Hrev_master [Healthcare in Low-resource Settings 2022; 10:9994] [page 37] Breast self–examination practice and the associated factors among Bule Hora University students, Oromia Regional State, Ethiopia. An institution based cross sectional study Tamrat Alemu Tegegn, Kaleb Mayisso Rodamo, Keneni Gutama Negeri Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia Abstract Regular breast self-examination in women is one of the practicable ways to screen, to detect earlier and to seek prompt medical attention of breast cancer in low- income countries. The study aimed to assess breast self-examination practice and associ- ated factors among female students of Bule Hora University from February- June 2019. A cross-sectional study was conducted using pretested, self-administered and structured data collection tools from regular and undergraduate class female students. Data were entered using Epi info. Version 7.2; and analyzed by SPSS version 20. Only 30 (14.78%) of the students were found to practice breast self-examination regularly. Being urban resident [(AOR= 2.757: 95% CI (1.471, 5.167)], perceived susceptibility to breast cancer [AOR =2.910, 95% CI (1.537, 5.508)] and having family history of the practice [AOR= 2.047: 95% CI (1.040, 4.028)] had shown a significant association with the practice of breast self -examina- tion. Discussion about breast cancer and practicing breast self-examination among the students is very low. The students who came from rural communities did not yet perceive the susceptibility and; therefore, health education pertaining to the subject is recommended. Introduction Incidence and the death rate due to of cancer is growing rapidly world-wide.1 The female breast cancer is the second most fre- quently diagnostic cause of death and accounts for about 2.1 million newly diag- nosed cause for cancer deaths.2,3 Cancer is an emerging public health problem in Africa with estimates of 715 000 new cases and 542 000 deaths secondary chronic infection of its origin being a cause for a majority of the deaths. In Africa, there was projected that the incidence and mortality due to can- cer will be as double to 1.28 million new cases and 970 000 deaths per year by 20304,5 with the incidences of breast cancer grown to unaccepted rate even though many cases remain undetected in the continent.6 Aging and rising population together with the adoption of lifestyle habits such as smoking, physical inactivity and unhealthy and high-calorie western diets are key risk factors.4 HIV epidemics and race-being white could be accountable risks for breast cancer.7,8 Besides to that the female’s reluc- tance and embarrassing nature to meet physicians in person to discuss their inti- mate body parts all contribute to the rise of cancer burden worldwide.9 In Ethiopia, cancer accounts for about 5.8% of total national mortality. As it was projected from population based data from Addis Ababa, the annual incidence and the mortality due to cancer was around 60,960 cases and over 44,000 deaths respectively with about 34% of the deaths were con- tributed by female breast cancer. For people below the age of 75 years, the probability of being diagnosed with cancer is only 11.3% and the risk of dying from the disease is 9.4%.10-12 Regular Breast Self-Examination (BSE) in women is one practicable ways of screening breast cancer. This is important especially in low income countries like Ethiopia where it plays a major role in early detection of breast cancer and helps to seek prompt medical attention.13,14 Since most healthcare facilities do not have advanced laboratory investigations for breast cancer denoting, BSE practice should be promoted to reduce the related morbidities and mor- talities. However, little is known of awareness creation on breast self-examination practice to detect abnormality and treat early before reach the advanced stage in the country in general and female students at higher edu- cation institutions of Ethiopia in particu- lar.15 Even less is known of awareness cre- ation on breast self-examination practice in female students at Bule Hora University (BHU). Therefore, the current study aims to assess BSE practice and associated factors among female students of BHU in southern Ethiopia. Materials and Methods Study site This a cross-sectional study was con- ducted in BHU among regular under gradu- ate class female students of 2016-2019 class years from February 1-June 30, 2019. BHU is one of third generation universities in Ethiopia, which is located at a distance of 455 km south of Addis Ababa. The univer- sity consists of 9 colleges and 53 depart- Healthcare in Low-resource Settings 2022; volume 10:9994 Correspondence: Kaleb Mayisso Rodamo, Hawassa University College of Medicine and Health Sciences, P.O Box: 1560, Hawassa, Ethiopia. Tel.: +251.919532392, Fax: +2510462208755 E-mail: kalebmayisso@gmail.com, Key words: Female student; cancer screening practice; breast self-examination. Acknowledgements: Our gratitude goes to Hawassa University College of medicine and health science for giving the opportunity of conducting the research. We are indebted to all the students who took part in the study. We are grateful for Bule Hora University staff for facilitating all necessary activities during data collection. Further, our appreciation goes to the study subjects for their willingly participa- tion in the study. Contributions: TAT conceived the title and prepared the draft manuscript. KMR and KGN participated in design of the study, statistical analyses and revised of the manuscript. All authors read and approved the final version of the manuscript. Conflict of interests: The authors have no con- flicts of interest to declare Further information: This work was supported by a budget for a student research of college of medicine and health sciences, Hawassa University. Availability of data: All data and materials of this study are available and can be accessed with a reasonable request from the correspon- ding author. Ethics and consent: Ethical approval was obtained from Institutional review board of Hawassa University College of Medicine and Health Science. Written informed consent was obtained from participants after a detailed explanation of the objective of the study before the individual data collection, and also each of the respondents were assured about the confidentiality of the information they pro- vided as well as their right to withdraw at any time during participation. Received for publication: 21 July 2021. Revision received: 25 March 2022. Accepted for publication: 25 March 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2022; 10:9994 doi:10.4081/hls.2022.9994 Non commercial use only [page 38] [Healthcare in Low-resource Settings 2022; 10:9994] ments; and expected to offer undergraduate degree programs in different fields of study. In 2019, the total number of regular stu- dents estimated to be 9583, of which female students account for 3233 (33.7%). Study population The source population was all BHU regular under graduate from third year and above class female students of all faculties and of 2017 and above years of enrollment. All randomly selected regular, under gradu- ate class female students of third year and above were considered as study subjects. The sample size was determined by 30.25% proportion of the students who had good knowledge and practices on breast self-examination from the study conducted in Debre Birhane University16 using single population proportion formula at 95% con- fidence interval (CI): N=Z(α/2)2 ×p (1-p)/ d2 = =324 where N is the required sample size, Zα/2 (Z Alpha over Two) = 1.96 at 95% CI, p is the proportion of the students who had good knowledge and practices on breast self- examination, q = 1 − p and d is the assumed marginal error (5%). Since the source popu- lation was less than 10,000, correction fac- tor was applied to estimate the final sample size required in the study using correction formula: NF= = (324/1+ (324/3233)) adjusted sample (NF) estimated to be ≈ 270. Where, NF= adjusted sample size, No = cal- culated sample size and N=source popula- tion. In addition, including with 10% non- response rate and a design effect of 1.5 [270+ (270 × 0.1) and 297* 1.5], the final sample size calculated to be 446. Data collection To allocate the number of participants from selected departments, a third and above year students’ records was assessed and the trend showed 3233 female students. Based on this, sample size distribution was done as follows: for instance, 24 students [(166/3233) ×446] from natural science department, and so on from all twenty four selected departments were expected to be included in the study. Finally, students were selected using systematic random sampling technique from these departments for the study. Socio-demographic and others rele- vant clinical information of the study sub- jects were collected using pre tested and self-administered structured data collection tools. Study variables While level of BSE practice among the female students was considered as depen- dent variable, the independent variables included; socio demographic factors like age, place of residence, educational status of parents, family occupation and average monthly income of house-hold. Data analysis Data was entered and cleaned using Epi info. Version 7.2 and exported to Statistical Package for Social Science (SPSS) version 20 for analysis.17 Descriptive statistics was used to see frequency, and percentages of the characteristics. Binary logistic regres- sion analysis was used to calculate Odds Ratios (OR) with 95% Confidence Intervals (CI) to estimate the association between the dependent and independent variables. To identify the relative effects of explanatory variables, variables having a p-value of less than 0.25 during bivariate analysis were transferred into multivariate analysis. Multivariate analysis was also used to con- trol confounding effect of explanatory vari- ables and to determine the Adjusted Odds Ratio (AOR). The result of the final model was expressed in terms of the AOR with the corresponding 95% CI and statistical signif- icance was declared at P-value less than 0.05. Results Out of the total 466 sampled study sub- jects, 454 female students with the age range from 20 to 26 years were participated, yielding 97% response rate. Age between 24 and 26 years was the dominant group account for 51% of a total study participant. About a half, 240 (52.86%) of the respon- dents were urban residents. Concerning year of University study, 181 (39.86%) of participants were from third year and above while 132 (29%) of them were in their first year of study as detailed in the Table 1 below. In the study, two hundred and four (44.9%) of the participants ever performed breast self-examination during the past 12 months. Of these, majority 104(22.9%) per- formed irregularly at any time. Only 30(6.6%) of the participants perform regu- larly on monthly bases. On the other hand, during BSE 81(17.8%) of them palpate with their three middle finger pads. Consequently, 27(5.9%) of the respondents said they perform BSE after menstruation within 7-10 days. Of those who do not per- form BSE, as a reason, 145(31.9%) said that they don’t have any problem on their breast (Table 2). Factors associated with practice of breast self-examination were assessed using bivariate and multivariate logistic regres- sion (Table 3). In bivariate logistic regres- sion analysis, explanatory variables having Article Table 1. Socio-demographic Characteristics of the study participants in Bule Hora University in June, 2019 (n=454). Variables Category No. % Age in year 20 - 23 Years 222 48.9 24 - 26 Years 232 51.1 Previous place of residence Urban 240 52.9 Rural 214 47.1 Years of study First year 132 29.1 Second year 141 31.1 Third year and above 181 39.9 Department of study Engineering 60 13.2 Health Science 44 9.7 Social science 77 17.0 Natural Science 70 15.4 Law 20 4.4 Agriculture 61 13.4 Faculty of business education 43 9.5 Education 36 7.9 Automotive 43 9.5 Non commercial use only a p-value of <0.25, as a candidate for multi- variable, were respondents original resi- dence, OR 2.180 at 95% CI (1.232, 3.858), family history of breast self – examination, COR 3.491 at 95% CI (1.984, 6.142) and perceived susceptibility towards breast can- cer with COR 3.865 at 95% CI (2.172, 6.876). Considering these variables as can- didate for multivariate analysis at P<0.05, and to rule out confounders the analysis was conducted. In multivariate analysis, respon- dents residing in urban were 2.76 times more likely practice BSE than who reside in rural areas [AOR 2.757 at 95% CI (1.471, 5.167)]. Respondents having family history of BSE practice perform BSE 2 times more likely than who don’t have family history of BSE practice [AOR 2.047 at 95% CI (1.040, 4.028)]. In addition, participants having perceived susceptibility of breast cancer were about 3 times more likely per- form BSE than who did not have perceived susceptibility [AOR 2.910 at 95% CI (1.537, 5.508). For the details see Table 3. Discussion Despite the advent of modern screening methods, more than 90% of cases of cancers of the breast are identified by women them- selves which still implies on the importance of breast self – examination.15 Most health- care facilities in Ethiopia do not have advanced laboratory investigations for diag- nosing breast cancer. Thus, like any resource limited countries, in Ethiopia, practice of breast self-examination should be promoted.18,19 In this institution based cross sectional study, we tried to identify practice of breast self-examination and fac- tors determining it in BHU. According to response from participants, only, 12.8% are had performed breast self-examination reg- ularly. This finding is in line with the result of the study conducted among undergradu- ate students in Ambo University, western Ethiopia.20 However, compared to a study conducted in Buea University of Cameroon in which 3% had performed BSE regularly, our finding is higher.21 Possible reason for the differences might be the differences in number of study participants and study set- tings. Contrary to this, the finding in this study is smaller than a study conducted in Jimma University, Ethiopia15 in which 21% of the study participants had performed BSE regularly. So also, it is smaller than the study conducted on nursing students in Article Table 2. Prior practice of t respondents on breast self - examination in Bule Hora University in June, 2019. Variables Responses Frequency % Ever practiced breast self -examination during the past 12 months No 250 55.1 Yes 204 44.9 How often do you perform breast self-examination Yearly base 66 32.4 Any time 104 62.9 Regularly on monthly base 30 14.7 Skill how to practicing breast self -examination Palpating with three middle fingers pads 81 39.7 Palpating with the whole fingers 52 25.5 Palpating with one or two fingers 42 20.6 Others ways than fingers 29 14.2 When you perform breast self -examination in relation to your menstrual cycle Any time 58 28.4 During menstruation 49 23.0 The date before start of menstruation 39 18.6 After menstruation 1-6days 31 15.2 After menstruation 7-10days 27 13.2 Reason why not performing breast self -examination Don’t have any problem and symptom on their breast 145 58.0 Don’t know how to perform breast self -examination 53 21.2 Don’t think it is important 44 17.6 It is not comfortable 8 3.2 Table 3. Factors associated with practice of breast self -examination among Bule Hora University female students, 2019. Variables BSE Practice COR (95% CI) AOR (95% CI) P-Value Yes No No. (%) No. (%) Age in year 17 - 21 Years 24(10.8) 198(89.2) 1 1 22 - 26 Years 34(14.7) 198(85.3) 1.417(0.810, 2.476) 1.264(0.695, 2.300) 0.442 Residence Rural 21(8.8) 219(91.3) 1 1 Urban 37(17.3) 177(82.7) 2.180(1.232, 3.858) 2.757(1.471, 5.167) 0.002* Family history of BSE No 28(8.5) 303(91.5) 1 1 Yes 30(24.4) 93(75.6) 3.491(1.984, 6.142) 2.047(1.040, 4.028) 0.038* Perceived susceptibility No 21(7.2) 272(92.8) 1 1 Yes 37(23.0) 124(77.0) 3.865(2.172, 6.876) 2.910(1.537, 5.508) 0.001* *statistically significant P-value < 0.05. [Healthcare in Low-resource Settings 2022; 10:9994] [page 39] Non commercial use only [page 40] [Healthcare in Low-resource Settings 2022; 10:9994] Amino Kano teaching hospital, Kano, Nigeria.22 Possible reasons for these gaps may be due to the difference in students’ educational back ground given that study participants in both Jimma University of Ethiopia and Kano University of Nigeria were Health science students who have bet- ter health related information as one would expect. According to the current study, BSE practice is significantly association with their family knowledge and practice. This is in line with the finding of the studies con- ducted on Nurses in University Hospitals in Addis Ababa and on Health Extension Workers in West Gojjam Zone, Northwest Ethiopia.23,24 Our study revealed that per- ceived susceptibility to breast cancer has significant association with practicing of breast self- examination. This is consistent with the result of the study conducted at Adwa town among women aged 20–70 years attending public health institutions.21 Compared to students who join the University from rural areas, urban based residents were more likely to perform BSE regularly. This is not unexpected as student urban residents are more accessible for health related information from the very beginning if not during their University stay.25 Conclusions In conclusion, the study revealed that the respondents’ BSE practice was low. Not experiencing breast self- examination among mothers of the respondents, not dis- cussing about the breast cancer and the importance of breast self-examination among the students, not perceiving of sus- ceptibility of the disease and coming from rural communities were independently associated with both knowledge and experi- ence towards breast self-examination. Thus, it is recommended that health care providers at all level should advocate breast self- examination regularly, and also display BSE posters in all examination rooms in health centers and hospitals. Operational definition Breast self-examination: Physical and visual self-checkup of breast by female stu- dents to examine any change or abnormality on their breast through palpation and inspection. Level of breast self-examination prac- tice: The frequency of performing one’s own breast self-examination both physical- ly with palpating and visually with inspect- ing at a regular time on monthly base after 7-10 days of menstrual cycle. Practicing: One is performing BSE every month at ideal time (7-10 days) after menstrual cycle. The ideal time of BSE practice: When BSE is performed on monthly base after 7- 10 days of menstrual cycle.26 Limitation of the study Since the study is cross-sectional by its design, causal conclusions cannot be drawn. Since this study has been done among female undergraduate students, the findings cannot be generalized to the other Universities in the country and also for the whole population in Ethiopia. References 1. Thorat MA, Cuzick J. Preventing inva- sive breast cancer using endocrine ther- apy. Breast 2017;34:S47-S54. 2. Bray F, Ferlay J, Soerjomataram I, et al. Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2018;68:394-424. 3. Cardoso F, Spence D, Mertz S, et al. Global analysis of advanced/metastatic breast cancer: Decade report (2005- 2015). Breast 2018;39:131-8. 4. Ekortarl A, Ndom P, Sacks A. A study of patients who appear with far advanced cancer at Yaounde General Hospital, Cameroon, Africa. Psycho-Oncology 2008;16:255-7. 5. Tsoka-Gwegwenia JM, Cumber SN, Nchanji KN. Breast cancer among women in sub-Saharan Africa: preva- lence and a situational analysis. Southern Afr J Gynaecol Oncol 2017;9:28-30. 6. Cumber SN, Nchanji KN, Tsoka- Gwegweni JM. Breast cancer among women in sub-Saharan Africa: preva- lence and a situational analysis. Southern Afr J Gynaecol Oncol 2017;9:35-37. 7. Reddy P, Ebrahim B, Singh B, et al. Breast cancer and HIV: a South African perspective and a critical review of the literature. SAJS 2017;55:10–15. 8. Omaka-Amari LN, Ilo CI, Nwimo IO, et al. Demographic differences in the knowledge of breast cancer among women in Ebonyi State, Nigeria. IJNMH 2015;1:18–27. 9. Khana R, Mahinderjit Singh M, Damanhoori F, etal. Breast Self- Examination System Using Multifaceted Trustworthiness: Observational Study. JMIR Med Inform 2020;8:e21584. 10. Birhane N, Mamo A, Girma E, etal. Predictors of breast self - examination among female teachers in Ethiopia using health belief model. Archives of public health = Archives belges de sante publique 2015;73:39. 11. Abay M, Tuke G, Zewdie E, etal. Breast self-examination practice and associat- ed factors among women aged 20-70 years attending public health institu- tions of Adwa town, North Ethiopia. BMC 2018;11:622. 12. Woldeamanuel YW, Girma B, Teklu AM. Cancer in Ethiopia. Lancet Oncol 2013;14:289-90. 13. Aker S, Öz H, Tunçel EK. Practice of Breast Cancer Early Diagnosis Methods among Women Living in Samsun, and Factors Associated with This Practice. J Breast Health 2015;11:115-22. 14. Hailu T, Berhe H, Hailu D, et al. Knowledge of breast cancer and its early detection measures. Clinical Medicine 2014;3:57-64. 15. Desta F, Workicho A, Atomsa A, et al. Knowledge, Practice and Associated Factors of Breast Self Examination Among Female Students of the College of Public Health and Medical Science, Jimma University, Ethiopia. Am J Health Res 2018;6:44-50. 16. Kalayu B, Miskir A, Belayneh A, et al. Practices of Breast Self-Examination and Associated Factors among Female Debre Berhan University Students. Int J Breast Cancer 2017;8026297. 17. Sullivan KM, Soe MM. Sample size for cross-sectional & cohort studies & clin- ical trials. 2007. Available from: http://www.openepi.com/PDFDocs/SS CohortDoc.pdf 18. Birhane K, Alemayehu M, Anawte B, et al. Practices of Breast Self-Examination and Associated Factors among Female Debre Berhan University Students. Int J Breast Cancer 2017;2017:8026297. 19. Getu MA, Kassaw MW, Tlaye KG, et al. Assessment of breast self-examina- tion practice and its associated factors among female undergraduate students in Addis Ababa University, Addis Ababa, Ethiopia, 2016. Breast Cancer 2019;11:21-8. 20. Natae SF, Health DoP. Assessment of Knowledge, Attitude and Practice of Breast Selfexamination among Ambo University Undergraduate Regular Female Students; 2015. Physiology and Biophysics 2015;32. 21. Nde FP, Assob JC, Kwenti TE, etal. Knowledge, attitude and practice of breast self-examination among female undergraduate students in the University of Buea. BMC 2015;8:43. Article Non commercial use only [Healthcare in Low-resource Settings 2022; 10:9994] [page 41] 22. Okolie UV. Breast self examination among female undergraduates in Enugu, Southeast Nigeria. Int J Nursing Midwifery 2012;4. 23. 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 2013;814395. 24. Zeru Y, Sena L, Shaweno T. Knowledge, Attitude and Practice; and Associated Factors of Breast Cancer Self-Examination among Urban Health Extension Workers in Addis Ababa, Central Ethiopia. J Midwifery Reproduct Health 2019:1-11. 25. Janni L, McKenzie S, Martin J, et al. Longitudinal patterns of breast cancer screening: mammography, clinical, and breast self-examinations in a rural and urban setting. Womens Health Issues 2014;24:e139-46. 26. Gale Encyclopedia of Medicine. Breast self-examination. 2008. Accessed: October 20 2021. Available from: https://medical-dictionary.thefreedic- tionary.com/breast+self-examination Article Non commercial use only