Breast Self-Examination Practice and Associated Factors Among Women Attending Family Planning Service in Modjo Public Health Facilities Southwest Ethiopia [Letter]

Dear editor

I read, with interest, the article by Workineh et al characterizing breast self-examination practice [BSE] in Ethiopia and its associated factors.¹ Effective methods of breast cancer detection in low resource countries remains a pertinent issue globally and I commend the authors on their contribution to tackling this important problem. As a final year medical student, with an intercalated BSc with focus on breast cancer, I propose some further factors which merit consideration in this analysis.

The authors highlight many important factors associated with BSE, including level of education and knowledge of BSE, and propose solutions in the way of improving this. However, whilst the authors acknowledged that over a third of the study cohort had a negative attitude towards BSE¹ they were hesitant to further evaluate reasons for this. It is important to characterize reasons for negative attitudes as women with positive attitudes towards BSE are more likely to practise it. Another study, by Getachew et al,² highlighted that key barriers include belief in traditional and religious medicine and lack of family support. Considering deep-rooted influences that culture and family may have on health behavior, further analysis of traditional and cultural factors would be of great interest and of use to tailor future efforts at improving BSE education and practice.

This is reinforced in a review by Yeshitila et al³ who identified poor health-seeking behaviors and lack of confidence in the healthcare system as barriers to BSE practice in Ethiopia. In this way, the study cohort selected from public health institutions is likely to introduce a selection bias, as those who are already attending a family planning service are naturally more likely to be concerned about health and have the means to access healthcare. Furthermore, Seifu et al have identified utilization of family planning services in the Oromia region to be low, at around 40.7%, and note that over a third of women interviewed deem family planning unacceptable.⁴ Thus by selecting patients from family planning clinics, the authors eliminate a significant proportion of the population which may practice or be unaware of BSE, and so this may affect the representativeness of this study.

Moreover, the eight-item questionnaire used to assess knowledge of BSE factors was defined by the authors rather than a validated tool. Future efforts may look to use a validated tool such as the Health Belief Model,⁵ which has been tested across different cultures to study BSE behaviors, and may help to further characterize beliefs and attitudes surrounding BSE.

Ultimately, Workineh et al¹ have produced a thought-provoking study which lays the foundations for future research and improvements in breast cancer awareness. To fully understand and improve awareness and practice of BSE, we must deliberate the cultural and health access barriers which may in turn influence attitudes and practice. Further work may also look to expanding to regions other than Oromia, in order to truly characterize the practice of BSE in Ethiopia.