reminders and educational talks also influenced attendance. Study E highlighted a high demand for more information about breast density, with 90.6% of women preferring healthcare professionals as the information source. Self-efficacy was associated with screening attendance (studies B and D), indicating that confidence in managing screening logistics enhances participation in the Maltese NBSP.

4.4. Illness Perceptions

The findings pertaining to illness perceptions were generally mixed. Study B reported that ‘attendees’ agreed that BC could be hereditary and linked to behaviour, while ‘non-attendees’ were more undecided about the impact of emotional state and personality on BC. ‘Attendees’ were also more likely to believe that a patient with BC experiences cycles of getting better and worse, and they often acknowledged the major life consequences, serious economic and financial impact and the life-changing nature of BC. By contrast, study C found that while no specific constructs were significant, several individual factors were associated with adherence or non-adherence to screening. These factors included negative mental attitude, family problems and worries, emotional state (feeling down, anxious, empty or lonely), personality traits and anxiety about BC. Study D reported several emotional representations associated with non-lifetime attendance, such as emotional state, belief that BC was hereditary, thinking that a ‘germ or virus’ is a risk factor, recognising the major consequences of BC, and experiencing anxiety and fear. These findings indicate that illness perceptions, including beliefs about the causes, timeline and consequences of BC, as well as emotional responses, play a role in influencing engagement with the NBSP.

4.5. Social Level

The impact of social and demographic variables on breast screening attendance varied across studies. Study A observed higher refusal rates among women with primary (71.6%) and secondary (70.4%) education level compared with those among women with tertiary education (52.3%). Similarly, study E found that knowledge of breast density was influenced by educational attainment, with the least and most knowledgeable participants at primary and tertiary education levels, respectively. Study E also noted that healthcare workers were the most knowledgeable about breast density and BC risks, while housewives were the least knowledgeable. Study B identified no significant associations between demographic variables and first screening uptake, except for family income; those with lower income were less likely to attend breast screening. This finding was corroborated by study D which also noted the influence of marital status on mammogram attendance, with widowers being the least likely to participate. These findings suggest that educational level, occupation, income and marital status all play notable roles in influencing breast screening participation. Addressing disparities in knowledge and access among different social and demographic groups could enhance the overall effectiveness and reach of the Maltese NBSP.

4.6. Healthcare Level

Patient satisfaction emerged as a crucial factor influencing attendance at the NBSP. Study A reported that 31.3% and 68.7% of participants rated their screening experience as ‘good’ and ‘excellent’, respectively. Satisfaction with screening appointments was also high, with 95.5% and 99.2% of participants ‘very satisfied with screening appointments’ and ‘very satisfied with care standards’. Key factors influencing patient satisfaction included a pleasant environment, cleanliness and staff professionalism. However, only 68.9% expressed overall satisfaction with the entire programme. Regarding radiographer interaction, 99.7% of participants reported ‘feeling at ease’, and 98.4% rated the care as ‘excellent’. Nonetheless, 68.9% of women indicated they would decline screening if the radiographer was male.

Accessibility issues were highlighted as barriers in studies A, B and D. Study A reported that 29.74% of participants experienced access issues, negatively impacting satisfaction with the NBSP. Difficulty with parking was also noted as a reason for lower satisfaction levels. Study D found that lack of a driving licence was associated with a decreased likelihood of attending a mammogram. Study B revealed that 13.7% of women reported never receiving an invitation, while 8.7% reported being busy, having transport issues and being ill or on vacation as reasons for non-attendance.

Lastly, discomfort experienced during mammograms was shown to reduce satisfaction and increase doubts about repeat mammograms (study A), indicating that improving the comfort of the procedure could enhance patient satisfaction and encourage ongoing participation in the NBSP.

5.1. Limitations and Future Research Directions

The present systematic review has certain limitations. Most studies focus on women aged 54.6–58.0, which does not fully represent the broader Maltese target age range of 50–69. Additionally, many studies are by the same lead author, Marmara, which may introduce bias and limit perspective diversity. It should also be noted that although studies B, C and D each used the same participant cohort, each study included different outcome measures which provided nuanced insights into barriers and facilitators influencing engagement in the NBSP. To expand, Study B focused on health beliefs and illness perceptions, study C screening adherence and Study D lifetime mammography use. Consequently, the total cohort (n = 911) included in the current systematic review was based on the total sample sizes of studies A, B and E, only, to avoid duplication and reporting of incorrect sample size. While Marmara et al.’s qualitative research is valuable, more comprehensive analyses like interpretative phenomenological analysis are needed to better understand the experiences of Maltese women and the role of GPs in screening engagement. The heterogeneity in study designs and methodologies also hindered meta-analysis. Finally, the review may not fully capture access variability across socio-economic and geographical subgroups, as noted by the EU’s ‘Beating Cancer’ plan [52]. Future research should broaden the age range, address accessibility issues, incorporate longitudinal and qualitative approaches, and use consistent, high-quality methodologies to enhance the generalisability and impact of findings on breast screening programmes globally. Moreover, future research should focus on understanding barriers to accessing breast screening in Malta among those who do not attend. This would lead to more targeted and effective public health interventions which would increase uptake in this population and thus has the potential to reduce BC-associated mortality due to early diagnosis.