Assessment of Practice of Breast Self-examination and Associated Factors among Health Science Female Students of Ambo University: Cross Sectional Study

Background: Breast Self-Examination is process whereby women examine their breasts regularly to detect any abnormal swelling or lumps in order to seek prompt medical attention. Breast cancer is the most prevalent cancer among women globally and the second commonest cancer overall. The aim of this study was to assess practice of breast self-examination and associated factors among Health science female students at Ambo University in 2019. Methodology: - Institutional based cross-sectional survey was carried out among Health science female students at Ambo University in 2019. Data was collected by using a pre tested and pretested self-administered questionnaires. The response was systematically tabulated and analyzed using SPSS version 20, and explanations were given separately. Result- A total of 150 respondents participated in the study, of these 80 (53.3%) of them had good knowledge and only 67(44.7%) of the respondents had practiced BSE before. Among study participants whose families had breast cancer, practice BSE 2.12 times more than study participants whose families didn’t have his tory of breast cancer (AOR=2.12; 95% CI, 1.09–3.95, P=0.044). Those who had good knowledge toward BSE were 5.5 times more likely to practice BSE than those who had poor knowledge (AOR=9.5; 95% CI, 5.5–18.8, P=0.002). Conclusions- The overall knowledge of female students towards breast self-examination was 62%. This study showed that only 67(44.7%) of the study participants ever practiced BSE. The independeent predictors of breast self examination was family history of breast cancer and knowledge how to perform breast self examination.


Introduction
Breast cancer is one of the most commonly diagnosed cancer globally which accounts for 1.7 million cases in 2012 and there were 6.3 million women diagnosed with breast cancer in the previous ve years (1).
The breast cancer continues to be a prominent women's health problem, representing 28% of all female cancer. The most common initial evidence of breast cancer is a lump. It is not known why cancerous tumors develop. At rst, they remained con ned in the breast, when they have grown a certain amount, they may spread to other parts of the body, this depends on the type of cell forming the tumor. The condition affects both breast only in 10% cased. (2,3) Breast Self-Examination (BSE) is process whereby women examine their breasts regularly to detect any abnormal swelling or lumps in order to seek prompt medical attention. (4) As many studies indicated the practices of BSE are low among university students. Limited knowledge about the realities of breast cancer and lack of knowledge about the importance of self-examination and how it is performed are the main barriers for not practicing BSE. (4,5) The growth and aging of the population of the countries of low or middle income countries, together with Westernization of life style and the rapid growth of tobacco smoking, change in life style habits (more sedentary lifestyle, weight gain and obesity) and societal changes (increasing age at rst birth and decreasing parity in women) are leading to large increases in breast and colorectal cancer (6).
In the United States, an estimated 246,660 new cases of invasive breast cancer are expected to be diagnosed in women in 2016, and about 40,450 of these women are expected to die (7). In Africa, breast cancer was also the most commonly diagnosed cancer and the second leading cause of death among women in 2008, 92,600 cases and 50,000 deaths were reported that year. Cancer are growing burden, and continues to receive relatively low public health priority in Africa, because of limited resource and more attention given to communicable disease (8,9).
In Ethiopia, currently about 60,000 new cases of cancer is diagnosed each year and each day around ten to fteen new patient seen (10).
The study conducted by Addis Ababa city cancer registry from 2011 to 2014, breast cancer is the leading type among females and accounts for 33% of all cases of cancer followed by cervix uteri which accounts for 17% (11).
The study done among female health science students at Adama science and Technology University showed knowledge and practice of breast self-examination was low. Only 8(5.5%) of the respondents practiced breast self-examination and 8.7% of the respondent had good knowledge (14). According to studies carried out in Ethiopia, there are several factors often cited by study participants as reasons for them not performing BSE. The prominent ones constitute lack of adequate awareness about the disease, not knowing the techniques, not seeing problems such as lumps on their breasts and having little or no information about BSE and its importance (12,13,14).
Therefore, this study attempted to assess the BSE practice and associated factors among 1 st year health science female students in Ambo University, West shoa zone, Ethiopia, oromia region, 2019

Methodology
The study was conducted in Ambo University among 1 st year health science female students by using institutional based cross-sectional study design. The study was conducted from October 15-February 13,

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The sample size was determined using single population proportion formula with the assumption of marginal error of 5%, 5% of non-response rate, 95% con dence level and the prevalence of the breast selfexamination practice to be 28.3% from the study conducted in Debre Behran University [15].
Since the sample was drawn from a nite population, the correction formula was applied. Finally, the sample size of 165 was determined. The calculated sample size was proportionally allocated to each Department based on the number of female students in the college.
After proportionally assigning sample size to each department, a simple random sampling technique was applied to select study participants.
All-female students who were actively on education during data collection at each department were included.
Data was collected using pre-tested self-administered questionnaire. Te questionnaire was developed in the English language after reviewing and extracting from different pieces of literature developed for the same purpose. The knowledge of breast self-examination was assessed by multiple questions. Each correct answer was given as score of 1 and a wrong response a score of 0.
According to bloom's classi cation cut off points for knowledge score Good knowledge: a score of 80-100% of correct responses for knowledge questions Satisfactory knowledge: a score of 60-79% of correct responses for knowledge questions Poor knowledge: a score less than 60% of correct responses for knowledge questions.
Good practice of breast self-examination was who performed breast self-examination practice a week after each menses by their palm and middle three ngers otherwise called poor practice.
The collected data was cleaned, cheeked for completeness, compiled and data analysis were systematically tabulated and analyzed using statistical package for social sciences (SPSS) version 20 software. Descriptive statistics was used to see frequency, and percentage. Presentation of data was done by using tables and gures. To assess the association between dependent and independent variables by controlling for confounders, rst binary logistic regression was run and variables with P-value≤0.05 and the variables which are known to have an association with dependent variables from reviewed literature were selected for multiple logistic regression analysis. Statistical signi cance was declared at P-value <0.05 with 95% con dence interval (CI).
To ensure the data quality of our study the following measures were taken: The questionnaire was developed by reviewing relevant pieces of literature on the subject. Also, the questionnaire was pre-tested and modi ed where necessary. One day training was given for data collectors and supervisors.
During the eldwork, the objective of the study was clearly explained for the study participants, the con dentiality of the data to be collected and the right not to participate also assured. Before starting the data collection process, written consent was taken from each respondent after they read and signed the consent form.

Results
Socio demographic characteristics of the study participants A total of 150 female students were responded to the distributed questionnaires, making a response rate of 91%. The participants ranged from ages of 20 to 27 years old. As it can be seen from the table, Majority of the respondents (53.3%) were protestants, 29.3% were orthodox, 16% were Muslim and there is 1.3% of waaqeffannaa religion followers (Table 1). From the study participants, the majority of them (58%) were Oromo, 31% were Amhara, and there is only 6.7% of the study participants were Tigre.
Their educational status was at the same level that all study participants was 1st year health science students of different department. From the total participants, majority, 40% of them were from nursing department, 20% of the were from midwifery department, 16% of them were from pharmacy, and only 2.7% of the study participants were from medical laboratory departments Knowledge about BSE Majority, 93(62%) of the participants had good knowledge, and 57(38.8%) of the study participants had poor knowledge of breast self-examination (Fig. 1). From total participants, 112(74.7%) was heard about BSE and 38(25.3%) of the respondents have no any information about BSE. The main source of information of the breast self-examination was from class room teaching (64.5%).

Practice of study participants toward BSE
This study showed that only 67(44.7%) of the study participants ever practiced BSE, including 38 (56.7%) participants who performed BSE every month, 17(25.4%) participants who performed once in a week and 12 (17.9%) participants who performed once in a year (Fig. 2).  (Fig. 3).
Regarding the questions about their family history 35(23.4%) of the participants have family history (mother or sister) breast cancer and were 115(76.6%) did not had family history of breast cancer, from the participant who had family history of BC 15(42.9%) were responds know that at risk for developing breast cancer and 57.1% should not know that at risk for developing breast cancer.

Factors associated with practice of Breast self-examination
To see the effect of independent variables on dependent variable (practice of BSE), bivariate and multivariate logistic regression analyses were carried out. The analysis was done by including sociodemographic characteristics, history of breast cancer, and knowledge of BSE.
A result obtained from bivariate and multivariate logistic regression showed that family history of breast cancer, and knowledge have a signifcant association with practice of BSE. Among study participants whose families had breast cancer, practice BSE 2.12 times more than study participants whose families didn't have his tory of breast cancer (AOR = 2.12; 95% CI, 1.09-3.95,P = 0.044).
Those who had good knowledge toward BSE were 5.5 times more likely to practice BSE than those who had poor knowledge (AOR = 9.5; 95% CI, 5.5-18.8, P = 0.002) ( Table 2). Another studies conducted in Mekele, Gojam, Ethiopia also showed that the main reasons for not performing breast self-examination were having no breast problem, not knowing breast self-examination technique, not knowing the importance of breast self-examination and absence of breast symptoms or disease.

Conclusions
The overall knowledge of female students towards breast self-examination was 62%. This study showed that only 67(44.7%) of the study participants ever practiced BSE, including 38 (56.7%) participants who performed BSE every month, 17(25.4%) participants who performed once in a week and 12 (17.9%) participants who performed once in a year.
The independeent predictors of BSE was family history of breast cancer and knowledge how to perform breast self-examination.
Finally, additional community based research should be needed for the future to improve understanding of the community on practice of breast self-examination.

Declarations
Ethics approval and consent to participate