https://orcid.org/0000-0002-2937-9822
Figures
Abstract
Background
Breast cancer is the second most common cancer in the world and also among Nepalese women. Breast self-examination is an important, cheap, and easy method for early diagnosis of breast cancer which can be cured in the majority of cases if diagnosed in the early stages. In developing countries like Nepal where the awareness regarding breast cancer and breast self-examination is poor, breast cancers are diagnosed at late stages resulting in a poor prognosis of the disease. The study assessed knowledge, practice, and factors associated with breast self-examination.
Methods
A cross-sectional survey was carried out among 262 women in the Butwal sub-metropolitan adopting multi-stage sampling. A pre-tested structured interview schedule and an observation checklist were used to collect the data. Data was entered in EPI-data and necessary univariate, bivariate, and multivariate analyses were done in SPSS.
Results
The study found that more than half of the participants (55.3%) had poor knowledge of BSE. Only one-fourth (27.1%) of them were practicing BSE and among them, most of them (93.0%) had poor practice. The factors such as ethnicity from Brahmin/Chhetri [AOR = 2.099, 95% CI (1.106–3.981)], use of contraceptive devices [AOR = 9.487, 95% CI (2.166–41.558)], personal history of breast lump [AOR = 12.502, 95% CI (1.639–95.387)], family history of breast cancer [AOR = 5.729, 95% CI (1.337–97.512)], and knowledge of BSE [AOR = 4.407, 95% CI = 2.160–34.650)] were significant determinants of BSE practice among 20–49 years women.
Conclusion
The study concluded that most of the women had poor knowledge and practice of breast self-examination. The study also indicated the influence of ethnicity, contraceptives, personal and family history of cancer/early warning signs, and knowledge for practicing breast self-examination. There is an immediate need to increase the knowledge and practice of breast self-examination to prevent and detect breast cancer in its early stage.
Citation: B. K. M, Kaphle HP (2023) Breast self-examination: Knowledge, practice and associated factors among 20 to 49 years aged women in Butwal sub-metropolitan, Rupandehi, Nepal. PLoS ONE 18(6): e0286676. https://doi.org/10.1371/journal.pone.0286676
Editor: Seifadin Ahmed Shallo, Ambo University, ETHIOPIA
Received: September 10, 2022; Accepted: May 20, 2023; Published: June 2, 2023
Copyright: © 2023 B. K., Kaphle. 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: All relevant data are within the manuscript and its Supporting information files.
Funding: Manisha B.K. corresponding author received grant with award number MRS-78-79-HS-04 from University Grant Commission (UGC), Nepal. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Breast cancer is a type of cancer that grows from breast cells and therefore the development starts from the inner lining of milk ducts (ductal carcinoma) or the lobules that offer milk (lobular carcinoma) [1]. It is the leading cause of cancer mortality among women in the world [2]. It’s the second commonest cancer among women in Nepal that is commonest in urban settings. It’s additionally common among young premenopausal women and plenty being diagnosed at a sophisticated stage [3]. Risk factors of breast cancer in Nepal are nulliparity or late age at first childbirth (>35 years of age), family history, smoking, excessive alcohol consumption, consumption of fat (BMI≥30Kg/M2), and exposure to radiation and hormone replacement therapy [4].
BC is the most common cancer in females, in both developing and developed countries, with an estimated 297,790 new cases and 43,170 deaths in the United States in 2023 [5]. There were an estimated 2.1 million newly diagnosed female breast cancer cases and 600 thousand breast cancer-related deaths occurred in 2018 [6]. In women, BC is the most commonly diagnosed cancer (11.7% of total cases) and the leading cause of cancer death (6.9%) in 110 countries among the 185 countries. It is the leading cause of global cancer incidence in 2020, with an estimated 2.3 million new cases, representing 11.7% of all cancer cases. It’s the fifth leading cause of cancer mortality in the world, with 685,000 deaths [7]. It accounts for one in four cancer cases and one in six cancer deaths, ranking first for incidence in the vast majority of countries (159 of 185 countries) and mortality in 110 countries [7]. In Nepal, according to the data from seven major cancer service hospitals in 2012, BC was the second most common cancer among women, after cancer of the cervix. According to GLOBOCAN 2012, an estimated 1,700 new BC cases were diagnosed in Nepal in 2012 with an age-standardized rate (ASR) of 13.7 new cases per 100,000 women, while 870 fatalities in women occurred with an ASR of 7.2 cases fatalities per 100,000 women [4]. GLOBOCAN 2018 estimates of cancer incidence and mortality, 2018 an estimated 2068 new BC cases were diagnosed in Nepal, with an ASR of fifteen cases per 100,000 women, whereas 1018 deaths occurred with an ASR of 7.6 cases per 100,000 women [8].
Early detection of breast cancer can reduce its morbidity and mortality. Mammography, clinical breast examination (CBE), and breast self-examination (BSE) are considered to be effective strategies for the early detection of breast cancer [9]. BSE is a patient-centered, cheap, and non-invasive method of screening for breast cancer, which improves the chances of early BC detection [2]. It’s a process whereby women examine their breasts frequently to detect any abnormal swelling or lumps to seek prompt medical attention. It’s one of the screening strategies used to detect breast-related issues like possible lumps, distortions, or swelling. BSE is usually recommended for each woman higher than the age of 20 years to be done for 20 minutes once monthly, between the seventh and tenth days of the menstrual cycle (2–3 days after the menses has gone), and goes an extended manner in detecting breast [10]. Early diagnosis has a positive impact on the prognosis and limits the development of complications and disability. It will increase life quality and survival [11]. In BSE, the patient observes and palpates their breasts and accessory anatomical structures to detect changes or abnormalities that will indicate the presence of cancer. Throughout the palpation of the breasts and adjacent structures (nipples, areolas, and axilla), lymph nodes and condensations also suggestive of neoplasias can be noticed [12]. Although BSE alone is not sufficient for early detection of breast carcinoma, it is still a very important screening tool for early detection of carcinoma in developing countries, because it is cheap, widely available, and doesn’t need complicated technical coaching, hospital visits, and specialized instrumentality [9].
BSE in conjointly with screening mammography is presently advocated by several organizations, and it’s also conjointly suggested for younger women beginning in their 20s who are nevertheless being screened by mammography [13]. Performing BSE is one method for a woman to understand how her breasts commonly feel so that she will notice any changes that do occur. Women who perform BSE monthly and properly are more likely to detect a lump within the early stage of its tumor. Evidence showed that comprehensive knowledge of BSE remains low in several developing countries [13].
This study aimed to assess knowledge, practice, and factors associated with breast self-examination among 20–49 years aged women in Butwal Sub-Metropolitan.
Materials and methods
Study setting
This study was conducted in the Butwal Sub-Metropolitan, Rupandehi district, Lumbini Province of Nepal. Since breast cancer is the most common cancer among women in urban settings [3], the Butwal sub-metropolitan is an urban area where the study on breast cancer and breast self-examination was inadequate.
Study population
The study population was women aged 20 to 49 years who are currently residing in the Butwal Sub-Metropolitan of Rupandehi district as BSE is recommended to start from the age of early 20 and breast cancer is more common in young pre-menopausal women.
Sample size
The prevalence of BSE practice in Butwal was 19.2% [14]. The required sample size was calculated with an assumption of 95% confidence interval (CI) & 5% maximum allowable error (d), the prevalence (p), and the population of 20–49 years women from the selected wards (N).
Here, n = required sample size, value of z at 95% confidence level = 1.96, d = 0.05, p = 19.2% = 0.192, q = 1-p = 1.0–0.192 = 0.808, and N = 22,332. Putting these values in the above formula we got n = 235.87 (n≈ 236) and adding a 10% non-response rate, the final sample size for the study was 262.
Sampling procedure
Multi-stage sampling technique was used for this study. In the first stage, among 19 wards of Butwal Sub-Metropolitan, 6 wards (33%) were selected randomly by simple random sampling. In the second stage, the required number of participants was identified based on proportionate sampling (Table 1). In the third stage, the participants to be included in the study were selected using systematic random sampling. The first household was selected by choosing a random number from 0 to 9. Another random number from 0 to 9 was selected for determining the interval. In a selected household, if there were more than one eligible woman then the participant with the highest age was chosen.
Selection criteria
Ethical considerations
Ethical approval was obtained from the Institutional Review Committee, Pokhara University with reference number 11/078/079. Permission was also taken from the Butwal Sub-Metropolitan. Participants were fully informed about the objectives and purpose of the study before the data collection. Both verbal and written consent was taken. Confidentiality and privacy were maintained properly. The right to refuse to take part in the study was highly respected.
Research tools and their development
A pre-tested structured interview schedule and an observational checklist were used for data collection. It was developed after an extensive literature review and consultation with experts.
The interview schedule included socio-demographic factors, gynecological and obstetric factors, knowledge, and self-reported practice of BSE.
Socio-demographic factors were age, marital status, religion, ethnicity, occupation, education, and household average monthly income. Gynecological and obstetric factors were age at marriage, parity, breastfeeding, contraceptive use, personal history of breast lump, family history of breast cancer, and mastectomy in the family.
Knowledge of BSE was assessed by self-constructed 10 multiple choice questions with three wrong and one right option on different dimensions of knowledge of BSE (see respective table in results for questions). Responses of the participants were categorized into 1 and 0 for right and wrong answers respectively and the mean knowledge score was calculated. Participants who performed below the mean score were classified as having poor knowledge and those who had mean or above mean were classified as having good knowledge of BSE.
Self-reported practice related to BSE was measured by self-constructed 14 different questions included in the interview schedule (see respective table in results for questions).
To observe the practice of BSE, an observation checklist was adopted from an Iranian study [15]. A female dummy was taken during the data collection to observe the steps of breast self-examination among those who practice. Twenty-two steps (see respective table in results for questions) were observed considering the dummy privately in a quiet room during the observation for breast self-examination practice. Participants were asked to show the steps on a dummy on how they performed breast self-examination. The scores ranged from 0 to 22 and each step was ticked if found to show in a dummy. The results were determined as good (15–22), medium (9–14), and poor (0–8).
Pretesting, validity, and reliability
Pre-testing was done in a similar setting on 10% (26) of the sample size excluding the study area and changes were made accordingly. The interview schedule and observation checklist were designed based on the reference to various research papers. The data collection tool was made in simple, clear, and Nepali language. The research guide and experts were consulted for appropriate suggestions on design and tools. The researcher herself was involved in data collection and analysis. The validity and reliability were confirmed by the supervisor, experts, and pre-testing.
Data collection procedure
Data were collected through face-to-face interviews and observation methods between April–May 2022. A structured questionnaire was used for the interview and an observational checklist for observing BSE practice. A female dummy was taken during the data collection to observe the steps of breast self-examination among those who practice. Data was gathered in the prescribed format. The interview was conducted after taking both verbal and written consent. The objective and purpose of the research were clearly described before taking consent. Confidentiality was also maintained. The Nepali language was used to collect the data and data collection was carried out following precautions against COVID-19.
Data analysis
Epi-Data software was used for data entry and analysis was performed with the help of the Statistical Package for Social Science (SPSS). Descriptive statistics (i.e. frequency, percentage, mean and standard deviation) were applied to describe the study population. Pearson’s Chi-square test was used to find out the association between dependent and independent variables i.e. association between the practice of BSE and socio-demographic, gynecological & obstetric, and knowledge-related factors. Bivariate logistic regression analysis was used among the associated factors. Multivariate logistic regression analysis was used to assess the predictors for the practice of BSE.
Results
Univariate analysis
Socio-demographic information.
The majority of the participants were of the age group 40–49 years (Mean & SD: 37.28±7.689), belonged to Brahmin/Chhetri ethnicity (37.8%) and Hindu religion (82.5%), and had a secondary level of education (27.9%). Similarly, the majority of participants were from nuclear families (59.5%), housewives (43.5%), and married (81.7%). Moreover, the monthly household income of about three-quarters (77.5%) was less than fifty thousand (Mean & SD: 41,431±18,900) (Table 2).
Gynecological and obstetric information.
More than half of the participants were married (59.3%), had ≤2 children (50.6%), and didn’t use any contraceptives (58.1%). Moreover, 13.4% had a history of breast cancer, and 6.5% and 4.2% had a family history of breast cancer and mastectomy respectively. Almost half (50.0%) had heard about BSE and the main source of information about BSE was the internet (46.6%) followed by healthcare providers (42.7%) respectively (Table 3).
Knowledge of BSE.
Out of the 262 participants, more than half of them (55.3%) had poor knowledge of BSE (Table 4).
The self-reported practice of BSE.
Based on the self-reported practice among 262 participants, only 27.1% of participants were practicing BSE in the last twelve months. However, among 27.1% who were practicing, only 59.3% started at the correct age, 36.6% were practicing BSE at the right frequency, and 53.6% were performing at right time. However, nearly all (94.4%) of them reported they were examining both breasts (Table 5).
The practice of BSE on observation.
However, the practice of BSE on observation on a female dummy revealed that nearly all of them have a poor practice of BSE (93.0%) (Table 6).
Bivariate analysis
Among the socio-demographic variables, the result showed that age, education, family type, occupation, household average monthly income, and marital status were significantly associated with the practice of BSE in Parson’s chi squire test (p<0.05) (Table 7).
Among the gynecological and obstetric variables, age at marriage, number of children, use of contraceptive devices, personal history of breast lump, family history of breast cancer, and family history of mastectomy were significantly associated with the practice of BSE in Parson’s chi squire test (p<0.05) (Table 8).
Moreover, the result showed that the level of knowledge was significantly associated with the practice of BSE (p<0.05) (Table 9).
The strength of the association of statistically significant factors with the practice of BSE in bivariate analysis logistic regression analysis is presented below (Table 10).
Multivariate analysis
On multivariate analysis after adjustment of covariates, participants from Brahmin/Chhetri ethnicity were two times more likely [AOR = 2.099, 95% CI (11.106–3.981)] to practice BSE as compared to others. Participants who use contraceptive devices were nine times more likely [AOR = 9.487, 95% CI (2.166–41.558)] to practice BSE as compared to those who didn’t use it. Participants who had a personal history of breast lumps were twelve times more likely [AOR = 12.502, 95% CI (1.639–95.387)] to practice BSE as compared to those who didn’t. Participants who had a family history of breast cancer were five and half times more likely [AOR = 5.729, 95% CI (1.337–97.512)] to practice BSE as compared to those who didn’t have. Furthermore, participants who had good knowledge were about four and half times more likely [AOR = 4.407, 95% CI = 2.160–34.650)] to practice BSE as compared to those who had poor knowledge (Table 11).
Discussion
The finding of this study indicates that most of the reproductive age group women had poor knowledge of BSE. Only 44.7% had good knowledge of BSE. A similar study conducted at Rapti Sonari Rural Municipality, Banke District showed about the same proportion of women had good knowledge (44.3%) [16]. Similarly, other studies conducted in Ghana (43.3%) [13], Southwest Ethiopia (30.0%) [10], and Southwest Cameroon (25.4%) [17] also reported less proportion of having good knowledge of BSE. The reason for the difference in knowledge in different studies from different countries might be due to the difference in the study setting and sociocultural factors across the world.
Moreover, the current study also showed that 27.1% of women were practicing BSE. A similar study in the Banke district of Nepal showed 19.6% of women were practicing BSE [16]. Similarly, studies conducted in the South district of Ghana (27.5%) [13], Tabriz, Iran showed (18.8%) [15], and Northwest, Ethiopia (32.5%) [18] showed a lower proportion were practicing BSE. However urban women of Shah Alam, Malaysia higher (55.0%) % of women were practicing BSE [19]. Studies from various countries showed somehow differences in the practice of BSE. The reason for this might be due to the difference in knowledge of study participants and the difference between study areas.
In observation, none of the women had good practice of BSE in this study. A similar study conducted among women in Tabriz, Iran showed performance of practice was very poor among 22.7%, poor among 46.7%, medium among 21.3%, good among 6.7%, and very good among 2.7% (17). It indicates that even though some women have knowledge of BSE and practice it, however, they aren’t practicing following the appropriate technique.
After adjustment of covariates in the Multivariate logistic regression analysis ethnicity (Brahmin/Chhetri) [AOR = 2.099, 95% CI (1.106–3.981)], use of contraceptive devices [AOR = 9.487, 95% CI (2.166–41.558)], personal history of breast lump [AOR = 12.502, 95% CI (1.639–95.387)], family history of breast cancer [AOR = 5.729, 95% CI (1.337–97.512)], and knowledge on BSE [AOR = 4.407, 95% CI = 2.160–34.650)] were significant predictors of the practice of BSE.
The finding of the current study showed ethnicity as a significant determinant for practicing BSE which in contrast with the study conducted among women of reproductive age of Rapti Sonari rural municipality, Banke district, Nepal that there was no significant difference [16]. This contrasting finding might be due to the differences in knowledge in different ethnic groups living in the two study settings.
Similarly, the current study showed the use of contraceptive devices as a significant determinant for practicing BSE which showed a contrast finding with the study conducted among women who attended primary health care, in Kuwait that there was no significant difference in BSE practice regarding the use of contraceptive devices [20]. This contrasting finding might be due to the reason that those who use contraceptive devices get health education regarding reproductive health and disease from the health institution.
Likewise, the current study revealed that personal history of breast lumps is a significant determinant for practicing breast self-examination (AOR = 12.505, 95% CI = 1.639–95.387). The finding of this study is supported by the study conducted in Ethiopia in 2018, where women with a personal history of breast problems were 3.27 times more likely to practice BSE [21]. This finding is also supported by another study conducted in Iran in 2018 [22]. This might be the reason that one with a breast lump or disease gets information and advice from the health institution and are conscious about their health disease.
Furthermore, the finding of this study revealed that a family history of breast cancer was also a significant determinant for practicing BSE (AOR = 5.729, 95% CI = 1.337–97.512). The finding of this study is supported by different studies [18, 23, 24]. This could be due to the reason of getting information and advice from health care providers and being aware as they might be at risk for breast cancer, so it can be detected earlier with breast self-examination.
In addition, this study showed women’s knowledge as a significant determinant for practicing BSE (AOR = 4.407, 95% CI = 2.160–34.650). This finding is supported by the various studies (AOR = 5.74) [18], (AOR = 4.32) [10], and (AOR = 12.02) [23]. This indicates that knowledgeable women motivate themselves to practice breast self-examination.
Conclusions
The study concludes that most of the women had poor knowledge. Also, very few women were practicing breast self-examination. Among those who were practicing breast self-examination, almost all of them demonstrated poor practice. Moreover, the study also concludes that ethnicity, use of contraceptives, personal history of breast lump, family history of breast cancer, and level of knowledge have a significant influence on practicing breast self-examination. There is an immediate need to increase the knowledge and practice of breast self-examination to prevent and detect breast cancer in its early stage.
Limitations
The study was carried out in selected wards of the Butwal sub-metropolitan of the Rupandehi district of Nepal and therefore, it might not be representative of the entire country. Likewise, the proportion of women practicing BSE in this study was assessed by a self-reported response regarding whether they have been practicing BSE in the last year or not. Other aspects of the practice such as frequency, timing, process, etc. of BSE weren’t considered while determining the factors associated with the practice of BSE.
Acknowledgments
The authors gratefully acknowledge the participants for providing information and their valuable time.
References
- 1. Hanson VF, Abd El-Kader RG, Ilesanmi RE. Practice and barriers of breast self-examination among women in a rural community in southwestern, Nigeria. International Journal of Studies in Nursing. 2019;4(3):46–53.
- 2. Baloushah S, Salisu WJ, Elsous A, Muhammad Ibrahim M, Jouda F, Elmodallal H, et al. Practice and barriers toward breast self-examination among Palestinian women in Gaza City, Palestine. The Scientific World Journal. 2020;2020:7484631. pmid:32292294
- 3. Ojha B, Kumar R, Prabhune A. Past, present and future of breast cancer in Nepal: A review. Global Journal of Medicine and Public Health. 2018;7(1):1–7.
- 4. Giri M, Giri M, Thapa RJ, Upreti B, Pariyar B. Breast Cancer in Nepal: Current status and future directions. Biomedical reports. 2018;8(4):325–9. Epub 2018 Feb 5. pmid:29541453.
- 5. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA: a cancer journal for clinicians. 2022;72(1):7–33. pmid:35020204
- 6. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2018;68(6):394–424. pmid:30207593
- 7. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2021;71(3):209–49. pmid:33538338
- 8. Giri M, Puri A, Upreti B. Current status of breast cancer in Nepal. Int J Res Med Sci. 2019;7(6):2463–69.
- 9. Akhtari-Zavare M, Juni MH, Ismail IZ, Said SM, Latiff LA. Barriers to breast self-examination practice among Malaysian female students: a cross-sectional study. SpringerPlus. 2015;4(1):1–6. pmid:26587360
- 10. Urga Workineh M, Alem Lake E, Asmare Adella G. Breast self-examination practice and associated factors among women attending family planning service in mojo public health facilities southwest Ethiopia. Breast Cancer. 2021;27(13):459–69. pmid:34349557
- 11. Birhane K, Alemayehu M, Anawte B, Gebremariyam G, Daniel R, Addis S, et al. Practices of breast self-examination and associated factors among female Debre Berhan university students. International journal of breast cancer. 2017;2017:8026297. pmid:28596921
- 12. Basegio DL, Corrêa MPA, Kuiava VA, Quadros C, Mattos M, Pavan NR. The importance of breast self-examination as a diagnostic method of breast cancer. Mastology. 2019;29(1):14–9.
- 13. Dadzi R, Adam A. Assessment of knowledge and practice of breast self-examination among reproductive age women in Akatsi South district of Volta region of Ghana. PLoS One. 2019;14(12):e0226925. pmid:31887161
- 14. Marahatta S, Sharma S. Knowledge and practice of breast self-examination among women of reproductive age in Butwal Sub Metropolitan City. Journal of Manmohan Memorial Institute of Health Sciences. 2018;4(1):117–29.
- 15. Farshbaf-Khalili A, Shahnazi M, Vahed L, Javadi L. Status of breast self-examination performance among women referring to health centers of Tabriz, Iran. Crescent J Med Biol Sci. 2014;1(3):90–6.
- 16. Gyawali P, Gautam S. Breast Self-Examination Practice and Its Associated Factor among the Women of Reproductive Age of Rapti Sonari Rural Municipality, Banke District. International Journal of Health Sciences and Research. 2021;11(4):75–82.
- 17. Azemfac K, Christie S, Carvalho MM, Nana T, Fonje AN, Halle-Ekane G, et al. A community-based assessment of knowledge and practice of breast self-examination and prevalence of breast disease in Southwest Cameroon. Journal of cancer epidemiology. 2019;2019:2928901. pmid:30713554
- 18. Dagne AH, Ayele AD, Assefa EM. 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. 2019;14(8):e0221356. pmid:31437209
- 19. Al-Dubai SAR, Ganasegeran K, Alabsi AM, Manaf MRA, Ijaz S, Kassim S. Exploration of barriers to breast-self examination among urban women in Shah Alam, Malaysia: a cross-sectional study. Asian Pacific Journal of Cancer Prevention. 2012;13(4):1627–32. pmid:22799379
- 20. Al-Azmy SF, Alkhabbaz A, Almutawa HA, Ismaiel AE, Makboul G, El-Shazly MK. Practicing breast self-examination among women attending primary health care in Kuwait. Alexandria Journal of Medicine. 2013;49(3):281–6.
- 21. Tewelde B, Tamire M, Kaba M. Breast self-examination practice and predictors among female secondary school teachers in Addis Ababa, Ethiopia: using the health belief model. BMC Women’s Health. 2022;22(1):1–8. pmid:35906601
- 22. Bashirian S, Barati M, Mohammadi Y, Moaddabshoar L, Dogonchi M. An application of the protection motivation theory to predict breast self-examination behavior among female healthcare workers. European Journal of breast health. 2019;15(2):90–7. pmid:31001610
- 23. Mihret MS, Gudayu TW, Abebe AS, Tarekegn EG, Abebe SK, Abduselam MA, et al. 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. Journal of cancer epidemiology. 2021;2021:1–9. pmid:33927761
- 24. Getu MA, Kassaw MW, Tlaye KG, Gebrekiristos AF. Assessment of breast self-examination practice and its associated factors among female undergraduate students in Addis Ababa University, Addis Ababa, Ethiopia, 2016. Breast Cancer: Targets and Therapy. 2018:21–8. pmid:30643451