Breast cancer self-examination practice and associated factors among women reproductive age group in southeast Ethiopia

Background: Breast cancer is the most prevalent and the second cause of cancer deaths among women worldwide especially in developing country. It is considered as a progressive disease with a poor prognosis if detected late. Therefore, its early detection using breast self-examination plays a significant role in reducing morbidity and mortality related to breast cancer. Objective: This study aims to evaluate breast self-examination practice and associated factors among women reproductive age group in southeast Ethiopia. Methods: A community based cross sectional study was conducted on 836 reproductive age group women. Interviewer administered questionnaire was used for quantitative part of the study and supplemented qualitatively using focus group discussions. Data was interred into Epi-info version 3.5.3, and analysed using SPSS version 20. Bivariate and multivariable logistic regressions were done to examine the effect of explanatory variables to the outcome variable. Variables with P. value <0.05 during multivariable logistic regressions were considered as significantly associated with the dependent variable. Result: Out of eight hundred thirty six total participants, 20.7% of them had ever heard about breast self-examination practice. Also only 13.2% of the mothers had practiced breast self-examination. Maternal age, mother’s level of education, and previous history of breast examination by health professionals were major predictors for breast self-examination practice. Conclusion: This study reported lower prevalence of breast self-examination practice. Therefore, enhancing maternal education and coverage of breast examination by health professionals are essential to raise the odds of breast self-3

examination practice among women reproductive age group.

Background
Breast cancer (BC) is the most common form of cancer among women worldwide and attacks women in their most productive and reproductive years of life [1]. It is characterized by the uncontrolled growth of anomalous cells in the milk producing glands of the breast or in the ducts that provide milk to the nipples; and it arises in the breast tissue that is made up of glands for milk production, called lobules, and the ducts that link the lobules to the nipple [2,5]. Breast cancer typically yields no symptoms when the tumor is small and most easily cured. Therefore, it is very essential for women to follow suggested screening rules for detecting BC at an early stage. When BC has developed to a size that can be felt, the most common physical sign is a painless lump or swelling even before the original breast tumor is large enough to be felt. Other common signs and symptoms include breast pain or heaviness, persistent changes to the breast (swelling, thickening, or redness of the breast's skin), and nipple abnormalities (spontaneous bloody discharge), erosion, inversion, or tenderness [1,5].
Aside from being female, age is the most important factor affecting BC risk in women. The other risk factors for BC are inherited mutations in BC susceptibility genes, a personal or family history of BC, high breast tissue density, and high dose radiation to the chest as a result of medical procedures [6], reproductive factors that increase risk (early start of menstrual periods and/or end later in life), not ever having children, prolonged use of oral contraceptives, and having child after age of thirty, some other factors that increase risk include being overweight or obese after menopause, use of menopausal hormone therapy (combined), physical inactivity, and consumption of alcohol [7].
The most imperative strategies for achieving early detection of BC are mammography and physical examination of the breasts by qualified health workers or clinical breast examination (CBE) and breast self-examination (BSE). Breast selfexamination has been broadly recommended as a comparatively simple, nonoffensive, non-harmful, and cost-free screening technique when comparing to other types of screening approaches for breast cancer. It is a technique established for the definite purpose of looking for cancer; a woman uses her hands to systematically examine her breasts and the immediate areas for unfamiliar lumps and shape changes. Usually done on a fixed monthly basis, the same technique is used each time, ensuring that all areas of the breast are sensed and checked thoroughly. The purpose is to screen for and discover BC as early as possible [11,12].
Breast cancer is the most prevalent cancer specially in developing countries [8,10].
In Ethiopia, BC is typically a fatal disease with high morbidity and mortality [9], unlike the experience of the western world where BC is treatable and with lower mortality [26]. Ethiopia has set comprehensive BC prevention, diagnosis, and treatment interventions and available for women [27]. However, stigma towards cancer, poor knowledge of BC related to signs, symptoms and its treatability, and system overload continue to account for delays in reaching care [28]. Ethiopian women usually present for care at a late stage in the disease [9], where treatment is most ineffective, and while system-related barriers to care account for a portion of that delay, women's attitudes and lack of awareness of BC also account for a stalled initiation of action [29]. Therefore, this study was designed to identify the breast self-examination practice and major causes among reproductive age women in Bale zone, southeast Ethiopia.

Study design, area and period
A community based cross-sectional study was conducted from March to May, 2017 in Bale zone. The Bale zone has 20 districts. Robe town is the capital city of Bale zone which far 430 kilo meters from Addis Ababa, the capital city of Ethiopia.

Sample size determination
Single population proportion formula was used to determine the sample size for the quantitative data. Proportion of breast self-examination practiced 53.6% [13], the desired precession 5% with 95% confidence level, design effect of 2, and 10% nonresponse rate was considered and the final sample size calculated to be 841.
For qualitative data six focus group discussions (FGD), two focus group discussions for each district, composing of 9 to 10 members in each group was conducted.
Totally, 59 discussants were participated in the discussions.

Sampling procedure
A multi-stage sampling technique was used to select the study participants. In the first stage three districts were selected randomly. The kebeles in the selected districts were identified and stratified into urban and rural kebeles. The selected districts have seven urban and 70 rural kebeles. Then three kebeles from the seven urban (one from each district) and nine kebeles from 70 rural kebeles were selected by using lottery method. The selection of kebeles was depending on their distance from the capital town of the district, taking the hospital as a center. For the three districts, furthest kebeles in average were at the distance of 45 kms. From the total kebeles closest to the town, those were at about 15 kms, three kebeles; from the middle distant kebeles those were at the second 15 kms, three kebeles; and from the furthest (third 15 kms) also three kebeles were selected randomly.
Lists of all households with eligible mothers were identified; finally, we used a sampling frame to pick the study participants using simple random sampling method.
For the qualitative data convenience sampling technique was used to select participants. From each selected districts, two groups of child-bearing age women, being that study population and not included in the quantitative study were participated in the focus group discussion.

Data collection and data quality assurance
For quantitative data collection, an interviewer administer structured and pre tested questionnaire was modified from different literatures according to the purpose of the study. Interview guide was used to conduct FGD for qualitative part of data collection, and tape recorder was also used [14][15][16]. The questionnaire and interview guide were originally prepared in English language then translated to the local language (affan Oromo), and translated back to English to check the consistency.
Quantitative data was collected using face to face interview method with twelve diploma nurses for data collectors and three supervisors were recruited and given two days training. The training of data collectors and supervisors mainly focused on issues such as data collection tools, field methods, inclusion-exclusion criteria and record keeping. The investigators coordinated the interview process, and reviewed the completed questionnaire on a daily basis to ensure the completeness and consistency of the data collected. The questionnaire was pre-tested on 5% of the sample outside the selected district for this study.
Each focus group discussion was conducted by two trained female diploma nurses; one did moderate the discussion and the other took notes and recorded tape. One gate keeper (non-health professional) for each FGD was assigned.

Data Analysis
The quantitative part of the data was entered into Epi-info, version 3.5.3, for data clearance and observation of data consistency and it was exported to SPSS version 20 for data analysis. First, descriptive statistics like frequency, percentages, mean and standard deviation were carried out to describe the data. Then, simple logistic regression analysis was done by taking each independent variable with dependent variable to examine the association between the two variables. On simple logistic regression analysis significant variables at P-value < 0.25 were retained for subsequent multivariable logistic regression. Strength of association was tested using adjusted odds ratio (AOR) and 95% confidence interval (CI). The significance level considered for multivariable logistic regressions was P-value <0.05.
For qualitative data, tape recorded and transcribed qualitative data was organized in narrative forms in congruent with the respondents' own words and analysed under selected themes based on the question guide and summarized manually.

Ethical consideration
Administrative approval was obtained before conducting the study and ethical considerations was respected. Ethical clearance letter was obtained from Madda Walabu University ethical clearance committee. Official letter of collaboration was written to Bale zone administration, Ginnir, Sinana and Madda Walabu districts administrations to get formal permission. Informed consent was obtained from each interviewee and they were also given the choice to refuse to participate in the study. it has hurt many women; and some people say it became ''hola" on a woman; some say cancer, and some other say another thing. Even at the moment, there is a women with breast problem, she has birth recently, her breast has not have milk, she has severe breast ache."

Socio-demographic characteristics
In this study only 13.2% of the mothers performed BSE. The main reasons given by the mothers were lack of knowledge, 37.1% and feared of detecting abnormalities, 21.7% (Figure 1). Those mothers who performed BSE had detected abnormalities in their breasts such as changes in contour 32.7%, and lump in breast 26.4%. The majority, 62.7% of the respondents who detected abnormalities in their breasts did consult health workers (

Discussion
Breast self-examination (BSE) is an important and inexpensive method for screening and early detection of breast cancer [17]. This study showed 20.7% of the participants responded that they have ever heard about BSE. This result was very low compared to study conducted in Malaysia and Libya [18,19]. Mentioned sources of information on BSE for 56.6% of the study participants was television and radio together. These findings consistent with study conducted in Libya [18]. The present study showed that only 13.2% of the respondents have practiced BSE. This result much better than the study conducted in Zambia, 5% and south India, 2.4% [22,23], and lower than the studies done in Malaysia, 48%, Nigeria, 43.5%, Ethiopia, 53.6% [13,19,25]. This difference seems that because of HEP that help women on preventive aspect of health services. The main reasons mentioned by nonperformers were lack of knowledge and fear of detection of abnormalities. This finding was similar with a study conducted in Iran [24]. This study showed that as age of the mother increases especially from twentieth to thirtieth, the practice of BSE has been increased. This is equivalent with a study reported from north Ethiopia [13], two studies conducted in Nigeria by Oladimeji et al., 2015 and Balogun and Owoaje, 2003 which revealed that current maternal age around second five of twentieth, the thirtieth and fortieth was significantly associated with BSE. This may be due to the fact that this age expected to be highly reproductive time, mothers' probability of giving attention to and seeking care for their breast, as the result increased contact to health facilities and health professionals become better than any other time. These may expose mothers to some information that can be obtained from health professionals and help them to practice BSE.
Different studies showed that practice of BSE was determined by educational level of mothers. A study done in Libya [18], and another study done in Nigeria [25] reported that higher level of education was significantly associated with BSE practice. In consistent to these previously conducted studies, the finding of our study revealed that BSE was remarkably related to mothers' level of education. This is because educated mothers have a greater awareness of the existence of health care and benefited from by using such services. As education empowers women, they have greater confidence and capability to make decision to use modern health care services [26].
In this study previous history of breast examination by health professional was also another predictor for BSE practice. This result was consistent with the study conducted in northwest Ethiopia which indicated that health extension workers who previously examined their breast by health professional were a significant predictor of BSE practice. This could be due to the fact that if mothers realized or came to know how breast examination is done, the probability of continuing examination by selves seems high [14].

Conclusion
The study revealed low breast self-examination practice among reproductive age women comparing with another studies conducted in Ethiopia. The proportion of the respondents who had ever heard about breast self-examination was also low. Present maternal age, mothers' level of education and previous history of breast examination by health professional were found to have significant association with breast self-examination practice, so increasing maternal education and coverage of breast examination by health professionals are crucial to raise the odds of breast self-examination practice.   Figure 1 Reasons of non-performing BSE reported by the participants