Knowledge and Practice on Breast Self-Examination and Associated Factors among Summer Class Social Science Undergraduate Female Students in the University of Gondar, Northwest Ethiopia

Background Breast cancer is a global health concern and a leading cause of morbidity and mortality among women. Early detection of breast cancer contributes to timely linkage to care and reduction of complications associated with breast cancer. In this context, breast self-examination is helpful to detect breast abnormalities particularly in settings with poor access to healthcare for clinical breast examination and mammography. Thus, all women in such settings are highly encouraged to perform breast self-examination regularly, and shreds of evidences are compulsory in this perspective. In the study setting, there was a scarcity of evidence on breast self-examination. Therefore, this study is aimed at assessing knowledge and practice on breast self-examination and its associated factors among summer class female students of social science at Maraki Campus, University of Gondar, Ethiopia. Methods An institution-based cross-sectional study was conducted from July 01 to September 15/2018. A total of 398 female summer students were included in the study. A simple random sampling technique was utilized to select the study participants, and interviewer-administered structured questionnaires were employed to collect the data. The data were then entered into Epi info version 7.0, and analysis was done by SPSS version 20.0. A bivariable and multivariable logistic regression model was fitted, and the level of significance was declared based on adjusted odds ratio with its 95% CI and a p value ≤ 0.05. Result The proportion of students having a good knowledge and practice of breast self-examination was found to be 27.6% (95% CI: 22.9, 32) and 17.4% (95% CI: 13.8, 21.6), respectively. In the multivariable logistic regression analysis, urban residency (AOR = 2.50; 95% CI: 1.27, 4.94) and discussion with someone on breast self-examination (AOR = 4.57; 95% CI: 2.42, 8.65) were predictors of good knowledge, whereas family history of breast cancer (AOR = 7.14; 95% CI: 1.75, 25), discussion with someone on breast self-examination (AOR = 3.85; 95% CI: 1.82, 8.33), and good knowledge on breast self -examination (AOR = 12.02; 95% CI: 5.97, 24.20) had been significantly associated with breast self-examination practice. Conclusion In this study, the proportion of students with good knowledge and practice towards breast self-examination was lower than most of the studies done so far. The predictors of breast self-examination are related to lack of information. Thus, awareness creation on breast self-examination would be helpful in this context.


Introduction
Breast cancer (BC) is a global health concern and a leading cause of morbidity and mortality among women [1]. It is among the top three leading causes of cancers and top five causes of deaths of cancers among women [2]. Globally, BC recent evidences exhibit that about 25% of new cancer cases and 15% of cancer deaths among females in globe are due to BC [3]. For instance, in 2018, it is estimated that about 627,000 women died from BC worldwide [4]. Breast cancer incidence rate (BCIR) remains highest in more developed regions, but mortality is relatively much higher in less developed countries [3,4]. This is mostly due to lack of advanced laboratory investigations for early screening and diagnosing BC in resource limited countries [5].
Early detection of BC plays a key role for better outcomes, and BC is preventable and treatable if it is detected and treated early [4]. In this aspect, there are two early detection strategies for BC. These are early diagnosis and screening. Screening consists of testing women to identify cancers before any symptom appears and can be undertaken through mammography, clinical breast exam (CBE), and breast selfexam (BSE) [3,4]. Although clinical breast examination and mammography are ideal for BC diagnosis, access to healthcare in most sub-Saharan African (SSA) countries may be a major challenge. Therefore, BSE is the most feasible option in such settings as it is easily workable, at any place and time [2,4]. Therefore, efforts need to be harmonized to increase awareness and practice of BSE among women. In this regard, gathering reliable and representative data on each segment of the population is an integral part of generating evidence-based strategies to improve women's health thereby to achieve target four of Sustainable Development Goal (SDG) three [6].
A recent scoping review on BSE among women in SSA demonstrates limited published research and revealed varied level of knowledge ranging from 8.7% [5] to 98.9% [7] and practice ranging from 11.7% to 78%. It further suggests that BSE practice remains a challenge in SSA [8]. In Ethiopia, studies regarding BSE largely focused on health care workers and health science students and were conducted in large cities of the country mainly at referral hospitals [9][10][11][12][13]. In this context, a systematic review (SR) and meta-analysis (MA) on BSE practice among female health care workers depicts that the pooled prevalence of BSE is 56.31% ranging from 32.5% to 80.7% and predicted by good knowledge, positive attitude, and family history of BC [14]. A more recent review article on BSE among all women in Ethiopia shows that the pooled BSE practice is 36.72% [15]. The regional distribution BSE ranged from 21.2% in Tigray to 61.5% in Gambela, whereas the pooled BSE practice in Amhara region is reported to be 40.5% [15]. However, as to the authors' deep review, there were limited shreds of evidences regarding BSE among social science and summer students in particular. Therefore, the current study is aimed at assessing knowledge and practice on BSE and associated factors among summer female social science students at Maraki Campus, University of Gondar, Northwest Ethiopia, 2018.

Study Design and
Setting. An institution-based crosssectional study was conducted from July 01 to September 15/2018. The study was carried out at Maraki Campus of University of Gondar which is located in Amhara national regional state at about 740 kilometers away from Addis Ababa, the capital city of Ethiopia. The University of Gondar (UoG) is one of the famous higher education institutions in Ethiopia. The University has five campuses, namely, College of Medicine and Health Sciences (CMHS), Tewodros Campus (Campus of Natural Sciences), Maraki Campus (Campus of Social Sciences), Fasil Campus (Campus of Technology), and Teda Campus (Campus of Agriculture). Maraki Campus was selected because it is the only campus of social science students who are less likely to get health-related information through their academic courses as compared to the natural science students.

Study Population.
In Maraki Campus, a total of 2,607 female students have been registered for summer program in different schools and colleges in 2018. Summer female students whose name had been registered at the registrar of Maraki Campus during the study period had been included in the study, whereas those female students who had been registered but leaving the campus due to different reasons had been excluded.

Sample Size Determination and Sampling
Technique. Sample size was determined for each specific objective by using Open-Epi Version 3 software. Accordingly, the largest sample size was found to be 362 which was calculated with the following assumptions: ratio between female students knowing the three positions of BSE and those students who were not aware of the three positions of BSE-1 : 1, odds ratio-2.25, power-80%, confidence interval-95%, and percent of unexposed group with outcome-12.8% and that of exposed group with outcome-50.3% [16]. After adding 10% nonresponse rate, the final sample size was turned to be 398.
The list of all female summer students had been obtained from the Campus's registrar. After allocating students' list to each college and school proportionally, the desired samples had been selected by using simple random sampling technique.

Study
Variables. This study has two outcome variables. These are knowledge and practice of BSE.
The explanatory variables included sociodemographic and general students' characteristics like age, residence, educational status, occupation, marital status, family history of breast cancer, prenatal visit, personal history of breast cancer, personal history of breast complication, history of contraceptive use, access to media, discussion with someone on the importance of BSE, and knowledge on BSE.
2.5. Operational Definitions. Knowledge on BSE status was defined as awareness of students regarding BSE as measured by a structured knowledge questionnaire on BSE. Accordingly, it had been dichotomized as good knowledge (a score of ≥40% correct responses) and poor knowledge (a score less than 40% of the correct responses) [17]. Similarly, about ten 2 Journal of Cancer Epidemiology criteria (checklists) had been employed to assess the respondents' BSE practice. Accordingly, the cut-off point for good BSE practice is ≥40% of correct response, whereas that of poor BSE practice is <40% [17].

Data Quality Management and Collection
Methods. Data were collected by trained female health care workers through an interviewer-administered structured questionnaire. The questionnaire was prepared in English language and translated into local (Amharic) language and back to English to check for accuracy and consistency. Pretest was done on 5% of the sample size among female students at the natural science campus prior to the commencement of actual data collection.
2.7. Data Analysis. The data had been checked for its completeness and missing information before leaving the participants. Thereafter, data were entered into Epi Info version 7 and then exported to SPSS version 20 for analysis. A bivariable and multivariable regression model was fitted. All explanatory variables with a p value of <0.2 in the bivariable logistic regression analysis were candidates for the multivariable logistic regression model. Finally, statistically significant association had been declared based on AOR with 95% CI and its p value of ≤0.05.

Sociodemographic and General Characteristics of the Participants.
A total of 384 participants responded to the questionnaire making the response rate of 96.5%. The age of the study participants ranged from 20 to 45 years with the median age of 28 years (IQR = 6). The majority (56.8%) of the respondents were urban residents. More than half (58.1%) of the participants had ever married. Most (78.9%) of the respondents were government employees, and more than half of the respondents (53.4%) were self-sponsored for education. And one-third of the respondent was third year students. Considerable proportions (5.2%) of the respondents reported that they had a family history of BC, and about 25 (7.0%) of the participants had a history of breast complication. Nearly half (48.2%) of the students had used contraceptive methods, and nearly one-sixth (16.2%) of the respondents had ever discussed with someone on the importance of BSE ( Table 1).

Knowledge and Practice on BSE.
The proportion of students reporting good knowledge on BSE was obtained to be 27.6% (with 95% CI: 22.9, 32). In addition, a notable number (41.7%) of the respondents had ever heard about BSE. Nearly one-fourth (22.9%) of the study participants knew how to perform BSE, and about 43.5% respondents said that a girl should start BSE at the age of between 20 and 30. The BSE methods as reported by students include inspection (3.6%), palpation (17.4%), and both inspection and palpation (28.6%) ( Table 2).
Concerning BSE practice, the overall proportion of students having good practice on BSE was found to be 17.4% (with 95% CI: 13.8, 21.6), and about 20.6% of the participants reported that they had ever practiced BSE (Table 3).

Factors Associated with Outcome
Variables. All explanatory variables had been tested in the bivariable logistic regression with each outcome variable (i.e., knowledge and practice

Discussion
Breast cancer screening is one potentially important strategy in achieving early detection of cancer thereby facilitating early treatment and reducing women's death of BC [12].
Most healthcare facilities in Ethiopia do not have advanced laboratory investigations for screening and diagnosing of BC. Fortunately, BSE is an alternative cost effective and feasible screening strategy which is easily workable in any place and time in resource-limited settings [5]. Hence, this study assessed knowledge and practice on BSE and associated factors among female summer class university students.
In this study, the proportion of students with good knowledge on BSE was 27.6%. This finding is comparable with studies done in Debre Berhan, Ethiopia (30%) [16], Eretria (30.1%) [18], and Nepal (27%) [19]. However, the proportion of knowledge in this study is much lower than what was reported in India (93.3%) [17], Korea (87.0%) [20], Saudi (79.0%) [21], Uganda (76.5%) [22], Nigeria (55.4%) [23], and Egypt (63.4%) [24]. It is also lower than local reports in Ethiopia such as in Bahir Dar (75.3%) [11], Harare (93.6%) [9], and Jimma (89%) [25]. The observed Journal of Cancer Epidemiology discrepancy could be due to the difference in socioeconomic and demographic characteristics among the study population and difference in professions among the study participants. On the contrary, the magnitude of good knowledge on BSE is higher than that of reported in Adama University (8.7%) [5]. This disparity could be attributed to the high cut-off point (80-100%) in the operational definition of "good knowledge" in the former study [5] unlike that of ≥40% in the current study. According to the current analysis findings, respondents' BSE knowledge is independently predicted by being urban resident and having ever discussion with someone else on BSE. The odds of having good knowledge on BSE were 2.5 times higher among urban residents than rural dwellers. This finding is supported by previous study done at Jimma University [25]. The possible explanation for this association could be due to the fact that respondents who reside in the urban area are likely to have better access to source of information such as mass media, Internet, and health care professionals. Similarly, good BSE knowledge is also predicted by ever discussion with someone on BSE. Hence, participants who ever discussed with someone on BSE were 4.5 times more likely to have good knowledge as compared to their congruent. This is possible as participants who discussed with someone on BSE are likely to gain more information than others.
In this study, about one in six (17.3%) of students had better BSE practice. The finding is similar with that reported in the study done in Silicon Valley of India (19.1%) [26], nationwide survey in Korea (16.1%) [20], and Addis Ababa university in Ethiopia (21.4%) [27]. The agreement in magnitude might be ascribed to the nonhealth profession of the respondents in common [26,27].
On the contrary, the proportion of BSE practice is higher as compared to the reports of previous studies done in Egypt (7.4%) [24] and Eritrea (11.7%) [18]. The observed disagreement in magnitude might be attributed to dissimilarity in sociodemographic and cultural characteristics of the respondents.
The study revealed that BSE practice is significantly associated with family history of BC, discussion with someone on BSE, and knowledge on BSE.
The current study revealed that the odds of having good practice of BSE were 7.14 times higher among students with family history of BC than those who had no. This finding is also supported by previous studies [14,15,29]. This could be explained by the fact that students having family history of BC are more likely to get the opportunity to notice the burden as well as the preventive and screening measures of BC including BSE than their counters.
By logic, having free discussion with someone on the important common public health issues is anticipated to foster awareness on that particular matter. The current analysis advocated the importance of carrying out free discussion on BSE. Accordingly, respondents who ever discussed with someone on BSE were 3.85 times more likely to do better BSE practice as compared to those students who had never discussed. Similar finding was also reported from the studies conducted in West Gojam Zone [13]. This could be explained by the reality that participants who discussed with someone Evidences support that people with better knowledge towards health promotion actions are more likely to have better compliance with endorsed disease-preventive practices such as BSE [30,31,36]. The result of current analysis also corroborates this fact. Thus, students having good knowledge on BSE were 12.02 times more likely to perform better BSE practice compared with those with poor knowledge. This finding is in agreement with results reported from studies conducted in India [26] and Nigeria [29]. It is also aligned with the findings of local studies done in Addis Ababa [27], Debre Tabor [33], Debre Birhan University [16], and West Shoa [34] and SR and MA in Ethiopia [14,15]. This might be due to the logic that students with better knowledge on the way how to do, the time when to do, and the purpose why to do BSE are more likely to test their health status by themselves in this particular issue and are likely to be enthused to know the result. This implies that awareness creation towards BSE is a pivotal part of prevention, early diagnosis, and treatment of breast cancer.
Finally, the authors would like to recommend that readers need to interpret the findings with cautions as the study recruited more specific study participants.

Conclusion
This study revealed that the proportion of good knowledge and practice of BSE among students was lower than many of other previous studies. The odds of having good knowledge were higher among respondents who resided in urban areas and ever had discussion on BSE. On the other hand, the independent predictors of good BSE practice included family history of BC, ever discussion with someone on BSE, and good knowledge on BSE. Thus, stakeholders need to work more on awareness creation on BSE taking the identified predictors of good BSE knowledge and practice into account. Moreover, the University of Gondar would better rearrange and deliver a planned tutorial on BSE targeting

Data Availability
The datasets employed in the current study can be available from the corresponding author upon the reasonable request.

Ethical Approval
The ethical clearance was obtained from the Institutional Review Board (IRB) of University of Gondar through School of Midwifery, College of Medicine and Health Sciences. An official letter of cooperation was written by the School of Midwifery to Maraki Campus.

Consent
Informed written consent of the respondents was then obtained and signed at the participant's consent sheet format after respondents got full information about the study. Moreover, the study participants were interviewed by female data collectors and individually to maintain privacy. In addition, confidentiality was maintained by numeric coding of questionnaires. The participants were also informed that they have full right not to participate in the study or to stop participation at any time during the interview.