Study design, period, and setting
An institutional-based cross-sectional study was conducted among women who were attending family planning (FP) services in Pastoralist health facilities in South Omo Zone, Southern Ethiopia from January to February 2022. This study was conducted in the pastoralist health facilities of South Omo, the zonal structure of Southern Ethiopia. The South Omo Zone is principally characterized by socially marginalized communities with the lowest socioeconomic status as well as dominated by nomadic and pastoralist ways of life. It has a diverse ethnic group that contains around 21 different tribes. It is also one of the border zones, and 750 km from the center of Addis Ababa, the capital of Ethiopia. Jinka town, the Capital of South Omo has 3 governmental health facilities such as; Jinka General Hospital (JGH), Millennium Health center, and Bethemal Health center.
Population
All women who visited governmental health facilities and were aged 20 years and above were the source population. All systematically selected women aged 20 years and above were the study population. Women who were 20 years and above, and had no history of breast-related diseases were included in the study. Women who were ill and didn't want to participate, and were not mentally sound were excluded.
Sample size determination
The sample size was calculated using the single population proportion formula. Different assumptions were used to calculate the sample size such as; a 95% confidence level, 5% margin of error, and 53.6% proportion of women who use BSE in Northern Ethiopia [21].
$${\text{n}} = \frac{{{\text{Z}}^{2} {\text{P}}\left( {1 - {\text{P}}} \right)}}{{{\text{W}}^{2} }}$$
where:—n = required sample size, Z (confidence interval of 95% which is = 1.96), P—the estimated proportion, W—Marginal error
$$\begin{aligned} & {\text{n}}_{{1}} = \frac{{\left( {1.96} \right)^{2} { }\left( {0.5} \right)\left( {1 - 0.5{ }} \right)}}{{\left( {0.05} \right)^{2} }} \\ & {\text{n}}_{{1}} = { 384} \\ \end{aligned}$$
A 10% of non-response rate was also added and yielded a total sample size of 411. Then, the sample size was allocated proportionally to the number of each health facility within the town. A total of 2820 women visited FP service in Jinka town health facilities in the past 06 months (JGH 1660, Millennium Health center 734, and Bethemal Health center 426). Finally, systematic random sampling, using every kth value (every seven) was employed to select each woman from each health facility in Jinka town (Fig. 1).
Data collection tools and procedure
Data were collected using structured, pretested, and interviewer-administered questionnaires. The questionnaires were initially adapted from the Ethiopian Demography and Health Survey (DHS) and the related published literature [8,9,10,11,12,13,14,15,16]. It addressed different factors such as sociodemographic factors (maternal age, place of residence, educational level, marital status, and occupational status), knowledge-related factors (Heard of BSE, where did you hear, common in your living area, detected early, the chance of survival, age screening recommended, family history of breast cancer), Attitudinal and practice-related factors.
Data quality control
Before data collection, the questionnaires were translated into Arigna and Amharic and then retranslated back to English by the language-translation experts and health professionals to check for their consistency. The pretest was also done with 5% (n = 21) of the total sample size at the nearby health center to check the questionnaires for appropriateness, simplicity, clarity, understandability, and coherence before collecting the actual data. Moreover, Cronbach's alpha (0.86 and showing good internal consistency of items) were used to check for the reliability of the questions, and the validity of the content was also cross-checked by senior expert midwives working in a nearby hospital other than the study area. The training was given to the data collectors before the data collection process. Data collectors were midwives working in other health facilities nearby. The women were also informed about the benefits and risks associated with the study before data collection to give accurate results as possible.
Eight questions were used to assess the level of women's knowledge. Women who scored the mean and above were added and decisions were given. Women who answered four and above were considered good knowledge, and women who had below four were regarded as having poor knowledge. Likewise, seven questions were used to assess the attitude of women toward BSE using the Likert scale items, and the score of mean and above was used to decide the level of women's attitude toward BSE. Women who responded four and above were considered as having a good attitude, while below four were regarded as having a poor attitude toward BSE. Finally, eight questions were used to assess the level of women's BSE practice. The women who answered four and above considered as good BSE practice and had below four were taken as having poor women practice toward BSE. Moreover, Cronbach's alpha was assessed to check for the internal consistency of the items.
Our analysis included BSE practice as a dependent variable while considering sociodemographic, knowledge, attitudinal, and Practice related factors as independent variables.
Data processing and analysis
The collected data was initially entered into Epi data version 7.2.2.6, then exported to SPSS version 25 for analysis. The descriptive statistics were computed such as means, frequencies, and proportions to summarize each relevant variable. Bivariate logistic regression analysis was carried out. Then, those variables that were significant at the bivariate level of analysis with p < 0.25 were taken into a multivariate logistic regression to identify the determinants. Finally, variables with a p value of < 0.05 in the final model were used to declare as determinants of BSE practices. Hosmer and Lemeshow test was also used to check for model fitness.
Operational definitions
Breast self-examination (BSE)—the woman one's self-examination of the breasts to find any possible changes [5].
Breast self-examination Practice—ever performed BSE by the woman at least once a month [22].
Age 20 and American Cancer Society—the recommendations for women who want BSE by American cancer society for women aged 20 and above [5].
Knowledge of BSE: is the knowledge of the woman regarding what BSE means, how one can do it, and when one can do it using eight-question with the response of either 1 or 0 [8].
The attitude toward BSE—is what the women think and believes about BSE and was assessed using common Likert scales starting from strongly disagree (1) to strongly agree (5) [17].
The practice of breast self-examination: is the woman's act toward BSE and is assessed using eight potential questions with the response of either 1 or 0 for the right and wrong responses respectively [5, 15].
