Assessing breast cancer awareness on reproductive age women in West Badewacho Woreda, Hadiyya Zone, South Ethiopia; Community based cross- sectional study.

INTRODUCTION: Breast cancer is the most commonly diagnosed cancer in women worldwide, in both high- and low-income countries. Individual and community awareness of breast cancer can be extremely beneficial. However, breast cancer awareness is extremely low among Ethiopian women, particularly in rural areas. Thus, the aim of this study was assessing awareness of breast cancer on reproductive-aged women in West Badewacho Woreda, Hadiya Zone, South Ethiopia, 2020.
METHOD: A community-based-cross sectional study was employed from April 18 to May 16, 2020. To obtain data, a pre-tested structured interviewer-administered questionnaire was employed. A multistage random sampling technique was employed to select reproductive-aged women from Woreda. Data was entered into a computer using Epi data version 3.1, and edited, cleaned and analyzed using SPSS windows version 20. Bivariable and multivariable analyses were used to identify determinants related to awareness of breast cancer. RESULT: A total of 578 reproductive-age women participated in this study. Only 364 women of reproductive-age (63%) had heard about breast cancer. 234 (64.3%) of the respondents were aware of breast cancer. After adjusting for other variables, husbands' educational status [AOR = 0.262; 95% CI (0.076, 0.900)], family history of breast cancer [AOR = 0.281; 95% CI (0.132, 0.594)] and having TV/Radio [AOR = 0.489; 95% CI (0.246, 0.972)] were significant predictors for awareness of breast cancer.
CONCLUSION: This study emphasized the importance of raising breast cancer awareness among women in the study area.

Introduction

Breast cancer is one type of cancer. It is a malignant tumor that develops from breast tissue, which contains milk-producing glands called lobules and ducts that connect the lobules to the nipple [1, 2].

The specific cause for breast cancer is unknown, but it is considered a disease mainly associated with some risk factors. Being a female, age, family history of breast cancer, especially a first-degree relative, early menarche at the age of 12 and under, late menopause after the age of 55 years, and having the first child after the age of 30, prolonged use of oral contraceptive pills, hormonal therapy, and being overweight or obese and null parity are risk factors. Breast milk, on the other hand, appears to be protective against breast cancer [3-5].

Breast cancer is the most commonly diagnosed cancer in women (24.2%, or roughly one in every four new cancer cases diagnosed in women worldwide), affecting 2.1 million women each year and causing the greatest number of cancer-related deaths in women. In 2019, an estimated 268,600 new cases of invasive breast cancer will be diagnosed among women and 41,760 women are expected to die from breast cancer. While breast cancer rates are higher among women in more developed regions, rates are increasing in nearly every region globally [6, 7].

Breast cancer is a disease that affects not only affluent countries, but also low- and middle-income countries. In reality, nearly sixty percent of women who die from breast cancer live in developing nations, where survival rates might be as low as 20%. Similarly, breast cancer is the most common malignancy among Ethiopian women. Many occurrences go unreported because women in rural regions sometimes seek treatment from traditional healers before seeking medical help [8]. Women in underdeveloped nations are more likely to be diagnosed late in breast cancer and in many situations due to weak health care systems and limited access to early detection and treatment; even access to supportive and palliative care is limited [9].

Though, the Ethiopian government invests a lot in the health sector, communicable, non- communicable and infectious diseases are still the major public health issues in the country [10].

The poor awareness, wrong beliefs and present for care at a late stage in the disease of breast cancer among women, where made treatment is most ineffective, negative perception of the curability of a cancer detected early [3, 11].

Promotion of women’s awareness about breast cancer and its symptoms can encourage them to perform better and timelier breast self-exams, but lower awareness about breast cancer in rural women reduces their chance of detecting breast cancer symptoms, causing the breast cancer to be detected at an advanced stage [12]. Because the majority of Ethiopian women live in rural areas, they face delays in receiving care and, as a result, are more likely to be diagnosed with late stages of breast cancer. As a result, there is an immediate need to raise breast cancer awareness levels. Despite the aforementioned facts, little was known regarding breast cancer awareness among reproductive-aged women in the southern part of Ethiopia. Therefore, the aim of this study was assessing awareness of breast cancer on reproductive-aged women in Hadiya Zone, West Badewacho Woreda, 2020.

Materials and methods

Study design, setting and sampling

A community-based cross-sectional study design was employed from April 18 to May 16, 2020 in West Badewacho woreda in Hadiyya Zone, Southern Nations, Nationalities and People’s Region, Ethiopia. The Woreda is situated 357 km southwest of Addis Ababa and 127 km from the regional capital, Hawassa. The Woreda has 20 rural and 2 urban kebeles that are arranged into 180 gotti (mahandar). As for the health infrastructure situation in Woreda, there are four health centers and 22 health posts that provide basic health care. In 2020, the woreda’s population was predicted to be 113,265 people. The overall number of households in the woreda was estimated to be 23,115, with 26,391 women of reproductive age (23.3%).

The source population was all reproductive-aged women. The study population consisted of reproductive-aged women who were randomly selected at a household level from the source population. Women who were not permanent inhabitants of the Woreda (less than six months), had significant sickness during data collection, or were under the age of 18 were excluded from the study.

The sample size of this study was calculated using a single population proportion formula, taking proportion of awareness/ knowledge of breast cancer in the Bale Zone [11], margin of error, confidence level, design effect and non-response rate were assumed to be 56.2%, 5%, 95%, 1.5 and 5%, respectively.

No previous study, to the best of our knowledge, has determined the proportion of the population in the study area who is aware of breast cancer. We used research from other areas, and because the variation in the study population was expected to be high, we needed a large sample size to detect a difference. In contrast, we used at least two stages lower in the sampling process to arrive at the final sampling unit. As a result, we used a design effect of 1.5 to multiply our sample size in order to minimize variability and detect the effect observed regarding breast cancer awareness.

Where: ni = Sample size; Z (α/2)2 = confidence level; p = proportion of awareness (0.562); d = marginal of error n = 378 Individuals Using design effect 1.5 i.e. 378*1.5 = 567 Thus, finally taking 5% non-response rate the final sample size was 595.

A multistage random sampling technique was employed. Initially, stratification of woreda into urban and rural was done. Then all the rural and urban Kebeles in the woreda were listed separately in the frame. Then, seven rural and one urban kebele were selected randomly using a lottery method. Proportional allocation was done to each selected kebele depending on the size of the houses containing the eligible population. A list of gotts (mahandar) was made for each kebele from the randomly picked kebele. The gotts (mahandar) were then selected using lottery techniques. As a sampling frame, the health extension works were used to extract a list of households containing eligible reproductive-aged women in selected kebele at each gott (mahandar) level. Again, a proportional allocation was made based on the number of eligible households in each selected gott from each selected kebele. The households with eligible reproductive-aged women were then selected from the sampling frame using a simple random method. Then, with the assistance of health extension workers, data collectors went to each household, using the name of the head of the household as a guide. Finally, the lottery method was used to select one woman interviewee whenever there were two or more women of child-bearing age (18–49 years) in the selected household.

Data collection method

A pretested structured questionnaire was used to collect data from each study participant. The questionnaire was adapted from related literatures [9, 11, 13] with minor changes to fit the objectives of this study and the local context.

Seven diploma nurses were recruited as data collectors, with three BSc nurses recruited as supervisors. The overall data collection procedure plan would be followed by the principal investigator.

The Ahmaric version of a structured questionnaire was used in a face-to-face interviewer administered method of data collection.

Study variables

Dependent variable

Breast cancer awareness

Independent variables

Socio-demographic characteristics

➣ Age

➣ Residences

➣ Marital status

➣ Woman educational status

➣ Woman occupation

➣ Income

➣ Religion

➣ Ethnicity

➣ Husband educational level

Communication related variable.

➣ Having TV/Radio

Past history characteristics.

➣ Family history of breast cancer

Awareness of breast cancer- was measured by asking questions about breast cancer awareness (risk factor, sign &symptoms, preventive measures, screening methods and treatment). Each correct answer was scored ‘Yes’ and each incorrect answer was scored ‘No’. The mean score was used to calculate the cumulative mean score of participants’ breast cancer awareness. Those who scored higher or equal to the mean value were considered “aware,” while those who scored lower than the mean were considered “unaware” of breast cancer. We used mean to categorize the awareness after reviewing previous research [13, 14].

Data quality assurance

Two-day training was provided to the data collectors and supervisors. The questionnaire was first prepared in English, translated into Ahmaric and then it was re-translated back to English to check for its consistency. A week before the actual data collection, investigators, supervisors, and data collectors pre-tested the Ahmaric version of the questionnaire in East Badewacho Woreda Ajeba and Wera Lalo kebeles, which have similar demographics to the research population. The appropriate changes were then made to standardize and ensure the validity of the document. The surveillance was done on a daily basis. Furthermore, the data was extensively cleansed before being carefully fed into the computer to begin the analysis.

Data processing and analysis

The data was coded and entered into Epi-data version 3.1 before being exported to the statistical software SPSS version 20 for analysis. Variable recoding and computation were done as needed. To summarize the data, descriptive statistics such as frequency, percentage, mean, standard deviation, and range were used. A binary logistic regression analysis was carried out. All variables in the bivariable analysis with a P-value < 0.25 were candidates for multivariable logistic regression. The back-ward likelihood ratios of logistic regression were performed to identify the factors associated with breast cancer awareness. The model’s goodness of fit was checked by the Hosmer-Lemeshow test and the p-value was found to be 0.723 (> 0.05), which revealed that the model was good. Adjusted odds ratios (AOR) at 95% CI were computed to measure the strength of the association between the outcome and the explanatory variables. P-value < at 0.05 was considered as statistically significant in the study in the multivariable model.

Ethical consideration

Ethical clearance and permission was obtained from the Institutional Review Board (IRB) (code 502/2012 E.C) of Hosanna College of Health Sciences with protocol reference number by HCHS 09/4452 and offered to Woreda Health Office, and then permission was obtained from study Kebeles. After a detailed explanation of the study’s goal, expectations for participation, and potential risks and benefits to each participant, informed oral agreement was obtained. Voluntary participation and responses were kept confidential and anonymous. Women were interviewed at their home in a private area and no family members were allowed to accompany the participants to permit freedom of expression, privacy, and confidentiality. According to the ethical criteria of the college’s institutional review board, we documented participant permission with the recorded data for at least two years.

Results

The interview was completed by 578 reproductive-aged women out of a total of 595 reproductive-aged women, yielding a response rate of 97%. The analysis did not include the seventeen incomplete questionnaires. The results are presented under subheadings as follows:

Socio-demographic characteristics of respondents

In this study, the age of participants ranged from 18 to 48 years. The mean age of respondents was 27.59±7.18 SD years. One hundred and eighty-two (31.5%) of study participants belonged to the age below 23 years. Four hundred and sixty-six (80.6%) of participants were rural. Regarding work status, 169 (29.2%) were farmers. One hundred and seventy-nine (31%) of the women were unable to read and write. Regarding religion, 434 (75.4%) of respondents were Protestant religious followers. Five hundred and forty-two (93.8%) of the respondents were Hadiya by ethnicity. Regarding marital status, nearly two-thirds of the women (368, or 63.7%) were married. One hundred and fifteen of their husbands (31.3%) were unable to read and write. Concerning monthly income, the majority 434 (75.4%) of respondents were < 1311 ETB. Only 103 (17.8%) of respondents reported that they had a family history of breast cancer. Around 37% of study participants had access to television or radio [.

General awareness of breast cancer

Three hundred and sixty-four reproductive-aged women (63%) of the respondents had heard of breast cancer. According to the operational definition, 130 (35.7%) of the respondents were unaware, i.e., scored less than the mean at (4.39 ±SD 4.27). But, 234 (64.3%) of respondents were aware, i.e., scored greater than or equal to the mean.

Breast lumps were mentioned by the majority of women (60.4%) as signs and symptoms of breast cancer. Family history was mentioned by nearly half of the respondents (51.1%) as a common risk factor for breast cancer. The majority (64.6%) of participants stated that breast cancer was preventable, and they reported regular screening (53.6%) as a common breast cancer preventive method. More than three-quarters (77.5%) of those who heard about breast cancer mentioned clinical breast examination as a common screening method for breast cancer, and 59.1% believed that breast cancer was treatable. More than half of the participants (68.4%) mentioned hormonal therapy as a major treatment method [].

Sources of information

One hundred eighty-seven (51.4%) of those who had heard about breast cancer had heard from health workers, neighbors 138 (37.9%), and friends 133 (36.5%). In addition, 124 (34.1%) came from radio/TV, 75 (20.6%) from class, 55 (15.1%) from books/nets, and 16 (4.4%) from other sources such as the internet and magazines [.

Factors associated with awareness of breast cancer

During bivariable analysis, all variables with a p-value of less than 0.25 were entered into multivariable logistic regression analysis. In the study, variables with p-values less than 0.05 in multivariate analysis were considered statistically significant. The variables that significantly predicted breast cancer awareness included the husband’s educational status, a family history of breast cancer, and having TV/Radio.

In a multivariable logistic regression analysis, those whose husbands attended primary school were 74% less likely to be aware of breast cancer compared to those whose husbands attended tertiary school [AOR = 0.26; 95% CI (0.07, 0.90)]. Similarly, those with no family history of breast cancer were 72% less likely to be aware of the disease than those with a family history [AOR = 0.28; 95% CI (0.13, 0.59)]. In the same way, those who did not have access to television or radio were 51% less likely to be aware of breast cancer than their counterparts [AOR = 0.49; 95% CI (0.24, 0.97)] [].

Discussion

Improved societal awareness of non-communicable diseases, particularly breast cancer and its predictors, is critical for the success of prevention interventions. As a result, the focus of this study was assessing breast cancer awareness on reproductive-aged women.

According to our study finding, 64.3% of study participants were aware of breast cancer based on the composite score for signs and symptoms, risk factors, prevention methods, common diagnosis methods, and treatment of breast cancer. This study agreed with studies conducted in Iran [12], central India [14], Nigeria [3], and Ethiopia [15]. This result is higher than that of a cross-sectional study conducted in Eastern China (18.6%) [16] and Saudi Arabia (39.7%) [17]. This discrepancy could be attributable to sample size, respondent inclusion criteria, data collection methods, total number of questions asked of respondents, and the construction and computation of the awareness item.

This study’s findings are also lower than those of a previous study conducted in Benin (92.6%) [18]. This is most likely due to sample size, study setting, socio-cultural characteristics of respondents and the item’s cut point score for awareness. In addition, participants received health education during multiple visits to the health facility to immunize their child.

Those whose husbands attended primary school were less likely to be aware of breast cancer than those whose husbands attended tertiary school. This finding was supported by research findings from Turkey [19] and China [20]. This is most likely due to the fact that people with higher levels of education are more capable of obtaining more and effective information from various sources, as well as having the opportunity to communicate with their families about these specific health problems. They also have a greater ability to equip their homes with various information sources and a higher income to do so.

This study revealed that a family history of breast cancer is associated with breast cancer awareness. Those who did not have a family history of breast cancer were less likely to be aware than their counterparts. This finding was consistent with previous research from Iran [21], China [16], and Ethiopia [15]. This could be because having a family history of breast cancer provided them with more information and increased their health-seeking behavior.

The current study showed a significant link between having TV/Radio and being aware of breast cancer. This finding was supported by research from Nigeria [22, 23] and Uganda [24]. It is possible that the mass media will play an important role in the development of awareness. The media are generally regarded as channels of communication capable of simultaneously reaching diverse audiences with the same messages. They also persuade and stimulate social mobilization. In other words, because of their ability to reach every segment of the community, the mass media can be regarded as powerful sources of information. They are able to spread messages about issues, ideals, and products. Furthermore, the media has the ability to raise awareness and knowledge about topics of interest. As a result, many scholars agree that awareness leads to knowledge, and knowledge leads to behavior modification.

Limitation of the study

Because of its cross-sectional design, this study is unable to show the temporal relationship between cause and effect. Furthermore, this study focuses solely on awareness rather than the practice and attitude that women need to combat breast cancer.

Conclusion

This study emphasized the importance of raising breast cancer awareness among women in the study area. The husband’s educational status, family history of breast cancer, and having TV/Radio were significantly associated with breast cancer awareness. It is preferable to improve health-care programs that can reach all women regardless of their geographical location. Also, it is preferable to take advantage of opportunities to raise breast cancer awareness through health programs such as newspaper, local written and oral, radio, and television coverage of breast cancer signs and symptoms, risk factors, early diagnosis, prevention, and management.

It is also preferable to use cancer literacy programs at the national and state levels, as well as collaborations with community-level organizations and all levels of health-care delivery systems.

(DOCX)

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24 Sep 2021

ASSESSING BREAST CANCER AWARENESS ON REPRODUCTIVE AGE WOMEN IN WEST BADEWACHO WOREDA, HADIYYA ZONE, SOUTH ETHIOPIA: COMMUNITY BASED CROSS- SECTIONAL STUDY.

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Reviewer #1: GENERAL COMMENTS

• The author states that since breast cancer awareness is not well-documented among Ethiopian women, this study assesses awareness of the breast cancer and associated factors among reproductive-aged women in Hadiya Zone, West Badewacho Woreda of Ethiopia.

• The study shows that factors like husband’s education status, family history of breast cancer and having TV/Radio were significantly associated with awareness of breast cancer among reproductive-aged women.

• There is not a strong case made for the need for the study. Also, the authors are making a broad assumption of the Ethiopian situation without any references.

• Some of the methodological parts have not been clearly described, and there are some inconsistencies, as suggested in the “Materials and Methods” section.

• Some elaborations and clarifications can be made in the Discussion section , as suggested in the “Discussion” section.

• Some of the Recommended Items from the Strobe Checklist have not been illustrated.

o Variables in the Methods Section

o Limitations and Interpretations in the Discussion Section

• There are multiple problems with language, grammar and sentence structure, sometimes making the sentences difficult to comprehend. I have indicated many of them in the PDF as well, but there might be additional issues. It is suggested to re-write the manuscript considering language and sentence structure issues.

The Section Wise Details have been uploaded in a separate Word File.

Reviewer #2: The paper discusses an important aspect of public health - i.e public awareness about a serious but preventable disease that has a significant social burden. The methodology is good. I would like to recommend acceptance of the paper after it is completely re-written by a native english writer.

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Reviewer #1: Yes: Seema Subedi

Reviewer #2: Yes: Dr Manikandan K

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10 Dec 2021

Response to editor and reviewers

Dear Editor and revewers

Thank you very much for your consideration of our manuscript and constructive, valuable and educational comments. We have considered each of them, and provide the changes affected below in turn. Where changes have not been made, we provide reasons for this to substantiate our view.

Thanks, we were rewriting our manuscript as you told.

Thanks, we also elaborated study design and design effect on the manuscript.

We used design effect for we have woreda, then kebeles, lastly gotti(mahandari). So, we have at least two stages. So, we used design effect.

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Thank you

All your requirements were incorporated in the manuscript like participants recruitments methods, recruitment date & range, inclusion and exclusion criteria.

3. Please ensure you have discussed any potential limitations of your study in the Discussion, including study design, sample size and/or potential confounders.

Limitation parts was added and considered.

4. Thanks a lot.

In the Methods, please state:

- Why written consent could not be obtained

- Whether the Institutional Review Board (IRB) approved use of oral consent

- How oral consent was documented

This entire question was addressed in manuscript part in detail. Our subjects were human. So, ethical part was applied as research ethics guideline

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Thanks, we have considered these parts. Our funders were the institution but have no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

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This information should be included in your cover letter; we will change the online submission form on your behalf.

Thank u, we also consider as your recommendation. So, the authors have declared that no competing interests exist.

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Thank u. we will provide full data information for you, if you want any time.

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Thank u. this was corrected in manuscript. It was figure 2.

9. Please ensure that you refer to Figure 3 in your text as, if accepted, production will need this reference to link the reader to the figure.

Also this part was corrected as figure 2. It was corrected in manuscript part

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Thanks a lot. We were considering it.

11. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

All this part was considered in manuscript. A manuscript was rewrite and cites all references.

Reviewer 1

Really we have great appreciation to your constructive and valuable comments and suggestion. In general, we have modified our manuscript completely as your comments and suggestion. For seek response we have some reaction on your comments

1. The author states that since breast cancer awareness is not well-documented among Ethiopian women, this study assesses awareness of the breast cancer and associated factors among reproductive-aged women in Hadiya Zone, West Badewacho Woreda of Ethiopia.

e.g. According to WHO report 2020

Cancer is a leading cause of death worldwide, accounting for nearly 10 million deaths in 2020 (1). The most common in 2020 (in terms of new cases of cancer) were:

breast (2.26 million cases);

lung (2.21 million cases);

colon and rectum (1.93 million cases);

prostate (1.41 million cases);

skin (non-melanoma) (1.20 million cases); and

stomach (1.09 million cases).

Between 30 and 50% of cancers can currently be prevented by avoiding risk factors and implementing existing evidence-based prevention strategies. The cancer burden can also be reduced through early detection of cancer and appropriate treatment and care of patients who develop cancer. Many cancers have a high chance of cure if diagnosed early and treated appropriately.

This means that a little known about breast cancer especially in rural women. Because of this they seek care in late stage of cancer and even some of them didn’t understand it was disease or not. Also, in our study area there was no study conducted. So, developing mother’s awareness to this disease may develop women to treat early and manage timely.

2. Some of the methodological parts have not been clearly described, and there are some inconsistencies, as suggested in the “Materials and Methods” section below.

Thank u. this part was considered. We made it clear and consistent in manuscript as your comments.

3. Some elaborations and clarifications can be made in the Discussion section, as suggested in the “Discussion” section below.

This has been revised according to your suggestion.

4.

Abstract part

• Line 29 – The author has used both bivariable and multivariable logistic regression to determine the independent predictors. Please use “Binary and multivariable logistic regression analyses.”

Thank u. It is considered in manuscript part as bivariable and multivariable analysis. For general knowledge binary logistic regression is used for categorical varibles especially dependent variable is dichotomies.

• Line 32 ( Result Section)- This is not a causal model of analysis. So, it would be better to say “Adjusting for other variables” instead of using the word confounders. This part is also considered in manuscript as you suggested.

• Line 37 ( Conclusion)- Please re-write the sentence “it needs to deal with awareness”. Here “it” is a vague word. Please clarify what the author wants to mention.

This was also considered in manuscript and re-written.

Introduction

• Line 57- Please re-write the sentence “Breast cancer is not only a disease of the developed countries although low and middle-income countries are also affected.”

This part is considered in manuscript as you suggest.

Materials and Methods

• Line 85- Please justify why the author used the 1.5 design effect.

Thank u my reviewer. we used at least two stages lower in the sampling process to arrive at the final sampling unit. As a result, we used a design effect of 1.5 to multiply our sample size in order to minimize variability and detect the effect observed regarding breast cancer awareness.

• Line 141- Please use the word “ bivariable” instead of bivariate. Also it would be better to use words uniformly; either “binary logistic regression”, or “bivariable logistic regression” in all the sections of the paper.

It was considered as you suggested. Generally, bivariable for one dependent variable with one independent variable, for multivariable dependent variable with two or more independent variables.

• Line 200- Please use the word “multivariable analysis/regression” throughout the manuscript instead of the word “multivariate analysis/regression”. Please see the references for your reading . From one of the papers below-“Statistically speaking, multivariate analysis refers to statistical models that have 2 or more dependent or outcome variables, and multivariable analysis refers to statistical models in which there are multiple independent or response variables.”

https://www.karger.com/article/FullText/345491#:~:text=The%20terms%20'multivariate%20analysis'%20and,outcome%20each%20time%20%5B1%5D.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518362/

-This part is also corrected as you suggest

• Line 142- Please clarify why the author used the p-value of 0.25 instead of 0.05 in the bivariable model.

As you know that bivariable analysis is one outcome variable with one explanatory variable analysis. So, we used p-value <0.25 to get important variables that predict outcome variable due to bivariate analysis only compute with one variable. So, increase candidate variables for multivariable analysis. This mostly determine true predictor for outcome variable. As convection use criteria to select variables in bivariable analysis.

• Also, please be consistent with the use of the p-value of 0.25 or 0.05, as the p-value of 0.05 has been indicated in line 366 of Table 3 ( Bivariable Analysis).

Thank u. we used consistent throughout manuscript as your suggestion. But we used p-value <0.25 for bivariable analysis and p-value <0.05 for multivariable analysis.

• Line 142-144- Please elaborate on why the author used the method “Back ward likelihood ratio of logistic regression”.

Thank u. why we used this backward likelihood ratio of logistic regression from others types of stepwise due it has better than other like Starting with the full model has the advantage of considering the effects of all variables simultaneously. Also, important in case of collinearity. Due to force to keep them all in the model.

• Line 145- “AOR” stands for Adjusted Odds Ratio, not just Odds Ratio.

It was considered in manuscript part

• Line 147-148- Please clearly indicate if this statement “P-value < 0.05 was considered as statistically significant in the study” is for multivariable model.

Yes. It was considered in manuscript as you suggest

• According the to the STROBE checklist, all the VARIABLES should be clearly defined in the Method Section.

o The outcome variable is the division of respondent’s score by the mean score. This sounds a bit arbitrary – what would happen if the mean is skewed because of outlier values? The usual method is to use the median – using quantile regression as the multivariable method. Please clarify on this.

Thank u. we used distribution of the outcome variable before mean score calculation. So, our data was normally distributed.

o The knowledge score is not well defined – what were the questions that went into the score? How much was the scale and what were the minimum and maximum? All these need to be part of the methods description of the variables.

It was considered in manuscript part specifically in operational definition part

o Please Insert a VARIABLE Section and define all the variables clearly.

It was inserted in manuscript part as you suggested.

Result

• Please check the tense in this section as indicated in General Comments section.

It was checked and re arranged in document.

• Line 196- Please be consistent with the use of the p-value of 0.25 or 0.05, as it is indicated p-value of 0.05 in line 366 of Table 3 ( Bivariable Analysis).

Thanks a lot. We used and try to clarify in above section we used p-value <0.25 in bivariate analysis to get candidate variables and p-value <0.05 for multivariable analysis. But, we use convection and rule of tump specially in bivariable analysis.

• Line 201-203: It would be better to include these sentences in the Data Analysis Section.

It was considered in document

• In the Result Section, as well as in the Tables, two significant digits after the decimal point are enough.

This part was also considered in document as you recommended

Discussion

• Line 222-224- “This difference might be due to sample size, respondent’s inclusion criteria, and data collection methods, total number of items they were used to ask the respondents, construction and compute of the awareness item”. The author could specify one or two instances of how the different methodological aspects like sample size or total number of items used to ask respondents could have led to lower prevalence of breast cancer awareness in Eastern China (18.6%) and Saudi Arabia (39.7%) , as compared to this study (64.3%).

Prevalence -The number of cases of a disease (or people with a particular characteristic) existing in a specified population at a given point in time. So, if sample size decrease cases probability to get cases might be decrease. Also, item they used to ask respondents different from us or categorization way may influence prevalence due to understandability of item to respondents affect responses to item. This mean that item number increase the clarity to answer increase.

• According to Strobe Checklist, there needs to be a section with LIMITATIONS and INTERPRETATION in the discussion. Please add that.

Considered and incorporated in manuscript part especially limitation. But interpretation was incorporated in conclusion part.

Conclusion

• This section requires re-writing as indicated in the General Comments Section.

This section was re-written in manuscript as you suggested.

COMMENTS ON THE TABLE

Table 1

• Check the case ( higher/lower) of the letters of the variables

It was checked and corrected in manuscript.

Table 2

• The author put asterisk sign in the footnote as “*more than one option is reported by a participant”, but the asterisk sign is not indicated anywhere in the table.

This part was corrected and asterisk was putted in correct place on table as you mentioned.

Table 3 and Table 4

• The author could show the information in Table 3 and Table 4 ( Crude Odds Ratio and Adjusted Odds Ratio) in a single table for better presentation and clarity.

Considered and merged in one table as your suggestion

• Line 366- “ Note: * p value of less than 0.05 in bivariate analysis”. The author had described in the Method Section (Line 142) that in the bivariable analysis, they used the p-value of 0.25. In this Line 366, they indicate p value of 0.05. Please apply consistent methods, and clarify.

It was mentioned above why we used p-value less than 0.25 and p- value less than 0.05.

• Line 366- Also check the appropriate use and label of asterisk sign “ * ” defined as “p value of less than 0.05 in bivariate analysis” , since this asterisk sign has also been used in “<0.001*”.

Why we used <0.001*, for those p-value was 0.000 and to show strong relationship between dependent and independent variables.

Reviewer 2

Really we have great appreciation to your constructive and valuable comments and suggestion. In general, we have modified our manuscript completely as your comments and suggestion

Submitted filename: response to editor and reviewer.docx

Click here for additional data file.

16 May 2022

30 May 2022

Response to reviewer

Dear Peer Reviewer,

Thank you very much still for your consideration of our manuscript and constructive, valuable and educational comments. We have considered each of them, and provide the changes affected below in turn. Where changes have not been made, we provide reasons for this to substantiate our view.

Really, we have great appreciation to your constructive and valuable comments and suggestion. In general, we have modified our manuscript completely as your comments and suggestion. For seek response we have some reaction on your comments

Result part

1. Remove FIGURE 2 AWARENESS OF BREAST CANCER AMONG REPRODUCTIVE-AGE WOMEN IN WEST BADEWACHO WOREDA, HADIYA ZONE, SOUTH ETHIOPIA,2020 (N=364). Describe it in text.

Thank u. this part was considered as you commented.

2. FIGURE 3 SOURCE OF INFORMATION FOR THE AWARENESS, present a simple bar diagram.

This has been revised according to your suggestion.

Discussion

Revise the discussion section, focused more on what is the existing health promotion program in the country. How this study findings will be useful to promote breast cancer screening in the country.

Thank u. we were discussed most of our findings with other findings conducted in other part of countries. As result we focused on contemporary issues. As you know that if women aware for breast cancer, they will be screened for breast cancer regularly. if not, the chance of screening is low. our aim was to identify level of awareness of reproductive aged women rather than screening awareness. Some how, it was raised on significant of study part and conclusion.

Submitted filename: Response to reviewer 3.docx

Click here for additional data file.

8 Jun 2022

Assessing breast cancer awareness on reproductive age women in West Badewacho Woreda, Hadiyya Zone, South Ethiopia; Community based cross- sectional study.

PONE-D-21-11416R2

Dear Dr. Lodebo,

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Reviewers' comments:

13 Jun 2022

PONE-D-21-11416R2

Assessing breast cancer awareness on reproductive age women in West Badewacho Woreda, Hadiyya Zone, South Ethiopia; Community based cross- sectional study.

Dear Dr. Funga:

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Table 1

Socio-demographic characteristic of respondents in West Badewacho Woreda, Hadiya Zone, South Ethiopia, 2020 (n = 578).

Variables	Categories	Frequency	Percentage
Age	= <23	182	31.5
	24–29	178	30.8
	30–34	101	17.5
	= >35	117	20.2
Residence	Rural	466	80.6
	Urban	112	19.4
Work status	Farmer	169	29.2
	Housewife	95	16.4
	Student	122	21.1
	Merchant	85	14.7
	Daily laborer	33	5.7
	Gov’t employee	74	12.8
Educational level of women	cannot read and write	179	31.0
	read and write	131	22.7
	Primary	109	18.9
	Secondary	84	14.5
	higher or tertiary	75	13.0
Religion	Orthodox	60	10.4
	Catholic	67	11.6
	Muslim	3	.5
	Protestant	434	75.1
	Others*	14	2.4
Ethnicity	Hadiya	542	93.8
	Kambata	18	3.1
	Wolayita	11	1.9
	Others**	7	1.2
Marital status	Married	368	63.7
	Single	188	32.5
	Divorced	12	2.1
	Widowed	10	1.7
Educational level of husband	cannot read and write	115	31.3
	read and write(non-formal)	98	26.6
	Primary	57	15.5
	Secondary	36	9.8
	higher or tertiary	62	16.8
Income	1311	434	75.1
	>1311	144	24.9
Family history of BC	No	474	82
	Yes	104	18
Having TV/Radio	No	362	62.6
	Yes	216	37.4

Others: only Jesus*, Adventist*, Ahmara**, Silte**, Gurage**

Table 2

General awareness about breast cancer in West Badewacho Woreda, Hadiya Zone, South Ethiopia, 2020.

Variables	Categories	Frequency	Percentage
Sign and symptoms *	Breast lump	220	60.4
	Breast pain	202	55.5
	Discharge	139	38.2
	Nipple retraction	68	18.7
	Redness and engorgement	72	19.8
	Itching	110	30.1
	Change in size of the breast	37	10.2
Risk factors *	Family history	186	51.1
	Contraceptive pills	93	25.5
	Increasing age/aging	38	10.4
	Being a woman	162	44.5
	Obesity	23	6.3
	Not breast feeding	71	19.5
	Early-onset of menarche	48	13.2
	Late menopause	43	11.8
	Smoking	44	12.1
	Alcohol	49	13.5
Breast cancer preventable (n = 364)	No	129	35.4
	Yes	235	64.6
By which method can it be prevented*?	Initiate breast feeding	118	50.2
	No smoking	61	26
	Not drinking alcohol	58	24.7
	Regular screening	126	53.6
	Physical Exercise	13	5.5
	Combat obesity	9	3.8
	Avoid OCP	34	14.5
	Wearing bra	34	14.5
What common screening methods are of breast cancer do you know?* (n = 364)	Breast self-examination	168	45.3
	Clinical breast examination	283	77.5
	Mammography	40	11
Is breast cancer is treatable? (n = 364)	No	149	40.9
	Yes	215	59.1
What is the treatment of breast cancer?*	Chemotherapy and radiotherapy	57	26.5
	Hormonal therapy	147	68.4
	Surgery or removal of the whole breast	135	62.8

*more than one option is reported by a participant.

Table 3

Bivariate and multivariable analysis of breast cancer awareness and associated factors among reproductive-age women in West Badewacho Woreda, Hadiya Zone, South Ethiopia, 2020 (n = 364).

Variables	Categories	Aware n (%)	Unaware n (%)	COR(95%CI)	P-value	AOR(95%CI	P-value
Residence	Rural	169(67.1)	83(32.9)	1.472(0.931,2.328)	0.098
	Urban	65(58)	47(42)	1
Work status	Farmer	37(50.7)	36(49.3)	0.131(0.055, 0.311)	<0.001
	Housewife	31(56.4)	24(43.6)	0.164(0.066, 0.407)	<0.001
	Student	47(52.2)	43(47.8)	0.139(0.060, 0.323)	<0.001
	Merchant	39(70.9)	16(29.1)	0.310(0.121, 0.791)	0.014
	Daily laborer	17(85.0)	3(15.0)	0.720(0.172, 3.010)	0.652
	Gov’t employee	63(88.7)	8(11.3)	1
The educational level of women	cannot read and write	50(60.2)	33(39.8)	0.366(.176, .759)	0.007
	read and write	56(65.1)	30(34.9)	0.451(.216, .938)	0.033
	Primary	37(59.7)	25(40.3)	0.357(.165, .774)	0.009
	Secondary	33(54.1)	28(45.9)	0.284(.132, .615)	0.001
	higher or tertiary	58(80.6)	14(19.4)	1
The educational level of husband	cannot read and write	29(64.4)	16(35.6)	0.333(0.130,0.850)	0.021	0.944(0.279,3.196)	0.927
	read and write(non-formal)	35(53)	31(47)	0.207(0.088,0.490)	<0.001	0.351(0.122,1.008)	0.052
	Primary	13(41.9)	18(58.1)	0.133(0.048,0.363)	<0.001	0.262(0.076,0.900)	0.033*
	Secondary	15(53.6)	13(46.4)	0.212(0.076,0.592)	0.003	0.356(0.106,1.167)	0.088*
	higher or tertiary	49(84.5)	9(15.5)	1		1
Income	1311	140(57.9)	102(42.1)	0.409(0.250,0.669)	<0.001
	>1311	94(77)	28(23)	1
Family history of BC	No	151(58.1)	109(41.9)	0.351(0.205,0.601)	<0.001*	0.281(0.132,0.594)*	0.001*
	Yes	83(79.8)	21(20.2)	1		1
Having TV/Radio	No	91(52.9)	81(47.1)	0.385(0.248,0.599)	<0.001*	0.489(0.246,0.972)*	0.041*
	Yes	143(74.5)	49(25.5)	1

Note:

*significantly associated, ‘1’ reference group