Breast self-examination practice and associated factors among female healthcare workers in West Shoa Zone, Western Ethiopia 2019: A cross-sectional study

DOI: https://doi.org/10.21203/rs.2.12644/v3

Abstract

Abstract Objective :  Breast cancer is the leading cause of death among reproductive-age women worldwide and the second leading cause of death among women in Ethiopia. Regular breast self-examination is the most cost-effective methods for early detection of breast cancer. Despite this fact, breast self-examination was low among women in the general population and it was not well documented among health care workers. Therefore, this study intended to assess the magnitude of breast self-examination practice and associated factors among female healthcare workers in public health facility in West Shoa zone, Ethiopia. Institutional based cross-sectional study was conducted among 379 female healthcare workers. The study participants were recruited by lottery method. Data were collected from March to April 2019. Data were entered into Epi data version 4.5 and analyzed using SPSS version 25. Bivariate and multiple logistic regressions analysis were done. With 95% CI,  significance level was decided at p-value≤ 0.05 Results: The magnitude of regular breast self-examination practice was 32.6%. Educational levels, breast cancer awareness, knowledge towards breast self-examination were predictors of breast self-examination. Regular awareness creation forum on breast self-examination technique, risk factors, and related matters should be facilitated so that all female health care workers will be reminded.

Introduction

Background  

Breast cancer is the leading cause of cancer mortality worldwide. In 2017, an estimated 252,710 new cases of invasive breast cancer were diagnosed among women and approximately 40,610 women were expected to die from breast cancer(1). It’s also the most frequently diagnosed cancer in women, with an estimated 1.7 million new cases and 521,900 deaths(2).

Since breast cancer is serious, an important factor in the prognosis of breast cancer is early detection of the disease(3). Breast self-examination (BSE) is one of the simple, quick, and cost-free procedures for early detection of breast cancer among women(4). In developing countries, breast self-examination is the recommended method because it is easy, convenient, private, safe and doesn’t require equipment(5)(6). Several studies proposed it because there is a difference among women who practice BSE and those not(7).

Early detection of breast cancer plays an important role in decreasing its morbidity and mortality. Studies from some African Countries indicated that the duration of onset of breast cancer to care seeking period is more than one year and implies that improving timely detection of breast cancer among women in SSA could have a great impact on stage at diagnosis, and gives opportunity for improved prognoses and treatment options. Most of the early breast tumors are self-discovered and the majority of early detection is by BSE, and 80% may be detected by expert professionals(8)(9). Evidence indicates that lack of time, lack of self-confidence in their ability to perform the technique correctly, fear of possible discovery of a lump, and embarrassment associated with manipulation of the breast have been cited as reasons for not practicing BSE(10).

Early detection and diagnosis rate of breast cancer among Ethiopia women is considerably low when compared to women in Western countries. This fact put the Ethiopian women’s to be diagnosed at the late stage of the disease. Therefore, many women miss early detection and treatment opportunities due to the lack of information and knowledge of breast cancer, as well as cancer screening skills(11).

The magnitude of BSE varies among different segments of females. For instance, a study conducted among undergraduate university student in Addis Ababa indicated 21%, study in Debra Birhan indicated 28%, while the study among female health care workers indicated somehow greater prevalence. For example study among health extension workers in Gojam, Northern Ethiopia shows 37% and 32% in Debre tabor.  Even though the finding among health care workers seems relatively higher when compared to other groups of females, it has two main limitations. The first is different studies used different tools for assessing the BSE practice and this curbs comparison of the studies. Secondly, even with the currently existing evidence, the difference in the prevalence of BSE among female health care workers and other female groups is not as it should be(12)(13). 

Therefore, this study attempted to assess the BSE practice and associated factors using input from different works of literature and applying the standard and correct definition of BSE.

Methods

This study was conducted in seven Public hospitals found in west Shoa Zone Oromia regional state, Ethiopia using institutional-based cross-sectional study design. Data were collected from March to April 2019.

The sample size was determined using single population proportion formula with the assumption of marginal error of 5%, 5% of non-response rate, 95% confidence level and the prevalence of the breast self-examination practice to be 37% from the study conducted in East Gojjam, North Ethiopia(14).

Since the sample was drawn from a finite population, the correction formula was applied. Finally, the sample size of 379 was determined. The calculated sample size was proportionally allocated to each Hospital based on the number of female health care workers in the hospital. After proportionally assigning sample size to each hospital, a simple random sampling technique was applied to select study participants.

Inclusion and Exclusion criteria

All-female healthcare workers who were actively on job during data collection at each selected hospitals were included.  

Data collection tools and techniques

Data was collected using a self- administered questionnaire.  The questionnaire was developed in the English language after reviewing and extracting from different pieces of literature developed for the same purpose. For measuring knowledge towards BSE, there were 10 questions developed. Answering a correct answer will result in scoring a mark and loosing will attract zero scores. Accordingly, the final total mark will be added up out of ten and graded for the decision of knowledge level.  

To measure attitude towards BSE, Likert scale based items were prepared (total of ten questions). The scales reached from strongly agree to strongly disagree. To assess the internal consistency of the items, Cronbach alpha was assessed and it was 0.87 indicating good internal consistency of the items.

Operational Definitions

Good practice of breast self-examination:- those who performed breast self-examination practice a week after each menses by their palm and middle three fingers otherwise called poor practice

Good knowledge: participant those who answered greater than 75% of the 10 knowledge questions towards breast self-examination.

Average knowledge: participants who answered 50–75% of knowledge questions toward breast self-examination.

Poor knowledge: participants who answered less than 50% of knowledge questions toward breast self-examination.

Favorable attitudes: participants who scored points equal to or greater than mean score of
breast self-examination related attitude questions as measured by Likert scale.

Unfavorable attitude: participants who scored points less than the mean score of attitude
questions (12)(15).

Data management and analysis

The collected data were checked visually for completeness, then coded and entered into Epi data version 4.5 statistical packages. Descriptive analysis was computed. To assess the association between dependent and independent variables by controlling for confounders, first binary logistic regression was run and variables with p-value <=0.25 and the variables which are known to have an association with dependent variables from reviewed literature were selected for Multiple logistic regression analysis. Statistical significance was declared at P-value <0.05 with 95% confidence interval (CI).

Data Quality Control

To ensure the data quality of our study the following measures were taken:

Dependent variable

Ethical consideration

Ethical clearance was obtained from the Ethical Review Committee of the College of Medicine and Health Sciences, Debra Markos University. During the fieldwork, the objective of the study was clearly explained for the study participants, the confidentiality of the data to be collected and the right not to participate was also assured. Before starting the data collection process, written consent was taken from each respondent after they read and signed the consent form.

Result

Socio-demographic characteristics of the study participants

A total of 340 female healthcare workers were responded to the distributed questionnaires, making a response rate of 89.7%.  The mean age of the respondents was 28.04.8 SD which was ranging from 19-43. About187 (55.0%) was married.  Out of the total participants, about 198 (58.2%) were nurse professionals and more than two thirds (232) of the participants were degree holder followed by diploma 71(20.9%).  

Knowledge towards breast self -examination and breast cancer

The majority of 227 (66.8%) the study participants know the screening methods of breast cancers.  The commonly mentioned breast self-screening techniques were: mammography (5.0%), clinical breast self-examination (7.9%), and 23.2% mentioned breast self-examination.  About one hundred-six (31.2%) stated the three screening methods of breast cancer. Out of the total participants, 228 (67.1%) ever heard about breast self-examination. The main source of information of the breast self-examination was the knowledge they received during the class lectures in the University or College which accounts for one hundred thirty-two (38.8%).

Table 1. Socio-demographic characteristics of the female health care workers in West Shewa zone public hospitals, Western, Ethiopia 2019.

Characteristics

Frequency

      Percentage

Age 

19-25

 

141

 

41.5

26-30

141

41.5

≥31

58

17.0

 

Marital status

 

 

 

Single

153

45.0

 

Married

187

55.0

 

Ethnicity

 

 

 

Oromo

276

81.2

 

Amhara

48

14.1

 

Others

16

4.7

 

Religion

 

 

 

    Orthodox

138

40.5

 

    Protestant

177

52.1

 

    Muslims

23

6.8

 

    Others

2

0.6

 

Profession

 

 

 

Nurse

198

58.2

 

Midwife

57

16.8

 

Pharmacy

21

6.2

 

Laboratory

18

5.3

 

Medical doctors

31

9.1

 

Others

15

4.4

 

 

Educational level

 

 

 

   Diploma

71

20.9

 

   Degree

232

68.2

 

   Masters

37

10.9

 

Work experience 

 

 

 

< 5

174

51.2

 

≥ 5

166

48.8

 

 ward units

 

 

 

    Inpatient service

240

70.6

 

   Outpatient service

100

29.4



The attitude of the study participants towards BSE practice

The attitude mean score of the study participants was calculated and used as a cutoff point for classifying attitude towards BSE as favorable or not. Accordingly, the mean attitude score was 30.04.5 SD.  More than half of the participants 202 (59.4%) had a favorable attitude towards breast self-examination.

Table 2. Multiple logistic regression analysis results for the association between the practice of breast self-examination and independent variables among female healthcare workers, West Shoa Zone Hospitals, Oromia region, Western Ethiopia, 2019.

VARIABLES

BSE practice

COR with 95% CI

COR with 95% CI

P-VALUE

 

 

  Good

Poor 

 

 

 

 

Educational level

 

 

 

 

 

 

   Diploma

23             

48

0.01(0.002,0.103)

0.03(0.004,0.260)

0.001*

 

   Degree

118

114

0.03(0.004,0.213)

0.08(0.008,0.490)

0.008*

 

   Masters

36

1

ref

Ref

 

 

Work experience

 

 

 

 

 

 

< 5

100

74

1.60 (1.02, 2.39)

0.90(0.56, 1.65)

0.8

 

≥5

 77

89

ref

Ref

 

 

Ward unit

 

 

 

 

 

 

Inpatient service

133

107

 1.60 (0.98, 2.53)

1.13 (0.64, 1.98)

0.7

 

Outpatient service

44

56 

Ref

Ref

 

 

Do you taught BSE to the client?

 

Yes

19

60       

0.25 (0.16, 0.39)

0.40(0.23, 0.75)

0.004

 

No

97        

47

Ref

Ref

 

 

Do you know people with Breast cancer

Yes

118

80

Ref

Ref

 

 

 

No

   59

83

0.50 (0.3, 0.75)

0.90 (0.45, 1.57)

0.6

 

 

Knowledge about  BSE

Good knowledge

   110

26

13.20(7.09,24.56)

6.70(3.24, 14.04)

<0.001*

 

 

Medium knowledge

 42           

59 

2.20(1.22,4.04)      

1.80 (0.96, 3.39)

0.067

 

 

Poor knowledge

25 

78

Ref

Ref

 

 

 

Attitudes towards BSE

Favorable

 112 

90  

0.70(0.46, 1.105)

    0.60(0.53, 0.9)

0.047*

 

 

Unfavorable

 65     

73  

      *

 

 

 

 

                   

** significantly associated, AOR= adjusted odd ratio COR: crude odds ratio

Discussion

In this study, the prevalence of the correct and regular practice of breast self-examination was low (32.6%).  This finding is comparable with study conducted among midwifes and Nurses in Turkey and lower when compared to study conducted in Nigeria among health care workers(16)(17).  But its higher than the finding in the study conducted in West Gojjam, of Amhara region (14.4%) (14). The differences could be due to the difference in the study period and study area.

This study indicated, as the educational level of the females' increase, the likely hood of BSE practices also increase.  Compared to those females’ in diploma level, degree holders were 12 times more likely to practice BSE correctly and regularly. This finding is consistent with a study conducted in Western Ethiopia Female  health care workers who don’t teach BSE to their  clients during routine clinical activities were more than 50% less likely to practice breast self-examination 0.42 (AOR= 0.42, 95% CI: 0.23, 0.75) (P-value 0.004) compared their counterparts.

This study also showed that there is a significant association between participants' level of knowledge about breast cancer and BSE practice. The commonest reasons reported why the females were practicing BSE were: for early detection and seeking treatment and fear of developing breast cancer in the future.

Though they had sufficient knowledge and awareness about BSE, about 27% of the females didn’t practice it because of negligence.

In conclusion, the finding of the study indicated that BSE practice was low and it was associated with different factors. There was also a gap in knowledge and awareness among the female health care professionals towards BSE, and even those who had sufficient knowledge were not practicing BSE because of negligence.

Short term training on breast cancer and breast self-examination should be better organized by the hospital administrator.

Limitation of the study

The self-reported information is subjected to bias specifically to social desirability bias. There was no internationally recognized standardized tool to assess BSE. Besides, since the majority of the existing works of literature were conducted among no health care females, this results in a variation of measurements which limit us comparing the findings of this study with other studies. Also, we didn't include a qualitative aspect in this study which could have strengthened the finding of a quantitative one.

Declarations

Ethical approval and consent to participate

The proposal for the study was submitted to the Ethical Review Committee of College of Health and Medical Sciences, Debra Markos University for approval and clearance. Accordingly, the study was checked for its ethical issue and permission letter was obtained. The letter for support was written from the college of medicine and Health Sciences, Debra Markos University to all concerned Hospitals.

Consent for publication

Not applicable

Availability of data and material

 All data generated or analyzed during this study were included in this published article and its supplementary information files are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests in this section.

Funding

The Ethiopian Federal Ministry of science and higher education has covered the costs of data collectors and supervisors per diem.  The funded organization has no role in designing the study, data collection, or manuscript preparation.

Authors' Information

Jibril Dori  – is maternity and reproductive health specialist at Ambo University referral hospital, Ethiopia.

Seifadin Ahmed- is a lecturer of reproductive health and researcher at Department of public health, College of medicine and health sciences, Ambo University, Ethiopia.

All authors read and approved the final manuscript.

Authors Contributions

JDB: Has developed the proposal, participated in data collection supervision, data insertion and data analysis

SAS: has participated in proposal development, data collection supervision, data analysis, and manuscript writing.

Acknowledgment

We would like to thank the Ethiopian ministry of science and higher education for covering data collectors and supervisors per diem. Also, we would like to thank data collectors and study participants including all hospital managers in the West Shoa Zone of Oromia state.

Abbreviations

ACS - American Cancer Society

AKTH - Aminu Kano Teaching Hospitals

AOR - Adjusted Odd Ratio

BC - Breast Cancer

BSE - Breast Self-Examination

CBE - Clinical Breast Examination

CI - Confidence Interval

COR - Crude odd ratio

DBU - Debra Berhan University

FHWs - Female healthcare workers

HEWS - Health Extension Workers

SHE - Ministry of Science and Higher Education of Ethiopia

SPSS - Statistical Package of Social Science        

References

  1. Breast Cancer Risk Factors 12 [Internet]. [cited 2019 Sep 8]. Available from: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2017-2018.pdf
  2. Lemlem SB, Sinishaw W, Hailu M, Abebe M, Aregay A. Assessment of Knowledge of Breast Cancer and Screening Methods among Nurses in University Hospitals in Addis Ababa, Ethiopia, 2011. ISRN Oncol [Internet]. 2013 Aug 6 [cited 2019 Sep 8];2013:470981. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23986873
  3. Watson C, Keeney G. The Effect of Breast Self Exams and Their Ability to Decrease Mortality Rates [Internet]. [cited 2019 Sep 8]. Available from: https://minds.wisconsin.edu/bitstream/handle/1793/61504/13McNair research.pdf?sequence=9&isAllowed=y
  4. Sujindra E, Elamurugan T. Knowledge, attitude, and practice of breast self-examination in female nursing students. Int J Educ Psychol Res [Internet]. 2015 [cited 2019 Sep 8];1(2):71. Available from: http://www.ijeprjournal.org/text.asp?2015/1/2/71/152216
  5. Nde FP, Assob JCN, Kwenti TE, Njunda AL, Tainenbe TRG. Knowledge, attitude and practice of breast self-examination among female undergraduate students in the University of Buea. BMC Res Notes [Internet]. 2015 Dec 15 [cited 2019 Sep 8];8(1):43. Available from: http://www.biomedcentral.com/1756-0500/8/43
  6. Alsaif AA. Breast self-examination among Saudi female nursing students in Saudi Arabia. Saudi Med J [Internet]. 2004 Nov [cited 2019 Sep 8];25(11):1574–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15573181
  7. Yakubu A, Gadanya M, Sheshe A. Knowledge, attitude, and practice of breast self-examination among female nurses in Aminu Kano teaching hospital, Kano, Nigeria. Niger J Basic Clin Sci [Internet]. 2014 [cited 2019 Sep 8];11(2):85. Available from: http://www.njbcs.net/text.asp?2014/11/2/85/140344
  8. Knowledge, Attitude And Practice Of Breast Self-Examination Among Female Medical Students In The University Of Lagos [Internet]. [cited 2019 Sep 8]. Available from: https://print.ispub.com/api/0/ispub-article/8251
  9. Black E, Richmond R. Improving early detection of breast cancer in sub-Saharan Africa: why mammography may not be the way forward. Global Health [Internet]. 2019 Dec 8 [cited 2019 Sep 11];15(1):3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/30621753
  10. Karayurt Ö, Özmen D, Çetinkaya AÇ. Awareness of breast cancer risk factors and practice of breast self examination among high school students in Turkey. BMC Public Health [Internet]. 2008 Dec 17 [cited 2019 Sep 8];8(1):359. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18928520
  11. Ameer K, Abdulie SM, Kumar Pal S, Arebo K, Kassa GG. Breast Cancer Awareness and Practice of Breast Self-Examination among Female Medical Students in Haramaya University, Harar, Ethiopia [Internet]. Vol. 2, International Journal of Interdisciplinary and Multidisciplinary Studies (IJIMS). 2014 [cited 2019 Sep 8]. Available from: http://www.ijims.com
  12. Birhane K, Alemayehu M, Anawte B, Gebremariyam G, Daniel R, Addis S, et al. Practices of Breast Self-Examination and Associated Factors among Female Debre Berhan University Students. Int J Breast Cancer [Internet]. 2017 May 17 [cited 2019 Sep 8];2017:1–6. Available from: https://www.hindawi.com/journals/ijbc/2017/8026297/
  13. Mikiyas Amare Getu, Mesfin Wudu Kassaw, Kenean Getaneh Tlaye, Awet Fitiwi Gebrekiristos. Assessment of breast self-examination practice and its associated factors among female undergraduate students in Addis Ababa University, Addis Ababa, Ethiopia, 2016. Breast Cancer - Targets Ther [Internet]. 2019 [cited 2019 Sep 8]; Available from: www.dovepress.com
  14. Azage M, Abeje G, Mekonnen A. Assessment of Factors Associated with Breast Self-Examination among Health Extension Workers in West Gojjam Zone, Northwest Ethiopia. Int J Breast Cancer [Internet]. 2013 Nov 5 [cited 2019 Sep 8];2013:814395. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24298389
  15. Chattu VK, Kumary S, Bhagavathula AS. Community-based study on the knowledge, awareness, and practices of females towards breast cancer in Buraimi, Oman. South Asian J cancer [Internet]. 2018 [cited 2019 Sep 8];7(4):215–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/30430084
  16. Ertem G, Kocer A. Breast self-examination among nurses and midwives in Odemis health district in Turkey. Indian J Cancer [Internet]. 2009 [cited 2019 Sep 11];46(3):208. Available from: http://www.indianjcancer.com/text.asp?2009/46/3/208/52955
  17. Sudan ©, Charles Oluwole O. Omolase Charles Oluwole Practice Of Breast-Self Examination Awareness, Knowledge and Practice of Breast-Self Examination amongst Female Health Workers in A Nigerian Community [Internet]. Vol. 3, JMS. 2008 [cited 2019 Sep 11]. Available from: https://www.ajol.info/index.php/sjms/article/viewFile/38521/7480