International Journal of Breast Cancer

Volume 2013 (2013), Article ID 814395, 6 pages

http://dx.doi.org/10.1155/2013/814395

Research Article

Assessment of Factors Associated with Breast Self-Examination among Health Extension Workers in West Gojjam Zone, Northwest Ethiopia

Muluken Azage, Gedefaw Abeje, and Alemtsehay Mekonnen

Department of Public Health, College of Medicine and Health Sciences, Bahir Dar University, P.O. Box 79, Bahir Dar, Ethiopia

Received 23 July 2013; Accepted 16 September 2013

Academic Editor: Robert-Alain Toillon

Copyright © 2013 Muluken Azage et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Background. Early detection of breast cancer using breast self-examination (BSE) plays an important role in decreasing its morbidity and mortality. Objective. To identify factors associated with BSE among health extension workers in Northwest Ethiopia. Methods. Cross-sectional study design was employed from October to November, 2012 in West Gojjam Zone of Amhara region. Simple random sampling technique was used to recruit a total of 390 health extension workers (HEWs). A structured Amharic questionnaire was used to collect the data. Data were entered and analyzed using SPSS statistical package version 16.0. Result. This study found that 37% of HEWs had ever practiced BSE and 14.4% practiced it regularly. The three main reasons for not doing regular BSE were no breast problem (53.2%), not knowing the technique of BSE (30.6%), and not knowing the importance of BSE (21.4%). Discussion with families on BSE and history of breast examination by health professionals were found significantly associated with ever practice of BSE. Conclusion. BSE practice was found low in this study. Having information on the importance of BSE was predictor of BSE practice. Therefore, it is important to give training on BSE techniques and its role on breast cancer prevention for HEWs.

1. Introduction

Globally, about 25 million people are living with cancer [1]. Recent estimates showed that cancer incidence will almost triple by 2030, with 20–26 million new cancer diagnoses and 13–17 million deaths [2]. Cancer is the second leading cause of death in the world. More than 70% of all cancer deaths occurred in low and middle-income countries [1, 3].

Of all types of cancers, breast cancer is the most common cancer among women both in developing and developed countries [4, 5]. It is the leading cause of death among women aged between 40 and 55 years [6]. Recent global cancer statistics indicated that breast cancer incidence is rising at a faster rate in populations of developing countries [7, 8]. Several studies reported that breast cancer is the most common cancer, and is the principal cause of cancer deaths in women and is therefore a world concern [9–17].

Early detection of breast cancer plays an important role in decreasing its morbidity and mortality. Breast self-examination (BSE) is one of the screening methods for early detection of breast cancer [18–20]. However, women in developing countries do not perform breast self-examination for various reasons [21].

Cancer was reported the second out of the ten top cancers registered at Tikur Anbesa Radiotherapy center [6]. Most healthcare facilities in Ethiopia do not have advanced laboratory investigations for diagnosing breast cancer. In resource scarce countries like Ethiopia, BSE should be promoted for early detection of breast cancer to prevent related morbidities and mortalities.

Therefore, the aim of this study was to determine BSE and identify factors associated with BSE among HEWs. Health extension workers (HEWs) are the main actors to implement health extension packages and to provide primary healthcare services at community level in Ethiopia. Thus, if BSE is integrated with these packages, deaths from breast cancer can be averted by early detection and treatment. Moreover, findings from the study can provide information on BSE for governmental health officials and other nongovernmental organizations which are working on health particularly on cancer to raise awareness amongst women about breast cancer and the role of BSE in breast cancer prevention and control.

2. Methods and Materials

Cross-sectional study design was employed in West Gojjam Zone of Amhara regional state, Ethiopia, from October to November, 2012. West Gojjam Zone is one of the 13 Zones of the region which had a total of 845 HEWs at the time of the study [22]. All health extension workers who were working at the time of the study in West Gojjam Zone were the study population. The total sample size was determined using single population proportion formula , where = proportion of BSE among HEWs is unknown and was as assumed 50%, at 95% CI (1.96) and = 5% margin of error (0.05). By considering 5% nonresponse, the final sample size was 403. HEWs who had mastectomy were excluded from the study. HEWs were selected by simple random sampling technique using list of HEWs of Zonal Health Office as sampling frame.

Data were collected using self-administered structured Amharic questionnaire. The questionnaire had three parts. The first part was about sociodemographic characteristics of respondents, part two was about knowledge of breast cancer and breast cancer risk factors, and the last part was about breast self-examination practice. One day training was given for data facilitators and three supervisors. The completeness of questionnaires was checked every day by supervisors and principal investigators. Pretest was done before the questionnaire was administered. Data were entered and analyzed using SPSS statistical package version 16.0. Descriptive statistics were used to summarize data. Logistic regression analysis was done to identify factors associated with breast self-examination. Adjusted odds ratios with 95% confidence intervals were calculated for each of independent variables using backward stepwise binary logistic regression model to control confounder effect for the outcome variable.

The study was conducted after getting ethical clearance from IRB of the Bahir Dar University. Permission was obtained from the respective Zonal and Woreda Health Offices. Informed verbal consent was obtained from the study participants after telling the objective of the study. Confidentiality and privacy were insured for collected information from the study participants.

3. Result

Three hundred ninety five HEWs participated in the study. The mean age of the study participants was 23.8 ± 2.7 that ranged from 16–37 years. Almost half of the study participants were married. Majority of the participants were Orthodox Christians (98%) and 91.9% had a certificate. Of the total study participants, about 29.6% and 85.1% had television and radio, respectively. Seventy two percent and 44.1% of the education status of mothers and fathers of study participants were illiterate, respectively (Table 1).

Table 1: Sociodemographic characteristics of health extension workers in West Gojjam Zone, Northwest Ethiopia, October 2012.

Variables
Total study participants

Number (395)
Percent

Age

    15–24
266
67.3

    25–34
126
31.9

    35–44
3
0.8

Marital status

    Married
196
49.6

    Unmarried
155
39.2

    Widowed
5
1.3

    Divorced
7
1.8

    Union
32
8.1

Education status

    Certificate
363
91.9

    Diploma
32
8.1

Religion

    Orthodox
387
98

    Muslim
5
1.2

    Protestant
3
0.8

TV at home

    Yes
117
29.6

     No
278
70.4

Radio at home

    Yes
336
85.1

    No
59
14.9

Father education status

    Illiterate
174
44.1

    Read and write
181
45.8

    Elementary school
22
5.6

    Secondary school and above
18
4.6

Mother education status

    Illiterate
285
72.2

    Read and write
95
24.1

    Elementary school
8
2.0

    Secondary school and above
7
1.8

Majority of the HEWs (93.4%) had no breast problem so far and 92.3% of the participants had no history of breast cancer from their families and/or relatives. About 59% were knowledgeable on risk factors of breast cancer. Almost half of HEWs reported that every woman is at risk of acquiring breast cancer. Three hundred twenty eight HEWs reported that breast cancer is communicable and 92.7% of the participants reported that breast cancer is a killer disease. Of the total participants, 81.3% reported that breast cancer is treatable if it is detected early and only 30.4% mentioned at least one methods of screening for breast cancer (Table 2). The methods of screening for breast cancer reported by health extension workers were clinical breast examination (22.3%), breast self examination (14.4%), mammogram (3%), ultra-sound (11.1%), and X-ray (7.1%).

Table 2: Knowledge of HEWs on breast cancer in West Gojjam Zone, Northwest Ethiopia, October 2012.

Variables
Total study subject

Number (395)
Percent

Knowledge of risk factors of breast cancer

    Knowledgeable
233
59

    Less knowledgeable
162
41

Every woman has a chance of acquiring breast cancer

    Yes
191
48.1

    No
204
51.6

Breast cancer is communicable

    Yes
67
17.0

    No
328
83.0

Breast cancer is a killer disease

    Yes
366
92.7

    No
29
7.3

Know at least one methods of screening for breast cancer

    Yes
120
30.4

    No
275
69.6

If breast cancer is early detected, it is treatable

    Yes
321
81.3

    No
74
18.7

Of all HEWs, only 14.4% practiced BSE regularly (every month) and 147 (37.3%) HEWs reported that they practiced BSE during their life time. The three main reasons for not doing BSE were no breast problem (53.2%), not knowing BSE technique (30.6%), and not knowing the importance of BSE (21.4%). One hundred thirty (32.9%) HEWs had discussions with families on the importance of BSE and 24.3% of participants had got information on BSE from health professionals. Almost 90% of HEWs had never examined their breast by health professionals (Table 3).

Table 3: Breast self examination practice among HCWs in West Gojjam Zone, Northwest Ethiopia, October 2012.

Variable
Number
Percent

Ever practiced breast self-examination ()

    Yes
147
37.3

    No
248
62.7

How frequent have you practiced BSE ()

    Every month
56
14.4

    Once every 6 months
70
17.9

    Once every 12 months
21
5.4

    Never practiced
248
62.7

Reasons for not doing breast self-examination ()*

    I don’t have breast problem
132
53.2

    I don’t think as I should be examined
44
17.8

    It is not comfortable
5
2.0

    I don’t know the technique
76
30.6

    Carelessness
22
8.9

    I don’t believe its importance
11
4.4

    I don’t know its importance
53
21.4

Discussion with someone on the importance of BSE ()

    Yes
130
32.9

    No
265
67.1

Got information on BSE by health professional ()

    Yes
96
24.3

    No
299
75.7

History of breast examination by health professional? ()

    Yes
43
10.9

    No
352
89.1

Multiple responses are there.

In bivariate analysis, breast problem so far, discussion with families on the importance of BSE, and history of breast examination by health professional were significantly associated with practice of BSE among HEWs (Table 4). However, discussion with families on the importance of BSE and ever had breast examination by health professionals remained significantly associated with practice of BSE by entering those variables, whose value is less than 0.2 in multivariate analysis. Those HEWs who had discussion with families on the importance of BSE {AOR : 5.51, 95% CI: (3.45, 8.79)} is 5.51 times more likely to practice BSE than those HEWs who had no discussion with someone on the importance of BSE. Similarly those HEWs who examined their breast by health professional {AOR : 2.69, 95% CI : (1.31, 5.52)} were 2.69 times more likely to practice BSE than their counter parts (Table 4).

Table 4: Factors associated with breast self-examination among HEWs in West Gojjam Zone, Northwest Ethiopia, October 2012.

Variables
Ever practice of BSE
COR (95%CI)
AOR (95%CI)

Yes
No

Age

    15–24
102
164
1.24 (0.11, 13.89)

    25–34
44
82
1.16 (0.75, 1.80)

    35–44
1
2
1.00

TV at home

    Yes
47
70
1.20 (0.40, 1.50)

    No
100
178
1.00

Radio at home

    Yes
128
208
1.30 (0.60, 1.65)

    No
19
40
1.00

Training on BSE

    Yes
7
10
1.19 (0.44, 3.20)

    No
140
238
1.00

History of breast problem

    Yes
15
11
2.45 (1.09, 5.49)

    No
132
237
1.00

History of breast cancer from families/relatives

    Yes
6
22
0.43 (0.17, 1.10)

    No
141
226
1.00

Discussion with someone on the importance of BSE

    Yes
84
46
5.86 (3.37, 9.79)
5.51 (3.45, 8.79)*

    No
63
202
1.00
1.00

Got information on BSE from health professional

    Yes
50
46
2.26 (1.42, 3.61)

    No
97
202
1.00

Ever had breast examination by health professional

    Yes
28
15
3.65 (1.88, 7.10)
2.69 (1.31, 5.52)*

    No
119
233
1.00
1.00

Know at least one method of breast cancer examination

    Yes
51
69
1.38 (0.89, 2.14)

    No
96
179
1.00

COR: crude odds ratio, AOR: adjusted odds ratio, CI: confidence interval, BSE: breast self-examination, and HEWs: health extension workers, .

4. Discussion

Breast self-examination (BSE) is an important and inexpensive method for early detection of breast cancer [23]. In this study, ever practice of BSE was reported by 37.3% of HEWs which is inconsistent with studies done among Ethiopian female healthcare professionals in Addis Ababa (75.1%) [24], Nigerian Nurses in Lagos general hospital (89%) [11], female health workers in a Nigerian urban city (95%) [25], Egyptian nurses (56.4%) [26], nurses in United Arab Emirates (84.4%) [27], and registered Nurses in Singapore (63%) [28]. This could be due to the level of education of study participants and the availability of mass media. In this study the availability of TV in the study group was low (30%) and only 4.3% of HEWs took training on BSE.

Of all HEWs only 14.4% performed BSE on monthly basis in this study which is inconsistent with other studies done among healthcare professionals in Addis Ababa Ethiopia (35.5%), Egypt (18.8%), and Nigeria (82%) [11, 25, 26]. This could be due to the difference of education level among the study participants.

In this study, about 30.4% of HEWs mentioned at least one methods of breast cancer screening which is incomparable to the studies done in Addis Ababa, Ethiopia (81.4%), Egypt (81%), and Nigeria (80.7%) [11, 25, 26]. Similarly only 24.3% of HEWs in this study had information about BSE which is inconsistent with the study done in Addis Ababa Ethiopia (77.6%), Egypt (69%), and Nigeria (46%) [11, 24, 25]. This difference could be due to the level of education of the study participants.

In this study, 59.0% of the study participants were knowledgeable about breast cancer risk factors. This result is incomparable with the studies done in Addis Ababa Ethiopia (85%), Egypt (73%), and Nigeria (63%) [11, 24, 25]. The difference may be due to difference in educational status, study area and accessibility to information, composition of the study population, and accessibility to mass media.

In many findings, practice of BSE was determined by the awareness of women or having of information of women about diagnostic methods of breast cancer [12, 15, 24–26, 29]. A study done in Nigeria reported that higher level of education was statistically significant associated with BSE practice [11]. This finding is consistent with the above findings that having information on BSE from health professional is a predictor of BSE practice, and those HEWs who examined their breast by health professional were also a significant predictor of BSE practice in this study which is consistent with other studies [24, 28].

In conclusion, practice of breast self-examination was low among health extension workers. Getting information on breast self-examination from health professional, discussion with families on the importance of BSE, and history of breast exam by health professional were the factors found associated with BSE practice. Therefore, training on breast self-examination should be given to increase the practice of breast self-examination which in turn would have the impact to avert the sever morbidity and mortality of breast cancer. Moreover, giving training on the techniques of breast self-examination for health extension workers is the way of reaching the wider community and the best opportunity to tackle the problem at wider perspective.

List of Abbreviations

AOR: | Adjusted odds ratio
BSE: | Breast self-examination
CI: | Confidence interval
COR: | Crude odds ratio
HEW: | Health extension workers
SPSS: | Statistical packages for social science
WHO: | World Health Organization.

Conflict of Interests

The authors declare that they have no conflict of interests.

Authors’ Contribution

Muluken Azage designed the study, developed the questionnaire, trained data collectors, supervised the data collection, analyzed the data, and wrote the paper. Gedefaw Abeje supervised the data collection, developed the questionnaire, contributed to the interpretation of the findings, and the drafting and writing of the paper. Alemtsehay Mekonnen contributed in data entry, analysis and interpretation of the findings and drafting and writing of the paper. All authors read and approved the final paper.

Acknowledgments

The authors acknowledge the Bahir Dar University for financing this research work. The authors would like to thank the commitment of the data collectors during data collection and study participants for their willingness to participate in the study. The authors also thank the staffs of the College of Medicine and Health Sciences, Bahir Dar University, for their constructive comments during proposal conception.

References

I. Harirchi, S. Kolahdoozan, M. Karbakhsh et al., “Twenty years of breast cancer in Iran: downstaging without a formal screening program,” Annals of Oncology, vol. 22, no. 1, pp. 93–97, 2011.

The LIVESTRONG Foundation, Foundation Information & Cancer Statistics: World Cancer Report Information, http://mediaroom.livestrong.org/livestrongInformation

WHO, “Cancer,” Fact Sheet 297, WHO, Geneva, Switzerland, 2011, http://www.who.int/mediacentre/factsheets/fs297/en/.

H. Rabia and G. Sebahat, “The effect of training on the knowledge levels and beliefs regarding breast self-examination on women attending a public education centre,” European Journal of Oncology Nursing, vol. 12, no. 1, pp. 58–64, 2008.

D. M. Parkin, F. Bray, J. Ferlay, and P. Pisani, “Global cancer statistics, 2002,” CA—A Cancer Journal for Clinicians, vol. 55, no. 2, pp. 74–108, 2005.

Ethiopian Cancer Association, “Breast cancer,” http://www.yeeca.org/Learn about Cancer.htm

F. Bray, P. McCarron, and D. M. Parkin, “The changing global patterns of female breast cancer incidence and mortality,” Breast Cancer Research, vol. 6, no. 6, pp. 229–239, 2004.

D. M. Parkin, S. L. Whelan, J. Ferlay, L. Raymond, and J. Young, Cancer Incidence in Five Continents, Volume VIII, IARC Press, Lyon, France, 1997.

S. L. Dibble, J. M. Vanoni, and C. Miaskowski, “Women's attitudes toward breast cancer screening procedures: differences by ethnicity,” Women's Health Issues, vol. 7, no. 1, pp. 47–54, 1997.

S. Ferro, A. Caroli, O. Nanni, A. Biggeri, and A. Gambi, “A cross sectional survey on breast self examination practice, utilization of breast professional examination, mammography and associated factors in Romagna, Italy,” Tumori, vol. 78, no. 2, pp. 98–105, 1992.

O. O. Odusanya and O. O. Tayo, “Breast cancer knowledge, attitudes and practice among nurses in Lagos, Nigeria,” Acta Oncologica, vol. 40, no. 7, pp. 844–848, 2001.

G. R. Sadler, S. K. Dhanjal, N. B. Shah et al., “Asian Indian women: knowledge, attitudes and behaviors toward breast cancer early detection,” Public Health Nursing, vol. 18, no. 5, pp. 357–363, 2001.

C. J. Maxwell, C. M. Bancej, and J. Snider, “Predictors of mammography use among Canadian women aged 50–69: Findings from the 1996/97 National Population Health Survey,” Canadian Medical Association Journal, vol. 164, no. 3, pp. 329–334, 2001.

K. Blanchard, J. A. Colbert, D. Puri et al., “Mammographic screening: patterns of use and estimated impact on breast carcinoma survival,” Cancer, vol. 101, no. 3, pp. 495–507, 2004.

B. Demirkan, A. Alacacioglu, and U. Yilmaz, “Relation of body mass index (BMI) to disease free (DFS) and distant disease free survivals (DDFS) among Turkish women with operable breast carcinoma,” Japanese Journal of Clinical Oncology, vol. 37, no. 4, pp. 256–265, 2007.

K. M. Elsie, M. A. Gonzaga, B. Francis et al., “Current knowledge, attitudes and practices of women on breast cancer and mammography at Mulago Hospital,” The Pan African Medical Journal, vol. 5, article 9, 2010.

H. R. Wabinga, D. M. Parkin, F. Wabwire-Mangen, and S. Nambooze, “Trends in cancer incidence in Kyadondo County, Uganda, 1960–1997,” British Journal of Cancer, vol. 82, no. 9, pp. 1585–1592, 2000, http://www.nature.com/bjc/journal/v82/n9/full/6691071a.html

S. S. Tavafian, L. Hasani, T. Aghamolaei, S. Zare, and D. Gregory, “Prediction of breast self-examination in a sample of Iranian women: an application of the Health Belief Model,” BMC Women's Health, vol. 9, article 37, 2009.

P. E. Dündar, D. Özmen, B. Öztürk et al., “The knowledge and attitudes of breast self-examination and mammography in a group of women in a rural area in western Turkey,” BMC Cancer, vol. 6, article 43, 2006.

I. A. Avci, “Factors associated with breast self-examination practices and beliefs in female workers at a Muslim community,” European Journal of Oncology Nursing, vol. 12, no. 2, pp. 127–133, 2008.

S. Fung, “Factors associated with breast self-examination behaviour among Chinese women in Hong Kong,” Patient Education and Counseling, vol. 33, no. 3, pp. 233–243, 1998.

Amhara Regional Health Bureau, Annual Report of Amhara Regional Health Bureau, Amhara Regional Health Bureau, Bahir Dar, Ethiopia, 2011.

G. A. Franek, Z. E. Nowak-Kapusta, and M. Cabaj, “Breast cancer prophylaxis among nurses,” Wiadomosci lekarskie, vol. 57, pp. 82–84, 2004.

S. Teferi, T. Mezgebe, M. Demissie, and A. Durgaprasada, “Knowledge about breast cancer risk-factors, breast screening method and practice of breast screening among female healthcare professionals working in governmental hospitals, Addis Ababa, Ethiopia,” IOSR Journal of Pharmacy and Biological Sciences, vol. 2, no. 1, pp. 5–12, 2012.

O. A. Adenike and O. O. Vivian, “Knowledge, attitudes and practice of breast cancer screening among female health workers in a Nigerian urban city,” BMC Cancer, vol. 9, article 203, 2009.

F. E. Karima and M. S. Ashraf, “Knowledge and practice of breast cancer screening among Egyptian nurses,” Journal of Hematology & Oncology, vol. 1, no. 4, pp. 122–128, 2010.

J. Sreedharan, J. Muttappallymyalil, M. Venkatramana, and M. Thomas, “Breast self-examination: knowledge and practice among nurses in United Arab Emirates,” Asian Pacific Journal of Cancer Prevention, vol. 11, no. 3, pp. 651–654, 2010.

M. Seah and S. Tan, “Am i breast cancer smart? Assessing breast cancer knowledge among healthcare professionals,” Singapore Medical Journal, vol. 48, no. 2, pp. 158–162, 2007.

N. Canbulat and U. Uzun, “Health beliefs and breast cancer screening behaviors among female health workers in Turkey,” European Journal of Oncology Nursing, vol. 12, no. 2, pp. 148–156, 2008.