Assessment Of Breast Self- Examination And Associated Factors Among Women Age 20-64 Years At Arba Minch Zuria District, Gamo Zone Snnpr Ethiopia, 2019

Background Breast self-examination is simple, low cost and non-invasive method of noticing breast cancer by the women themselves for looking at and feeling for any change in their breast. Studies have shown that in Ethiopia the practice of breast self-examination is poor. So, the aim of this study is to address breast self-examination practice and associated factors among women aged 20-64 years at Arba Minch Zuria district, Gamo Zone southern Ethiopia. Methods community-based cross-sectional study was conducted among 634 women aged 20-64 years at Arbaminch Zuria district using multi-stage sampling technique to select the study participants. Structured, pretested and interviewer-administered questionnaire was used to collect data. Data were entered in to EPI INFO version 3.5.1 and exported to SPSS version 22 for analysis. A binary logistic regression model was used to assess the association between independent and outcome variables. Adjusted odd ratio with 95% condence interval and P-value of <0.05 was considered to declare a result as statistically signicant.


Background
Cancer is a group of diseases that cause cells in the body to change and spread out of control. It is a global public health problem, touching all area of the world and socioeconomic groups affecting 12% of all cancer death worldwide. Breast cancer is the second most common, frequently diagnosed cancer in the world and, by far, characterized by abnormal growth of cells lining the breast lobules or duct (1,2) Worldwide, there were about 2.1 million newly diagnosed female breast cancer cases in 2018, accounting for almost 1 in 4 cancer cases among women (3,4). Breast cancer-related illness and death can be decreased by timely detection by means of screening programs, as it not only increases the probability for successful medication and cure of the disease but also improves chances of survival and lessens the need of invasive treatment (1) The three screening methods currently recommended by the American Cancer Society are clinical breast examination (CBE), mammography, and breast self-examination (BSE). Breast self-examination (BSE) is one of the early detection methods used for early detection of breast cancer and females can check by themselves in private in their own by getting the know-how of the normal breast look and feel (5,6).
Breast cancer is a manageable disease, in case of early diagnosis with su cient treatment protocols such as advanced surgical intervention, chemotherapy, and radiation therapies. But the main focus is early detection through screening (7) Breast self-examination (BSE) is simple, very low cost, non-invasive early detection method used to detect breast cancer at early stage, which involves women who are 20 years old and above can practice by herself looking at and feeling for any change in their breast (8,9). Breast self-examination practice remains low in many countries, a study conducted in Saudi Arabia showed that breast selfexamination was only 8.4% (10). Another study conducted in Ethiopia ,Adwa town showed that BSE was only 6.5% (11).
Breast cancer is the uppermost cancer in females both in the developed and the developing countries.
The incidence of breast cancer is increasing in the developing countries due to increase life expectancy, increase urbanization and adoption of western lifestyles (12,13).
According to Global cancer statistic, there were an estimated 2.1 million new cases of breast cancer and 630,000 deaths due to breast cancer in 2018 (14).In the United States alone, there were an estimated 270,000 cases of breast cancer diagnosed in 2018 along with 41,000 deaths, and approximately 1 in 8 women (15).The disease is the leading cause of cancer death in over 100 countries (3).
In Ethiopia, breast cancer is the rst leading cancer among females with 24.4% prevalence rate. In 2014, 12,956 women were diagnosed with breast cancer and 26,200 women died by breast cancer(17)(16).
Despite the fact that Prevention is the best alternative to undertake the rising morbidity and mortality by breast cancer, some early detection methods such as mammography are inaccessible for women who live in developing countries like Ethiopia. In such area's mammography cannot be an option in routine practice since it is expensive and needs sophisticated technology trained professionals. Even Clinical Breast Examination is not much viable for them as it needs professional skills and regular health facility visit which is especially hard to women living in rural areas (17) However Breast Self-Examination is said to be the least costly, less time consuming and noninvasive screening method, several studies shown in Ethiopia reported that the practice of breast self-examination is poor and the most frequently revealed reasons for not practicing this behavior were not knowing the technique of performing BSE, not having breast related problem or symptoms, fearful of being detected with breast cancer and no advice or recommendation from Health care workers (HCWs) (18-20). There is limited study conducted in Ethiopia on the breast self-examination. Moreover, there is no study done in Arba Minch zuria district that reveal Breast self-examination and its associated factors. So the aim of this study is to assess level of breast self-examination and its associated factors among women aged 20-64 years old in the study area.

Study setting, design and population
Arbaminch zuria Districtis is found in Southern Nation Nationalities and People Region Gamo Zone, around Arbaminch Town located 505 km southwest from the capital city, Addis Ababa and 275km far from Hawassa city of SNNPR. Based on the 2007 census conducted by the Central statistical Agency of Ethiopia and population projection for 2017, the total population of Arbaminch zuria District is 195,858; of whom 50.01% are women (21).

Source population
All Women who are Age between 20-64 Years old

Study population
All Women who are Age between 20-64 Years old during the study period Study design A community based cross-sectional study design was conducted

Sample size determination
In this study, sample size was determined by using single population proportion formula by considering the level of breast self-examination 50%, margin of error of 5%, and con dence level 95%, design effect 1.5 and adding non-response rate of 10%. So, the sample size for this study was 634.
Sampling procedure A multi-stage sampling technique was employed to select the study participants. Arba Minch Zuria district has 29 kebeles (the smallest administrative unit in Ethiopia) from which nine kebeles were selected by lottery method. First, eligible households were identi ed from family folder belongs to health post in each kebeles. If there are two and more than two participants in the house one of them would be taken by lottery methods. Three visits were conducted during data collection in case when the data collectors didn't get the study participants. Then, eligible households were coded in to computer, nally, computer generated random numbers were used to select households with eligible study participants.

Data Collection tools and techniques
The tool was adapted from the champion's breast self-examination questionnaire and from different literature reviews (53, 54). The questionnaire was rst prepared in English and, it was translated to Gamoegna language and back to English by language expert. The data were collected by nine data collectors and two supervisors using face-to-face interviewer administered pre-tested questionnaires.

Data quality control
The questionnaire was pre-tested on 5 % (32) of the total sample size of non-study subjects in Mirab Abaya woreda Delibo Kebele before the actual data collection. Training was given for data collectors & supervisors for 2 days by the investigators on the purpose of the study, method of interviewing; keeping con dentiality of information and other essential principles. The overall activities of data collection were supervised and coordinated by the investigators. The completeness of the questionnaire was checked by supervisor at the end of each day and double checked by investigators.

Data processing and analysis
Collected questionnaire were checked manually for its completeness, coded entered in to EPI INFO version 3.5.1and exported to SPSS version 22 for data cleaning and analysis. Each of the 3 breast selfexamination questions were summed and the result with mean and higher score denoting good practice. The Hosmer-Lemeshow test was used to check the goodness of t of the model. Bivariate analysis was done to identify associations between dependent and independent variables, with crude and adjusted odd ratios, 95% CI and p-values were used to assess the strength of associations and statistical signi cance. Variables with a p-value of <0.25 in bivariate analysis were considered as candidate for multivariable analysis; and variables with a p-value of <0.05 level in the multivariable analysis were considered as signi cant factors of breast self-examination practice in the nal logistic regression analysis.

Operational de nition
Breast self-examination practice: If the woman has performed breast self-examination monthly during menses (regular) or ever performed breast self -examination (irregular) we considered as practiced BSE.
Knowledge towards breast self-examination: -was assessed through 7 items on breast Self-examination.
Respondents who score less than or equal to the mean value was considered as Poor knowledge (23).
Attitude towards breast self-examination: -was assessed through 3 questions and Respondents who scored above the mean value, was considered as having "favorable" attitude while those who scored below or equal to the mean value was considered as having "unfavorable" attitude towards breast selfexamination (23).
Perceived susceptibility towards breast self-examination: -participants who scored mean and above the mean values regarding their risk of breast cancer from the provided 3 close-ended questions were considered as having good perceived susceptibility (54).
Perceived severity towards breast self-examination: -participants who scored mean and above the mean values regarding their consequence of breast cancer from the provided 4 close-ended questions were considered as having good perceived seriousness (54). Perceived bene ts toward breast self -examination: -participants who scored mean and above values regarding the bene t of BSE from the provided 4 close ended questions were considered as having good perceived bene ts (53) Perceived barriers towards breast self-examination: -participants whose answered to barrier related questions to do BSE measured by 3 questions, and scored mean above values was considered as having a perceived barrier to do BSE (53)

Socio demographic characteristics of Respondents
From the total of 634 respondents, all of them had completed the questionnaire su ciently making the response rate of 100 %. The age of the study participants ranged from 20 to 62 years with a mean age of 34.96 ±11.038 SD. The mean monthly income was 1029.01 while (52.4 %) of the participants earn less than 500 ETB. Occupations of the respondents and the rest were also mentioned in the table (table 1).

Knowledge and attitude of respondents towards breast selfexamination practice
From the overall participants, 34.2 % of the respondents have knowledgeable on BSE. Broad castings were the predominant source of information which was, 53.1% of the total respondents followed by Health professionals, 29.7%, and 17.1% were from families and friends. Among total respondents around 14.5 % participants have positive attitude towards to BSE (table 2).

Perception of respondents about breast self-examination practice
From the total respondents, 21.3% where practiced BSE and having good perceived bene t which accounts 98.5 %. A good perceived bene t respondent (38.1 %) was between 20-29 age groups.
Regarding perceived self-e cacy towards BSE in the study (82.8%) had good perceived self-e cacy. All respondents who have good perceived self-e cacy were experienced breast self-examination ( gure 1).

Magnitude of Breast Self-Examination among respondents
In this study the magnitudes of breast self-examination practice among respondents showed was (21.3%).

Frequency of BSE practice among respondents
Out of those who performed BSE (13.3%) were reported to practice monthly interval and the rest do not practice regularly ( gure 2).

Respondents reason for BSE practice
From the total respondents less than one fourth (21.3%) were practice BSE, and the main reason of performing BSE (75.4%)) were for early detection and treatment, (8.3%) had breast problem, (13.4%) fear of breast cancer, and the rest (3.0%) were Fear of developing breast cancer from family.

Reasons of respondents for not practicing breast self-examination
From the total respondents nearly three-fourth (78.7%) of them did not practice BSE. The main reasons for not practicing BSE identi ed in the present study were (50.7%) not knowing how to perform it, (20.4 %) not having breast problem, (16.4%) not having breast symptom, and (12.4%) lack of knowledge about its importance.
Factors associated with breast self-examination practice Discussion This study aimed to assess the practice of breasts self -examination and associated factors among women aged 20-64 at Arba Minch zuria district, southern Ethiopia. It was found that the magnitude of BSE was 21.3% .This nding was consistent with the study conducted in Debre Birhan which was (28.3% ) (22).The nding of this study was lower than the study conducted at Mekele , Wolayita zone, and Nigeria which was 53.6%, 45.6% and 43.5% respectively (23, 24) (25). This may be due to different Socio demographic factors like low level of educational and economic status in the district. On the other hand the nding of this study was higher than studies conducted at Ondo state and Aduwa town which was 13% and 6.5% respectively (11,26). This difference might be due to sample size difference, participant's knowledge towards BSE practice, and socio economic and cultural variation.
The nding of this study revealed that 34.2% of participants were knowledgeable on BSE practice. This nding is consistent with the study conducted at Debre Birhan and Malaysia which was 35% and 38.4% respectively (22,27).This nding is also lower than a study conducted at Buea Cameroon which was 59.17 %(28).This might be due to sampling procedure ,and socio demographic characteristics of participants in the previous study.
In this study women age was one of the signi cant factors for the breast self-examination practice, women practice, women whose age 40-49 years were nearly three times more likely to practice BSE than those women whose age greater than 50 with (AOR: 2.95; 95% CI: 1.23, 7.06). Study conducted in rural areas of south India, the practice was highest among those aged 51-60 years which was (37.21%) and it was lowest for those aged less than 30 years (11.54%) which was found to be statistically signi cant (P=0.004) (29).The current study indicates that age increases performance of BSE decrease.
In this study women's educational level was one of the signi cant factors for the practice of breast selfexamination, Women who attended elementary level of education were 67% with less likely to practice breast self-examination as compared with those college and above level of education with ((AOR: 0.33; 95%CI: 0.17, 0.62).This nding was supported by the Study done in Nigeria ,south India , and Mekele (29) (28). This indicates that as the educational status of the women get improved; breast self-examination behavior of the women's possibly increases.
The nding of this study showed that knowledge of women was signi cant factor for BSE practice, Those Women knowledgeable on BSE were 58% times (AOR 0.42, 95% CI: 0.27, 0.65) more likely to examine their breast than those who were not knowledgeable. This study was in line with the study conducted in Addis Ababa, (30) .This indicates that women who were knowledgeable on BSE were more likely to practice than those who were not knowledgeable.
This study revealed that signi cant association was observed between perceived bene t and the practice of breast self-examination, the odd of women with good perceived bene t had nearly two times more likely to practice breast self-examination as compared with the counterparts with (AOR: 2.22; 95%CI: 1.18, 4.19) .This nding was supported by a study done in western Turkey (31).

Conclusion
Despites the importance of breast self-examination, the practice of breast self-examination was signi cantly low. This study revealed that educational status being at elementary level, age 40-49 years, having good knowledge, and good perceived bene t were found to be signi cantly associated with BSE practice. Arba Minch Zuria district Health o ce should stress on educating women's regarding to Breast Self-Examination. All stake holders: civil society, NGO, and government agencies should work jointly to develop community awareness and to improve women educational status. Ethical approval was obtained from Institutional Ethics Review Board (IRB) of Arba Minch University. In addition, an o cial letter was issued from the College of Health and Medical Sciences, Arba Minch University to Arba Minch Zuria District. After securing permission from the district, the actual data collection was commenced after obtaining written and signed voluntary consent from each study participant. All information collected from the participants was kept con dential.