Knowledge of breast cancer and practice of breast self-exam among rural Ethiopian women

COLLEGE OF HEALTH SCIENCES
KNOWLEDGE OF BREAST CANCER, PRACTICE OF BREAST SELF-
EXAMINATION AND ASSOCIATED FACTORS AMONG RURAL REPRODUCTIVE
AGE WOMEN OF DIRE WAREDA, BORENA ZONE, ETHIOPIA, 2022
PRINCIPAL INVESTIGATOR: SIRAJ GEBI (BSc)
A THESIS SUBMITTED TO SALALE UNIVERSITY COLLEGE OF HEALTH
SCIENCES, DEPARTMENT OF MIDWIFERY IN PARTIAL FULFILLMENT OF
MASTERS DEGREE IN MATERNITY AND NEONATAL HEALTH
SEPTEMBER, 2022
FITCHE, ETHIOPIA

KNOWLEDGE OF BREAST CANCER, PRACTICE OF BREAST SELF-
EXAMINATION AND ASSOCIATED FACTORS AMONG RURAL REPRODUCTIVE
AGE WOMEN OF DIRE WAREDA, BORENA, OROMIA,ETHIOPIA.
INVESTIGATOR: SIRAJ GEBI (BSc)
MAIN ADVISOR: TADESSE NIGUSSIE (ASSSISTANT PROFESSOR)
CO-ADVISOR: MULUGETA FEYISA (ASSSISTANT PROFESSOR)
SEPTEMBER, 2022
FITCHE, ETHIOPIA

I
APPROVAL SHEET
Salale University
Post graduate Program Directorate
I hereby certify that I have read and evaluate this thesis entitled by “Knowledge of breast
cancer, practice of breast self-examination and associated factors among rural reproductive age
women of dire wareda, Borana, Oromia, Ethiopia: cross-sectional study, 2022” prepared under
my guidance by Siraj Gebi Wako. I recommend that it be submitted as fulfilling the thesis
requirement.
Major Advisor Signature Date
Tadese Nugusie __________________ _______________
Co-Advisor Signature Date
Mulugeta Feyisa __________________ ________________
As a member of the Board of Examiners for the MSc Thesis Defense Examination, I declare
that I read, reviewed, and studied Siraj Gebi Wako`s thesis. I recommend that the thesis be
recognized as fulfilling the Masters of Science in Maternity and Neonatal Health degree
requirement.
Fikadu Tolosa ______________ _________
Chairperson Signature Date
Mukamil Awel _________________ __________
Internal Examiner Signature Date
___________________________ _________________ __________
External Examiner Signature Date
Final approval and acceptance of the thesis contingent upon the submission of its final copy to
the Council of Graduate Studies (CGS) through the candidate`s department or school of
Graduate Committee (CGS or CGS).

II
ACKNOWLDEGEMENT
First of all, I appreciate the Almighty ALLAH for the courage, competence and protection to
carry out this research project successfully.
I appreciate Salale University to approve this interesting research topic and funding and
supporting technically the project. I am grateful to my supervisors Mr. Tadese Niguse
(Assistant Professor) and Mr. Mulugeta Feyisa (Assistant Professor) for their tireless efforts,
enthusiasm that has always encouraged me to carry on with this thesis. Their advice was both
parental and educative which encourage me to complete this study.
I wish to express my appreciation to Dire woreda health office for their assistance in giving
necessary data and support. Lastly, I would like to thanks all data collectors and supervisors.

III
ABBREVATIONS
AOR-Adjusted Odds Ratio
BC-Breast Cancer
BSE-Breast Self-examination
CI- Confidence interval
SNNP- Southern Nation, Nationalities and People
SSA-Sub-Saharan Africa

IV
Table of Contents
APPROVAL SHEET....................................................................................................................I
ACKNOWLDEGEMENT...........................................................................................................II
ABBREVATIONS..................................................................................................................... III
List of tables..............................................................................................................................VII
List of Figures......................................................................................................................... VIII
ABSTRACT...............................................................................................................................IX
1. INTRODUCTION ................................................................................................................... 1
1.1 Background ........................................................................................................................ 1
1.2 Statement of the problem ................................................................................................... 2
1.3 Significance of the study.................................................................................................... 5
2. LITERATURE REVIEW ........................................................................................................ 6
2.2 Knowledge of breast cancer ............................................................................................... 6
2.3 Practice of Breast Self-Examination .................................................................................. 7
2.4 Factors Associated with Knowledge of Breast Cancer ...................................................... 8
2.5 Factors Associated with practice of Breast Self-Examination........................................... 9
2.5 Conceptual Frameworks................................................................................................... 14
3. OBJECTIVE OF THE STUDY............................................................................................. 15
3.1 General Objective............................................................................................................. 15
3.2 Specific Objectives........................................................................................................... 15
4. METHODS AND MATERIALS........................................................................................... 16
4.1 Study Area and period...................................................................................................... 16
4.2 Study design..................................................................................................................... 16
4.3 Population......................................................................................................................... 16
4.3.1 Source population...................................................................................................... 16
4.3.2 Study Population........................................................................................................ 16
4.3.3 Study unit................................................................................................................... 16

V
4.4 Sample size determination and sampling technique ........................................................ 17
4.4.1 Sample size determination for quantitative study...................................................... 17
4.4.2 Sample size determination for qualitative study........................................................ 18
4.4.3 Sampling procedure and Technique .......................................................................... 18
4.4.3.1 Sampling technique for quantitative study............................................................. 18
4.5 Data collection tool and personnel................................................................................... 20
4.5.1 Data collection tool for quantitative study ................................................................ 20
4.5.2 Data collection tool for qualitative study .................................................................. 20
4.5.3. Data collection procedure for quantitative study...................................................... 21
4.5.4. Data collection procedure for qualitative study........................................................ 21
4.6 Inclusion and exclusión criteria........................................................................................ 21
4.6.1 Inclusion criteria........................................................................................................ 21
4.6.2 Exclusion criteria....................................................................................................... 21
4.7 Variables........................................................................................................................... 22
4.7.1 Dependent variables .................................................................................................. 22
4.7.2 Independent Variables ......................................................................................... 22
4.8 Operational definitions..................................................................................................... 22
4.9 Data analysis procedures.................................................................................................. 23
4.9.1 Data process and analysis for quantitative study....................................................... 23
4.9.2 Data process and analysis for qualitative study......................................................... 23
4.10 Data Quality Assurance.................................................................................................. 23
4.10.1 Data quality control for Quantitative study............................................................. 23
4.10.2 Data Quality Control for Qualitative study ............................................................. 24
4.11 Ethical consideration...................................................................................................... 25
4.12 Dissemination of the result.......................................................................................... 26
5. RESULTS AND DISCUSSIONS.......................................................................................... 27
5.1 Quantitative part results....................................................................................................... 27

VI
5.1.1 Socio-demographic characteristics of Respondents .................................................. 27
1.2 Participants` wealth index ............................................................................................ 28
5.1.3 Respondents knowledge of breast cancer (N=611) ................................................... 29
5.1.4 Respondents knowledge of breast self-examination ................................................. 31
5.1.5 Findings on attitude toward breast self-examination................................................. 33
5.1.6 Respondents` personal and family history of breast cancer ...................................... 34
5.1.7 Participants` practice of breast self-examination....................................................... 35
5.1.8 Logistic regression analysis of factors associated toward knowledge of breast cancer
37
5.1.9 Logistic regression analysis of factors associated toward practice of breast self-
examination ........................................................................................................................ 40
5.2 Qualitative Research findings Section ............................................................................. 43
5.3 DISCUSSIONS................................................................................................................ 48
6. Strength of the study and Limitation of the study.................................................................. 52
6.1 Strength of the study ........................................................................................................ 52
6.2. Limitation of the study.................................................................................................... 52
7. Conclusion and Recommendations........................................................................................ 52
7.1 Conclusion........................................................................................................................ 52
7.2 Recommendations............................................................................................................ 53
ANNEX 1: REFERENCES ....................................................................................................... 54
ANNEX 2: INFORMATION AND CONSENT SHEET.......................................................... 60
ANNEX 3: QUESTIONNAIRES.............................................................................................. 62
English version....................................................................................................................... 62
Afaan Oromoo Version.......................................................................................................... 71
DECLARATION....................................................................................................................... 82

VII
List of tables
Table 1: Sample size calculation by single population proportion for the research conducted
among reproductive age women of Dire wareda, Borena zone, Ethiopia, 2022 ....................... 17
Table 2: Sample size calculation by different factors for the research conducted among
reproductive age women of Dire wareda, Borena zone, Ethiopia, 2022 ................................... 18
Table 3: Distribution of socio-demographic characteristics of respondents on knowledge of
breast cancer, practice of breast self-examination and associated factors among reproductive
age women of Dire woreda, Borena zone, South Ethiopia, 2022 (N=611) ............................... 28
Table 4: Wealth index classification for the study conducted among reproductive age women
of dire wareda, Borena zone, Ethiopia, 2022............................................................................. 29
Table 5: Knowledge of breast cancer among reproductive age women of Dire woreda, Borena
zone, Ethiopia, 2022 .................................................................................................................. 30
Table 6: Knowledge of breast self-examination among reproductive age women of Dire
woreda, Borena zone, South Ethiopia, 2022.............................................................................. 32
Table 7: Attitude toward breast self-examination among reproductive age women of Dire
woreda, Borena zone, Ethiopia, 2022 (N=611) ......................................................................... 34
Table 8: Practice of breast self-examination among reproductive age women of Dire woreda,
Borena zone, Ethiopia, 2022...................................................................................................... 36
Table 9: Bivariable logistic regression analysis of the knowledge of breast cancer among
Table 10: Multivariable logistic regression analysis of the factors associated toward knowledge
of breast cancer among reproductive age women of Dire wareda, Borena, Ethiopia 2022....... 39
Table 11: Bivariable logistic regression analysis of practice of breast self-examination among
Table 12: Multivariable logistic regression analysis of the practice of breast self-examination
Table 13: Themes and sub-themes emanating In-depth interview about breast cancer and
practice of BSE among women of reproductive age in Dire woreda, Borena zone, Oromia state,
Ethiopia, 2022............................................................................................................................ 44

VIII
List of Figures
Figure 1: Conceptual framework adapted by reviewing different literatures for the study
conducted among reproductive age women of Dire wareda, Borena zone , Ethiopia, 2022..... 14
Figure 2: Sample size proportionally allocated to selected kebele‟s for the study conducted
Figure 3: Respondents Breast cancer knowledge level among reproductive age women of Dire
woreda, Borena zone, Ethiopia, 2022 (N=611) ......................................................................... 31
Figure 4: Practice of breast self-examination among reproductive age women of Dire woreda
Borena zone, Ethiopia, 2022...................................................................................................... 37

IX
ABSTRACT
Introduction: Breast cancer is now a worldwide problem, yet it is still detected in its advanced
stages. Globally, by 2020 breast cancer were about 11.7% of all new cases. Breast self-
examination is an easy and cost effective method which is helpful in early detection of breast
cancer that everyone can practice.
Objective: To assess the knowledge of breast cancer, practice of breast self-examination and
associated factors among reproductive age women of Dire wareda, Borana zone, 2022.
Method: A community based cross-sectional study with a convergent qualitative study design
was conducted among 624 reproductive age women of Dire Wareda, Borana zone. Multistage
sampling technique for quantitative and purposive sampling for qualitative part was used to
select the study participants. Interviewer administered questionnaires for quantitative study and
semi-structured questionnaires for qualitative study were used to collect data. For analysis,
quantitative data was exported to SPSS version 25. In bivariate logistic regressions analysis,
variables having p-value < 0.25 were candidate for multivariable logistic regression analysis.
Significantly associated variables were reported on adjusted odds ratio with 95% confidence
interval and p-value <0.05. Narrative analysis was done for qualitative result manually.
Result: Overall, 198(32.4%) of women had good knowledge about breast cancer, and only
30(4.9%) were ever practiced breast self-examination. Women who had high income and
learned high school and above were 3 times more likely to knew about breast cancer than those
who had low income and had no formal education, AOR=3.37, (95%CI: 1.91, 5.95) and
AOR=3.54, (95%CI:1.96, 6.37) respectively. Women aged from 25-34 were 6 times more
likely to knew about breast cancer as compared to women aged from 15-24, AOR=6.12, (95 %
CI: 2.85, 13.14). Employed women were 2 times more likely to know about breast cancer than
housewives, AOR=2.12, (95 %CI: 1.11, 4.06). Women who learned high school and above
were 2 times more likely to practice breast self-examination than women who had no formal
education AOR= 2.91(95%CI: 1.09, 7.79). Employed women were 3 times more likely to
practice breast self-examination than housewives, AOR=3.2 (95%CI: 1.27, 8.99).
Conclusion and recommendations: This study identified that the knowledge of breast cancer
and practice of breast self-examination were poor among women of reproductive age in the
study area as compared to other studies. Stakeholders and concerned bodies should arrange and
participate in teaching the community on breast cancer and practice of breast self-examination.
Keywords: Breast cancer, breast self-examination, Dire Borana, Ethiopia

1
1. INTRODUCTION
1.1 Background
Breast cancer is a type of cancer that develops in the breast and spreads to other parts of the
body. It can begin in either one or both of the breasts and it can start in a variety of places in
the breast. If cancer cells have spread to your lymph nodes, there's a probability they've gone
through your lymph system and spread to other places of your body (metastasized) (American
Cancer Society, 2017).
Breast cancer has a fairly excellent prognosis when diagnosed early and treated appropriately.
The number of women alive today who were diagnosed with breast cancer during the last 5
years is expected to be about 8 million, which is more than any other cancer type's number of
survivors. However, breast cancer survival rates are not the same all over the world
(International Agency for Research on Cancer - World Health Organization, 2021). In
comparison to high-income nations in SSA countries, treatment choices are limited, most
women present with severe disease and have a poor prognosis (Black and Richmond, 2019).
It's usual to wait a long time between the onset of symptoms and seeking medical help, early
detection measures such as mammography and breast inspection are underutilized, which
contributes to diagnosis at a late stage. While early diagnosis of breast cancer by screening has
contributed to significant decreases in mortality in many high-income countries, most countries
in SSA have been unable to launch and continue screening programs (Black and Richmond,
2019).
Breast self-examination (BSE) is something that all women can undertake to get a better
understanding of how their breasts naturally feel, which will help them spot changes in the
future. Once a month, when your breasts are the least sensitive, examine them (usually 5-10
days from the first day of your period) (Global cancer, 2016).. If you don't get periods
anymore, set aside one day each month to remind yourself to do BSE. The majority of breast
lumps are discovered by women or their spouses. Women should have received BSE
instruction and execute BSE on a monthly basis by the age of 20 (Global cancer, 2016). The
techniques used to perform BSE were; standing before a mirror and look at both breasts,
pressing your hands firmly on your hips and lean slightly toward your mirror, looking in the
mirror raise your arms and rest your hands behind your hand and place your left hand on your
waist, roll your shoulder forward and check underarms for enlarged lymph nodes.

2
1.2 Statement of the problem
Despite the development of many technologies and advanced care in recent years, female
breast cancer has surpassed the number of new instances of lung cancer for the first time, with
2.3 million cases diagnosed in 2020 and accounting 11.7% of all new cases of cancer
worldwide (Lera, 2020; International Agency for Research on Cancer - World Health
Organization, 2021; Sung et al., 2021). In 2019, women diagnosed with 268,600 new instances
of invasive breast cancer and it is estimated to claim the lives of 41,760 women (Shumway,
Sabolch and Jagsi, 2020). Breast cancer mortality is high in Iranian women due to a lack of
screening exams and delayed treatment visits (Bashirian et al., 2019).
Among women, breast cancer accounts for 1 out of 4 cases of cancer and one out of six cancer
deaths, and it is the most common disease in majority of countries (159 of 185 countries)
(Sung et al., 2021). In developed countries, the incidence rate is 88% greater than in
developing countries (55.9 and 29.7 per 100,000, respectively), however, women in
developing nations have a 17 percent higher mortality rate than women in developed countries
(15.0 and 12.8 per 100,000, respectively) (Sung et al., 2021).
Breast cancer is the leading cause of cancer death in African women, accounting for 28% of all
cancers and 20% of all cancer fatalities(Clegg-Lamptey, 2016).. Incidence rates in Africa are
still relatively low, with most nations reporting rates of less than 35 per 100,000 women
(compared to about 90–120 per 100,000 in Europe or North America) (Clegg-Lamptey, 2016).
Late-stage presentation is largely to blame for low survival rates in Sub-Saharan Africa,
according to a survey based on 83 studies from 17 countries in Sub-Saharan Africa, 77% of all
staged cases were stage III/IV at the time of diagnosis because coordinated population-based
mammography screening programs in low-resource areas may not be cost-effective or
practicable (Jedy-Agba et al., 2016).
In 2020, breast cancer is the most common diagnosed new cases of all female cancers in
Ethiopia accounting about 16133(31.9%) (Country-specific et al., 2020). In rural Ethiopia,
among, 7573 only half of the women were aware of breast self-examinations, and only one in
eight had done so in the past. After becoming aware of aberrant breast changes, just one-third
of the women sought formal medical help and, this study recommends that breast cancer
awareness initiatives may help to educate the public (Wondimu Ayele And , Andreas Wienke,
Susanne Unverzagt, Ahmedin Jemal, Lesley Taylor, 2021).

3
There are controversial among different studies regarding factors associated toward knowledge
of breast cancer and practice of breast self-examination. For instance, the studies conducted
among reproductive age women at Ghana and among young women in United Arab Emirates
revealed that there were no significant association of women`s age and marital status and
knowledge of breast cancer (Younis et al., 2016; Dadzi and Adam, 2019). Another community
based cross-sectional study conducted among reproductive age women of Bale zone, revealed
that maternal age had no association with knowledge of breast cancer (Hussen et al., 2019).
But, as described by the study conducted in Bidura district, Zimbabwe, age of women had
significant association with knowledge of breast cancer and Jimma town women 35 years and
below were more knowledgeable about breast cancer than women above 35 years old (Yonas
Biratu, Samuel Abdu, 2021). This study also described that, single women were more
knowledgeable about breast cancer than divorced or separated women (Yonas Biratu, Samuel
Abdu, 2021).
As described by the studies conducted at Urban setting of southern nation nationalities and
people, Southeast Ethiopia Bale zone and Modjo town, maternal age, educational level,
marital status, occupation, source of information, and monthly income, as well as a positive
family history of breast cancer, number of children, marital status, knowing someone who has
been screened for breast cancer, family history of breast cancer were associated with practice
of breast cancer and recommendation by health professionals were associated with practice
BSE (Mohammed, 2020; Assefa, Abera and Geta, 2021; Workineh, 2021). But there are
controversial ideas between studies. For instance, according to studies by Naglaa Mohammed
Abd-Elaziz and colleagues, and at Rapti Sonari rural of Banke district and at Rwanda among
reproductive age women, no statistical significance of BSE practice with socio-demographic
such as residences, marital status, and occupation of the studied participants (Abd-elaziz et al.,
2021; Gyawali and Gautam, 2021; Igiraneza et al., 2021).
Breast cancer (30.2%) is the most frequent cancers among Ethiopian women accounting for
around two-thirds of all cancer deaths each year (FMoH, 2021). Low awareness of cancer signs
and symptoms, insufficient screening, early detection, and treatment services, and insufficient
diagnostic and treatment facilities are the main causes of high cancer mortality (FMoH, 2021).
In these conditions, BSE is the greatest option for early detection of breast cancer due to the
fact that it is free, safe and everybody can perform at their home.

4
Many studies regarding knowledge of breast cancer and breast self-examination has been
performed on female health workers, students and at urban residents, but a small number of
researches were conducted on rural pastoralist community on the topic. Many researches
showed that women from rural area presented with advanced stage of cancer diseases, among
which breast cancer is the commonest one. From principal investigator level of literature
review, there was no such study conducted at Dire wareda Borena zone pastoralist area. Thus,
the study might fill the gap.

5
1.3 Significance of the study
Breast cancer is now a worldwide problem, yet it is still detected in its advanced stages due to
women's neglect in self-inspecting and clinically examining their breasts. Early detection is the
necessary factor for preventing deaths due to breast cancer. Breast self-examination is an easy
method which is helpful in early detection of breast cancer and decrease late-staged cancer
presentation, improves utilization of health system resources. Every woman can practice BSE.
The results of this study will benefits for the followings:
 Health care providers can utilize the early detection methods of breast cancer
 Supports the strategies of Ethiopian health system transformation plan II in
providing information for local health officers and policy makers
 Community will be aware of breast cancer and BSE practice
 It motivates scholars and researchers in the field.
Thus, I felt necessity to conduct study on knowledge of breast cancer, practice of breast self-
examination and associated factors among rural reproductive age women of Dire Woreda,
Borena zone.

6
2. LITERATURE REVIEW
2.1 Overview of breast cancer and breast self-examination
This chapter presents literature reviewed from relevant previous researches and books in
relation to specific objectives of the study which include knowledge of breast cancer, practice
of breast self-examination and associated factors.
Detecting breast cancer early in its natural history improves survival, lowers morbidity, and
reduces the cost of care. Most breast tumors are discovered by women themselves, whether
through formal or informal breast self-exam (Global cancer, 2016). Teaching breast self-
examination can be part of breast awareness teaching. The critical components of techniques of
breast self-examination are visual examination and palpation of entire breast, preferably with
finger pads of the three middle fingers in an effective search manner (Global cancer, 2016).
Breast self-examination can improve a woman`s breast knowledge and her willingness to
present for evaluation and care for a breast concern (Global cancer, 2016).
2.2 Knowledge of breast cancer
In Bangladesh three-fourths (77.74%) of 1051 girls aged 20 and above years knew (heard or
read) about BC, and their main source of information was electronic media (74.54%) (Sultana
Tithi et al., 2018). 205 (81.7%) of the 251 Indian women who consented to participate in the
study had knowledge of breast cancer (Omotoso et al., 2021). Another study in Napur, India,
found that 59.33% of people knew about breast cancer (89/150) (Heroor et al., 2021). 98% of
100 female nursing undergraduate students in the Northern Border University had heard of BC,
but only a few had poor knowledge of it (Jothirajan, 2020). Nearly half of the 697 Saud women
who took part in the study had a knowledge of breast cancer (48.7% 17.2%) (Allohaibi et al.,
2020). In a study of 309 female students in Kedah, Malaysia, 304 (98.4%) had heard of breast
cancer and media was the most important source of information (Paruchuri et al., 2021).
According to a study conducted among 86 female University students in Gaza, the majority of
them (80.2%) had previously acquired information about breast cancer from various sources,
including university studies (57%), the Internet (45%), and social media (45%), and low
knowledge scores (70%) were found for general knowledge of the disease (Abo Al-Shiekh,
Ibrahim and Alajerami, 2021). According to the findings of a study conducted with 371
Lebanese females aged 18 to 65 in Beirut, the mean overall score for breast cancer knowledge
was 55.5 plus or minus 17.1% (El Asmar et al., 2018).

7
Only 9.5 percent of 348 female senior secondary school students in Ibadan, Nigeria, had good
awareness of BC, with radio/TV (82.5 percent) and health personnel as the primary sources of
information (81.6%) (Akpo, 2021). The overall knowledge score of the study of 330 female
detainees in Khartoum, Sudan, found that 185 (56.2%) of them had low knowledge regarding
breast cancer (Ahmed Mohamed et al., 2020). According to a community-based survey
conducted among reproductive-age women (750 participants) in the Ethiopia, Bale zone, 56%
of the respondents were knowledgeable of breast cancer (Hussen et al., 2019).
2.3 Practice of Breast Self-Examination
Breast self-examination is a technique which allows an individual to examine her tissue for any
physical or visual changes. It is often used as early detection method for breast cancer. Women
should perform breast self-examination at least once each month a week after period starting at
age of 20 years.
According to a study done by Rizwana Anjum, Sobia Nawaz, and Somayyaha Bibi, who
interviewed 1500 women in a community-based study, only 1.9% of women practice breast
self-examination on a regular basis, (Anjum, Nawaz and Bibi, 2017). Although early screening
for BC was deemed highly important by 58.90% of responders, and only 13.13% of 1051
females aged 20 and above years from female population of Bangladesh, actually practice BSE
(Sultana Tithi et al., 2018). Among 1000 female students in Karanchi, Pakistan, only 33.1%,
had practiced BSE (Ahmed et al., 2018). 295 (74.7%) of 395 female health-care workers at
King Fahad Medical City, Saudi Arabia, said they practice breast self-examination (Heena et
al., 2019). Among 100 female nursing undergraduate students at Northern Border University,
only 34% of them were practice BSE on a monthly basis (Jothirajan, 2020). According to one
study only 76 (30.3%) of the 251 Indian women had practice BSE (Omotoso et al., 2021).
According to a survey of 86 female university students in Gaza, only 31.4% practiced BSE
regularly (Abo Al-Shiekh, Ibrahim and Alajerami, 2021).
Only 101 (29%) of 348 female senior secondary school students in Ibadan, Nigeria, had ever
practiced BSE and the main sources of information were radio/TV (82.5%) and health
personnel (74.6%). (81.6%) (Akpo, 2021). 315 (95.5%) of 330 female detainees in Khartoum,
Sudan, of the participants had poor practice of breast self-examination (Ahmed Mohamed et
al., 2020). The overall prevalence of ever and frequent breast self-examination practice in
Africa was found to be 44.0% and 17.9% correspondingly in a meta-analysis of 56 studies
involving 19, 228 research participants (Black and Richmond, 2019; Seifu, 2021).

8
According to the community based study conducted in Jimma, among 686 women, only 15%
of them practiced breast self-examination, in case of Bale community (Community based
study), from 836 reproductive age women, from Bale community, only 13.2% of the mothers
had practiced breast self-examinations and 20.5% of 420 women attending family planning
service at Modjo town had ever practiced BSE (Mohammed, 2020; Terfa, Kebede and Akuma,
2020; Workineh, 2021). Another community based cross-sectional study conducted at Arba-
Minch zuria district showed that among 634 women age 20-64 years only 21.3% had ever
practiced BSE (Mereta and Desalegn, 2020).
2.4 Factors Associated with Knowledge of Breast Cancer
Age:- The studies conducted among reproductive age women at Ghana and among young
women in United Arab Emirates revealed that there was no significant association between
women`s age and knowledge of breast cancer (Younis et al., 2016; Dadzi and Adam, 2019).
Another community based cross-sectional study conducted among reproductive age women of
Bale zone, revealed that maternal age had no association with knowledge of breast cancer
(Hussen et al., 2019). But, as described by the study conducted in Bidura district, Zimbabwe,
age of women had significant association with knowledge of breast cancer, and another study
conducted in Jimma town also revealed that, women 35 years and below were more
knowledgeable about breast cancer than women above 35 years old (Yonas Biratu, Samuel
Abdu, 2021).
Educational status:- According to the findings of a survey done with 371 Lebanese women
aged 18 to 65 in Beirut, with 150 female patients at Sohag University Hospital, Egypt, and
community based cross-section study conducted at Jimma town reported that higher
education was associated to higher knowledge of breast cancer (El Asmar et al., 2018; Elsayed
Atwa, Hassan and Ahmed, 2019; Yonas Biratu, Samuel Abdu, 2021). Similarly, the studies
conducted in Iran and Ghana showed that women`s level of education had significant
association with knowledge of breast cancer (Rakhshkhorshid, 2018; Dadzi and Adam, 2019).
Marital status: - The studies conducted among reproductive age women at Ghana and among
young women in United Arab Emirates revealed that there was no significant association
between women`s marital status and knowledge of breast cancer (Younis et al., 2016; Dadzi
and Adam, 2019). But described by the studies conducted at Jimma town, single women were
more knowledgeable about breast cancer than divorced or separated women (Yonas Biratu,
Samuel Abdu, 2021).

9
Women`s occupation: - The study conducted at Ghana among reproductive age women
revealed that employed women were knowledgeable about breast cancer than unemployed
women (Dadzi and Adam, 2019). As described by the studies conducted at Jimma town,
employed women were more knowledgeable about breast cancer than housewife women
(Yonas Biratu, Samuel Abdu, 2021).
Personal and family history of breast cancer: - As described by the study conducted at
Jimma town, personal and family history of breast cancer had no significant association with
knowledge of breast cancer (Yonas Biratu, Samuel Abdu, 2021).
Income: - The study conducted at Bale zone rural area stated that mothers with higher income
had knowledge of breast cancer than their counterparts (Hussen et al., 2019).
2.5 Factors Associated with practice of Breast Self-Examination
Maternal Age: - The study conducted in Ghana reported that higher age had associated with
lower practice of BSE, women aged below 30 were more likely to practice BSE than women
above 40 years old (Dadzi and Adam, 2019). According to the study conducted among
reproductive age women in southeast Ethiopia women in the age range of 25-34 and 35-49
were more likely practice BSE than in the range of 15-24 (Mohammed, 2020). Similarly, the
study conducted among women following family planning service at Mojo town health
facilities, revealed that women age 30-39 were practice BSE than others (Workineh, 2021). But
study conducted among rural women of reproductive age in Banke district, Nepal, showed that
there was no association between women`s age and practice of BSE (Gyawali and Gautam,
2021).
Educational level of woman: - Higher education was shown to be associated with better
practice of BSE in a study of 371 Lebanese women aged 18 to 65 in Beirut (El Asmar et al.,
2018). Similarly practice of breast self-examination had increases with educational status
according to different studies (SAFIYA, 2017; Sani and Journal, 2018; Wang et al., 2020; Ms.
Leena Mathew, 2021; Saadoon, Al-attar and Alani, 2021). Another study conducted among
rural women of south India showed that, women with higher educational level practice BSE
than counterparts (Rahul Ganavadiya, , Suma S2 , Pallavi Singh3 and Poonam Tomar Rana,
2018). According to the study conducted among reproductive age women in southeast
Ethiopia, women who have finished primary, secondary school and above were more practice
BSE than illiterate women (Mohammed, 2020). Similarly, the study conducted among women

10
following family planning service at Mojo town health facilities revealed that, women with
tertiary level of education practice BSE than those with lower level (Workineh, 2021). But
there was no association between women`s educational level and practice of BSE (Gyawali
and Gautam, 2021).
Income:-According to community based study conducted in Cameroon higher economic status
was significantly associated with women`s practice of breast self-examination (Azemfac et al.,
2019).
Marital status of women: - As described by the studies conducted at urban setting of
southern nation nationalities and people, Southeast Ethiopia (community based, Bale) and
Modjo town marital status was associated with practice BSE (Mohammed, 2020; Assefa,
Abera and Geta, 2021; Workineh, 2021). In contrast to this, no statistical significance of BSE
practice with marital status of participants according to studies by Naglaa Mohammed Abd-
Elaziz and colleagues, and at Rapti Sonari rural and at Rwanda among reproductive age
women (Abd-elaziz et al., 2021; Gyawali and Gautam, 2021; Igiraneza et al., 2021). Also
there was no association between women`s marital status and practice of BSE (Gyawali and
Gautam, 2021).
Occupation of woman:- As described by the studies conducted at Urban setting of southern
nation nationalities and people, Southeast Ethiopia ( Bale) and Modjo town occupation of
women was associated with practice BSE, employed women were more practiced BSE than
housewives (Mohammed, 2020; Assefa, Abera and Geta, 2021; Workineh, 2021). In contrast
to this, no statistical significance of BSE practice with occupation of women, according to
studies by Naglaa Mohammed Abd-Elaziz and colleagues, and at Rapti Sonari rural and at
Rwanda among reproductive age women (Abd-elaziz et al., 2021; Gyawali and Gautam, 2021;
Igiraneza et al., 2021). Even the study conducted among rural women of south India showed
that, housewives practiced BSE than employed women (Rahul Ganavadiya, , Suma S2 ,
Pallavi Singh3 and Poonam Tomar Rana, 2018). Another study conducted among rural women
of reproductive age in Banke district, Nepal, also showed that there was no association
between women`s occupation and practice of BSE (Gyawali and Gautam, 2021).

11
Family history of breast cancer:- The study conducted among rural women of south India
showed that, women with family history of breast cancer or lump practiced BSE than others
(Rahul Ganavadiya, , Suma S2 , Pallavi Singh3 and Poonam Tomar Rana, 2018). As described
by the studies conducted at Urban setting of southern nation nationalities and people, Southeast
Ethiopia ( Bale) and Modjo town positive family history of breast cancer was associated with
practice BSE (Mohammed, 2020; Assefa, Abera and Geta, 2021; Workineh, 2021).
Having children:- having children were shown to be associated with better practice of BSE in
a study of 371 Lebanese women aged 18 to 65 in Beirut (El Asmar et al., 2018). As described
by the studies conducted at Urban setting of southern nation nationalities and people, Southeast
Ethiopia ( Bale) and Modjo town the number of children women had was associated with
practice BSE (Mohammed, 2020; Assefa, Abera and Geta, 2021; Workineh, 2021). But study
conducted among rural women of reproductive age in Banke district, Nepal, also showed that
there was no association between the number of children women had and practice of BSE
(Gyawali and Gautam, 2021).
Knowledge of Breast self-examination: Lack of knowledge, lack of confidence and lack of
awareness were the main reason for not performing breast self-examination (Bashirian et al.,
2019; Assefa, Abera and Geta, 2021; Gyawali and Gautam, 2021; Igiraneza et al., 2021). 1500
women interviewed, among which only 1.9% stated they did breast self-examination on an
occasional basis and the biggest reason why women do not perform breast self-examination is
that they do not know how to conduct it (97.5%) (Anjum, Nawaz and Bibi, 2017). Among 230
women of reproductive age at Rapti Sonari Rural, Banke District, Nepal, only 19.6% have
known about breast self-examination (Gyawali and Gautam, 2021). In India, the study of 56
health care provider indicated that only 34 of them were knowledgeable about breast self-
examination (Ms. Leena Mathew, 2021). The study in University of Sri Jaye wardenepura, Sri
lanka, describe that among 213 last year female students only 36.6% had knowledge on BSE
(Ms. Leena Mathew, 2021).
Of 246 women aged 16–49 years in four Health Centers in the Rwinkwavu catchment area,
South Kayonza District, Rwanda, 20.8% of respondents had lack of understanding of BSE
(Igiraneza et al., 2021). The study performed among 4141 nurses at Asmara hospital, Eritrea,
showed that more than three quarters (80%) knew how to perform BSE (Andegiorgish, Kidane
and Gebrezgi, 2018).

12
Among 420 women of aged 20-49 following family planning service conducted at Mojo town
showed, 30% of respondents were knowledgeable, when compared to their counterparts,
women who knew about breast self-examination had 4.32 times higher odds of practicing
breast self-examination (Workineh, 2021). According to surveys conducted in Jimma town
among 329 participants only 22% of respondents were want to look for lump using tips of their
fingers (Yonas Biratu, Samuel Abdu, 2021). Among 398 female undergraduate summer
students of Gondar University only 22.9% of the students knew how to perform BSE and
inspection 3.6%, palpation 17.5% and both inspection and palpation are the methods of BSE
(Mihret et al., 2021). Of 836 respondents of reproductive age women in Southeast Ethiopia's,
Bale, a community based study, 491 (58.7%) of the survey participants had some
understanding of how BSE is performed (Mohammed, 2020).
From 429 (227 laywomen and 202 screening attendees) Hungarian women 38.8% of
laywomen and 51.2% of screening attendees correctly recognized the recommended age of
first breast self-examination (at age of 20 years) and recommended timing of breast self-
examination (one week following period) was correctly answered in 32.2% of laywomen and
31.8% of screening attendees (Kissné et al., 2021). But among 142 female students in Al-
Bayan University, Iraq, only 14.8% of the participants were knew the timing of breast self-
examination (Saadoon, Al-attar and Alani, 2021).
In Uganda`s Namuwongo zones among 143 women Majority 62 (43.2%) believed that BSE
should be done monthly (SAFIYA, 2017), among 4141 nurses at Asmara hospital, Eritrea,
75.8% of them had awareness on appropriate age(20) to begin breast self-examination,
however, less than half (42%) knew the recommended frequency of BSE (Andegiorgish,
Kidane and Gebrezgi, 2018). About 43.5% of the participants among 398 female
undergraduate summer students of Gondar University considered the age between 20 and 30 to
start BSE (Mihret et al., 2021).
Attitude toward breast self-examination: Among 390 participants of the study in Saud
Arabia only 20 (5.1%) believed that any women is at risk of developing breast cancer and 9.4%
of the participants believe it is preventable while the study conducted by Naglaa Mohammed
Abd-Elaziz, Hany Hassan Kamal and Hanaa Abd-Elhady, at Minina University maternity and
child hospital among 100 reproductive age women showed 86% of the women had positive
attitude toward breast self-examination, among 300 women attending outpatient clinic at
Babcock University teaching hospital reported that 67.7% and 32.3% of the participants had

13
positive and negative attitude regarding breast self-examination respectively (Heena et al.,
2019; Wang et al., 2020; Abd-elaziz et al., 2021).
59.4% of 379 female health professionals working in west shoa hospitals had positive attitude
regarding BSE, while only 14.5% of total participants (634) had positive attitude toward breast
self-examination as revealed by the study of women of age 20-64 years at Arba Minchi zuria
district, and over a third of the 634 participants of the study in SNNP aged 20-64 of urban
setting, 259 (42.5%), showed a positive attitude toward breast cancer screening (Shallo and
Boru, 2019; Mereta and Desalegn, 2020; Assefa, Abera and Geta, 2021). About 283 (67.4%) of
420 women who received family planning services in Mojo town health facilities scored
median or above and had a positive attitude toward BSE, whereas 32.6% had a negative view
toward BSE and women with a positive attitude toward breast self-examination were more
practicing breast self-examination than those with negative attitude (Workineh, 2021).

14
2.5 Conceptual Frameworks
The following conceptual frameworks were taken by reviewing related literatures (Safiya,
2017; Hussen et al., 2019; Shallo and Boru, 2019; Mereta and Desalegn, 2020; Mohammed,
2020; Terfa, Kebede and Akuma, 2020; Ms. Leena Mathew, 2021; Yonas Biratu, Samuel
Abdu, 2021)
Figure 1: Conceptual framework adapted by reviewing different literatures for the study
conducted among reproductive age women of Dire wareda, Borena zone, Ethiopia, 2022
Practice of BSE
Personal factors
 Privacy
 Confidence on BSE
 Attitude toward BSE
 Knowledge of BSE
Socio-demographic
factors
 Age of woman
 Marital status
 Educational status
 Occupation
 Number of
children
 Income
Medical factors
 Family history of BC
 Personal history of
BC
Knowledge of
breast cancer

15
3. OBJECTIVE OF THE STUDY
3.1 General Objective
To assess Knowledge about breast cancer, practice of breast self-examination and associated
factors among rural reproductive age (15-49) women of Dire woreda, Borana zone, 2022
3.2 Specific Objectives
 To determine the magnitude of knowledge of breast cancer among rural reproductive
age women, 2022
 To determine the magnitude of Breast self-examination practice among rural
reproductive age women, 2022
 To identify factors associated with knowledge of breast cancer among rural
reproductive age women, 2022
 To identify factors associated with breast self-examination among rural reproductive
age women, 2022
 To explore barriers toward practice of breast self-examination among reproductive age
women, 2022

16
4. METHODS AND MATERIALS
4.1 Study Area and period
The study was conducted in rural kebeles of Dire woreda from May 18 to June 18, 2022. Dire
woreda is one of the administrative woredas of Borena zone. According to 2019 central
statistical agency population projection, Dire woreda has a total population of 99992 people,
with 50184 males and 49808 females (Central Statistics Agency, 2019). Currently, according
to the woreda`s health office 2014 E.C plan, the woreda has 12086 reproductive age women
and 11378 households(Hays, 2021).
Dire woreda's administrative center is Mega town. It's in the country's south, 100 kilometers
from, Yabelo, the center of borena zone and 668 kilometers from the capital, Addis Ababa, on
the road to Moyale. Dire is bordered on the south by Miyo woreda, on the west by Dillo, on the
north by Dubuluk, on the northeast by Arero, and on the east by Moyale. The woreda has total
of 11 kebeles (10 rural and 1 urban kebele).
4.2 Study design
Community based cross-sectional study design convergent by qualitative study was conducted
to assess knowledge of breast cancer, practice of breast self-examination and associated factors
among rural women of reproductive age in Dire woreda, Borena zone.
4.3 Population
4.3.1 Source population
Quantitative: The source population is all rural reproductive age women of dire woreda.
Qualitative: Women aged from 18-49 who have been living in the study area (rural kebeles)
for at least 6 months were included in the study. The study populations were reproductive age
women who ever have heard, learned or trained about breast cancer and practice of breast self-
examination and not included in the quantitative study were selected for in-depth interview.
4.3.2 Study Population
Eligible reproductive age women (15-49 years), living in the Dire woreda rural kebeles during
study period.
4.3.3 Study unit
Individual woman who gave response

17
4.4 Sample size determination and sampling technique
4.4.1 Sample size determination for quantitative study
For first objective the required sample size was estimated using a single population proportion
formula with a 95 percent confidence interval (CI), a 5% margin of error, and using 56.2
proportion of women who were knowledgeable about breast cancer from Bale zone, Ethiopia
(Hussen et al., 2019).
Table 1: Sample size calculation by single population proportion for the research
Single population proportion for first objective
Variable Proportion Confidence
level
Margin
of
error
Sample
size
10%
nonresponse
rate
Design
effect
Final
sample
size
Reference
Knowledge
of breast
cancer
56.2% 95% 5% 378 38 416x1.5 624 (Hussen
et al.,
2019)
The sample objectives 2, 3 and 4 were calculated by using statcalc function of Epi Info version
7.2.5.0 software, and the maximum calculated sample size has been taken for this study with a
95% confidence interval (CI), a 5% margin of error.

18
Table 2: Sample size calculation by different factors for the research conducted among
reproductive age women of Dire wareda, Borena zone, Ethiopia, 2022
Objectives Variable Proportio
n
COR Calculated
sample size
Reference
2 Practice of BSE 13.2 176 (Mohammed, 2020)
3
Thinking breast
cancer is treatable
20.8 3.65 102 (Hussen et al., 2019)
Information on
breast cancer
26.2 2.4 202 (Hussen et al., 2019)
4
Age(35-49) 31.8 3.44 100 (Mohammed, 2020)
High school and
above educational
level
11.7 5.68 74
(Mohammed, 2020)
By adding design effect (x1.5) and 10% of non- respondent rate, the final sample size was 624,
which was selected from the first objective as it is larger than the sample size for other
objectives.
4.4.2 Sample size determination for qualitative study
A total of 16 women were interviewed, 4 from Dida mega kebele, 3 from soda, 2 from romso,
3 from haralo, 4 from madhecho kebele.
4.4.3 Sampling procedure and Technique
4.4.3.1 Sampling technique for quantitative study
Multistage sampling technique was used to select study participants. There are 10 rural
kebele‟s (kebele is the smallest administrative unit in Ethiopia) in the woreda. First, 5 kebeles
were selected by simple random sampling method. Lists of all eligible women with their
household were identified by using family folder from each kebele`s health post in
collaboration with health extension workers. Sampling frame (list of households) was prepared
for each kebele based on eligible women in the household. Finally, simple random sampling
method was used to select study participants. In case of more than one reproductive age
women in the household, the study participant was selected by lottery method. The sample size
for each selected kebele was proportionally allocated to the number of eligible women in the
household to give equal chance of participation.

19
* kebele: The smallest administrative structure in Ethiopia
Figure 2: Sample size proportionally allocated to selected kebele’s for the study
NB. Unpublished Data taken from Dire woreda health office and Health posts 2014E.C plan
(Hays, 2021).
10 Rural kebele’s of Dire wareda
Haralo
=619
Romso
=312
Dida Mega
=362
Madhecho
=470
Soda
=530
5 kebele(50%of total kebeles) selected by simple random
method
144
168
85
99
128
Proportionally allocated sample size
Number of eligible women with
household (N=2293)
624

20
4.4.3.2 Sampling technique for qualitative study
For the qualitative data, a purposive sampling technique was used to select the study
participants. From each selected kebele, eligible women were interviewed until the saturation
point was reached by ensuring that the participants were not included in the quantitative study.
The study participants for the face-to-face in-depth interview were reproductive age women
who are over 18 years old and living in the area for at least of 6 months and who had
information, education, awareness or training on breast cancer and breast self-examination in
collaboration with health extension workers.
4.5 Data collection tool and personnel
4.5.1 Data collection tool for quantitative study
For the quantitative study, pretested and interviewer-administered electronic data collection
tool, kobo toolbox mobile, device was used. The questionnaires were developed by reviewing
similar articles (Maggie, 2015), American Cancer Society and WHO checklists prepared to
assess knowledge of breast cancer and practice of BSE (Barry, 2018; National and Pillars,
2018; Quality of Life Group, 2018). After an extensive literature search, the various survey
questions were formulated and the questionnaire was divided into seven (7) sections: socio-
demographic characteristics, questions related to wealth index of household, knowledge about
breast cancer, knowledge of BSE, the practice of breast self- examination, attitude toward
BSE, personal and family history of breast cancer. The questionnaires were prepared in
English and had translated into Afaan Oromo, then back to English to ensure the consistency
by language experts.
4.5.2 Data collection tool for qualitative study
For qualitative studies, face-to-face in-depth interviews data was collected by Afaan Oromo by
using semi-structured guide for in-depth interview. The guide were prepared in English by
investigator and translated to Afaan Oromo by language expert and check by advisors for more
clarity. The in-depth interview guide has a list of points such as identification, barriers toward
the knowledge of breast cancer and practice of breast self-examination and with follow up
probes by taking short notes.

21
4.5.3. Data collection procedure for quantitative study
After having list of all eligible women in the household, data were collected using semi-
structured face-to-face interview method. 5 health extension workers and 1 BSc midwife and 1
public health officer as supervisor were recruited for data collection. For women who were not
present during data collection time, re-visit for at least of 3 times were arranged. If a woman
was still unavailable or refused to participate after the third visit, the household was skipped
and the immediately following household in the sample frame was visited.
4.5.4. Data collection procedure for qualitative study
Two females with principal investigator were employed to conduct data collection. Every
interview was conducted at quite space in the selected area and time was convenient for the
participants. During interview each person has his/her own role, one female interviewer, one
facilitator and principal investigator as note taker.
During interview the note was taken and data was recorded via digital recorder (audio
recorder) and each interview took 30-45 minutes.
4.6 Inclusion and exclusión criteria
4.6.1 Inclusion criteria
Eligible reproductive age women who reside in the selected district for at least of 6 months
during data collection period were included for quantitative study.
Reproductive age women from18-49 years that are believed to have information on breast
cancer and practice of breast self-examination were included for face-to-face in-depth
interview purposively for qualitative study.
4.6.2 Exclusion criteria
Respondents unable to respond the questions, due to illness were excluded from the study.

22
4.7 Variables
4.7.1 Dependent variables
 Knowledge of breast cancer
 Practice of breast self-examination
4.7.2 Independent Variables
Socio-demographic factors (Age of women, marital status, educational level, occupation of the
women, number of children, family income), knowledge of breast self-examination, attitude
toward breast self-examination, family and personal history of breast cancer.
4.8 Operational definitions
Regular BSE practice- a woman who perform BSE per month, one week after period
(SAFIYA, 2017; Hussen Et Al., 2019; Lera, 2020).
Practiced of BSE- Performing BSE at least once at any time using any technique in the last 12
months (Lera, 2020).
Occasional BSE- When BSE is 1 to 3 times a year (Dinegde, Demie and Diriba, 2020)
Good knowledge: - A women who scored greater than or equal to average (50%) from
knowledge about breast cancer questions (Dadzi and Adam, 2019).
Poor knowledge - A women who scored below average (50%) from knowledge about breast
cancer questions (Dadzi and Adam, 2019).
Positive attitude- Based on likert scale measurement of the attitude, participants who scored
greater than or equal 50% score from attitude toward BSE questions (Heena et al., 2019; Wang
et al., 2020)
Negative attitude- Based on likert scale measurement of the attitude, participants who scored
below 50% score from attitude toward BSE questions (Heena et al., 2019; Wang et al., 2020)

23
4.9 Data analysis procedures
4.9.1 Data process and analysis for quantitative study
Data exported and downloaded from kobo toolbox through excel and then converted to SPSS
version 25 software package to edit, clean for missing values, and finally for analyses.
Descriptive statistics, like frequencies, proportions, mean and media were used to present data.
Binary logistic regression analysis was carried out to determine the association between
independent variables and dependent variables among the study participants with a 95%
confidence interval. The variables at p-value < 0.25 were candidate for multivariable logistic
regression to control possible confounding effect. Hosmer and Lemeshow were used to test
model goodness of fit and it was well fitted. No multicollinearity between independent
variables seen (VIF found to be <2 for all independent variables). Statistical significance was
declared at p-value of < 0.05 and the indicators of outcome variables were identified
accordingly. Significantly associated variables were reported on adjusted odds ratio (AOR), p-
value and confidence interval. The income and attitude of respondents were analysed by
principal component analysis. The income was classified into three components (low, middle,
high income) and the attitude of participants was classified into two (negative and positive
attitude) after computed. Knowledge of breast cancer was assessed by 6 sets of questions
which include information about breast cancer, sources of information, causes of breast cancer,
risk factors, sign and symptoms of breast cancer, and early detection methods and practice of
breast self-examination was assessed by 8 categorical variables. Each response has categorized
as 1 for correct answer and 0 for incorrect answer and computed for final analysis.
4.9.2 Data process and analysis for qualitative study
Qualitative data was obtained from participants` conversations in afaan orormo and tapes
recordings were transcribed into text by own words of participants and then translated into
English by language experts. Narrative analysis was conducted in congruent with the
respondents` own words under selected themes and summarized manually.
4.10 Data Quality Assurance
4.10.1 Data quality control for Quantitative study
At the questionnaire level
To assure data quality, a data collection tool was prepared after an intensive review of relevant
literature from similar studies. Then the questionnaire was pre-tested on 55 reproductive age

24
women at Dida Jarsa kebele before conducting actual data collection. Internal consistency
among questionnaires items was 0.8 Cronbach`s alpha and considered within acceptable range.
Based on this the pretest was done to evaluate the data collection tool for its validity and
reliability, accuracy of responses, language clarity, appropriateness of the tools and the
necessary amendments was done based on the result before actual data collection has been
started. Data quality was ensured by giving identification number and code to help checking.
At data collection stage
Two days training was given to data collectors and supervisors on the objective of the research,
eligible study participants, data collection tools and procedures, interview method and what to
do if the study participant is not present during data collection time. On every day of data
collection time, the investigator has been communicated with data collectors and supervisors
and some collected data was checked by investigator and any forwarded problem was managed
accordingly.
During data Processing stage
After data has been collected, it was checked for completeness, accuracy, clarity and
consistency by principal investigator and necessary correction was done. After data has been
converted to SPSS, the outliers, missing values and fulfillment of assumption was done
through running descriptive statistics and data cleaning measure was taken before data
analysis.
4.10.2 Data Quality Control for Qualitative study
To ensure the quality of data, the following trustworthiness has been considered.
A. Credibility (related to internal validity)
Credibility depends on how closely the collection, presentation and interpretation of data
match the underpinning philosophy of the research methodology used to answer research
questions. So to maintain credibility of the research findings in-depth interview guideline was
evaluated before data collection. Orientation on the purpose of in-depth interview and
responsibility was given to prevent interruption and keep the rights of participants.

25
B. Transferability (related to generalizability)
Transferability is about providing enough information in accessible language to others answer
questions to transfer other setting. To maintain the transferability of the finding appropriate
probes were used to obtain detailed information on responses. Detailed field notes and audio
recordings were taken for all in-depth interviews.
C. Dependability (related to reliability)
Dependability is making sure the research questions were clear and appropriate to the study
design, ensuring transparency of the researcher`s role and the use of appropriate data
collection. So, to maintain the dependability of the finding of the research process checking
of participant was made by returning the preliminary finding to the participants to correct
errors and challenge what were perceived as wrong interpretation. The interpretation of the
researcher was challenged through discussion of preliminary analysis in group meeting
with data collectors and supervisors.
D. Conformability (related to objectives)
To ensure conformability of the findings in-depth interview guidelines were followed and
the interview were conducted by two females to make the participants freely react to the
interviewed issue.
4.11 Ethical consideration
The study was approved by Ethical Review Board of Salale University and permission letter
was obtained and presented to Dire woreda health office to obtain official permission to
perform research activities in the selected kebeles. The local administrators then introduced the
researcher to kebele leaders. Written informed consent was obtained from every study
participant before data collection and parent permission for those who were under 18 years old.
Respondents were only included in the study after explaining them the purpose of the study
and consent to participate. Those respondents who were not willing to participate in study were
not forced to be involved. The entire information collected from study participants were
handled confidentially. Names or any identification was not used. Data are kept in a password
locked laptop.

26
4.12 Dissemination of the result
The finding of the study was submitted to Salale University, College of health sciences
department of Midwifery and publicly defended following submission. Copies of the finding
will be provided to relevant stake holders including governmental and nongovernmental
organizations working on the area. Efforts will be made to publish the findings on peer
reviewed reputable journal.

27
5. RESULTS AND DISCUSSIONS
5.1 Quantitative part results
5.1.1 Socio-demographic characteristics of Respondents
Out of 624 planned, 611 participants gave complete response, which provides response of rate
of 98%. Regarding respondents‟ characteristics, high proportion 271(44.4%) were age from
25-34 with mean age of 31.61, majority of the respondents (76.8%) were married. Regarding
educational level and occupation, more than half (59.7%) of the participants had no formal
education and 68.1% of them were housewives. Around half (46.6%) of the participants had 3
and above children while 16% never gave birth. (Table 3)

28
Table 3: Distribution of socio-demographic characteristics of respondents on knowledge
of breast cancer, practice of breast self-examination and associated factors among
reproductive age women of Dire woreda, Borena zone, South Ethiopia, 2022 (N=611)
Variable response category N %
Age (years) 15-24
25-34
35-49
109
271
231
17.8
44.4
37.8
Marital status Single
Married
Divorced
Widowed
94
469
37
11
15.4
76.8
6.1
1.8
Educational level No formal education
Can read and write
Elementary(1-8)
High school(9-12)
Diploma and above
364
32
131
61
23
59.7
5.2
21.4
10.0
3.8
Occupation Housewife
Merchant
Government employer
Nongovernment
Employer
Laborer
416
129
39
24
3
68.1
21.1
6.4
3.9
.5
Number of children 1
2
3 and above
Never gave birth
60
168
285
98
9.8
27.5
46.6
16
1.2 Participants` wealth index
Based on principal component analysis result of the family income (wealth index), high
proportion (40.3%) of the respondents had low income, while (25.7%) had high income (Table
4).

29
Table 4: Wealth index classification for the study conducted among reproductive age
women of dire wareda, Borena zone, Ethiopia, 2022
5.1.3 Respondents knowledge of breast cancer (N=611)
Knowledge of breast cancer was assessed by 6 main questions which cover information about
breast cancer, sources of information, causes of breast cancer, risk factors, sign and symptoms
of breast cancer, and early detection methods of breast cancer.
Overall 32.4% 95% (CI: 28.8, 35.8), (SD =1.8) of respondents had good knowledge about
breast cancer, while 67.4%, 95 %( 64.2, 71.2) had poor knowledge about breast cancer. Among
respondents, 199(32.6%) knew (heard or read) about breast cancer and their major sources of
information were healthcare providers 79(39.7%), peer/family 61(30.6%), the media (radio or
TV) 37(18.6%) and books and magazines 22(11.1%). Among women who had information on
breast cancer (199), majority of them 112(56.3%) didn`t knew the causes of breast cancer
while 43.7 % of them were knew at least one cause of breast cancer and 164(84.4%) of
respondents were knew at least one risk factor for breast cancer from which majority of the
participants 76(62.3%) considered family history of breast cancer as the risk factor for breast
cancer. Among 199 respondents 180(90.5%) of them knew at least one sign and symptom of
breast cancer and, breast lump and ulceration were reported by 143 of the respondents as the
sign and symptom of breast cancer. Among respondents who ever heard about breast cancer,
106(53.3%) responded mammography as the means of early detection method of breast cancer
and 18(9%) of them knew BSE as early detection method of breast cancer. (Table 5)
Classification n %
Low income 246 40.3
Middle income 208 34.0
High income 157 25.7
Total 611 100.0

30
Table 5: Knowledge of breast cancer among reproductive age women of Dire woreda,
Borena zone, Ethiopia, 2022
Variable response category (Questions)
Women heard about breast cancer?(N=611)
Yes
No
N
199
412
%
32.6
67.4
Women`s source of information about breast cancer (n=199)
Books and magazines
The media (TV, radio)
Peers/family
Health care provider
22
37
61
79
11.1
18.6
30.6
39.7
Women know the causes of breast cancer(n=199)**
No
Yes
Contact with a variety of chemicals/carcinogens
The use of oral contraceptives for a long time and at a young age
X-ray exposure prior to the age of 30 years
Estrogen replacement therapy
Other causes (inherited)
112
87
56
17
38
4
1
56.3
43.7
64.4
19.5
43.7
4.6
1.1
Women know the risk factors for breast cancer(n=199)**
No
Yes
Breast cancer in the family
Diet and diet related factors such as obesity
Smoking
Alcohol consumption
Lack of exercise
35
164
76
10
34
30
14
15.6
84.4
46.3
6.1
20.7
18.3
8.5
Women know symptoms and signs of breast cancer?(n=199)**
No
Yes
Breast lump and ulceration
Breast discharge
Breast pain or soreness
Breast change in size and shape
19
180
143
110
84
24
9.5
90.5
79.4
61.1
46.7
13.3
Women know the approaches used to detect breast cancer at early
stage?(n=199)**
No
Yes
Mammography
Breast self-examination
Clinical breast examination by healthcare provider
4
195
106
18
75
2
98
53.3
9.0
37.7
Note: **- indicates the presence of multiple responses

31
Figure 3: Respondents Breast cancer knowledge level among reproductive age women of
Dire woreda, Borena zone, South Ethiopia, 2022 (N=611)
5.1.4 Respondents knowledge of breast self-examination
From total respondents only 122(20%) had ever heard about breast self- examination and
health personals were the main source of information 83(68%), and regarding the methods of
breast self-examination, 117(96%) were knew at least one method of breast-self-examination.
Regarding the techniques of breast self-examination, 118(97%) knew at least one technique of
breast self-examination, in which circular technique is reported by 99 respondents. 119
(97.5%) of respondents who have ever heard about BSE know the reason to perform breast
self-examination, 71 of them thought the main reason to perform breast self-examination were
to know how breast feel and look normally. Overall, only 115(18.8 %) 95 %( CI: 15.5, 21.9),
SD 1.6 of the respondents had adequate knowledge about breast self-examination, while
496(81.2%), 95 %( 78, 84.3) had inadequate knowledge. (Table 6)
32%
68%
Good knoweldge Poor knowledge

32
Table 6: Knowledge of breast self-examination among reproductive age women of Dire
woreda, Borena zone, South Ethiopia, 2022
Variables N %
Women heard about breast self-examination (n=611)
No
Yes
489
122
80
20
Source of information about BSE(n=122)
Through education
Health personnel
Mass media( TV, Radio)
21
83
18
17.2
68
14.7
Women know the age at which BSE should be started is 20 years old
(n=122)
No
Yes
4
98
3.3
96.7
Women know how to do BSE(N=122)**
No
Yes
Looking breast in the mirror
Feeling the breast using finger pads
Squeezing each nipple
5
117
107
62
38
4
96
91.4
53
32.5
Women know the techniques used during BSE(n=122)**
No
Yes
Vertical strip technique
Circular technique
Wedge technique
4
118
72
99
22
3
97
61
84
18.6
Women know what should looked for while performing
BSE(n=122)**
No
Yes
Change on color of skin
Shape and site of breast and feeling for lumps(mass)
Directions of nipple and discharge from nipple
3
119
54
94
62
2.5
97.5
45.4
79
52
Women know the reason to perform BSE(n=122)**
No
Yes
For early discovery and treatment of breast lump
To know how my breast feel and look normally
To detect cancer in the breast
3
119
50
71
26
2.5
97.5
42
59.7
22
The recommended timing of BSE is a week after period9n=122)
No
Yes
39
83
32
68
Women know how often BSE should be performed(n=122)
No
Yes
Regularly each month or more often
Occasionally( 1 times a year or every 3 months)
30
92
54
38
24.6
75.4
58.7
41.3

33
Other( any time) 2 2.2
Table 6(Continued)
Women know the advantages of BSE(n=122)**
No
Yes
It is cheap and non-invasive
It is private and can be done at home
It is safe and free
122
50
60
45
100
41
49
37
Women know what should do if something abnormal found on their
breast(n=611)
No
Yes
Immediately contact healthcare provider
Consulting relatives
Go to traditional healer
489
122
115
1
6
80
20
94.3
0.8
4.9
The age at which BSE should be started is at 20 year old(n=122)
No
Yes
94
28
77
33
BSE is useful tool for early detection of breast cancer(n=122)
No
Yes
5
117
4
96
Note: **- indicate the presence of multiple response
5.1.5 Findings on attitude toward breast self-examination
The results from respondents` attitudes toward breast self-examination were measured by using
a likert scale of 1-5. This was presented as 1=strongly disagree (SD), 2= disagree (D),
3=neutral (NS) 4=agree (A) and 5=strongly agree (SA). (Table 7)

34
Table 7: Attitude toward breast self-examination among reproductive age women of Dire
woreda, Borena zone, Ethiopia, 2022 (N=611)
Attitudes toward breast
self-examination
SD D NS A SA
1 2 3 4 5
Any woman is at risk for
breast cancer 76(12.4%) 260(42.6%) 89(14.6%) 150(24.5%) 36(5.9%)
Breast cancer can be
prevented 44(7.2%) 265(43.4%) 107(17.5%) 172(28.2) 23(3.8%)
If I examine my breast
by myself, I cannot
detect abnormalities in
my breast
56(9.2%) 203(33.2%) 121(19.8) 218(35.7%) 13(2.1%)
There is no reason to
examine my breasts 50(8.2%) 212(34.7%) 83(13.6) 254(41.6%) 12((2%)
If I know the benefit of
breast self-examination, I
would have do it by now
29(4.7%) 76(12.4%) 57(9.3%) 296(48.4%) 153(25%)
Early detection methods
have no effect on
treatment
108(17.7%) 285(46.6%) 93(15.2%) 112(18.3%) 13(2.1%)
By early diagnosis of
breast cancer, the person
will have prolonged life.
37(6.1%) 144(23.6%) 95(15.5) 260(42.6%) 75(12.3)
Overall, among the respondents 320(52.4%), 95 % (CI: 48.3, 56.3), (SD =2) had negative
attitude toward breast self-examination, while 291 (47.6%), 95 %( CI: 43.7, 51.7), (SD=2) had
positive attitude
5.1.6 Respondents` personal and family history of breast cancer
Of the participants, 17(2.8%) had a family history of breast cancer while 2(0.3%) had a
personal history of breast cancer, and 123(20.1%) believe that any women can develop breast
cancer.

35
5.1.7 Participants` practice of breast self-examination
Among total respondents only, 30(4.9%) 95% (CI: 3.1, 6.7) had practiced breast self-
examination in the Dire woreda Borena zone, among which 22(73.3%) practiced occasionally,
8 (26.7%) on regular basis (each month or often), 23(76.7%) had performed a week after
period, 26(86.7%) inspected their breast in the mirror. From respondents who had practiced
breast self-examination 15(50%) looked for shape and site of breast feeling for lump (mass).
Lack of knowledge and lack of confidence were the main reasons why the respondents didn`t
practice breast self-examination 362 (62.3%) and 99(17%) respectively.

36
Table 8: Practice of breast self-examination among reproductive age women of Dire
woreda, Borena zone, Ethiopia, 2022
Variables N %
Performed breast self-examination(within last 12 months)
(n=611)
Yes
No
30
581
4.9
95.1
Frequency of breast self-examination performed=30)
Regularly each month or more often
Occasionally
8
22
26.7
73.3
Breast self-examination performed a week after
period(n=30)
No
Yes
7
23
23.3
76.7
Technique used during examination (n=30)
Inspecting the breast in the mirror
Feeling the breast with the hand
26
4
86.7
13.3
Looking for while performing breast self-examination
(n=30)
Change on the color of the skin
Shape and site of breast and feeling for lumps (mass)
Direction of nipples and discharge from nipple
The entire above
3
15
7
5
10
50
23.3
16.7
Possible reason not practicing breast-self-examination
(n=581)
Lack of confidence
Fear of detecting something abnormal
Examining breast is not acceptable
Lack of privacy
Lack of knowledge
99
61
4
55
362
17
10.5
0.7
9.5
62.3

37
Figure 4: Practice of breast self-examination among reproductive age women of Dire
woreda Borena zone, Ethiopia, 2022
5.1.8 Logistic regression analysis of factors associated toward knowledge of breast cancer
The associations of factors such as family income, marital status of women, educational level
of women, occupation of women, age of women, and family and personal history of breast
cancer of the respondents with knowledge of breast cancer were investigated by using binary
logistic regression analysis. Those variables having a p-value of 0.25 were candidates for
multivariable logistic regression analysis. These include the age of respondents, family income,
marital status of women, occupation of women, women‟s educational level, and family history
of breast cancer. Finally, variables, including high family income, educational level of women,
occupation of women, and age of women, were significantly associated with the knowledge of
breast cancer.
Women who had high family income were 3 times more likely to know about breast cancer
than those who had a low income, AOR = 3.37, 95% (CI: 1.91, 5.95). Women who learned in
high school and above were 3 times more likely to know about breast cancer than those who
had no formal education, AOR = 3.54, 95%(CI: 1.96, 6.37). Women aged 25-34 were six times
more likely than women aged 15-24 to know about breast cancer; AOR = 6.12, 95% (CI: 2.85,
13.14). Similarly, employed women were 2 times more likely to know about breast cancer than
housewives, AOR = 2.12, 95 % (CI: 1.11, 4.06). (Table 9 & 10)
Perfomed BSE
5%
Not performed BSE
95%

38
Table 9: Bivariable logistic regression analysis of the knowledge of breast cancer among
reproductive age women of Dire wareda, Borena zone, Ethiopia, 2022
Variable Category
Knowledge of breast
cancer
Poor
knowledge
Good
knowledge
P-
value
COR 95%(CI)
Family income
Low income
Middle income
High income
188
143
82
58
65
75
1
0.068
0.000
1.47(0.97, 2.23)
2.96 (2.3, 5.6)
Marital status of
women
Single
Married
Separated
72
317
24
22
152
24
1
0.086
0.002
1.56(0.93, 2.62)
3.27(1.56, 6.86)
Education of
women
No formal
education
Elementary school
High school and
above
279
88
46
117
43
38
1
0.47
0.006
1.16(0.76,1.78)
1.96(1.21,3.18)
Women`s
occupation
Housewife
Merchant
Employed
290
88
35
126
44
28
1
0.51
0.026
1.15(0.75,1.74)
1.84(1.07,3.15)
Women`s age 15-24
25-34
35-49
95
183
135
14
88
96
1
0.000
0.000
3.26(1.76, 6.04)
4.82(2.59, 8.98)
Family history
Of breast cancer
No
Yes
405
8
189
9
1
0.075 2.41(0.91, 6.34)
COR-Crude Odds Ratio, CI; Confidence Interval, 1: Indicates reference category

39
Table 10: Multivariable logistic regression analysis of the factors associated toward
knowledge of breast cancer among reproductive age women of Dire wareda, Borena,
Ethiopia 2022
Variables Category
Knowledge of breast
cancer
Poor Good P-value AOR95%(CI)
Family income
Low Income
Middle income
High income
188
143
82
58
65
75
1
0.038
0.000
1.71(1.03, 2.86)
3.37(1.91, 5.95)
Marital status
of women
Single
Married
Separated
72
317
24
22
152
24
1
0.286
0.705
0.68(0.34, 1.36)
1.19(0.48, 2.93)
Educational
level of women
No formal education
Elementary
High school and
above
279
88
46
117
43
38
1
0.038
0.000
1.70(1.02, 2.82)
3.54(1.96, 6.37)
Occupation of
women
Housewife
Merchant
Employed
290
88
35
126
44
28
1
0.247
0.023
1.32(0.82, 2.12)
2.12(1.11, 4.06)
Women`s age 15-24
25-34
35-49
95
183
135
14
88
96
1
0.000
0.000
6.12(2.85, 13.14)
5.93(2.75, 12.78)
Family history
of breast
cancer
No
Yes
405
8
189
9
1
0.299 1.83(0.58,5.73)
AOR: Adjusted Odds Ratio, CI: Confidence Interval, 1: Indicates reference category

40
5.1.9 Logistic regression analysis of factors associated toward practice of breast self-
examination
The association of different background factors of the respondents` with practice of breast self-
examination was investigated by using binary logistic regression analysis. Variables such as
attitude of respondents toward BSE, age of participants, income, marital status of women,
occupation, educational level, personal history of breast cancer, family history of breast cancer,
number of children of respondents and knowledge of breast self-examination were analyzed
under binary logistic regression. Variables with p-value <0.25 were candidate for multivariable
logistic regression to control confounding effect among variables. These include attitude
toward BSE, educational level, occupation, knowledge of BSE and income of the respondents.
Finally, only two variables namely educational level and occupation were statistically
significant with practice of breast self-examination. However, there was no observed
association between practice of breast self-examination and attitude toward BSE, marital
status, knowledge of breast self-examination, age, and a number of children the women had
personal and family history of breast cancer.
Women who learnt high school and above were 2 times more likely to practice breast self-
examination than women who had no formal education AOR= 2.91(95%CI: 1.09, 7.79).
Employed women were 3 times more likely to practice breast self-examination than
housewives, AOR=3.2 (95%CI: 1.27, 8.99). (Table 11&12)

41
Table 11: Bivariable logistic regression analysis of practice of breast self-examination
among reproductive age women of Dire wareda, Borena zone, Ethiopia, 2022
Practice of BSE
Variable Category No Yes P-value COR 95%(CI)
Attitude toward BSE Negative
Positive
313
268
7
23
1
0.002 3.83(1.62, 9.08)
Family income Low income
Middle income
High income
241
195
145
5
13
12
1
0.029
0.011
3.21(1.12, 9.16)
3.98(1.37, 11.55)
Knowledge of BSE Inadequate
Adequate
481
100
15
15
1
0.000 4.81(2.27, 10.15)
Educational level of
women
No formal
education
Elementary
High school and
above
383
123
75
13
8
9
1
0.158
0.005
1.91(0.77, 4.73)
3.53(1.45, 8.56)
Occupation of
women
Housewife
Merchant
Employed
401
125
55
15
7
8
1
0.39
0.003
1.49(0.59, 3.75)
3.88(1.57, 9.59)

42
Table 12: Multivariable logistic regression analysis of the practice of breast self-
examination among reproductive age women of Dire wareda, Borena zone, Ethiopia,
2022
Practice of BSE
Variable Category No Yes P-value AOR 95%(CI)
Attitude Negative
Positive
313
268
7
23
1
0.10 2.4(0,82, 7.02)
Income Low income
Middle income
High income
241
195
145
5
13
12
1
0.047
0.2
3.35(1.0, 11.0)
2.43(0.61, 9.55)
Knowledge of
BSE
Inadequate
Adequate
481
100
15
15
1
0.2 1.8(0.72, 4.58)
Educational level No formal
education
Elementary
High school and
above
383
123
75
13
8
9
1
0.077
0.033
2.49(0.90, 6.80)
2.91(1.09, 7.79)
Occupation Housewife
Merchant
Employed
401
125
55
15
7
8
1
0.43
0.024
1.48(0.55, 3.97)
3.2(1.27, 8.99)
Note: BSE-Breast Self-examination, AOR-Adjusted Odds ratio, CI-Confidence Interval,
1- indicates the reference category

43
5.2 Qualitative Research findings Section
Description of Participants
All participants who involved in the in-depth interview were women who had information on
breast cancer and breast self-examination, including community leaders who had previously
trained on breast self-examination, health extension workers, member of kebele`s women
association and women health professionals. A total of 16 women were interviewed for this
qualitative section study. The ages of participants were ranged from 23-37 years and their
educational level is different, 8 women have no formal education, 5 women have diploma and
3 of them have university degree. The saturation of the idea was reached on 12th
respondent.

44
Table 13: Themes and sub-themes emanating In-depth interview about practice of BSE
among women of reproductive age in Dire woreda, Borena zone, Ethiopia, 2022.
S.N Main theme Sub-themes
1 Aware of BSE Practice Thinking performing BSE is important
Information about breast self-examination
The right technique and position to perform BSE
2 Challenges and barriers
encountered in the practice of
BSE
Lack of awareness about breast cancer
Lack of awareness about BSE
Limited knowledge about the best time to perform BSE
Does it relate to knowing how to do it, and write time to
practice?
Unable to seek treatment if the disease is not severed
Opportunities to over-come challenges

45
Theme 1: Practice of breast self-examination
The overall practice of breast self-examination by the respondents is low. Even if the women
have been heard about practice of breast self-examination, they don`t practices it, because they
don`t know how to perform BSE, timing of BSE, frequency of BSE and the right age to start
BSE.
A 25-year-old housewife stated... "I trained breast self-examination at a zonal level many
years ago, and I have used to practicing it by looking in the mirror while I have a shower,
sometimes when I feed my child, I palpate a hard mass with my hand, my breast should be soft
and relaxed, it is expected of healthcare workers to teach women how to practice breast self-
examination over time, training women at an appropriate time of breast self-examination, if I
examine my breast and I can detect something abnormal, I would seek treatment before it
reaches the dangerous stage."
A 28-year-old health extension worker showed… "I used to do breast self-examination every
month, and I also teach women how to do breast self-examination and breast self-examination
when they come to our health post; it is a useful tool for detecting breast abnormality at an
early stage, as much as possible, all women should perform breast self-examination every
month."
Another 28-year-old civil servant stated..."I have been performing breast self-examination
monthly or when I feel discomfort in my breast by palpating with my hand, sometimes looking
in the mirror, I think it is a good method to check breast health at home and it has no cost."
In addition, a 29-year-old housewife, a member of Kebeles Women's Association, stated... "I
have heard breast self-examination from health extension workers, it should be performed
monthly by looking in the mirror, women should also examine their breasts during pregnancy
and when they visit healthcare facilities for family planning, I didn`t practice breast self-
examination regularly, but sometimes I look for a mass, it should be removed."
Another 25-year-old merchant stated: "I have heard about breast self-examination from my
neighbor, I didn't practice it, because I am busy, when I go to market I will come home at night
time, I think it should be performed during pregnancy, it is important to perform breast self-
examination for early detection of cancer and seek treatment at a health center or hospital."

46
Also, a 27-year-old merchant stated... "I didn't practice breast self-examination, I don't have
time, I don't know if it should be performed every month, but I think it is performed to check
breast health, breast cancer can appear; I will go to a health care facility if any problem
arises in my breast, I cannot differentiate abnormality in my breast."

47
Theme 2: Challenges and barriers encountered in the practice of BSE
As confirmed from the interview of the participants, Lack of information about breast cancer
and breast self-examination, lack of health education by health workers, unable to know the
timing of breast self-examination are the main reason why many women didn`t practice breast
self-examination. Some women also stated the reason not to practice breast self- examination is
age. They think breast cancer doesn`t appeared at young age.
"Breast cancer appears in women over 40 years old, so I don't think it appears at a young
age," said a 26-year-old health extension worker. "Health workers should counsel the women
on the presence of treatment options and how to practice breast self-examination when they
seek healthcare facilities for different services."
A 37-year-old housewife stated: "I don't think the importance of breast self-examination as
early detection of breast cancer, women developed breast cancer as a result of their sin,
`abaarsa rabbitiin`, it is from supernatural; no one can prevent breast cancer, if I feel a
problem in my breast, I will go to `Cidheessa Booranaa` which means Borana traditional
healer."
In addition, a 25-year-old housewife stated: "I do not have enough information about breast
cancer, I go to a health facility only if there is a problem with my health, don`t know about
breast self-examination and the right time of breast self-examination. I think it is important to
perform breast self-examination; I will perform it if I know the techniques of breast self-
examination to know the health of my breast, government and other concerned bodies should
teach and work on creating awareness for women on breast self-examination."
Another housewife stated: "Breast cancer is a dangerous disease if not treated at an early
stage, it has no medicine, and it is deadly disease, it appears on females, there is something
hard like a gland in the breast if cancer developed in the breast, I don`t know the presence of
medical treatment and screening methods of breast cancer, once cancer appear on the human
body there is no chance to survive, my grandmother has died of breast cancer a years ago
after she had treated by a traditional healer, a years ago I have trained breast self-
examination techniques but now I have forgot the method of breast self-examination."

48
5.3 DISCUSSIONS
The primary aim of this community-based study was to measure the magnitude of knowledge
of breast cancer, the magnitude of breast self-examination practice, and to identify associated
factors among rural reproductive age women of dire woreda, 2022. The knowledge of breast
cancer among rural reproductive women was poor and the practice of breast self-examination
was also low as compared to other studies.
This study identified that 32.4% of the women had good knowledge about breast cancer, which
is higher than the studies conducted at Pakistan (15.1%) and Nigeria (9.5%) (Anjum, Nawaz
and Bibi, 2017; Akpo, 2021). The variations were may be due to the difference in study
population. The studies in above researches were performed on the young high school student,
at teenage age many women are not familiar with their developing breast and had no concern
about their breast health. But this finding was found lower as compared to the studies
conducted at India (2 studies, 81.7% and 59.33%), Saud Arabia (48.7%), Labenese (55 plus or
minus 17.1%), Ghana (65%), Sudan(56.2%) and Ethiopia(56%) (El Asmar et al., 2018; Hussen
et al., 2019; Ahmed Mohamed et al., 2020; Allohaibi et al., 2020; Abo Al-Shiekh, Ibrahim and
Alajerami, 2021; Heroor et al., 2021; Omotoso et al., 2021). The difference in these studies
may be because of many studies performed on healthcare workers, educated women those who
have enough information facilities than this study area since the study is performed at
pastoralist area (rural) where the source of information about the cancer is limited, no enough
health facilities to teach women about cancer and seek treatment and also due to the difference
in study period and many studies were performed at urban setting.
In this study, the main source of information about breast cancer for respondents was
healthcare providers accounting about 39.7%. This was consistent with the conducted at
Nigeria (81.6%) (Akpo, 2021). But the finding was inconsistent with the study conducted in
Bangladesh and Malaysia in which the main source of information about breast cancer was
electronic media 74.54% and 86.1% respectively (Sultana Tithi et al., 2018; Paruchuri et al.,
2021). The similarities and differences in the above studies could be attributed to the fact that
in developing countries like Ethiopia, there is a lack of access to electronic media that
disseminates information to rural communities, whereas respondents in other countries were
educated and had access to a variety of media (Balamurugan, 2018). The use of electronic
media for awareness creation among governments may also be different (Balamurugan, 2018).

49
The study discovered that factors such as the age of women between the ages of 25 and 34, a
high educational level, and a high income were statistically associated with knowledge of
breast cancer. Women aged 25-34 knew more about breast cancer than women aged 15–24.
This finding was consistent with the study conducted in Bidura district, Zimbabwe, and in
Jimma town (Vahabi, 2021; Yonas Biratu, Samuel Abdu, 2021). This indicates that, the
women gave concern to their breast during these ages, due to the fact that at these ages, women
are paying attention to their breast health as a result of increased contact with health
professionals to care for their reproductive health. Also, many women start reproductive
activity and become mature enough to think about their reproductive health at this age
category. In contrast, a study conducted in Ghana and among young women in the United Arab
Emirates found no significant relationship between women's age and knowledge of breast
cancer (Younis et al., 2016; Dadzi and Adam, 2019). The discrepancy might be due to the
difference in study population since the two studies were conducted among only younger
women, at which age the women showed less concern for their reproductive health, and this
study was conducted among reproductive-age women, who may visit health facilities for
different health issues and get information and health education from health care professionals.
Women who learned high school and above were more likely to knew breast cancer than those
who had no formal education. This finding was similar with the studies conducted at Lebanese,
Egypt, and Ethiopia (at Jimma town) which reported that higher education was associated to
higher knowledge of breast cancer (El Asmar et al., 2018; Elsayed Atwa, Hassan and Ahmed,
2019; Yonas Biratu, Samuel Abdu, 2021). The similarities might be due to the fact that women
may get knowledge about breast cancer through education, or educated mothers have a greater
awareness of their health and access to information. They may get information from reading
materials. Women who had a high income were more likely to know breast cancer than those
who had a low income. This finding was consistent with the study conducted at Bale Zone,
which stated that mothers with higher income had knowledge of breast cancer than their
counterparts (Hussen et al., 2019). This implies that women who have a high income have
access to information than women with a low income. In fact, many women get information
about breast cancer from healthcare providers, it indicates women with higher income were
more likely to seek healthcare services than women with lower incomes (Bustreo, 2015).
Employed women were more likely to know about breast cancer than housewives. This finding
agrees with the studies conducted at Jimma town; employed women were more knowledgeable

50
about breast cancer than housewife women (Yonas Biratu, Samuel Abdu, 2021). The
similarities might be due to the fact that many employed women were educated and had access
to information (Nowakowska-Głab and Maniecka-Bryła, 2011).
This study also identified that only 4.9% of women were ever practiced breast self-
examination. This result was in line with the study conducted at Sudan (5.5%) (Ahmed
Mohamed et al., 2020). The similarities might be due the similarity in study population where
both studies were conducted among reproductive age women. This finding was higher than the
study conducted at Pakistan in which the magnitude of practice of BSE was 1.9% (Anjum,
Nawaz and Bibi, 2017). The difference might be due to the fact that training has been given at
study area and extension health worker also teaches women while they visit health facility.
This is supported by qualitative part of the study, many interviewees responded as they had
trained breast self-examination at zonal level years ago even if it was not enough. But the
result of this study was lower than the studies conducted at Bangladesh (13.13%), Pakistan
(33.1%), Saudi Arabia (74.7%), India (30.3%), Ethiopia (Jimma, 15%, Bale, 13.2% Modjo
20.5% and Arba Minch, 21.3% ) (Sultana Tithi et al., 2018; Heena et al., 2019; Ahmed
Mohamed et al., 2020; Mereta and Desalegn, 2020; Mohammed, 2020; Terfa, Kebede and
Akuma, 2020; Omotoso et al., 2021; Workineh, 2021). The discrepancies were might be due to
the difference in population as many of these studies conducted among female healthcare
workers, female health science students, at urban communities, the difference in study area and
approach and this study included participants only from pastoralist rural area where many
infrastructure and access to health facility is low.
According to this study, women with higher educational levels and employed women were the
statistically significant variables with the practice of breast self-examination. As the
educational level of women increases, so does the practice of breast self-examination. Women
who have high school and above educational level were more likely to practice breast self-
examination than those who have no formal education. This was supported by the qualitative
study, women who had a higher educational level had more practiced BSE than those who had
no formal education and had access to information about breast self-examination; they could
read and write and could practice breast self-examination techniques and methods repeatedly
(Lawrence, 2019). This finding was in agreement with the study conducted in Lebanon, India,
Iraq, Uganda, Nigeria, and Ethiopia(Bale) (SAFIYA, 2017; El Asmar et al., 2018; Rahul
Ganavadiya, , Suma S2 , Pallavi Singh3 and Poonam Tomar Rana, 2018; Heena et al., 2019;

Knowledge of breast cancer and practice of breast self-exam among rural Ethiopian women

Knowledge of breast cancer and practice of breast self-exam among rural Ethiopian women

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Knowledge of breast cancer and practice of breast self-exam among rural Ethiopian women