literature review on breast self examination

• Open access
• Published: 14 May 2022

Knowledge, attitude, practice towards breast self-examination and associated factors among women in Gondar town, Northwest Ethiopia, 2021: a community-based study

• Kibret Asmare 1 ,
• Yeneabat Birhanu 1 &
• Zerko Wako 2  

BMC Women's Health volume  22 , Article number:  174 ( 2022 ) Cite this article

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Introduction

Breast cancer is the most common type of cancer among women, particularly in low and middle-income countries. Breast self-examination is one of the non-invasive methods of screening in which a woman looks at her breast for any abnormal findings like lumps, distortions, or swellings. Despite, realized effects of breast self-examination in detecting breast cancer earlier, the vast majority of the cases still present with an advanced stage.

This study aimed to assess knowledge, attitude, and practices toward breast self-examination and associated factors among women in Gondar Town, Northwest Ethiopia, 2021.

A community-based cross-sectional study was conducted on women living in Gondar town. A simple random sampling method was used to select 571 participants. Interviewer administered questionnaires were used for data collection. Data was entered into Epi-data version 4.6 and exported to Statistical Package for Social Science (SPSS) version 25 for analysis. Multivariate logistic regression was used where a p -value < 0.05 was used to identify variables significantly associated with the outcome variable.

From the total of 571 women, about 541 participants were involved in the study with a response rate of 94.7%. Of these, 56%, 46% and 45.8% of women had adequate knowledge, favourable attitudes, and performed breast self-examination (BSE) respectively. Women College and above AOR: 3.8 (95% CI: 1.43–10.14) and spouses College and above AOR: 3.03 (95% CI: 1.04–8.84), Women College and above AOR: 4.18 (95% CI: 1.59–10.92) and history of breast cancer AOR: 6.06 (95% CI: 2.19–16.74) and knowledge level AOR: 2.67 (95% CI: 1.18–6.04) were significantly associated with knowledge, attitudes, and practices towards breast self-examination respectively.

The findings of this study were considerable for inadequate knowledge, unfavourable attitude and poor practice towards BSE among women. Emphasis should be made on boosting the knowledge, attitude, and practice of the women toward breast self-examination and strengthening the implementation of comprehensive, systematic, and continuous BSE educational programs that were recommended along with a breast cancer awareness campaign.

Peer Review reports

Breast cancer is a type of malignant tumor that starts in the cells of the breast and commonly occurs in women [ 1 ]. This abnormal cell could destroy healthy tissue and then, spread beyond its usual boundaries [ 2 ]. Non-communicable diseases (NCD) including breast cancer considered not prevented, which is a noticeable common false perception of the community but it is a preventable cause of morbidity, disability, and mortality [ 3 ]. The most common risk factors of breast cancer are being a woman and getting ≥ 50 years old, having dense breasts, having a family history of breast cancer, early menstruation, and late menopause, late pregnancy, being on birth control pills, race, atypical hyperplasia of the breast, and previous treatment using radiation therapy [ 4 , 5 ]. Lifestyle factors are obesity, lower amounts of physical activity, alcohol, and foods like high fats and low fiber diets [ 5 ]. Evidence suggested that; getting regular physical activity, staying at a healthy weight, limiting the amount of alcohol drink, avoiding the use of postmenopausal hormone therapy, breastfeeding, eating more fruits, vegetables, and fewer animal fats is linked with many health benefits and lower the risk of breast cancer [ 5 ]. Besides, it not only affect the breast tissue, but also spread to other part of the body organs like liver and lungs [ 6 , 7 ].

According to global cancer statistics; breast cancer accounts for about 25% and 15% of total incidence and death respectively [ 8 , 9 ]. In American an average risk of a woman of developing a breast cancer was 13% which is equivalent to one in every eight women had a chance of developing in their life time [ 10 ]. It is an important public health issues, not only in the developed world but also in resource limited nations [ 11 ]. It is the most frequent cause of death among women and estimated that 70% of all breast cancer cases worldwide were reported in low and middle-resource countries [ 12 ]. The incidence of breast cancer accounts for 22.6% of all cases of cancer in Ethiopia [ 13 ]. Breast self-examination (BSE) is one of the non-invasive methods of screening in which a woman looks at her breast for any abnormal findings like lumps, distortions, discharges or swellings with an intention to detect it early for early initiation of treatment and better chance of survival for breast cancer patients [ 14 , 15 ].

Knowledge, attitude and practice of BSE have been reported in different countries. In regards to BSE knowledge 22.7% in Vietnam [ 16 ], 63.8% in Turkey [ 17 ], 41.5% in Libya [ 18 ], 34% in Sudan [ 19 ], 78% in Cameroon [ 20 ], 25.6% in Addis Ababa [ 21 ], 34.2% in Arba Minch [ 22 ], 43.1% in Jima [ 23 ], and 55.5% in Adwa town [ 24 ] had an adequate knowledge about breast self-examination. As per women’s attitude 64.01% in Saudi Arabia [ 25 ], 87.2% in Pakistan [ 26 ], 74.9% in Libya [ 18 ], 53.4% in Addis Ababa [ 21 ], and 46.3% in Adwa town [ 24 ] had a favorable attitude towards BSE. Considering practice towards BSE 43% in Saudi Arabia [ 27 ], 24.9% in Pakistan[ 26 ], 21% in Oman [ 28 ], 15.8% in Vietnam [ 16 ], 8.5% in turkey [ 17 ], 37.6% in Ghana [ 29 ], 38.5% in Cameroon [ 30 ], 39.2% in Egypt [ 31 ], 12.1% in Libya [ 18 ], 20.6% in Sudan [ 19 ], 13.3% in Arba Minch [ 32 ], and 18.6% in Addis Ababa [ 33 ] had a good practice of breast self-examination.

Factors affecting knowledge of the BSE were reported from the different countries. These are age, marital status, level of education, information of BSE, medical background, access to internet, source of information, and level of income. However, only the education levels and medical background for attitude towards BSE [ 16 , 18 , 26 , 31 , 33 , 34 ]. Practice factors are almost similar to that of knowledge other than health education on breast cancer, knowing BSE techniques, occupation, and family history of breast cancer were related to women’s knowledge, attitude and practice towards BSE [ 16 , 18 , 33 , 34 , 35 , 36 , 37 , 38 ].

BSE is the only feasible approach that is cheap and easily applied method across wide population. Its ultimate purpose is early detection and treatment. Despite, its importance as an early detection strategy, poor knowledge of women has been a major obstacle. So, amplifying women’s knowledge, attitude, and practice towards BSE through creating breast cancer awareness campaign [ 39 , 40 , 41 , 42 , 43 ].

In our study area, there is a lack of evidence on women’s knowledge, attitude, and practice towards breast self-examination (BSE). Therefore, this study was aimed at assessing women’s knowledge, attitude, and practice on breast self-examination and thereby generates appropriate information that can be used by the central Gondar zonal health office and non-governmental organizations in the prevention and interventions of breast cancer.

Methods and materials

Study design, and period.

A community-based cross-sectional study was conducted from April to May 2021.

Study setting

The study was conducted at Gondar Town, Northwest Ethiopia. Gondar Town is located 748 km from Addis Ababa the capital city of Ethiopia and 180 km from Bahir Dar capital city of Amhara regional state. The town has 6 sub-cities with 25 Kebele and 127,115 houses. Gondar Town is one of the ancient and densely populated towns in Ethiopia. According to the central Gondar zonal health office 2021 GC report, Gondar has a total population of 432,191 of whom 215,663 are men and 216,538 women. Nowadays the town is growing and it had 8 health centers, more than 15 private medical clinics, one private primary hospital, and one Comprehensive Specialized Hospital serving about 5 million populations.

Source population and study population

All adult women who are living in Gondar town were the source population. All women who are living in Gondar town during the data collection period were considered as the study population.

Inclusion and exclusion criteria

All women who were 20–70 age group living in Gondar town during the study period were included. Women who are severely ill during data collection time and those who refuse to participate in the study were excluded.

Sample size determination and calculation

The actual sample size for the study was determined using single population proportion formula with the assumption of 34.2% knowledgeable of BSE [ 32 ], 95% confidence interval; (α = 0.05), 5% margin of error, 10% none response rate, and 1.5 design effect.

where n = is the minimum sample required; P = population proportion, 0.342; d = the margin of error, 0.05; Z = the upper percentile of the normal distribution at 95% CI.

By Multiply 1.5 design effect n = 519, adding 10% non-response rate = 52 and the final sample size would be 571 (Table 1 ). Sample size calculation on second the objective in the same study showed that only practice was significantly associated with BSE (Table 2 ).

The final sample size was from a single population proportion and the second objective was used the maximal one take from single population proportion knowledge of BSE = 571.

Sampling technique and procedures

A multi-stage sampling method was applied for the selection of houses from each Kebele. Firstly, Out of 25 kebeles in the Gondar town, 7 kebeles such as Aribengochi, Adebabayeyesuse, Abajalie, kehaeyesus, Shiwaber, Hidasie, and Aba Samuel kebele were randomly selected by lottery method to represent all kebeles (28% representativeness). Secondly, a systematic sampling technique was used to label the households within each Kebele The proportional allocation formula for each Kebele is \(n = \frac{njXnf}{N}\) ; Were, nf = final sample size, nj = total number of houses each Kebele, N = total number of houses (Fig.  1 ). Lastly, a simple random sampling was used to select 571 study participants within households using the sampling frame.

The schematic presentation of sampling procedure to select the study households of women aged 20–70 at Gondar Town, Northwest Ethiopia, 2021 (n = 571)

Data collection tools and procedures

The questionnaire was adapted from different works of literature [ 26 , 44 , 45 ]. The questionnaire was first prepared in English, and then it was translated into Amharic language and back to English. It contains four parts such as socio-demographic characteristics (n = 9), knowledge (n = 12), attitude (n = 13), and practice (n = 8) items. Then the data were collected by 5 data collectors using face-to-face interviewer administer questionnaires. The overall supervision was carried out by the principal investigator.

Operational definition

Adequate knowledge : It refers to participants who scored mean and above values 8 from the provided 12 close-ended questions about the knowledge of BSE [ 46 ].

Inadequate knowledge : It refers to participants who scored below mean values 8 from the provided 12 close-ended questions about the knowledge of BSE [ 46 ].

Favorable attitude : It refers to participants who scored mean and above values 6 for attitude-related questions towards BSE, which was measured by the provided 12 questions [ 46 ].

Unfavorable attitude : It refers to participants who scored below mean values 6 for attitude-related questions towards BSE, which was measured by the provided 12 questions [ 46 ].

Good practice : It refers to those who checked or perform BSE at least once per month just a week after each menses [ 47 ].

Poor practice : It refers to those who practice BSE other than the correct time in the cycle [ 47 ].

Data quality control

Pretest was done on 5% of the total sample size from the non-selected kebele of the same population before 4 days of actual data collected. Two days of training were given for data collectors and supervisors by investigators on the objectives of the study, ethical considerations, the content of the questionnaire, and how to conduct the interview. Based on the pre-test, questionnaires were edited, and necessary corrections made were on order of questions and that poses participant to confusion. The reliability of the tool on Cronbach’s alpha results knowledge = 0.81, attitude = 0.86, and practice = 0.71. The collected data was checked out for completeness, accuracy, and clarity by the principal Investigators before data entry.

Data processing and analysis

Data were entered using Epi data version 4.6 software and analyzed using SPSS version 25. Data cleaning and cross-checking were done before analysis. Descriptive statistics were summarized using the mean, and standard deviation. Frequencies and percentages were used in the presented table, figures and text. Multivariate logistic regression analysis were used to identify factors where p -value < 0.05 was declared as significantly associated with knowledge, attitudes, and practices of breast self-examination.

Socio-demographic characteristics

Out of 571 participants, 541 agree to participate in the study, yielding a response rate of 95%. Nearly half (47.5%) of the participants were within the age range between 20 and 29 years. The minimum and maximum age of the participants was 20 and 69 respectively, the majority of women (87.4%) and 36.8% were orthodox and completed secondary education level respectively. Among the participants, 62.1% and 49.9% were married and housewives respectively (Table 3 ).

Knowledge towards breast self-examination and their information source

Among the respondents, 66% of participants heard about breast self-examination. The majority (56%) (95% CI: 51–61) of participants had adequate knowledge (Fig.  2 ) and their main source of information was television/radio (43.2%), health institution/profession (30.8%), peer group, and school training (15.6%) and from newspaper and internet (10.2%) (Table 4 ).

The overall status of knowledge, attitude, and practice towards Breast self- examination among women aged 20–70 at Gondar Town, Northwest Ethiopia, 2021 (n = 571)

Attitude towards breast self-examination

Among 541 study participants, 46.0% (95% CI: 42–52) had positive attitudes towards breast self-examination, 60.3% of the respondents score breast self-examination as necessary (Table 5 ).

Practices towards breast self-examination

Among 541 study participants, 248 (45.8%) performing breast self-examination and 31% (95% CI: 25–37%) had good practices of breast self-examination (Fig.  2 ). From the total respondents, more than half 54.2% (n = 293) of them did not practice BSE. The main reasons for not practicing BSE 175 (57.4%) were not having breast problems and 31.7% (n = 93) don’t know how to breast self-examine (Table 6 ).

Factors associated with breast self-examination

All independent variables entered into the logistic regression (multivariable logistic regression analysis). Women’s and husbands' education level were significantly associated with knowledge. The age of the women and women’s educational level was significantly associated with the attitude of BSE. History of breast cancer and good knowledge of BSE were significantly associated with performing BSE. Women college and above were about 4 times [AOR: 3.8, (95% CI: 1.43–10.14)] more likely to know of BSE than those who uneducated women. The spouses whose educational level College and above was about 3 times [AOR: 3.03, (95% CI: 1.04–8.84)] more likely to be knowledgeable towards BSE than those who had an illiterate husband (Table 7 ).

Women College and above was about 4 times [AOR: 4.18 (95% CI: 1.59–10.92)] and secondary school was about 3 times [AOR: 2.80 (95% CI: 1.25–6.29)] had favorable attitudes towards BSE than those women who are illiterate (Table 8 ).

Women who have personal and family history of breast cancer were about 6 times [AOR: 6.06, (95% CI: 2.19–16.74)] more likely to perform BSE than women who do have not the history of breast cancer. A woman who has adequate knowledge of BSE about 3 times [AOR: 2.67 (95% CI: 1.18–6.04)] is more likely to perform BSE than women who have inadequate knowledge (Table 9 ).

The aim of this study was to assess knowledge, attitude, practice, and associated factors of breast self-examination among women in Gondar town. In this study, more than half 56% (n = 200) (95% CI: 52–62%) of the study participants had adequate knowledge regarding BSE, which is comparable with study conducted in Ethiopia that indicated 55.5% in Adwa town [ 24 ]. This similarities could be due to similar study subjects.

However, the finding is higher than that of Vietnam 22.7% [ 16 ], 34% Sudan [ 19 ], 41.5% Libya [ 18 ], 34.2% Arba Minch [ 32 ], 43.1% Jimma [ 23 ], and 25.6% Addis Ababa [ 21 ]. The difference might be due to by self-reporting data collection technique in Vietnam and Sudan, and the clustered sampling procedure was used in Libya. The self-reporting data collection method requires participants to respond to the researcher's questions without his/her interference [ 48 ]. In Ethiopia, the possible justification might be the educational level difference. In our study, 29.8% of participants were College and above educational status, but only 14.4% of study participants in Arba Minch, and 18.8% in Jima were college and above educational status. This finding is lower than the study conducted in Cameroon 78% [ 20 ], and 63.8% in Turkey [ 17 ]. The possible justification might be due to socio-economic, and study population differences. The current study was community-based, but that of Cameroon was conducted on patients attending a surgical outpatient clinic.

In this finding, about 46% (95% CI: 42–52%) of participants had a positive attitude towards breast self-examination, which is comparable with the study conducted in Ethiopia that indicated 46.3% in Adwa town [ 24 ].This consistency might be due to similar socio-cultural status and study population whose age were 20–70. However, it is lower than the studies conducted in Saudi Arabia 64.01% [ 25 ], 87.2% Pakistan [ 26 ], and 74.9% Libya [ 18 ]. This difference might be due to sampling size difference, educational level, and participant’s knowledge towards BSE, occupational difference, and information access availability.

In this finding, Nearly one-third 31% (n = 77) (95% CI: 25–37%) of participants had good practices towards BSE, which is comparable with the study done in Addis Ababa, 28.4% [ 33 ]. This consistency might be due to similar socio-cultural and economic status. Besides, factors that affect practice for early detection of BSE might be similar in both study settings. On contrary, this study is higher than the studies conducted in Arba Minch 13.3% [ 32 ], 12.1% Libya [ 18 ], and 8.5% Turkey [ 17 ]. The difference might be knowledge difference, and in Arba Minch, the majority (45%) of the participants are illiterate. On the other hand, this finding was lower than the studies conducted in Saudi Arabia 43% [ 27 ], and 37.6% in Ghana [ 29 ]. The possible justification might be educational and knowledge differences. In Saudi Arabia, the majority (65%) of participants had adequate knowledge about BSE, and 79% of the participant had an educational level completed university, whereas 88% of participants were aware of BSE in Ghana.

In this study, women’s educational level at College and University were about 4 times [AOR: 3.8, 95% CI: (1.43–10.14)] more likely to be knowledgeable with BSE than those who are illiterate. Also, the women whose husbands had an educational level College and University were about 3 times [AOR: 3.03, 95% CI: (1.04–8.84)] more likely to knowledgeable than those had illiterate husbands. Evidence shows that training women about breast self-examination goes correspondingly with their educational attainment of College level and above has a positive impact on their related knowledge and practices [ 49 , 50 ].

Women’s College and above was also one of the significant factors for the attitudes of breast self-examination, women’s College and above was about 4 times AOR:4.18, (95% CI: 1.59–10.92) and secondary school was about 3 times [AOR: 2.80, 95% CI: (1.25–6.29)] more likely to had positive attitude towards BSE than women those who are illiterate. it was supported by the study done in Libya [ 18 ], and Turkey [ 17 ]. This might be due to educational attainment of secondary school and above could increase women’s attitudes towards breast self-examination besides it also enhance compliance towards breast self-examination behavior [ 51 ].

In this study, women who have a history of breast cancer were about 6 times [AOR: 6.06, 95% CI: (2.19–16.74)] more likely to perform BSE than their counter parts. This study was in line with the studies conducted in Jimma [ 23 ], Addis Ababa [ 36 ], and Libya [ 18 ]. A family history of breast cancer is positively affecting the practice of breast self-examination [ 52 ]. This could be women with a history of breast cancer performing breast self - examination at a regular basis and making them more cognizant , which in turn may lead to an earlier diagnosis of breast cancer .

Limitations

As practice was not directly observed rather we used checklist that will not know how exactly they were practicing it. Other limitations were being conducted in a single urban community, which may not be representative of the rural community or other urban communities in Ethiopia.

The findings of this study were considerable for inadequate knowledge, unfavorable attitude and poor practice towards BSE among women. Emphasis should be made to boost the attitude and practice of the women towards breast self-examination and strengthening of the implementation of comprehensive, systematic, and continuous BSE educational programs were recommended along with a breast cancer awareness campaign.

Availability of data and materials

The datasets used/or analyzed during the current study is available from the corresponding author on reasonable request.

Abbreviations

American Cancer Society

Breast Cancer

• Breast self-examination

Clinical breast examination

Ethiopian Cancer Association

Statistical package social science

Crude odds ratio

Adjusted odds ratio

Confidence interval

University of Gondar

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Acknowledgements

Our gratitude goes to the School of Nursing, College of Medicine and Health Sciences, the University of Gondar for giving us the chance to conduct this research. The authors' thank also goes to Gondar Town Kebele administrators and all study participants.

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KA, ZW, and YB: Conceived, designed and organized the whole procedure of this article production, performed data analysis and interpreting of findings and performed data analysis, interpreting of findings and coaching and mentoring, and equally prepare the manuscript. All authors read and approved the final manuscript.

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Asmare, K., Birhanu, Y. & Wako, Z. Knowledge, attitude, practice towards breast self-examination and associated factors among women in Gondar town, Northwest Ethiopia, 2021: a community-based study. BMC Women's Health 22 , 174 (2022). https://doi.org/10.1186/s12905-022-01764-4

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Women’s knowledge, attitude, and practice of breast self- examination in sub-Saharan Africa: a scoping review

• Roseline H. Udoh 1 ,
• Mohammed Tahiru 1 ,
• Monica Ansu-Mensah 1 ,
• Vitalis Bawontuo 1 , 2 ,
• Frederick Inkum Danquah 1 &
• Desmond Kuupiel   ORCID: orcid.org/0000-0001-7780-1955 2 , 3  

Archives of Public Health volume  78 , Article number:  84 ( 2020 ) Cite this article

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Breast cancer (BC) is a non-communicable disease with increased morbidity and mortality. Early detection of BC contributes to prompt linkage to care and reduction of complications associated with BC. Breast self-examination (BSE) is useful for detecting breast abnormalities particularly in settings with poor access to healthcare for clinical breast examination and mammography. Therefore, we mapped evidence on women’s knowledge, attitude, and practice of BSE in sub-Sahara Africa (SSA).

We conducted a systematic scoping review using Arskey and O’Malleys’ framework as a guide. We searched PubMed, Google Scholar, CINAHL, and Science Direct databases for relevant studies on women’s knowledge, attitude and practice on BSE. Studies included in the review were from SSA countries as defined by the World Health Organization published from 2008 to May 2019. Two reviewers independently screened the articles at the abstract and full-text screening guided by inclusion and exclusion criteria. All relevant data were extracted, and a thematic analysis conducted. The themes were collated, and a narrative summary of the findings reported.

Of the 264 potentially eligible articles identified from 595,144, only 21 met the inclusion criteria and were included for data extraction. These included studies were conducted in 7 countries of which 11 were conducted in Nigeria; two each in Ethiopia, Ghana, Cameroon, and Uganda; and one each in Kenya and Sudan. Of the 21 included studies, 18 studies reported evidence on BSE knowledge and practice; two on only knowledge; one on only practice only; and six presented evidence on women’s attitude towards BSE. The study findings suggest varying knowledge levels on BSE among women in SSA countries. The study findings also suggest that BSE practice is still a challenge in SSA.

There is a paucity of published literature on women’s knowledge, practice, and attitude of BSE in SSA. Hence, this study recommends further studies on knowledge, practice, and attitude of BSE, to identify contextual challenges and provide evidence-based solutions to improve women’s knowledge, practice, and attitude of BSE in SSA.

Peer Review reports

Breast cancer (BC) has been described as the most commonly diagnosed cancer in women and the leading cause of cancer death globally [ 1 ]. In 2018, of the 8.6 million new cases of cancer globally, BC accounted for 24.2% of which 8.1% occurred in SSA. BC also accounted for nearly 15% of the 4.2million mortality due to cancer worldwide with SSA accounting for 11.8% [ 1 ]. It is estimated that 1 in 8 women will develop BC over a lifetime and in the next decade 19.7 million new cases are expected globally by 2020, and 10.6 million will occur in low-and-middle-income countries (LMICs) [ 2 , 3 ]. Similarly, it is projected that 43.1% of women will die due to BC worldwide and 36.8% will occur in LMICs by the end of 2020 [ 2 ].

These regional projections of BC incidence and mortality are worrying. Hence, demand immediate action to prevent and detect BC early through the different screening methods, as a mandate to help achieve the agenda for sustainable development goal (SDG) 3.4 by 2030 [ 4 ]. To facilitate early detection of BC, knowledge, attitude, and practice on the screening methods are essential. Although clinical breast examination and mammography are ideal for BC diagnosis, access to healthcare in most SSA countries may be a major challenge. Economic constraints in most SSA countries may impede the availability of mammography in the majority of the health facilities [ 5 , 6 , 7 ]. In addition, both clinical breast examination and mammography require expertise, specialized equipment, and a visit to the health facility [ 7 ]. However, breast self-examination (BSE) is a non-invasive procedure performed by the individual monthly to determine a normal breast and recognize any change on the breast for early medical care to be sought [ 8 , 9 ]. Evidence shows that nine out of the ten breast lumps are detected by the women themselves [ 9 ].

To this end, knowledge, attitude, and practice of BSE among women are essential. Knowledge of BSE involves having information on signs of BC, BSE procedures and how to perform BSE [ 10 , 11 , 12 , 13 ]. Evidence shows that having knowledge of BSE has a positive impact on early detection of BC [ 14 ]. Knowledge of BSE may also influence the attitude and practice of BSE [ 13 , 15 ]. Attitude is a settled way of thinking about BSE which includes acceptance that BSE is necessary, all women should perform it, ready to encourage other people to get information and to practice it and seeking early medical care with any abnormalities [ 10 , 13 , 16 ]. The practice of BSE involves the act of palpating one’s breast monthly, just after menstruation, and the ability to detect abnormalities [ 10 , 13 , 17 ]. The practice of BSE makes the individual becomes familiar with the structure of her breast and be responsible for her health since the detection of any abnormality will necessitate seeking early medical care [ 5 , 18 ]. Despite this, to date, no study has methodically explored and described literature and identified research gaps on knowledge, attitude, and practice of BSE for future studies in SSA to the best of our knowledge. This current study, therefore, aimed to systematically map literature and describe the evidence on women’s knowledge, attitude, and practice of BSE in SSA.

We employed Arksey and O’Malley’s and Levac et al. recommendations [ 19 , 20 ] to conduct a systematic scoping review focused on women’s knowledge, attitude, and practice of BSE in SSA. The Arksey and O’Malley framework included in this study are as follows: identifying the research question, retrieving relevant studies, selection of studies, charting data, and collating, summarizing, reporting evidence. A detailed description of this study’s methodology has been previously reported in the published protocol [ 21 ]. The preferred reporting items for systematic reviews and meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist was followed to report this study (Supplementary file  1 ).

Identifying the research question

The main review question was: What evidence exists on women’s knowledge, attitude, and practice of BSE in SSA?

The Sub review questions were as follows:

What is the evidence on the knowledge of BSE among women in SSA?

What is the evidence on the attitude toward BSE among women in SSA?

What is the evidence on BSE practice among women in SSA?

Literature search

An exhaustive search for potentially eligible articles was conducted in the following databases: PubMed, CINAHL, Google Scholar, and Science Direct to obtain relevant articles. The database search occurred in May 2019 using the following keywords: “women”, “female” “self-breast examination”, “breast self-examination”, “knowledge”, “attitude”, “practice”, “breast”, “cancer”, “breast cancer”, “Africa”, “sub sahara africa”, south of the sahara”, and “SSA”(Supplementary file  2 ). Boolean terms (AND/ OR) were used to separate the keywords. We also included Medical Subject Heading (MeSH) terms during the keywords search in the databases. To widen the scope of the search and capture the full range of literature on KAP of BSE, language and study design restrictions were removed during the databases search but the search date was limited from 2008 to the search date in 2019. We further search the reference list of all the included studies for eligible articles.

Study selection

Guided by the eligibility criteria, RHU conducted database search and title screening. RHU and MT independently screened the abstracts and full articles in parallel. The discrepancies in the investigator’s responses at the abstract screening stage were discussed by the review team until a consensus was reached. However, DK resolved the discrepancies between RHU and MT at the full-text screening stage. Then, Cohen’s kappa coefficient, κ statistic between the reviewers was calculated after the full-text screening. This study included primary studies: conducted in SSA, published between 2008 to May 2019, reporting evidence among women 18 years and above, presenting evidence of women’s knowledge, attitude, and practice of breast self-examination, and published in English. However, studies conducted in other countries outside SSA, articles reporting evidence among men, studies focused on cost-effective of BSE, articles presenting evidence on CBE as well as articles presenting evidence on a mammogram, and other review articles were excluded.

Charting the data

A thorough reading of the included studies for data extraction of bibliographic details, study title, aim/objectives, study design, target population, study setting, significant findings of interest were extracted. Other information like geographical location (urban or rural), country of study, sample size, and conclusion were also extracted to answer this review question. To ensure consistency and reliability of this study findings, RHU and DK independently extracted all relevant data from the included studies using a piloted form designed in Microsoft word.

Collating, summarizing, and results

All relevant data extracted were analysed thematically. The themes were collated, and a summary report of the finding presented narratively with a focus on this study outcome of interest (knowledge, attitude, and practice).

In all, 365 articles met the eligibility criteria out of 595,144 at the title screening stage. Out of the 365 articles, 175 were duplicates hence, they were deleted prior to abstract screening. Subsequently, 143 and 26 articles were also excluded following abstract and full-text screening respectively (Fig.  1 ). There was a significant level of agreement between the investigators” responses at full article screening stage (Kappa statistic = 0.80, p  < 0.01). Of the 26 full-text articles excluded, eleven did not report on any of this study outcome of interest [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]; five studies were conducted outside this study setting [ 8 , 33 , 34 , 35 , 36 ]; three reported on CBE and mammography [ 37 , 38 , 39 ]; three were review articles [ 40 , 41 , 42 ]; two studies reported on cost-effective of BSE [ 5 , 7 ]; one study reported evidence on male [ 43 ] and one full text could be accessed [ 44 ] despite several emails to the authors requesting for it. At the end of the study section process, 21 articles met the inclusion articles were included for data extraction.

PRISMA 2009 Flow Diagram

Characteristics of included studies

Of the 21 included studies, one was a pre-experimental study [ 45 ], two were mixed methods studies [ 46 , 47 ], and eighteen were descriptive cross-sectional surveys [ 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 ]. The majority (11/21) of the included studies were conducted in Nigeria [ 46 , 49 , 50 , 51 , 52 , 53 , 54 , 57 , 60 , 62 , 63 ] and the rest in Sudan [ 65 ], Kenya [ 64 ], Uganda [ 47 , 59 ], Cameroon [ 55 , 61 ], Ethiopia [ 45 , 56 ], and Ghana [ 48 , 58 ]. A total of 18 studies were conducted in urban settings [ 45 , 46 , 47 , 48 , 50 , 51 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 64 , 65 ] while three were in a rural setting [ 49 , 52 , 63 ]. Table  1 presents a summary of the characteristics and findings of the included studies.

Study findings

Of the 21 studies, 18 studies reported evidence on knowledge and practice [ 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 ] while 2 studies reported on knowledge only [ 53 , 55 ], and one study on practice only [ 54 ]. Six of the included further reported evidence on the attitude of women towards BSE [ 49 , 52 , 56 , 58 , 60 , 63 ].

Knowledge of women on BSE

Of the total 20 included studies that presented evidence on women’s knowledge of BSE, eleven reported high (> 70% of study participants) knowledge on BSE [ 46 , 47 , 48 , 50 , 58 , 59 , 61 , 62 , 63 , 64 , 65 ], two reported average BSE knowledge (≥ 50% of the study participants) [ 49 , 60 ], and seven reported low (< 50% study participant) BSE knowledge [ 45 , 51 , 52 , 53 , 55 , 56 , 57 ]. Of the eleven studies that revealed more than 70% of their study participants having knowledge on BSE, four were conducted in Nigeria [ 46 , 50 , 62 , 63 ], two each in Ghana [ 48 , 58 ] and Uganda [ 47 , 59 ], one each in Cameroon [ 61 ], Kenya [ 64 ], Sudan [ 65 ].

In Cameroon, Nde et al. reported that 73.5% of their study participants had knowledge on BSE of which 37.3% knew BSE is performed monthly, 9% knew how to perform it, and 88.6% knew BSE is important for early detection of BC [ 61 ]. In Sudan, Idris et al. study reported 86% BSE knowledge among the participants [ 65 ]. Kimani & Muthumbi study in Kenya among female medical students in 2008 reported BSE 94.4% BSE awareness [ 64 ].

Fondjo et al. study evaluated the knowledge among senior high school and tertiary students in Ghana and reported 90.9% BSE knowledge among participants, of which 91.6% knew BSE as a tool for early detection of BC, 45.8% knew BSE was done monthly, 21.1% knew BSE is performed after menstruation, and the majority (63%) knew the posture to assume during the performance of BSE [ 48 ]. Sarfo et al. also reported 95% BSE knowledge among female nursing students and of which 60% of them knew BSE as a screening method for BC detection [ 58 ].

Two studies conducted in Uganda (Obaikol et al. & Godfery et al.) revealed 81.5 and 76.5% BSE knowledge respectively among their participants [ 47 , 59 ].

In Nigeria, a study reported 98.9% BSE knowledge in Owerri [ 62 ]. Casmir et al. reported that the participants who knew the age to begin BSE were 20.5 and 96.7% knew BSE was beneficial [ 62 ]. BSE knowledge of 85.1, 82, and 74% was reported by Gwarzo et al.; Faronbi &Abolade; and Sambo et al. among participants in their respective studies [ 46 , 50 , 63 ]. However, Faronbi & Abolade study found that only 22% of the study participants understood the purpose for the performance of BSE, 12% knew BSE is done monthly, and 16% knew the exact age to begin BSE [ 63 ]. Nonetheless, two studies involving rural women at a health facility and senior high school students in Nigeria respectively found 52.8 and 56.4% of the participants had access to information on BSE [ 49 , 60 ]. Isara & Ojedokun, in 2011 reported that 56.4% of the participants had information on BSE, of which, 52.3% knew BSE was a means of screening for BC, 12.5% knew the correct time to perform, and 18.8% knew BSE performance was a monthly required [ 60 ].

Of the seven studies that reported evidence of low BSE knowledge among their study participants [ 45 , 51 , 52 , 53 , 55 , 56 , 57 ], four were conducted in Nigeria [ 51 , 52 , 53 , 57 ], two in Ethiopia [ 45 , 56 ], and one in Cameroon [ 55 ]. Abere et al. assessed the effectiveness of planned teaching program on knowledge and practice of BSE among first-year female midwifery students in Hawassa Health Sciences College [ 45 ]. Their study showed that before intervention; 23% had heard of BSE, and 32% knew BSE helps to detect lump early [ 45 ]. But after the teaching program, the study found that 100% had heard of BSE, and 96.7% knew BSE facilitates early detection of breast lumps [ 45 ]. Makanjuola et al. study also reported that 40% of the study participants had poor knowledge of BSE [ 52 ], while 48% of students were reported to have poor knowledge of BSE by Faronbi & Abolade in their study [ 63 ]. Similarly, Isara & Ojedokun study aimed at assessing the knowledge of senior high school students on BSE in Nigeria reported that 75.6% of the students had poor knowledge of BSE [ 60 ]. Whilst, Segni et al. study among University students found that 91.3% had poor knowledge of BSE [ 56 ]. These findings revealed varied knowledge levels on BSE among women in SSA countries, hence, requires further investigations.

Attitude toward BSE

Six studies out of the 21 included studies reported on the attitude of the participants toward BSE [ 49 , 52 , 56 , 58 , 60 , 63 ]. The study by Isara & Ojedokun in 2011 showed that the majority (82.6%) of senior high school students in Nigeria had a positive attitude toward BSE [ 60 ]. Sarfo et al. study also reported that female nursing in Ghana had a positive attitude toward BSE [ 58 ]. Whereas in Ethiopia, 59.2% of the study participants were found to have a positive attitude toward BSE [ 56 ], and moderate attitude was reported by Nde et al. in Cameroon [ 61 ]. Faronbi & Abolade; and Olowokere et al. in their studies in a rural setting in Nigeria reported poor attitude toward BSE [ 49 , 63 ]. This finding demonstrates limited literature on women’s attitudes towards BSE.

Practice of BSE

Of the 21 studies, 19 reported evidence on the practice of BSE [ 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 54 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 ]. Four studies gave evidence of over 50% of participants who had practiced BSE [ 46 , 50 , 54 , 57 ] while 15 studies recorded evidence of low practice [ 45 , 47 , 48 , 49 , 51 , 52 , 56 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 ]. Agbonifoh, 2016 study among tertiary students in Edo state in Nigeria found out there was a high level of practice of BSE among participants [ 54 ]. Similar reports of high (78%) practice of BSE was recorded by Onwere et al. in 2009 among antenatal patients in a teaching hospital in a South Eastern Nigeria [ 57 ]. Sambo et al. study in 2013 also reported that 55% of the undergraduate students in Northern Nigeria were practicing BSE [ 50 ]. Gwarzo et al. study in 2009 reported that 57% of the participants had ever practiced BSE 32.1% [ 46 ].

Of the 15 with a low level of practices, six were conducted in Nigeria [ 49 , 51 , 52 , 60 , 62 , 63 ], two each in Ethiopia [ 45 , 56 ], Ghana [ 48 , 58 ], and Uganda [ 47 , 59 ]; one each was conducted in Cameroon [ 61 ], Kenya [ 64 ] and Sudan [ 65 ]. Gwarzo et al. reported that only 19% of their study participants were currently practicing BSE monthly [ 46 ]. Among the rural women in Ala community in Nigeria, 13% of the women practiced BSE as reported by Makanjuola et al. [ 52 ]. The study by Casmir et al.in 2015 also reported 32.5% of the participants practiced BSE [ 62 ], 31.4% was also reported among senior secondary school students in Abuja Nigeria [ 60 ]. Again, in Nigeria, two studies found 12 and 11.7% of the study participants who practiced BSE [ 49 , 63 ]. The lowest percentage (0.4%) of BSE practice was reported by Obaji et al. in their study in Nigeria involving market women in 2013 [ 51 ]. These findings show BSE practice remains a challenge in SSA and further studies are needed to investigate the barriers and facilitators of BSE practice.

We conducted a scoping review to explore evidence on knowledge, attitude, and practice of BSE (KAP) among women in SSA. This study revealed evidence of women’s KAP on BSE in seven SSA countries (Sudan, Nigeria, Ghana, Cameroon, Kenya, Ethiopia, and Uganda). The results generally demonstrate limited published research on knowledge, attitude and practice of BSE among women in SSA. The results also revealed varied knowledge levels on BSE among women in SSA countries. It further suggested that BSE practice remains a challenge in SSA.

We found evidence of women’s KAP on BSE reported in seven SSA countries. This implies that we found no evidence in about 39 countries classified among SSA countries including the following: Angola, Benin, Botswana, Burkina Faso, Burundi, Cape Verde, Central African Republic, Chad, Comoros, Congo, Côte d’Ivoire, the Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Gabon, Gambia, Guinea, Guinea-Bissau, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, South Africa, Swaziland, Togo, United Republic of Tanzania, Zambia, and Zimbabwe although BC may be also be rising in these countries. This finding suggests limited research on knowledge, attitude, and practice of BSE among women in SSA. Similarly, Che Mut et al. systematic review BSE among female students also found limited studies [ 66 ]. This is worrying since BSE is a primary screening technique to detect breast abnormalities reporting for CBE or mammography.

We also found knowledge variations on BSE among women in SSA countries. It ranges from a low level to a higher level of knowledge with more of the low level of knowledge been reported. This, therefore, requires an intervention to increase the knowledge level of women in SSA. BSE has been reported as one of the screening methods for early detection of BC [ 5 ] therefore, in-depth knowledge, monthly practice and good attitude toward BSE are important for recognition of a normal breast and for detection of any abnormalities which is necessary for the control of morbidity and mortality associated with BC through early diagnosis of BC [ 16 ]. It further suggested that BSE practice remains a challenge in SSA. This challenge would require an intensive public campaign to help improve the practice of BSE in SSA.

Implication for practice

The review study included studies conducted in SSA where most of the clients with BC still present with end-stage of BC [ 67 ], thus increasing the morbidity and mortality associated with BC in SSA [ 5 , 68 ]. BSE is one of the screening methods for early detection of symptoms of BC, even though CBE and mammograms are the most reliable methods. CBE is done at the health facility by trained personnel and mammogram also done at the facility but for clients 40 years and over. This implies that the women will have to go to a facility for any of these screening method and for mammogram at the age of 40 year, for a woman to go to the facility for screening except where mass screening are carried out, she need to have observed an abnormality which will be detected through BSE [ 69 ]. Our findings from the studies reviewed showed that some participants were able to detect lumps and other abnormalities in their breast from a regular practice of BSE [ 46 , 47 , 61 , 65 ] It implies that planned tutorial on BSE will have a lot of impact especially among the health personnel’s as reported in some of the studies [ 45 , 54 , 65 ] and if the women are taught to practice BSE regularly, knowing what is abnormal in their breast, and any detection will necessitate seeking early medical care since they would have known the consequences of delays in reporting breast abnormalities [ 51 , 58 , 60 , 65 ] This study’s findings showed most of the participant indicated that BSE was a form of a screening method for early detection of abnormalities, therefore, an intensive public and institutional education is required on KAP of BSE with the aiming at early detection of abnormalities and subsequently seeking of early medical care, thereby reducing morbidity and mortality associated with BC.

Implication for research

Our study shows limited published research on BSE in SSA. Most of the studies were conducted among tertiary students in an urban setting indicating a gap in literature among rural women. We hope our study will stimulate research studies on KAP of BSE among rural women in SSA who are more disadvantaged in accessing other CBE and mammography screening methods. We also recommend primary studies to assess KAP in those countries we found no evidence since the prevalence of BC is increasing in SSA. We further recommend primary research to assess the practice of BSE among midwives and nurses who had formal training on BSE during their course of study. We further recommend a systematic review and a meta-analysis to assess the impact of BSE knowledge and practice of BSE in SSA. Knowledge of the factors that influence the practice of BSE may be useful. Moreover, most of the included studies were descriptive cross-sectional surveys. This demonstrates the need for more interventional studies to identify innovative contextualised strategies or approaches to improving the practice of BSE among women in SSA.

Strengths and limitations

This scoping review probably is the first broad study to map evidence on KAP of BSE among women in SSA countries. The study showed a noteworthy gap in the literature on KAP of BSE among women in SSA countries. This study’s methodology allowed the identification of eligible articles methodically, charting and analysing the outcomes [ 20 ]. Nonetheless, this study also has several limitations. This study sought to present recent evidence (within the last 10 year) hence, it included only articles published from 2008 onward. So, it possible some relevant articles published before 2008 were excluded. No quality appraisal was conducted as part of this study, but it is not essential due to the explorative nature of scoping reviews although we planned to assess the methodological quality of the included studies in the published protocol. We realized the number of included studies was few hence, reporting the risk of bias with these few studies may not be useful. Nonetheless, we will endeavour to perform the quality appraisal in the next phase of this study (a follow-up study full systematic review and meta-analysis). We also search for literature in only four databases, but it possible other relevant studies exist in other databases such as Scopus, Web of Science, and EMBASE that were not captured. We recommend future studies to conduct additional searches in those databases that were not captured by this study. It is possible researches on KAP of BSE existed under different terminologies that were not captured in the review. Nevertheless, we included MeSH terms to help address this. Furthermore, a meta-analysis using the quantitative data could generate more information but, this is not essential for scoping review studies. There may be several factors such as religious and cultural beliefs contributing to the KAP of BSE which were not captured by this study. We, therefore, recommend researches on the factors influencing KAP of BSE in SSA.

This study demonstrated that there is a paucity of published literature on women’s knowledge, practice, and attitude of BSE in SSA. Most of the included studies reported low KAP of BSE. Considering the resource constraints in most health facilities in SSA countries, adequate knowledge and practice, as well as a good attitude towards BSE, is essential. Hence, this study recommends further studies on knowledge, practice, and attitude of BSE, to identify contextual challenges and provide evidence-based solutions to improve women’s knowledge, practice, and attitude of BSE in SSA.

Availability of data and materials

The data supporting the conclusion of this paper are available through the detailed reference list. No original datasets are present since this is a review of the existing literature.

Abbreviations

• Breast cancer
• Breast self-examination

Clinical breast-examination

Disability-adjusted life years

Knowledge, attitude, and practice

Mixed method quality appraisal tool

Low and middle-income countries

Population, content and context

Preferred reporting items for systematic reviews and meta-analyses modified for scoping reviews

Sustainable development goal

Senior high school

Senior secondary

Sub-Sahara African

World health organization

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Acknowledgements

We would like to express our gratitude Catholic University College of Ghana, Department of Health and Allied Sciences, University of KwaZulu-Natal, and Handmaids of the Holy Child Jesus congregation (Ghana Province) for making available the necessary resources for completion of this research.

This study was funded by the Handmaids of the Holy Child Jesus congregation (Ghana Province). The funder played no role in the data collection, analysis, interpretation, and the preparation of the manuscript.

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RHU conceptualized and designed the study together with DK. RHU and MT contributed in the abstract, full article screening. RHU and MT contributed to the quality assessment of the included studies. RHU and DK contributed to the design and data extraction process as well as synthesis of data. RHU wrote the manuscript and MAM, BV, and DK critically reviewed it. All authors approved the final draft manuscript.

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Udoh, R.H., Tahiru, M., Ansu-Mensah, M. et al. Women’s knowledge, attitude, and practice of breast self- examination in sub-Saharan Africa: a scoping review. Arch Public Health 78 , 84 (2020). https://doi.org/10.1186/s13690-020-00452-9

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Research Article

Assessment of breast self- examination practice and associated factors among female workers in Debre Tabor Town public health facilities, North West Ethiopia, 2018: Cross- sectional study

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected] , [email protected]

Affiliation Department of Midwifery, Debre Tabor University, Debre Tabor, Amhara Region, Ethiopia

Roles Software, Writing – original draft, Writing – review & editing

Roles Formal analysis, Methodology, Writing – original draft

Affiliation Department of Midwifery, Debre Tabor Health Sciences College, Debre Tabor, Amhara Region, Ethiopia

• Asrat Hailu Dagne, 
• Alemu Degu Ayele, 
• Ephrem Mengesha Assefa

• Published: August 22, 2019
• https://doi.org/10.1371/journal.pone.0221356
• Reader Comments

Although breast Self-Examination is no longer tenable as a standard method to detect early breast cancer, world health organization recommends breast self -examination for raising awareness of women about breast cancer. Secondary prevention through monthly breast self-examination is the best option to tackle the rising incidence of breast cancer. Therefore, the aim of this study was to assess breast self -examination practice and associated factors.

This cross-sectional study was conducted from April 23 to May 23, 2018. A total of 421 female workers in Debre Tabor Town public health facilities were included. The study participants were selected using simple random sampling technique from the study population. The collected data were checked for completeness. The data were entered and cleaned using EpiData version 3.1 then exported to SPSS version 20 for analysis. Crude odd ratio and probability value were identified for each independent variable and all independent variables with probability value of less than 0.2 were entered into multivariables logistic regression. Statistically significant associated factors were identified based on probability value (p-value) less than 0.05 and adjusted odd ratio with 95% confidence interval.

The mean age of participants was 25.2 (S.D = 4.12) and 137 (32.5%) of the participants had practiced breast self -examination and 64 (15.2%) of them performed it monthly. Family history of breast cancer (adjusted OR = 6.5, CI = 1.54–21.4), Knowledge about breast -self examination (adjusted OR = 5.74, CI = 2.3–14.4) and self- efficacy in practicing breast self -examination (adjusted OR = 4.7, CI = 1.84–12.11) were significantly associated with breast self -examination practice.

Conclusions

The study showed that the prevalence of breast self-examination was low. Family history of breast cancer, knowledge about breast self -examination and self- efficacy in practicing breast self- examination did have statistically significant association with breast self—examination practice.

Citation: Dagne AH, Ayele AD, Assefa EM (2019) Assessment of breast self- examination practice and associated factors among female workers in Debre Tabor Town public health facilities, North West Ethiopia, 2018: Cross- sectional study. PLoS ONE 14(8): e0221356. https://doi.org/10.1371/journal.pone.0221356

Editor: Tebit Emmanuel Kwenti, University of Buea, CAMEROON

Received: March 3, 2019; Accepted: August 5, 2019; Published: August 22, 2019

Copyright: © 2019 Dagne et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Concerning data availability, when ethical approval and permission letter was obtained from the managers /head of health facilities, the governmental body and ethics committee imposed restriction. We agreed and signed not to publish the raw data retrieved from the respondents’ information. However, the datasets collected and analyzed for the current study can be obtained from the chief manager of Debre Tabor Hospital on behave of all selected health facilities for reasonable request (Name: Mr. Mequanint Melaku, Email [email protected] , Phone: 251918071560).

Funding: The funder was Debre Tabor University, and we would like to thank Debre Tabor University for financial support during data collection and the support of stationary materials, printing and copy. But all the other activities of our research work were accomplished through the effort of investigators as part of free community service of the university. We would also like to inform you that we did not have grant number.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Breast self -examination is one of the early noticing way of breast cancer which involves the woman herself looking at and feeling each breast for possible mass, discharge, swelling, dimpling and other abnormalities [ 1 ]. Breast cancer is more common among women than men and it is a type of malignant tumor which begins in the cells of the breast [ 2 ].

Breast self -examination is a kind of examination made by each woman and it is cost effective, painless, easy to apply, safe, and non invasive procedures without special material or tool requirements. It is an important noticing way of breast cancer which takes five minutes to apply [ 3 ]. Breast cancer awareness improves the outcome of breast cancer treatment [ 4 ]

Breast self- examination is useful for women’s awareness of warning signs and symptoms of breast cancer like redness of the breast skin, changes in the size of the breast or nipple, a breast lump, pain in the breast or armpit, lump under the armpit, nipple rash, changes in the shape of the breast or nipple, bleeding or discharge from the nipple, pulling of the nipple, dimpling of the breast skin and changes in the position of the nipple [ 5 ].

Breast self -examination is also important to increase breast health awareness which helps to allow for timely detection of anomalies for those who do not have access to health facility and advanced laboratory investigations for diagnosing breast cancer [ 1 ].

It is known that clinical breast examination, Mammography, Ultrasound and Magnetic resonance imaging are breast cancer screening methods [ 6 – 11 ] and Mammography, Ultrasound and magnetic resonance imaging methods of breast cancer screening are not available in our study area. Using mammography instead of magnetic resonance imaging did not significantly increase screening sensitivity [ 8 ]. In clinical breast examination, the sensitivity, specificity and accuracy was 54%, 78% and 57% respectively [ 10 ]. The sensitivity of magnetic resonance imaging method of screening of breast cancer was higher than mammography and ultrasound [ 11 ].

Early identification of breast cancer through breast self -examination and diagnosis plays an important role in reducing its morbidity and mortality [ 9 ]. But most of women do not perform breast self- examination in low income countries because of lack of awareness and lack of knowledge of breast self- examination [ 12 – 16 ].

The incidence of breast cancer has been increasing in different regions of the world. The expected incidence rate of breast cancer is similar in different countries [ 17 ]. However, breast cancer mortality rate is much higher in low income countries than well developed countries due to lack of early screening methods and treatment of breast cancer [ 17 , 18 ].

Worldwide, breast cancer is the second common cancer next to lung cancer and the fifth cause of cancer mortality [ 19 , 20 ]. The incidence rate of breast cancer in North Africa and Sub-Saharan Africa (SSA) was 29.3 per 100000 and 22.4 per 100000 respectively. This incidence rate also indicated that breast cancer was increased between 2000 to 2015 [ 21 ]. According to breast cancer estimate in 2018, about 626,679 of women died from breast cancer in the world which accounted a crude mortality rate of 13 per 100.000 women [ 18 ].

About 10,000 Ethiopian women have already faced breast cancer and thousands of more patients are unreported as most women living in rural areas seek treatment from traditional healers before getting support from health facility [ 22 ].

Female health facility workers should be role model and they should educate the community to create awareness of early detection of signs and symptoms of breast cancer using breast self- examination. But health workers have not considered breast self- examination as a support for standard breast cancer screening method. Moreover, they had low practice of breast self examination [ 12 , 23 – 26 ].

The findings of this study will help programme managers, stakeholders and health service providers to design appropriate intervention to increase practice of breast self- examination. Furthermore, it will also be helpful for better documentation of practice of breast self -examination of females working in public health facilities to design interventions aimed at reducing breast cancer mortality through increasing community awareness and improving early diagnosis and treatment of the disease.

Therefore, the aim of this study was to determine breast self- examination practice and identify associated factors among female workers in Debre Tabor Town public health facilities, North West Ethiopia.

Study design and setting

This cross- sectional study was conducted from April 23 to May 23, 2018 among females working in public health facilities of Debre Tabor Town. Debre Tabor is the capital of South Gondar Administrative Zone of Amhara Region, Ethiopia. There were 606 female workers in all health facilities. The town has one General hospital, three health centers and two colleges of health science. Female workers in Debre Tabor University Health Science College, Debre Tabor Health Science College of Amhara region, Debre Tabor General Hospital, Debre Tabor Health Center, Ginbot 20 Health Center and Hidar 11 Health Center were taken as study population.

Sample size determination and sampling procedures

Sample size was calculated using single population proportion formula and the required sample size for this study was determined using the following assumptions; desired precision (d) = 5%, Confidence level = 95% (Zα/2 = 1.96 value) and 45.6% of the prevalence of breast self -examination practice among female health extension workers in Wolaita zone of Southern Ethiopia was taken [ 27 ]. Hence, the calculated sample size by considering 10% non- response rate was 421.

To collect the data, initially all female health facility workers were listed from each health facilities. Then, Simple random sampling technique was conducted using lottery method based on the proportion of the number of female workers in each health facility to select the samples.

Data collection instrument and procedures

Data collection tool comprised of structured questionnaires that were prepared after thorough literature review and the local situation of the study area and purpose of the study were considered to prepare the questionnaire. Questionnaires were prepared first in English then translated to Amharic which is the vernacular language of the respondents by language expert for ease of understanding of the respondents. Data were collected via face- to- face interview technique using structured questionnaires.

Two nurses and two midwives who have BSc degree were selected and trained for data collection. They had previous exposure in data collection. Data were collected on socio-demographic, health and individual level related characteristics. Questionnaires were pretested on 22 (5%) of health facility workers of Nifas Mewucha Town in South Gondar Zone before final data were collected. The investigators and research assistants were involved to incorporate changes in questionnaires after pretest. To guarantee internal validity, only completed questionnaires were adopted.

Measurement

Face- to- face interview questionnaires were used as data collection tool. The knowledge of the respondents was assessed by using 14 questions and the correct responses of each respondent for all questions were added to decide whether the respondent was knowledgeable or not.

The attitude, self- efficacy, barriers of breast self -examination and benefits of breast self -examination items were all answered as strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree (on a five-point likert scale). Questionnaires related to attitude contain 6 questions with total score ranging from 6–30. Self- efficacy questionnaires include 10 questions with total score ranging from 10–50. Barriers of breast self- examination questionnaires also contain 8 questions with total score ranging from 8–40 and benefits of breast self -examination related questionnaires contain 4 questions with total score ranging from 4–20.

Therefore, the mean value of each variable for each respondent and the overall mean were identified to determine attitude, self- efficacy, and barriers of breast self -examination and benefits of breast self- examination.

Data management

The collected data were checked for completeness. The data were entered and cleaned using EpiData version 3.1 then exported to SPSS version 20 for analysis. Descriptive analysis was employed to summarize the data. Crude odd ratio (OR) and probability value (P-value) were identified for each independent variable and all independent variables with probability value of less than 0.2 were entered into multivariables logistic regression. Statistically significant associated factors were identified based on probability value (p-value) less than 0.05 and adjusted odd ratio (AOR) with 95% confidence interval (CI).

Operational definitions

Knowledgeable : participants who scored half and above values from all close-ended questions about the knowledge of breast self- examination [ 28 ].

Positive attitude : participants who scored mean and above values from all attitude-related questions towards breast self- examination [ 26 ].

Self- efficacy in practicing breast self -examination : participants who scored mean and above values from all close-ended questions of self- efficacy of breast self -examination [ 29 ].

Not Knowledgeable : participants who did not score half and above values from all close-ended questions about the knowledge of breast self- examination.

Negative attitude : participants who did not score mean and above values from all attitude-related questions towards breast self -examination.

Participants who did not self -efficacy in practicing breast self- examination : participants who did not score mean and above values from all close-ended questions of self- efficacy of breast self -examination.

Barrier of breast self -examination : participants who scored mean and above values from all close-ended questions of the barriers of breast self- examination [ 29 ].

Benefits of breast self -examination : participants who scored mean and above values from the total of benefits of breast self -examination related questions [ 29 ].

Breast self- examination Performed means breast self- examination was performed monthly during menses (regular) or ever performed breast self -examination (irregular) [ 29 ].

Ethics approval and consent to participate

Ethical clearance was obtained from Institutional Review Board of Debre Tabor University, health Science College. Formal letter of cooperation was written for Debre Tabor town health facilities. We stated for the participants that they had the right of unwilling to participate in the study and they had also the right to quit their participation at any stage without any restriction. Moreover, we informed the purpose, procedures, advantage and disadvantage of the study to the participants. Finally, informed written consent was obtained from each study participants.

Socio-demographic characteristics

In this study, there were a total of 421 respondents with a response rate of 100%. The respondents’ age ranges from 20–50 years. The mean age of the study population was 25.3 (SD ± 4.12) years. Majority of respondents were Orthodox (87.4%) and 53 (12.6%) of participants were Muslim. Among participants, 252 (60%) were unmarried and 169 (40%) were married (see Table 1 ).

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https://doi.org/10.1371/journal.pone.0221356.t001

Practice, knowledge and attitude on breast self-examination

From the total sample of 421, 32.5% of respondents had ever practiced breast self- examination and only 64 (15.2%) of them practiced breast self-examination regularly or monthly. The other 73 (17.3%) of participants had practiced breast self- examination irregularly. Among the total respondents, 167 (39.7%) of them had self- efficacy in practicing breast self- examination. Majority of the participants (70.3%) scored more than half of the knowledge question and 77.4% of the respondents had positive attitude (see Table 2 ).

https://doi.org/10.1371/journal.pone.0221356.t002

Factors associated with breast self -examination practice

Factors found to be associated with breast self- examination practice using bivariate analysis were marital status, husband’s occupation, age of female workers, family income, year of experience, profession, knowledge of the respondents, attitude of the respondents, family history of breast cancer, personal history of breast cancer, barriers of breast self- examination, self- efficacy in practicing breast self- examination and benefits of breast self- examination.

Moreover, we found that knowledge of female health facility workers towards breast self- examination, family history of breast cancer and self- efficacy in practicing breast self- examination had statistically significant association with breast self- examination practice.

The odds of practicing breast self- examination was 5.74 (AOR, 95% CI: 2.3–14.4) times higher among knowledgeable female workers for breast self- examination compared to female workers who were not knowledgeable. Female health facility workers who had family history of breast cancer and self- efficacy in practicing breast self- examination were 6.5 (AOR, 95% CI: 1.54–21.4) and 4.7 (AOR, 95% CI: 1.84–12.11) times more likely to practice breast self- examination compared to those female health facility workers who had no family history of breast cancer and self- efficacy in practicing breast self- examination respectively (see Table 3 ).

https://doi.org/10.1371/journal.pone.0221356.t003

According to the result of this study, 32.5% of participants had ever practiced breast self- examination and this practice was generally low. This might be due to health professionals concerned that breast self- examination is not a standard method to detect breast cancer but they should consider breast self- examination for the early awareness of signs and symptoms of breast cancer. A similar finding was found in the studies which were conducted in Iran and Nigeria [ 14 , 29 ]. This could be because of knowledge or awareness of study participants and similarity of study settings. But the finding of this study was lower than the studies conducted in Malaysia, Turkey, Cameroon, Nigeria and among female health extension workers in wolaita zone, Southern Ethiopia [ 27 , 30 – 33 ]. The reason for this might be due to the difference in considering breast self- examination for the awareness of signs and symptoms of breast cancer, knowledge difference of study participants and the difference between study areas.

The odds of breast self- examination practice among women who were knowledgeable were 5.74 times higher than women who were not knowledgeable. A similar result was found in a study conducted in Malaysia and among female health professionals in Western Ethiopia [ 28 , 30 ]. This is due to knowledgeable respondents’ motivation to practice breast self-examination.

The study indicated that the odds of breast self- examination among women who had family history of breast cancer were 6.5 times higher among women who did not have family history of breast cancer. This finding is in line with the study conducted in Ethiopia [ 28 ]. This could be due to getting information, their better awareness towards severity of the disease and advice on breast self- examination in noticing any change at early stage. Therefore, awareness of women towards breast self- examination increases if they had family history or personal history of breast cancer.

This study also showed that the odds of breast self- examination among female health facility workers who had self- efficacy in practicing breast self- examination were 4.7 times better than female health facility workers who did not have self- efficacy in practicing breast self- examination. The finding of this study is consistent with the study conducted in Iran [ 29 , 31 ]. This is due to respondents who had self- efficacy had knowledge and skill to perform breast self- examination.

There could be possibility of recall bias because of the participants were not actually assessed on their ability to correctly perform breast self-examination.

The study showed that the prevalence of breast self-examination was low. Family history of breast cancer, knowledge about breast- self examination and self- efficacy in practicing breast self- examination do have statistically significant association with breast self- examination practice. Therefore, there is a need for health intervention on breast self- examination and self- efficacy to increase breast self- examination practice for the awareness of women towards breast cancer.

Supporting information

S1 tools. the questions or questionnaire used in the study were both amharic and english language..

https://doi.org/10.1371/journal.pone.0221356.s001

Acknowledgments

We are thankful to data collectors and all female workers in Debre Tabor Town health facilities for their willingness to participate in the study and we would also like to thank Debre Tabor Town health facility managers for giving us information on the study population and the support during data collection.

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• 4. Nelson HD, Cantor A, Humphrey L, Fu R, Pappas M, Daeges M, Griffin J. Screening for Breast Cancer: A Systematic Review to Update the 2009 U.S. Preventive Services Task Force Recommendation. AHRQ Publication. 2009.

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Article Contents

Introduction, case presentation, acknowledgements, conflict of interest statement, ethical approval.

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Apocrine and clear cell metaplasia in the gallbladder: the first finding in the medical literature

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Moatasem Hussein Al-Janabi, Apocrine and clear cell metaplasia in the gallbladder: the first finding in the medical literature, Oxford Medical Case Reports , Volume 2024, Issue 5, May 2024, omae052, https://doi.org/10.1093/omcr/omae052

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Apocrine metaplasia, specifically, involves the development of cells resembling those in apocrine glands, characterized by their distinctive cytoplasmic features. Apocrine metaplasia in the gallbladder represents a new and intriguing discovery, marking a significant milestone in medical literature. Furthermore, clear cell metaplasia is often observed in other organs like the cervix and has never been documented in the gallbladder. The coexistence of apocrine and clear metaplasia challenges existing paradigms surrounding gallbladder pathology, prompting a reevaluation of the underlying mechanisms that drive these cellular transformations.

Apocrine metaplasia involves the development of cells resembling those found in apocrine glands, exhibiting distinct cytoplasmic characteristics. These apocrine-like cells typically present a cuboidal or columnar shape, often accompanied by frequent apical blebs or snouts. This type of metaplasia is commonly observed in breast lesions [ 1 ]. Likewise, clear cell metaplasia, which describes a condition when cells undergo a transformation causing them to lose their typical staining properties, is frequently noted in various organs such as the cervix and lungs [ 2–4 ]. Both apocrine and clear metaplasia in the gallbladder remain largely unexplored.

This case involves a 55-year-old man with a history of autoimmune hemolytic anemia (AIHA) who presented with symptoms suggestive of acute cholecystitis. Following diagnosis and subsequent laparoscopic cholecystectomy, histopathological examination revealed the presence of apocrine metaplasia with foci of clear metaplasia, alongside acute inflammatory changes and biliary pigment deposition.

Gross image displaying multiple fragments of the excised gallbladder. The average wall thickness measures 10 mm, and the mucosa appears dark green and velvety.

( A – F ) Microscopic images of the gallbladder reveal the presence of apocrine metaplasia (blue asterisk), accompanied by foci of clear cell metaplasia (black asterisk). Infiltration of acute inflammatory cells, including neutrophils and eosinophils, is observed. Additional features include mucosal erosion, congestion, activated fibroblasts, and the presence of biliary pigment (40×,100×,200× magnifications, H&E stain).

A 55-year-old man presented to the emergency department with severe abdominal pain persisting for a day, unresponsive to analgesics. The pain, located in the right upper quadrant and radiating to the right shoulder, was accompanied by nausea, vomiting, and fever. His past medical history includes autoimmune hemolytic anemia (AIHA), diagnosed one year prior. He has maintained stability on chronic prednisone (20 mg daily) for one year with no flares of anemia. There is no family medical history. He is a non-alcoholic smoker. Physical examination indicated tenderness in the right iliac fossa, and Murphy’s sign was positive. Laboratory investigation revealed a hemoglobin of 11.9 g/dl, blood white cell count of 11.3 × 10^9/l, and glucose of 134 mg/dl. The liver function tests revealed the following: total bilirubin of 3.7 mg/dl, direct bilirubin of 2.9 mg/dl, indirect bilirubin of 0.8 mg/dl, ALT of 143 U/l, AST 76 U/l, and alkaline phosphatase 155 U/l. The rest of the laboratories were within normal limits. Abdominal ultrasound displayed small stones in the gallbladder, along with wall thickening of approximately 2.5 mm, and pericholecystic fluid. The common bile duct was not dilated. The diagnosis was acute cholecystitis, and the patient underwent laparoscopic cholecystectomy. The specimen was divided by the surgeon, extracted stones, and sent to the pathology department. On gross examination, the excised gallbladder was received in two fragments, opened, and measured 80 mm in length with a 35 mm average diameter. The average wall thickness was 10 mm. The mucosa is dark green and velvety ( Fig. 1 ), and no gallstones were noted. Multiple sections were submitted. Microscopically, apocrine metaplasia with foci of clear metaplasia are identified, particularly in specific regions of the body and fundus. The examined tissue revealed the presence of acute inflammatory cells, including neutrophils and eosinophils (exceeding 15 eosinophils per high-power field), along with mucosal erosion, edema, congestion, activated fibroblasts, and the existence of biliary pigment in the examined tissue ( Fig. 2 ). Apocrine cells exhibited periodic acid-Schiff (PAS) positivity ( Fig. 3 ). The postoperative course was uneventful, and he was discharged the first day after the operation. His condition remained stable after three months of follow-up.

The periodic acid-Schiff reagent (PAS) staining image reveals the presence of glycolipid granules predominantly located in subapical regions within apocrine cells (400× magnification, PAS stain).

Apocrine metaplasia, specifically, involves the development of cells resembling those in apocrine glands, characterized by their distinctive cytoplasmic features [ 1 ]. Moreover, these apocrine cells usually assume a cuboidal or columnar appearance with frequent apical blebs or snouts [ 1 ]. Apocrine metaplasia is most commonly found in fibrocystic breast changes [ 1 ]. Nevertheless, its presence in the gallbladder has never been reported in the existing medical literature, marking a significant milestone in our understanding of gallbladder pathology.

The gallbladder, typically associated with bile storage and release, is not commonly linked with apocrine metaplasia, rendering this discovery particularly noteworthy.

Similarly, the presence of clear metaplasia, also known as clear cell change, a phenomenon where cells lose their usual staining characteristics, adds further complexity to the narrative [ 2 , 3 ]. Clear cell change, often observed in other organs like the cervix and lungs [ 3 , 4 ], has never been documented in the gallbladder.

Transitioning to the discussion of metaplasia within the biliary tract, two primary types are observed: gastric (pyloric) and intestinal. Pyloric gland metaplasia, resembling gastric pyloric-type glands, is the most prevalent, while intestinal metaplasia, characterized by the presence of goblet cells without a clear brush border, hence termed as ‘incomplete’ metaplasia, is less frequently encountered in gallbladder specimens. Notably, this form of metaplasia is believed to have a closer association with gallbladder carcinogenesis [ 5 , 6 ].

The development of both pyloric gland metaplasia and intestinal metaplasia is attributed to prolonged inflammation and the presence of gallstones [ 5 ]. However, in our case, apocrine and clear metaplasia occur during acute inflammation alongside gallstones.

Moreover, recent research has recognized foveolar metaplasia as another notable addition to the spectrum of metaplastic changes, characterized by the replacement of acidophilic cytoplasm with a voluminous mucinous appearance reminiscent of gastric/foveolar epithelium. Additionally, squamous metaplasia is observed infrequently within the biliary tract [ 6 ].

The coexistence of apocrine and clear metaplasia in the gallbladder challenges existing paradigms, suggesting potential factors like inflammation or hormonal influences. Although the direct association with acute cholecystitis remains unclear, the uniqueness of these findings demands further investigation into their implications and mechanisms.

While uncertainties persist in understanding gallbladder malignancies, particularly regarding metaplastic changes as potential precursors [ 7 ], it is crucial to recognize that the rarity of this condition may have limited comprehensive reporting within the gallbladder field. However, numerous cases of gallbladder clear cell carcinoma have been documented [ 7 ]. The possibility that this case’s pathological result represents a precancerous lesion can be explored by drawing parallels with similar occurrences in other organs [ 3 ]. Although the specific link remains uncertain, acknowledging reports from other organs provides valuable context to the discussion.

Consequently, further studies and comprehensive investigations into similar cases are necessary to elucidate potential connections and determine the clinical significance of such histopathological variations in gallbladder pathology.

In conclusion, our case report documents the first occurrence of apocrine and clear cell metaplasia in the gallbladder, representing a groundbreaking contribution to the field of gallbladder pathology. This unprecedented finding challenges conventional understanding and underscores the need for further research to explore the potential implications and underlying mechanisms of these extraordinary cellular transformations. Our work paves the way for a deeper understanding of gallbladder pathology and may inspire future investigations into the clinical significance of apocrine and clear metaplasia in this organ.

No conflict of interest.

There was no funding for this publication.

No ethical approval was required for this publication.

Informed and written consent from the patient was taken prior to publication.

Moatasem Hussein Al-janabi.

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Knowledge, attitude and practice of breast self-examination among female undergraduate students in the University of Buea

Fon peter nde.

Department of Nursing, Faculty of Health Sciences, University of Buea, P.B. 63, Buea, Cameroon

Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, P.B. 63 Buea, Cameroon

Jules Clement Nguedia Assob

Department of Biomedical Sciences, Faculty of Health Sciences, University of Buea, P.B. 63 Buea, Cameroon

Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Buea, P.B. 63 Buea, Cameroon

Tebit Emmanuel Kwenti

Anna longdoh njunda, taddi raissa guidona tainenbe.

The incidence of breast cancer is on the rise in many parts of Africa. In Cameroon, there were an estimated 2625 cases per 100,000 in 2012. The awareness of breast cancer preventive methods is therefore critical in the reduction of breast cancer morbidity and mortality. This study evaluated the knowledge, attitude and practice of breast self-examination (BSE), among female undergraduate students in the University of Buea.

The study comprised 166 female students of ages 17-30years (mean = 22.8 ± 3) sampled randomly. Data was collected by a pretested self-administered questionnaire.

Nearly three quarter (73.5%) of the respondents had previously heard of BSE. Only 9.0% knew how to perform BSE. Similarly, only 13.9% knew what to look for while performing BSE. Television (19.9%) was the main source of information on BSE. Although perceived by 88% of the respondents as important, only 3% had performed BSE regularly. Furthermore, only 19.9% of the respondents have been to any health facility to have breast examination. Overall, although a majority (63.3%) of the respondents had a moderate attitude towards BSE as an important method for early detection of breast cancer, just a modest 9.6% were substantially aware of it. Lack of knowledge on BSE was cited as the main reason for not performing BSE. A significant association was observed between knowledge and the practice of BSE (P = 0.029), and between attitude and the practice of BSE (P = 0.015).

Conclusions

These findings highlight the current knowledge gap that exists in the practice of BSE in the prevention of breast cancer in the study population. Sensitization campaigns and educational programmes ought to be intensified in order to address this issue.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1004-4) contains supplementary material, which is available to authorized users.

Breast cancer is the most common cancer among women in developed and developing countries [ 1 ]. Worldwide, over 1.15million cases of breast cancer are diagnosed every year [ 1 ], and 502,000 women die from the disease each year, making it second only to lung cancer as the cause of cancer related deaths among women [ 2 , 3 ]. Breast cancer incidence has been on the rise in many parts of Africa – studies performed in Cameroon [ 3 ] and Ghana [ 4 ] revealed that breast cancer is the most common malignant cancer in women. In Cameroon, the incidence of breast cancer was estimated at 2625 per 100,000 in 2012 [ 5 ]. Breast cancer is becoming an increasing urgent problem in low-resource regions where incidence rates have been shown to increase each year by as much as 5% [ 6 ].

The risk factors for breast cancer include advancing age [ 7 ], women with history or family history of breast cancer [ 8 ], women who started menstruation early or went through menopause late [ 9 , 10 ], and the use of hormonal replacement therapy (HRT) with combined estrogen and progesterone [ 11 , 12 ]. Breast cancer in the early stages typically do not produce symptoms but as the tumour enlarges, symptoms produced include; painless lump in the breast, lump under the armpit, breast pain, swelling or thickness of the breast’s skin, spontaneous discharge of the nipple particularly if bloody and erosion or inversion in the nipple [ 7 ].

The control of breast cancer in most developing countries including Cameroon is under the auspices of national control programmes promoted by the WHO [ 1 ], and this involves educating and screening young women for signs of breast cancer. The earlier breast cancer is detected, the better the effectiveness of the treatment and the likelihood of survival [ 1 ]. Breast cancer screening methods include breast self-examination (BSE), clinical breast examination and mammography, and these are usually done in combination [ 13 ]. Among these methods, mammography is the only method that has been proven to be effective, but the method is very costly, and is cost-effective and feasible in countries with good health infrastructure [ 1 , 7 ]. BSE is the recommended method in developing countries because it is easy, convenient, private, safe and requires no specific equipment [ 14 , 15 ]. Its purpose is to make women familiar with both the appearance and feel of their breasts as early as possible, so that they will be able to easily detect changes in their breast. Several studies have revealed that a positive association exists between the performance of BSE and detection of breast cancer [ 16 ], and most of the early breast tumour detection have been self-discovered [ 17 ]. In Cameroon, cancer surveillance system is not well organized as many deaths related to cancer are not reported nor recorded. Control of cancer including breast cancer is through the organisation of periodic screening campaigns which are often not very effective since they are organized in only the major urban centers [ 18 ]. Buea like most semi-urban areas in Cameroon, women often learn of BSE from health personnel. Sensitization through the media including radio, television are rare.

BSE for the early detection of breast cancer is not often done by women. In studies performed by Godazandeh [ 19 ], and Nafissi et al. [ 20 ], only 17% and 12% of women respectively were observed to perform BSE monthly. This does not differ from what transpire among health personnel. In one study, only 14% of nurses and midwifes were observed to regularly perform BSE [ 21 ]. As a result, most cases of women diagnosed with breast cancer are usually in an advanced stage of the disease. In a study performed in Ghana, 70% of women who were diagnosed with breast cancer were already in an advanced stage [ 22 ]. Although BSE is a simple, quick and cost-free procedure, it appears that many women either perform it incorrectly or not at all. The purpose of this study was to evaluate the knowledge, attitude and practice of BSE among female undergraduate students of the University of Buea, in order to generate data that may be useful in designing interventions aimed at creating awareness of BSE as a screening method for the early detection of breast cancer.

Study design and settings

In a cross sectional descriptive study which lasted from April to July 2014, female undergraduate students were randomly selected in the University of Buea (commonly referred to as UB). UB is located in Buea (coordinates: 4°10′N 9°14′E) in the South West region of Cameroon. The University of Buea is one of the two Anglo-Saxon state universities in Cameroon and is a center of attraction for youths who either move there for studies or benefit from the economy triggered by the presence of the university.

Data collection

Participants were selected proportionately according to the population of the various academic levels by simple random sampling. Written informed consent were obtained from all the participants prior to data collection.

Data were collected using a self-administered semi-structured questionnaire. The questionnaire was pretested using ten (10) students selected from a neighboring higher institution of learning before the final study. Printed copies of the questionnaire were handed to the respondents in person. To ensure confidentiality, no name was collected, instead codes were used to identify the respondents. Furthermore, the respondents were also provided with an envelope to seal the questionnaire upon completion before submission.

Ethical approval for the study was obtained from the Faculty of Health Sciences Institutional Review Board (FHS IRB) of the University of Buea, Cameroon. Administrative clearance was obtained from the Delegation of Public Health, South West Region of Cameroon.

Assessment of knowledge on BSE

There were 14 knowledge indicators used to evaluate the respondents. Knowledge was scored on 14, one for each indicator. Respondents who scored between 10 and 14 were considered as substantially aware of BSE, scores between 7 and 9, as partially aware, and scores between 0 and 6 as not aware.

Assessment of attitude towards BSE

There were 10 attitude indicators used to evaluate the respondents. Attitude was scored on 20, 2 for every response to the indicators which demonstrated that the respondent was highly in favour of BSE and 1 for every response which demonstrated that the respondent was partially in favour of BSE and 0 for response that was not in favour of BSE.

Data analysis

Data from the questionnaire was processed using Epi Info version 7.1.3.0 (Epi Info™, CDC) and analysed using statistical package for the social sciences (SPSS) version 17.0 (SPSS Inc., USA). Statistical analysis performed included the Pearson Chi-square test to determine the association between knowledge and attitude stratified according to the scores, and the practice of BSE. Statistical significance was set at P < 0.05.

Characteristic of study population

One hundred and eighty two (182) students were selected to participate in the study and 166 (91.2%) completed and returned the questionnaires. The respondents were between 17 and 30 years (mean ± SD = 22.8 ± 3) of age. Among the 166 respondents, 151 (91%) were still single while 15(9%) were married. Five (3%) of the 166 respondents had a family history of breast cancer.

• Knowledge on BSE

Nearly three-quarter (73.5%) of the respondents had heard about BSE before (Table  1 ). Approximately 4 in 10 (37.3%) of the respondents were aware that BSE should be performed monthly. Very few (9.0%) of the respondents actually knew how to perform BSE. Furthermore, only a few (13.9%) knew what to look for while performing BSE. A majority (88.6%) of the respondents perceived BSE as an important technique in the early detection of breast cancer. The other indicators are summarized in Additional file 1 : Table S1. Overall, just a modest 9.6% of the respondents were substantially aware of BSE, 53% were partially aware, and 37.4% had never heard of BSE.

Knowledge and sources of information on BSE among the 166 respondents

*Knowledge on BSE was scored on 14. Substantially aware was considered as score between 10 and 14; partially aware, 7–9; and not aware, 0–6.

The main sources of information on BSE cited by the respondents were television (19.9%), friends (19.3%) and doctors (17.5%) (Table  1 ).

• b) Attitude towards BSE

Approximately 6 in 10 (59%) of the respondents were in accord that they can actually detect breast cancer by themselves (Table  2 ). Half (51.4%) admitted that they were not afraid to detect breast cancer meanwhile 26.5% were afraid. A majority (88%) of the respondents approved that BSE was important and useful in the early detection of breast cancer. A majority (81.9%) of the respondents cited that they were motivated by publicity and campaigns to perform BSE. Approximately 8 in 10 (77.1%) of the respondents did not consider BSE as a “disgraceful” practice. The other indicators used to evaluate the attitude of the respondents are summarized in Additional file 2 : Table S2. Overall, 34.3% of the respondents were highly in favour of BSE, 63.3% moderately in favour, and only 2.4% were not in favour.

Attitude of the 166 respondents towards BSE

*Attitude was scored on 20. High attitude was considered as score between 17 and 20; Moderate attitude, 10–16; and Low attitude, 0–9.

Health personnel (15.1%) and peers (12.7%) were cited by the respondents as the main factors that influenced them to perform BSE (Table  2 ).

• c) Practice of BSE

Only 62 (41%) of the 166 respondents in this study had ever performed BSE, 49 (29.5%) claimed to have performed BSE within the past 12 months. Only 5(3%) had performed BSE regularly (10-12 times) within the past 12 months.

Among the 49 respondents who had performed BSE within the past 12 months, 9 (18.4%) admitted to have noticed one or more of the following breast abnormalities: abnormal pains 2 (22.2%), abnormal lump 1 (11.1%), discharge of pus from the nipple 1 (11.1%), abnormal size increase 1 (11.1%) and others 4 (44.4%).

In this study, only 19.9% of the respondents had ever been to any health facility to have their breast examined. Only 36.1% of the respondents said that they had encouraged other people to practice BSE.

The main reason for not performing BSE as cited by the respondents were the lack of knowledge 73 (44%); followed by the reason that the respondents did not have any signs of breast cancer 61 (36.7%); forgetfulness 33 (19.9%); lack of time 16 (9.6%); fear of finding lumps 12.9 (7.8%); and embarrassment 8 (4.8%).

In this study, a significant association was observed between knowledge and the tendency to perform BSE (χ 2  = 6.98, df = 4, P = 0.029), and between attitude and the tendency to practice BSE (χ 2  = 10.58, df = 4, P = 0.015).

As mentioned earlier, the incidence and mortality due to breast cancer is on the rise in many parts of Africa. Breast cancer is preventable if detected early enough [ 1 ]. There are several methods by which the early onset of breast cancer can be detected including breast self-examination. Although there are some controversies regarding the techniques used in performing BSE, the method is still considered as relevant, and is therefore recommended in developing countries where access to diagnostic and curative facilities may be a problem [ 14 , 15 ]. The rising trend in the incidence of breast cancer in Africa may be an indication that many young women still do not screen for the early detection of breast anomaly. This study performed among female students in the University of Buea was aimed at evaluating their knowledge, attitude and practice of BSE.

The level of practice of BSE observed in this study was generally low. Only three in ten of the students had performed BSE within 12 months prior to the study. Moreover, only 2 in 10 of the students have ever been to any health facility to have their breast clinically examined. Similar findings have been reported among students in Malaysia [ 23 ]. Furthermore, among those who had performed BSE before, only 3% practiced it regularly on a monthly bases, which is not different from what was observed in the study in Malaysia [ 23 ]. An earlier study performed among women in Buea had also revealed that women did not perform BSE regularly [ 3 ]. The main factor that could be attributed to this is the lack of knowledge on BSE which was generally observed to be unsatisfactory, with only 9.6% of the respondents substantially aware of BSE as a method. Lack of knowledge has also been implicated as the main reason for the poor practice of BSE in similar studies performed elsewhere [ 24 , 25 ]. A majority (88.6%) of the respondents in this study perceived BSE as an important technique in the early detection of breast cancer, but just 9% knew how to perform it, and only 13.9% knew what to look for while performing BSE. Similar observations have been reported elsewhere [ 23 , 25 ]. The main source of information on BSE as cited by the respondents in this study was television which is not different from what has been observed in studies performed elsewhere [ 23 , 25 - 27 ]. This finding shows that the media especially television can be used to sensitize women on the importance of BSE, as well as instruct women on how to perform BSE.

Physicians, nurses and other health personnel also have a role to play in sensitizing and educating young women on the importance of BSE and how it should be performed, which is evident in this study as 15.1% of the respondents cited health personnel and peers as their main influence for practicing BSE. This observation is in accordance with the study among university students in Ghana [ 25 ]. The general attitude of the respondents in this study towards BSE was moderate, implying that just a little motivation may easily sway their attitude towards highly in favour of practicing BSE. Motivation to practice BSE could be through the organisation of health campaigns and publicity as was observed in this study. Fear of detecting breast cancer was one of the factors cited by the respondents for not practicing BSE. Educating these young women could also help instill some courage in them. Further studies will be required to throw more light on the role of health personnel and the media on the uptake and practice of BSE in women in the study area.

Although this study has revealed the inadequate knowledge on the practice of BSE by female undergraduate students in the University of Buea, as well as provided information on the possible methods that can be used to improve on the interest and practice of BSE among young women, the study is however limited in that it is confined to a sample of young educated women in a semi-urban area which does not necessarily reflect what transpire among women in rural areas. Furthermore a majority of students in the University of Buea are from the two English speaking regions of Cameroon (i.e. the North West and the South West). All of these limits its generalization to the entire population of Cameroonian women. The study could also be limited to the fact that it was based on self-report – women were not assessed on their ability to correctly perform BSE, which may have led to the overestimation of their knowledge on how to perform BSE.

Our findings indicate that a majority of female students in the University of Buea do not practice breast self-examination as a screening method for the early detection of breast cancer. Also a majority of the students have never been to any health facility to have their breast examined. The attitude of the students was observed to be moderately in favour of BSE but the knowledge on BSE was generally unsatisfactory which could have affected the practice of BSE by these young women. Sensitization campaigns using the audiovisual media and other programs designed to create awareness about BSE should be intensified in order to change the attitude of young women in the study area towards the practice of BSE in the prevention of breast cancer.

Acknowledgement

The study was funded through the departmental research grant of the Department of Nursing of the Faculty of Health Sciences, University of Buea. The funding body had no role in the design, in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

Abbreviation

Additional files.

Other indicators used to evaluate the knowledge of the 166 respondents.

Other indicators used to evaluate the attitude of the 166 respondents toward BSE.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

FPN conceived the study, participated in its design and coordination, and critically revised the manuscript. JCNA participated in the design of study, statistical analysis and critically revised the manuscript. TEK participated in data collection, statistical analyses, conducted the literature search and review, and wrote the first draft. ALN participated in the design and coordination of the study, statistical analysis and critically revised the manuscript. TRGT participated in data collection, statistical analysis, conducted the literature search and review, and wrote the first draft. All authors read and approved the final manuscript.

Contributor Information

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