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

Dear editor

I (on the behalf of all authors) read the letter of Alexandra MacKenzie on areas to be improved on our previously published article “breast self-examination practice and associated factors among women attending family planning service in Modjo public health facilities Southwest Ethiopia.” Firs I would like to thank Alexandra MacKenzie for his valuable insights indicating the area of improvement for future researchers. I share some of the points he raised. As he discussed, breast cancer is the leading cause of cancer death worldwide and breast self-examination is one of the cheapest methods used for the early detection of breast cancer in asymptomatic women in resource-limited settings.¹ Unlike clinical breast examination and mammography, BSE is as a general approach to increase breast health awareness allowing for early detection of abnormalities.² Despite its prevalence, breast cancer are not addressed as major public health problems at any level of the health care system in Ethiopia.³ Based on our study finding, breast self-examination practice was low within the study area. Tertiary level of education, having Knowledge on breast self-examination and a positive attitude towards breast self-examination were found to have a significant association with breast self-examination practice. To remind the author every study has aim and scope, so the aim of our study was to assess breast self-examination practice and associated factors among women attending family planning service. Due to this, we were tried to assess the overall practice of our respondents (women attended for family planning service), reasons for not practice and determinant factors to practice BSE. The first thing, investigating the reasons for developing negative attitude was not our scope of study. Secondly attitudes develop reasonably from the beliefs people hold about the object of the attitude or we form beliefs about an object by associating it with certain attributes, ie, with other objects, characteristics, or events. Each belief links the behavior to a certain outcome, or to some other attribute such as the cost incurred by performing the behavior. Since the attributes that come to be linked to the behavior are already valued positively or negatively, we automatically and simultaneously acquire an attitude toward the behavior.⁴ Third, multiple items with Likert scale of measurement measure attitude, which is difficult to assess the reasons for bad insights. Another concern by the author was not investigating traditional and religious barriers. According a qualitative study conducted by Getachew et al among twelve-breast cancer patients by using in-depth interviews in urban and rural areas of south Ethiopia, belief in traditional medicine and religious practices for treatment, and lack of social and financial support to seek care at a medical facility were barriers for early diagnosis of breast cancer.⁵ In this study women already develop breast cancer and may worry and intended to consult traditional or religious healers rather than visiting health facility because of low resource for diagnosis of breast cancer.^2,6 Here our study excluded women who were diagnosed with breast cancer in order to decrease bias. Although not our scope of study, traditional, cultural and religious barriers related to the practice of breast self-examination may need further investigation through qualitative study. The author had also concern about study participant selection 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. He tried to review article of a systematic review and meta-analysis done by Yeshitila et al who identified poor health seeking behaviors and lack of confidence in the healthcare system as barriers to BSE practice in Ethiopia.⁷ In this study there is no data showing the association between health seeking behavior and breast self-examination. The findings of this study indicated that Women who had non-formal educational, family history of breast cancer, good knowledge of breast self-examination and favorable attitude toward breast self-examination were significantly associated with practice of breast self-examination. First our study was intended to assess beast self-examination practice and associated factors among women attending family planning service and made generalization on these source population. Second our study population seek family planning service not seek breast cancer diagnosis which may not be biased. There is no study showing the association between family planning service seeking and breast self-examination practice. Furthermore the author had concern on study participants, since 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 unacceptable⁸. 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. First, I want to correct the author that we were selected clients not patients. Because our study participants primary aim of visiting health facility were not for treatment of breast cancer, rather for using family planning service. Second, the utilization figure here cited in Oromia region was among postpartum women only. Our study participants were reproductive age group of women of general population. Third, though 40.7% utilization was among postpartum women, this figure is higher than the national prevalence of EDHS 2016, which is 35%.⁹ The last was the issue of validity of knowledge related items. We tried to validate the not only knowledge related items but also attitude related items. Finally I want to appreciate the author for his critics and possible suggestions for future researchers.