Breast self-examination and associated factors among women in Wolaita sodo city, Ethiopia: Community based cross sectional study

Background: Early detection of breast cancer plays an important role in decreasing morbidity and mortality associated with breast cancer. Breast self-examination (BSE) is one of the screening methods for early detection of breast cancer. BSE involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling. BSE is a simple exercise which can potentially save the life of a woman but it is not well focused yet. So, this study was aimed to assess breast Self-Examination and associated factors among women in Wolaita Sodo city, Ethiopia. Methods: Community based cross-sectional study design was employed. Systematic random sampling technique was used to select 626 women aged 20-65 years old. The data were collected using pre-tested and structured questionnaire. The data was entered using Epi data version 3.5.1 and exported to SPSS version 21 software for statistical analysis. Bivariable and multiple logistic regression analysis were done.Variables with P-value less than 0.05 were considered as statically significant. Results: A total of 629 women were included in the study. More than half (60.9%) of the participants were in the age range of 20-29 years. Women who had mentioned BSE as method for early detection of breast problem were 6.36 times (AOR: 6.36, 95% CI :( 3.72, 10.71) more likely to perform BSE than those who say that they don’t know any method. Women breast feed 13-24 months were 2.43 times AOR: 2.43, 95% CI :( 1.28, 4.59) more likely to examine their breast than those who breast feed different duration. Employed women were 3.13 times more likely AOR: 3.13 95% CI :( 1.14, 8.58) to practice BSE than women not employed. Likewise being student was 3.73 times AOR: 3.73, 95% CI (1.19, 11.73) more likely to perform BSE than others. Conclusion: The finding of this study showed that women’s practice of breast self-examination is relatively low. Knowledge of BSE, breast feeding 13-24 months, being employed and being student were factors affecting performing breast self-examination. Therefore, educating girls and increasing awareness on electronics media is important.


Introduction
Breast cancer has increasingly become an issue of public health importance in both developed and developing nations. Because of its high prevalence, it over-burdened health system and direct medical expenditure. Breast cancer is the second leading cause of death among women worldwide with an estimated 1.38 million new cases diagnosed annually which accounts for 10.9% of all cancer cases next to lung cancer (1,2). Its incidence is increasing both in developed and developing regions.
In 2008, an estimated 636,000 incident cases were diagnosed in high resource countries, while 514,000 cases were diagnosed in low and middle resource countries. Breast cancer is the most frequent cause of death among women both in developing (269,000 deaths (12.7%) of total) and developed region with an estimated 189,000 deaths. It is estimated that 70% of all breast cancer cases worldwide will be in low and middle resource countries by 2020 (3).
The incidence varies across the continent ranges from 19.3 per 100,000 per year in Eastern Africa to 38.1 per 100,000 in Southern Africa (4).
Breast self-examination (BSE) is one of screening methods, which involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling. BSE is a simple exercise which can potentially save the life of a woman. It is recommended for every woman to start breast self-examination at age of 20 years and this expected to be done for 20 minutes every month (5). However, women in developing countries do not perform BSE for various reasons (1). A woman who performs BSE may be more motivated to seek medical attention, including Clinical Breast Examination (CBE) and mammography (6).
In Ethiopia more than half of women with breast cancer were age 50 and younger.
Evidence shows that 69.6% of patients ignored their symptoms initially for an average of more than one and half year (7). BSE is still recommended as a general approach to increasing breast health awareness and thus potentially allow for early detection of any anomalies, because it is free, painless and easy to practice (5).
The American Cancer Society also recommends that women, starting from the age of 20 years should be educated on the pros and cons of performing a monthly BSE (8).
Breast cancer in low to middle income countries has late presentation with poor treatment outcomes due to several factors such as unequal access to prompt high quality treatment and lack of early screening(3) Despite the fact breast cancer comes out recently as the worst killer of young women especially those in urban area, Ethiopia health system has traditionally concentrated on communicable diseases prevention (7).
Even though breast cancer is among the leading causes of morbidity and mortality among women, very limited report has been published that measures the level of BSE So, this study will contribute towards building on breast self-examination related issues. And also seeks to identify the need for information on breast cancer selfexamination. Therefore, this study was aimed to assess breast self-examination and associated factors among women aged 20-65 years in Wolaita Sodo city.

Study setting and design
The study was carried out in Wolaita Sodo city. The city has a total population of 250521. Male 79871 (52%), female 73650 (48%) and the city has three sub cities, 18 kebeles, three health centers, one hospital owned by MOH and one private hospital. The city is located 160km from regional city Hawassa and 327 km from Addis Ababa, the capital of Ethiopia (9). A Community based cross-sectional study design was employed.

Source population
All women age 20-65years were considered as a source population.

Study population
The house in selected kebeles were taken by systematic random sampling technique and study unit was selected by simple random sampling technique.

Inclusion and exclusion criteria
Women age 20-60 years were included in the study and women who were seriously ill during data collection time, having known breast cancer and those not willing to participate in the study were excluded.
Sample size and sampling procedure Sample size was calculated with open-Epi statistical software version 3.03 using single population proportion statistical formulas. n = Z (1.96)2 P (1-P)/ d 2 With assumption of: z = 1.96, at 95% confidence level. P-prevalence of breast self-examination 53.6 %( 0.536) from previous study (10).
Non-respondent rate 10% and confidence levels of 95% and 5% margin of error. Therefore a calculated sample size was 572 and after considering 10% non-response the final sample size was 629.

Sampling procedure
Multi stage sampling technique was used to select the respondents of the study.
First, among the 18 kebeles in the city, 6 kebeles were randomly selected by simple random sampling method to represent all kebeles. The number of source population in each selected kebeles was identified from Wolaita Sodo finance economic development department data (9). The calculated sample size allocated to the selected kebeles proportionate to the number of source population in the kebele.
Sampling interval was calculated by diving source population to our sample (N/n) = 15098/629 = 24. The first house hold was selected by simple random sampling method from 1-24 households listed and 10 th household was chosen randomly Sampling frame (households) containing lists of the population from selected kebeles was obtained and every 24 th house was visited to select the study population by systematic random sampling technique until the given sample size filled for a given kebele and the respondents from each selected house hold was taken by simple random sampling technique whenever there were more than one eligible women in a selected household.

Data collection procedure
Structured, pre-tested and interviewer administered questionnaires were used.
Questions on the questionnaire include the socio demographic characteristics and BSE related issues. The questionnaires were adapted from Ethiopian Development and Health Survey (EDHS) and different published literatures. Data were collected for the period of 24 November 2018 to 2 December 2018 by trained data collectors.
Data were collected through face-to-face interview maintaining the pre-determined sampling intervals. The data collectors informed the respondents all details of the research purpose and procedures and what was expected of them, potential risk and benefit in order to encourage accurate and honest response. When the woman was not available in the first visit, data collectors arranged alternative visits. If a woman was still not available on second visits or declined to participate in the study, the household was jumped and the immediate next household in the sampling frame was considered.

Data quality management
Before data collection the questionnaire was first prepared in English and translated into Amharic and back to English to keep the consistence of questionnaire. Two days training was given to data collectors and supervisors by the principal investigator before data collection.
A pretest was conducted in Dilbetigil kebele which was other than selected kebele and 5% of total sample size was tested. Based on the pretest, questionnaires were revised, edited and the necessary corrections made accordingly. Daily check-up of data for completeness and consistency was done during data collection.

Data analysis procedures
The data entry was done using EPidata version 3.1 and cleaned to check for accuracy, consistencies, completeness, values and any error identified was corrected.
The data was exported to SPSS version 21 software for analysis. Descriptive statistics was done. Bivariable analysis was computed and variables with p-value of less than 0.25 was made candidate for multiple logistic regression analysis. Multiple logistic regression analysis was done and variables with P-values ≤ 0.05 were considered as statistically significant. Adjusted Odds Ratio (AOR with 95% C.I) used to declare statistically significant association.

Ethical issues
Ethical clearance was obtained from Wolaita sodo university Institutional Review Board (IRB). Written permission was obtained from Sodo city health department.
During data collection all respondents were asked their permission and informed consent was obtained from each study participants.

Operational definitions
Breast self-examination (BSE): The examination of their breast by themselves, to identify any changes in the breast (25).

Result
Socio demographic characteristics of the subjects A total of 629 women were interviewed and subjected to analysis. The participants were between the age 20 and 65 years. More than half (60.9%) of the participants were in the age range 20-29 years and 8.2% were greater than 50 years. Majority of women (87.3%) were Wolaita in ethnicity and 444 (70.6%) were protestant. Three hundred thirty eight (53.7%) of the respondents had completed secondary education and majority (76%) of the study participants were married. (Table1).

Knowledge and practice of BSE and information sources of women
Among the respondents, 591 (94%) knew (heard or read) about breast cancer and their main source of information was electronic media (62.4%). The contribution of health professionals as a source of breast cancer information was found to be (14.7%). Electronic media, family/friends, and health workers were respectively reported as a major source of information. Forty five (7.6%) of the respondents who  Table 2).
Knowledge of the right age to perform BSE and the reasons given to perform or not Different responders, those who perform BSE, cited different prospective on correct age at which BSE commenced, which is at the range of 10 -30 year (mean age 18.41±2.8 SD). Of these, 63(29%) recommend it at the age of 20 years and one hundred forty four (144) responded, I don't know. Breast -Self Examination performers claimed to have their own performance at varying time period. Of these; few days after menses, few days before menses were ninety seven (44.7%), thirteen (6%) respondents respectively and one hundred seven (49%) answers no specific time/ any time they remember. From those participants who have ever done BSE, One hundred thirty three (61.2%) of them reported to practice it on a regular basis.
Among the participants who practiced BSE on regular basis, 98(45%) were practicing monthly, and any time they observe a change were 65(30%). ( Table3).

Reasons of not performing breast self-examination
From those responded as ever heard breast self-examination (BSE), ninety eight (45%) believed that they have some kind of barrier to practice BSE. pressure of work/too busy, I don't have enough privacy to do BSE, I know I can never have Bca, and forgetfulness, doubt about its effectiveness were mentioned as main barriers/reason not to perform BSE by 30(14%), 14 (6.4%), 13 (5.9%), 10(4.6%), and 11(5%) of the respondents, respectively. However more than half of performers 119(54.8%) claimed that there is no obstacle (Figure 2

Discussion
This study showed that 94% of respondents had ever heard or read about breast cancer. This is higher than the study done among Mekelle town women which showed 83% (10), lower than study findings done in Malaysian among female students is 99.5% (14) This could be due to the difference of education level among the study participants and difference in time interval between the studies. The present study also revealed that 46% of the women have previously heard about breast self-examination. This is lower than study done among Women in Malaysia where 78.4% heard about breast self-examination (13),Jordanian Women 67 (15) study done among female undergraduate students in a higher teachers training college in Cameroon 47% (17) (26) and on the other hand this study was higher than study result done in Benghazi, Libya which showed only 41.5% heard BSE (16). The difference observed could be due to the difference in socio-economic and demographic characteristics among the study population. The relatively low knowledge of our respondents about BSE might preclude them from practicing BSE, which might lessen chances of early detection of the disease. Three-fifth (62 %) of those who had breast cancer information indicated that their major source of information was media. Colleagues/friends were also mentioned as important sources of information on breast cancer. Surprisingly, the proportion of respondents who mentioned health professionals as major source of breast cancer information was lower than the above once 13.8%. This is consistent to the findings of a similar study conducted among Jordanian females where relatives, friends and neighbors were found to be the main sources of breast cancer information (15).and inconsistent with study done among Iranian women which the health professionals are the major source of information 32.4% (27).
In the present study, large proportion [98%] of breast cancer informed participants knew that early detection of breast cancer improves chances of survival from the disease. This finding is supported by the study of Mekelle town women (10) (10). And Being health 100 (44.8%) and lack of knowledge 60 (26.9%) were the most barriers mention for not practicing BSE in Adama Science and Technology University (25).
The current study revealed that women who responded BSE as an early detection method of breast cancer were 6.36 times more likely to practice breast selfexamination than women who do not know any methods of early detection breast cancer. This finding is consistent with study conducted among women in Malaysia which showed that knowledge of women that BSE is an early detection method of breast cancer was significantly associated with breast self-examination (13).
In current study women engagement in occupation ns other than housewife was significantly associated with performing BSE AOR: 3.12 95% CI:( 1.14, 8.58).These results are in agreement with findings that were reported among Nigerian women (30), study in Benghazi, Libya (16) and study done in Southern Ethiopia (21).
Those women who breast had feed their child 13-24 months were 2.43 times more likely to examine their breast than those who mention different duration of breast feed, this may be due to, those who optimally breast feed were conscious/educated to perform BSE.
Women who use electronic media as source of information were 1.59 times more likely to practice BSE than women who use other media types. This may be due to its relative accessibility than other source of information for women get information about BSE.

Strength and limitation of the study
Strengths: previous studies conducted in Ethiopia were merely focused on health professionals at their institution but this study was focused on the urban community.
Limitations: this study was conducted in urban community, Sodo city which may not equally represent the rural community and also in this study causal conclusions cannot be drawn. stating about the general objective of the study and issues of confidentiality which was discussed by the data collectors before proceeding with the interview.

Conclusion and recommendation
Confidentiality of the information was ensured by coding. The interview was undertaken privately in separate area. Only authorized person was getting access to the raw data collected from the field.

Consent for publication
Not applicable examination and mammography in a group of women in a rural area in western     Adjusted odds ratio (AOR), Significant at P-value<=0.05 Figures Figure 1 Breast cancer information sources among women in Sodo city, 201 Sample size determination of the study.docx Tool and consent statement.docx