Perceptions and knowledge of breast cancer and breast self-examination among young adult women in southwest Ethiopia: Application of the health belief model.

BACKGROUND: Breast cancer is still a recognized public health issue in Ethiopia. Despite this, the viewpoints and comprehensions of young women about the situation are unknown. Therefore, this study was carried out to assess the knowledge and perceptions of young adult women in Southwest Ethiopia about breast cancer and breast self-examination (BSE).
METHODS: A community-based cross-sectional study was carried out in the Gurage zone, southwest Ethiopia, in 2021. A total of 392 young adult women were randomly selected from both urban and rural strata using a three-stage stratified sampling process. A pretested questionnaire was used to collect the data. For data entry, Epi-data 4.6 with a double-entry approach was used, and for analysis, SPSS 26 was used. Bivariate and multivariable logistic regression analyses were performed to identify variables associated with BSE behavior. A p-value of 0.05 or below was considered statistically significant with a 95% CI.
RESULTS: The respondents' ages ranged from 20 to 24, with a mean of 21.25 (±1.32) years. Breast cancer and BSE were unknown to more than 80% of the study participants. A large proportion of young adult women had low perceived susceptibility (97.6%), low threat of breast cancer (96%), and low self-efficacy to perform BSE (91.4%). BSE was conducted by 23.1% of the participants occasionally. Being married (AOR = 5.31, 95% CI = 2.19-12.90), having good outcome expectations of BSE (AOR = 2.05, 95% CI = 1.16-3.61), having good BSE knowledge (AOR = 1.22, 95% CI = 1.04-1.45), having high perceived susceptibility (AOR = 1.12, 95% CI = 1.05-1.20), high perceived severity (AOR = 1.78, 95% CI = 1.02-3.09), and having high self-efficacy to do BSE (AOR = 1.05, 95% CI = 1.01-1.09) were all significant predictors of BSE practice.
CONCLUSIONS: Young adult women were less concerned about breast cancer and had insufficient knowledge of breast cancer and breast self-examination. They have little knowledge of, confidence in, or experience with BSE. The practice of BSE was associated with increased perceived susceptibility, self-efficacy, severity, outcome expectations, and BSE knowledge. Therefore, these variables should be considered when developing educational interventions for young women.

Introduction

Breast cancer has surpassed lung cancer as the most common malignancy among women, with 2.3 million new cases and 685, 000 deaths recorded in 2020 [1]. Every year, it kills approximately 500,000 women, and disproportionate deaths occurs in low-resource countries [2].

In Ethiopia, breast cancer is widely recognized as a serious public health concern and a priority cancer for intervention [3,4]. Approximately 10,000 Ethiopian women are affected. 90% of women are diagnosed with advanced breast cancer, with tens of thousands more cases undetected [4].

Many people believe that breast cancer only affects women in their forties and fifties [5,6]. Breast cancer, on the other hand, can and does affect young women. Every year, about 13,000 women under 40 are diagnosed with breast cancer. More than 80% of young women find out about their abnormal breast condition on their own. The global increase in breast cancer incidence is evident in all age categories, with women under 50 experiencing the greatest increase [7,8]. The number of young women with risk factors for breast cancer has been shown to be alarmingly high [9]. Young women with cancer are often diagnosed with advanced stage breast cancer. They have a variety of issues, including a higher likelihood of biologically aggressive illness and metastatic disease at diagnosis, which leads to a worse prognosis, more aggressive treatments and long-term treatment-related toxicities, and unique psychosocial concerns [10-12]. As a result, their survival rate is lower than older women [13].

The impact of early detection of breast cancer on morbidity and mortality is significant. If this cancer was detected early, a 95% chance of survival could be achieved [8,14]. The American Cancer Society recommends three screening options: mammography, clinical breast examination (CBE), and breast self-examination (BSE). Despite the fact that mammography is the most effective tool for early breast cancer detection, it is prohibitively expensive in developing nations [8].

When a woman palpates (feels) and inspects her own breasts for lumps, abnormalities, or swelling, this is known as breast self-examination [14]. Although there is debate about the efficacy of BSE in countries where mammography and CBE are widely available, BSE remains a simple, non-invasive, cost-effective, and accessible method of early detection in developing countries like Ethiopia, where mammography is extremely difficult to obtain [5,8,13,15].

It is critical for women to understand their own breasts and be mindful of any changes. Women can be empowered by BSE and other health practices that allow them to take control and responsibility for their own health [13,15].

BSE is still recommended as a general method for increasing breast health awareness, which makes it easier for women to detect any changes that may arise [8,16,17]. Despite the benefits, many women in many countries do not perform regular self-breast checks [8,13,15,18]. Many women cited a lack of competence as the primary reason for not doing BSE [16,17,19]. For younger women, BSE education and adherence are a doorway to health-promoting behaviors, laying the groundwork for eventual adherence to clinical breast examination and mammography screening, if available [13,15]. Breast cancer fundamentals, such as risk factors, early warning signs, and screening modalities, such as BSE, should be taught to all women starting at a young age [8,9,18,20,21]. To promote breast self-examination practice, their concern and confidence should be improved [8,22].

Model-based educational interventions are more effective for the BSE screening behavior of women [23]. Interventions that target the threat of breast cancer and the benefits of breast self-examination may help improve knowledge and skills for performing breast self-examinations [24].

However, little is known about Ethiopian young adult women’s perceptions of breast cancer and BSE. Therefore, the current research attempted to determine how young adult women in Southwest Ethiopia perceive and understand breast cancer and BSE. The findings may be useful in national and local breast health promotion efforts.

Material and methods

Study area and study design

The study was conducted in the Guraghe zone, southwest Ethiopia, from June 15 to September 30, 2021. The zone is one of the zonal administrations in the regional state in southern Ethiopia. Its administrative center, "Wolkite," is located 158 kilometers away from Addis Ababa. It was divided into five town administrations and sixteen districts, which were further divided into 423 (403 rural and 20 urban) smaller administrative units, “kebeles” and 88,587 households. In 2021, the zone had a population of 1,807,892 people, of whom 43.8% were urban dwellers. Young adult women accounted for 7.6% of the total, while non-pregnant reproductive-age (15–49 years old) women accounted for 19.8%. The zone has eight hospitals (1 referral, 1 general, and 6 primaries), 75 health centers, and 416 health posts, all of which provide various levels of health care to the public [25].

To investigate views and understanding of breast cancer and BSE, a community-based cross-sectional study was done on randomly selected 392 young adult women.

Study population and eligibility criteria

All young adult women (aged 20 to 24) living in the Guraghe zone were the source population, while those who were permanent residents in selected districts were the study population for this study. The study included young adult women who were available throughout the data collection period, consented to participate in the study, and completed all the questions. Those who refused to participate or were critically ill to interact with data collectors were excluded.

Sample size determination and sampling procedure

The sample size required for this study was determined by using the formula to estimate a single population proportion, assuming 20.3% of young adult women have ever practiced BSE [8], 95% CI, 5% margin of error, at alpha 0.05.

The formula produced n = 249. After adding 5% for non-response, and multiplying by 1.5 for design effect, the final calculated sample size was 392 young adult women.

The study participants were selected using a three-stage stratified sampling technique from urban and rural strata. In the first stage, three town administrations and six districts were randomly selected. 4 kebeles from each of the 3 selected town administrations and 48 kebeles from each of the 6 selected districts were randomly picked in the second stage of the sampling process. The sample size was proportionally assigned to each kebele, depending on the number of households eligible to participate in each kebele. A census survey was conducted to determine eligible households. In the third stage of the selection process, households containing young adult women were recruited using a systematic random sampling technique. A sampling interval was determined for each kebele, and the first dwelling was randomly selected. When there were multiple eligible participants in a house, a lottery method was employed to choose one. The data were collected by 25 trained health extension workers under the supervision of five health officers and nurses. Households that were either closed or lacked a respondent were visited three times. Those who were unavailable on the third (last) visit were listed as non-respondents.

Data collection tools and measurements

A pretested questionnaire was used as a data collection instrument, adapted from literature [13,26-30]. It was organized into four sections: sociodemographic, knowledge, perception, and practice of BSE. Participants fill out questionnaires in the presence of data collectors. when someone couldn’t read due to visual difficulties or illiteracy interviewer-administered questions, which had the same wording and form as self-administered questionnaires were used. Using the American Cancer society guidelines [29], the knowledge of breast cancer warning signs and awareness of breast cancer risk factors were assessed using 11 questions with "yes" or "no" response and 10 items with a “true or false” response option, respectively. Five multiple-choice questions adapted from prior research were used to test knowledge of breast self-examination [13]. This form detailed the proper age to begin BSE, the best time to perform BSE, the frequency of BSE, and the BSE procedure.

Correct responses were coded as 1, while incorrect responses were coded as 0. Each correct response was added together to create a composite score. The greatest possible scores for knowledge of risk factors, warning signs, and BSE were 10, 11, and 5 respectively. The higher the score indicated, the better knowledge. The Cronbach’s alpha coefficient for the internal consistency reliability of warning signs, BC risk factors, and measurement of BSE knowledge was 0.788, 0.572, and 0.635, respectively. A revised Bloom’s cut-off of 80% was used to determine adequate knowledge [30].

The revised Champion Health Belief Model Scale was used to assess respondents’ perceptions. It’s a widely used tool for analyzing variables like perceived susceptibility, severity, perceived barriers, benefits, and self-efficacy. According to previous literature, the reliability coefficient for each subscale calculated using Cronbach’s alpha ranged from 0.58 to 0.91 [26-28]. On a five-point scale, participants were asked to rate each item, ranging from 1 strongly disagree to 5 strongly agree. The corresponding scores were added together, with values ranging from 7 to 35 for susceptibility, 8 to 40 for severity, 7 to 35 for benefits, 7 to 35 for barriers, and 10 to 50 for self-efficacy. Higher scores were expected to suggest a more positive attitude toward breast cancer and BSE, with the exception of BSE barriers.

Respondents’ perceived threat was calculated as the sum of susceptibility and severity scores. By subtracting the perceived barrier score from the perceived benefits, the perceived outcome expectation was computed. The mean value served as the cutoff point for dichotomizing each subscale. In this study, Cronbach’s alpha values were calculated as 0.72 for susceptibility, 0.75 for severity, 0.77 for BSE benefits, 0.63 for BSE barriers, and 0.79 for BSE self-efficacy.

Respondents under investigation were also asked about the practice of their breast self-examination for breast cancer. Those who answered "Yes" were considered performed the behavior and were coded as 1. Three more inquiring questions were then used to examine the appropriateness of the examination time and method. Monthly self-examination with three middle finger pads a week after each menstruation was considered good breast self-examination practice in this study [13].

Data processing and analysis

The data were double-checked for accuracy and consistency. For data entry and analysis, EPI-data version 4.6 software package and the Statistical Package for Social Sciences (SPSS) version 26 software package were used. Frequency, tables, figures, mean, and standard deviation (SD) were used to present the descriptive data. Variables with a p-value <0.25 in the bivariate binary logistic regression analysis were selected to fit the final model. Variance inflation factor (VIF) of >10 and tolerance <0.1 was considered suggestive of multi-collinearity. However, no multicollinearity was detected during the analysis. Multivariate logistic regression analysis was performed to control the potential effect of confounders and identify the major factors influencing breast self-examination practice. The model’s fitness was assessed using the Hosmer and Lemeshow goodness-of-fit test (p-value = 0.301). Finally, the Adjusted Odds Ratio (AOR) with 95% CI was used to evaluate the strength of the association between the explanatory and outcome variables. Independent variables with a P-value < 0.05 were declared to have a statistically significant association with the outcome variable after controlling for the effects of confounders.

Data quality control

The questionnaire was pilot tested on 5% of the sample in an unselected district one week before the actual data collection period to ensure data quality. The research objectives, data collection processes, and interview protocols were all explained to data collectors and supervisors. All the data collection processes were closely overseen, and the completeness of collected data was checked daily by the lead investigator and supervisors. The information was properly coded, and a double-entry strategy was applied.

Ethical clearance and consent for participation

Ethical approval was obtained from Wolkite University’s institutional ethical review board. The purpose of the study was communicated to the respondents, and signed consent from each participant was obtained prior to data collection.

Results

Socio-demographic characteristics and sources of information

A total of 373 young adult women responded to the questionnaire, with a rate of 95.15% response. The participants’ ages ranged from 20 to 24, with a mean of 21.25(±1.32) years. The majority of the study’s participants were single (92.23%) and rural dwellers (62.73%).

About half (54.42%) of them attended primary to secondary school. Only 50.13% had heard of breast self-examination before. The media was cited as the key source of information by nearly sixty percent (57.91%) of young adult women. Fifteen (4.04%) of respondents had a positive family history (Table 1).

Table 1

Socio-demographic profile of young adult women Gurage zone.

Variables	Category	Frequency	Percent (%)
Mean age = 21.25 (±1.32) years.
Resident area	Rural	234	62.73
	Urban	139	37.27
Educational Background	Illiterate	9	2.41
	Primary to Secondary	203	54.42
	College and above	161	43
Marital status	Single	344	92.23
	Married	29	7.77
Ever heard about breast cancer	Yes	370	99.1
	No	3	0.80
Heard about BSE	Yes	187	50.13
	No	186	49.87
Sources of information	Media/TV/radio	216	57.91
	Health workers	107	28.69
	Friends	42	11.26
	Not remembered	8	2.14
Had family history of BC	Yes	15	4.04
	No	358	95.98

Knowledge of risk factors for breast cancer

In terms of respondents’ knowledge of breast cancer risk factors, alcohol drinking (49.06%) and cigarette smoking (47.72%) were the two most well-known risk factors. Only a small percentage of respondents knew that a high-fat diet (34.58%), oral contraceptive pill use (31.37%), late menopause (28.15%), having their first child at a late age of 30 years (29.22%), family history (29.76%), early onset of menarche (19.30%), and advanced age (25.74%) are risk factors for developing breast cancer. Overall, 305 young adult women (81.77%) showed low risk factor awareness, while only 55 (14.70%) and 13 (3.50%) had moderate and high knowledge about risk factor, respectively (Table 2).

Table 2

Knowledge of young adult women on breast cancer risk factors Gurage zone.

Variables	Category	Frequency	Percent (%)
Alcohol consumption	Yes	183	49.06
	No	190	50.94
Cigarette smoking	Yes	178	47.72
	No	195	52.28
Consumption of high-fat diet	Yes	129	34.58
	No	244	65.42
Oral contraceptive pills Use	Yes	117	31.37
	No	256	68.63
Late menopause (after the age of 55 years)	Yes	105	28.15
	No	268	71.85
First child at the late age of 30 years	Yes	109	29.22
	No	264	70.78
Family history	Yes	111	29.76
	No	262	70.24
Early-onset of menarche before 12 years	Yes	72	19.30
	No	301	80.70
Advanced age	Yes	96	25.74
	No	277	74.26
Overall knowledge about breast cancer risk factors	Low	305	81.77
	Moderate	55	14.70
	High	13	3.50

Knowledge of early warning signs of breast cancer

Around three-quarters of study participants reported soreness in the breast (76.41%), pain in the breast region (77.48%), and ulceration (74%) as breast cancer warning signs. Discoloration of the breast (65.68%), painless breast lump (66.22%), change in breast size (62.73%), dimpling of breast skin (60.86%), and dry skin (60.32%) were the next most reported warning signs, followed by a nipple discharge (58.45%) and a lump under the armpit (50.40%). Less than half (40.75%) of the participating young women knew that weight loss is a warning sign for breast cancer. In this study, 37.53%, 21.72%, and 40.75% of respondents had good, moderate, and low warning sign knowledge, respectively (Table 3).

Table 3

Respondents knowledge about warning signs of breast cancer, Gurage zone.

Warning sign	Responses	Frequency	Percent (%)
Mean ± SD = 7.18 ±2.82 out of 11
Overall warning sign knowledge	High	140	37.53
	Moderate	81	21.72
	Low	152	40.75
Painless breast lump	Wrong	126	33.78
	Correct	247	66.22
Lump under armpit	Wrong	185	49.59
	Correct	188	50.40
Nipple discharge	wrong	155	41.55
	correct	218	58.45
Change in breast size	wrong	139	37.27
	correct	234	62.73
Pain in breast region	wrong	84	22.52
	correct	289	77.48
Dimpling of breast skin	wrong	146	39.14
	correct	227	60.86
Dry skin in nipple region	wrong	148	39.68
	correct	225	60.32
Weight loss	wrong	221	59.25
	correct	152	40.75
Pain or soreness in the breast	wrong	88	23.59
	correct	285	76.41
Discoloration /dimpling of the breast	wrong	128	34.32
	correct	245	65.68
Ulceration of the breast	wrong	97	26
	correct	276	74

When it came to overall BC knowledge, nearly three-quarters of young adult women (73.70%) had inadequate information (Fig 1).

Fig 1

Young adult women’s knowledge of breast cancer Gurage zone.

Knowledge and practice of breast self-examination

In this study, only 86 (23.06%) and 7 (1.88%) of young adult women had conducted BSE at least once and regularly, respectively. In terms of BSE knowledge, 79.89% of respondents had poor knowledge of BSE. The optimal time for BSE and frequency is unknown to 58.71% and 65.68% of subjects, respectively. More than seventy percent of them (71.05%) have no idea how to do BSE (Table 4).

Table 4

Young adult women’s BSE knowledge and practice, Gurage Zone.

Knowledge of and practice of BSE	Category	Frequency (n)	Percent (%)
Have you ever done BSE	Yes	86	23.06
	No	287	76.94
Do you know how to perform BSE	Yes	146	39.14
	No	227	60.86
Can you successfully do BSE	Yes	127	34.05
	No	246	65.95
Knowledge about the frequency of BSE (n = 373)	Wrong response	245	65.68
	Correct response	128	34.31
Knowledge about appropriate time for BSE (n = 373)	Wrong response	219	58.71
	Correct response	154	41.29
Knowledge about BSE procedure (n = 373)	Wrong response	265	71.05
	Correct response	108	28.95
Overall BSE knowledge (n = 373)	Poor knowledge	298	79.89
	Good knowledge	75	20.11

Perception towards breast cancer and BSE

This study showed that 97.59% of young women believed they were not susceptible to BC, and their perceived severity score was high (54.16%). Two hundred fifty-four (68.10%) of respondents had a high perceived benefit score on breast self-examination, while 269 (72.12%) had low perceived confidence or self-efficacy to performing BSE. The vast majority of young women (95.98%) were less concerned about breast cancer, and over half (59.79%) had low expectations regarding the outcome or net benefit of BSE. When it comes to the barriers to practice BSE, more than ninety percent of young adult women (91.42%) have low perceived barriers (Table 5).

Table 5

Perception of young adult women towards breast cancer and BSE Gurage Zone.

Variable	Response category	Frequency	Percent (%)
perceived susceptibility	Low	364	97.59
	high	9	2.41
Perceived severity	Low	171	45.84
	high	202	54.16
Perceived threat	Low	358	95.98
	high	15	4.02
Perceived benefit	Low	119	31.90
	high	254	68.10
Perceived barrier	Low	341	91.42
	high	32	8.58
Perceived self-efficacy	Low	269	72.12
	high	104	27.88
Perceived outcome expectation	Negative	223	59.79
	Positive	150	40.21

Factors associated with breast self-examination

According to the multivariate logistic regression analysis, married young adult women were 5.31 times more likely than unmarried young adult women to perform BSE (AOR = 5.31, 95% CI: (2.19–12.90). BSE knowledge was significantly associated with BSE practice. After all the other factors were kept constant, per one-unit increase in knowledge of BSE, the odds of practicing breast self-examination increased by 1.22 times (AOR = 1.22, 95% CI: 1.04–1.45). For each unit increase in perceived susceptibility to breast cancer and perceived self-efficacy to do BSE, the odds of performing BSE increased by 1.12 (AOR = 1.12, 95% CI:(1.05–1.20) and 1.05 (AOR = 1.05, 95% CI: (1.01–1.09), respectively. The study found that young adult women with a high perceived severity score and positive outcome expectations for BSE were 1.78 (AOR = 1.78, 95% CI: (1.02–3.09) and 2.05 (AOR = 2.05, 95% CI: (1.16–3.61) times more likely than their counterparts to engage in BSE behavior, respectively (Table 6).

Table 6

Factors associated with breast self-examination based on multivariate logistic regression analysis among young adult women Gurage zone.

		BSE practice
	Category	Yes	No	COR 95% CL	AOR (95%CL)
Marital status	Married	16	13	4.82(2.21–10.48) *	5.31(2.19–12.90) **
	Single	70	274	1	1
Family History of BC	Yes	8	7	4.10(1.44–11.67) **	2.23 (0.63–7.89)
	No	78	280	1	1
Severity	high	55	147	1.69 (1.03–2.78) **	1.78 (1.02–3.09) *
	low	31	140	1	1
BSE knowledge a				1.38(1.19–1.60) *	1.22(1.04–1.45) **
Susceptibility a				1.14(1.08–1.20) *	1.12(1.05–1.20) *
Barriers a				0.93(0.88–0.99) **	0.94(0.88–1.01)
Self-efficacy a				1.07(1.03–1.12) *	1.05(1.01–1.09**
Outcome expectations	Positive	46	104	2.02(1.24–3.29) **	2.05(1.16–3.61) **
	Negative	40	183	1	1

** p< = 0.05

*p-value <0.001, Hosmer and Lemeshow goodness-of-fit test (p = 0.301)

a continuous variables.

Discussion

Young adult women are an important target group for breast health promotion [13,15]. Breast self-examination should be done beginning the age of 20. Therefore, it’s critical for women to understand their own breasts and be aware of any changes [13]. However, little study has been done in Ethiopia on young adult women’s perceptions and comprehension of breast cancer and BSE. The purpose of this study was to find out what young adult women in Southwest Ethiopia thought about breast cancer and BSE. A full grasp of these key concepts is considered crucial for developing a successful public health intervention to increase women’s awareness and concern about their breast health [16,20].

In the current study, approximately half (49.87%) of young adult women had never heard of breast self-examination. Similarly, 47.5% of young college students in Addis [31] and 62.1% of female high school students in Turkey [13], and 26.5% of young women in Cameroon [18] had never heard of BSE. This data implies young women are less informed about breast self-examination and breast health in general. It is possible that this is due to the fact that cancer receives less attention [3]. Breast health should be given sufficient attention and included in school curricula so that all women are informed about it from an early age [8,9,18,20,21].

More than half of our respondents mentioned the media as their primary source of information on breast cancer and BSE, which is consistent with prior studies [13,31]. These findings reveal the significance of media outlets, such as audio-visuals and social media platforms, in disseminating breast health-related information to the general population.

Congruent with other studies [13,32,33]. a great proportion (81.77%) of the present study participants had poor knowledge of breast cancer risk factors. Almost three-fourths (73.70%) of young adult women had low knowledge of breast cancer. Similarly, 75.90% of female students in Mekelle University [34] and 56.20% in Sudan Khartoum had poor knowledge of breast cancer [35]. Nearly 38% of respondents have excellent warning sign knowledge, whereas 138 (40.75%), on the other hand, have insufficient warning sign knowledge. On the other hand, the knowledge of warning signs (72.80%) in Lebanese women in Beirut was the highest proportion [36].Since older and married women are more interested in and aware of BC [20,37,38], this difference could be explained by our younger participants (20–24 years of age), who were younger than those in Beirut (18–65 years), and whose proportion of married people (7.77%) was significantly lower than Beirut’s (49.5%) [36].

Breast self-examination knowledge was found to be quite low in this study. More than three quarters (79.89%) of young women had poor knowledge of BSE, and 71.05% of them were unfamiliar with the process. Moreover, 58.71% and 65.68% of them were unaware of the right timing and frequency of breast self-examination, respectively. This finding was consistent with the study conducted in Turkey, which showed that 66%, 75.4%, and 65.4% of high school female students were unaware of the frequency of BSE, the appropriate time for BSE, and the BSE procedure, respectively [13]. The data demonstrates that BSE is a lesser-known practice that requires extensive public involvement and attention to improve uptake. It could be because of socioeconomic disparities in access to health education [37] the Low living standards, a lack of health awareness, and less societal visibility and attention paid to BSE may all contribute to their lack of in-depth understanding of BC risk factors and BSE [3,14,38].

According to the current study, there is a strong link between BSE knowledge and BSE practice. In keeping with this, it was noted that the likelihood of performing BSE was much higher among those who had better knowledge of BSE than their counterparts [13]. Studies conducted among undergraduate female students in Cameroon [18] substantiate the finding.

In this study, only 23.06% and 1.88% of young adult women performed breast self-examination occasionally and regularly, respectively. In line with this conclusion, 20% and 6.7% of female high school students in Turkey [13], and 24.1% and 8.1% of female secondary school students in Ghana, respectively, performed BSE regularly and occasionally, as indicated [8]. However, in Sri Lanka’s Colombo [15], a lesser percentage (6.17%) of adolescent girls had ever performed it. This lower practice of BSE could be due to lack of knowledge about the BSE procedure. Because 71% of our participants were unaware of it. In previous research, not knowing how to perform BSE was the main reason for not doing so [19,34]. These findings underscore the importance of providing young women with accurate breast health information to promote self-examination behavior. Participants’ demographic characteristics, such as age and marital status, could potentially be associated to their lack of BSE knowledge and experience. In this study 92.23% of young adult women were single and married young adult women were 5.31 times more likely than unmarried young adult women to perform BSE (AOR = 5.31, 95% CI: (2.19–12.90). Research undertaken in southern Ethiopia and Malaysia [19,39] supports this finding. In other words, unmarried women may face more perceived barriers to breast screening [40]. This could also be due to the fact that married women receive greater social support and are exposed to maternal health care and related information during antenatal care, delivery, and the postpartum period.

The majority of young adult women had reduced perceived susceptibility (97.59%), low self-efficacy (72.12%), and severity (45.84%). According to the current study, a high proportion of study participants have low perceived obstacles (91.42%). This was higher than the findings of a study conducted in Adwa town [22], which indicated 47% low perceived susceptibility, 58% low barrier, and 38% low self-efficacy. In the Philippines, female teachers had a low perception of their susceptibility (9%) and a low degree of confidence (33%) in executing BSE [16].

Overall, our study revealed that 95.98% of young adult women were less concerned about breast cancer, and 59.79% had a lower expectation or net benefit from BSE. Because our respondents were substantially younger, it is possible they felt less threatened and had lower expectations.

The results of a multivariate logistic regression analysis revealed that the perceived susceptibility score of young adult women under study was substantially related to breast self-examination practice. This finding is consistent with studies from Ethiopia [22,24], which revealed that high personal breast cancer susceptibility increased the likelihood of BSE.

Furthermore, young women’s confidence was strongly associated with their breast self-examination performance. Other researchers corroborated this finding [19,22,41]. Knowledge builds confidence. More successful BSE could result from interventions aimed at enhancing women’s confidence in their ability to do BSE, as well as initiatives to improve breast cancer awareness.

Our study showed that young adult women with positive expected outcomes were more than twice as likely to perform BSE as their counterparts. This claim backed up a study conducted in Ethiopia [24]. As a result, educating women about the benefits of BSE and reducing barriers such as lack of knowledge about BSE could be an intervention area for improving BSE practice.

Consistent with a study done in Iran [20], the current study found that respondents’ perceived benefits and perceived barriers scores were not statistically associated with actual BSE practice. This conclusion, however, contradicts the findings of Iranian studies [21,41], which found that high perceived benefit and lower perceived barriers were better predictors of BSE. It is possible the disparity is due to the difference in study population and study period.

The strengths and limitations of the study

The application of the revised champions’ health belief model as a theoretical framework can be the strength of this research work. Since only young adult women participated in the study, it does not reflect the perceptions and knowledge of young adult males. Moreover, as a cross-sectional study, the results cannot demonstrate the causal relationship between dependent and independent variables.

Conclusions

Generally, the findings of this study revealed that the knowledge, threat, and performance of breast self-examination were very low. The likelihood of practicing BSE was higher in young adult women who had exhibited higher susceptibility, severity, self-efficacy, positive outcome expectations, and good BSE knowledge. Therefore, interventions targeting young females should be devised based on these variables, to improve the rates of regular breast self-examination.

9 May 2022

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Academic Editor

PLOS ONE

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Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: No

Reviewer #2: No

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Perceptions and knowledge of breast cancer and breast self-examination among young adult Ethiopian women: application of the health belief model .

REVIEW COMMENTS

The study was carried out to assess the knowledge and perceptions of young adult women in Southwest Ethiopia about breast cancer and breast self-examination (BSE). This is a good manuscript with very robust methods. The methodology has been comprehensibly and logically described for reproducibility. The write up and presentation good, however, some concerns need to be addressed. I recommend a major revision

Major Revision

Abstract

Methods

Line 24 State the community used

begin with…. A total of 392

Line 31 with a mean of 21.25 years (sd = 1.32)…. rewrite as Mean (�  SD) ie.

21.25( �  1.32)

Line 35 “on occasion” should be replaced with…occasionally.

Conclusion

BC should be defined on first use

Introduction

Line 53 delete “lying”

Line 55 is the sentence in reference to Ethiopia? If otherwise can author back up with references?

Line 61 “Young women's cancers are mostly diagnosed at an advanced stage” Could be rewritten as….. Young women with cancer are often diagnosed with advanced stage breast cancer.

Line 72 these references does not speak BSE in Ethiopia but rather other African countries.. Could a reference to that effect be included? Or sentence rephrased?

Materials and Methods

Line 89 period design…? What is that exactly

Line 99 study design: Information on study design is quite scanty I recommend a beef up. Or can be merged with study area… as study area and study design.

Line 103 were the young adults purposively selected? Please state so.

Line 125 The data were collected by 25 trained health extension workers under the supervision of five health officers and nurses…..Considering this information, I find it intriguing that this manuscript is a sole authorship one. Any comments on this?

Line 126… “that were closed households or had no participants were visited three times”. Should be rephrased sentence seem incomplete.

Line 133 “signals” ... change to “signs”

Line 142 BSE forms?

Line 188 the appropriate consent for participation should be a written informed consent.

Results

Line 193 Mean And SD data should be presented in standard formats

write as…. Mean (�  SD)

Table 1 remove the year in the title.

If the questionnaire was self-administered, how was the 2.4% illiterate population assessed using the questionnaire? This must be elaborated in the methods.

Table 1 A 7.8% of married young adult in the study aea is worth a mention in the discussion.

Mean And SD data should be presented in standard formats through the manuscript

Percent should be written as Percent (%) to avoid the use of the symbol through the table

Academic status could be replaced with Educational Background.

The inclusion of the year in the table and figure titles should be revised.

Table 2 Percent should be accompanied by its Symbol.

Line 240.. title is not reflective of the information provided

Discussion

Line 273.. only one study is cited.

Line 275.. what is accounting for the poor knowledge in your study area?

Line 267 why so? Any suggestions to improve this outcome. That should a more precise focus of the discussion. Not merely stating what the data says.

Line 283 what is accounting for this low/poor knowledge BSE in south Ethiopia or your study population. Explain

Use consistent decimal points for all the percentage sated in the tables and discussion

Line 311 it is .. rather than it’s..

Line 317 “Confidence is supposed to come after knowledge”. Can be rewritten as….. “Knowledge builds confidence”

Line 323 what some of these barriers… as they are not mentioned clearly in the write up

Line 328 it is .. rather than it’s..

Line 332 I think that….. “The possible limitation of this work is that perceptions and behavioral practices of other breast cancer screening methods, such as clinical breast examination and mammography, were not assessed”. …. Is not the scope of the study and thus does not constitute a study limitation but may be a recommendation for additional studies. Do Reconsider!

Conclusion

Line 339 may not be necessary as part of the conclusion. Conclusion should be precise, concise, straight to the point.

Reviewer #2: 1. It is not clear why only women 20-24 were included in the study while older women are also eligible for BSE. This raises a question in the significance of the study? Otherwise the findings need to be put in context and discussed accordingly.

2. The title of the study seems as if the study is generalizable to Ethiopian women but only included women in one town. This is misleading and need to be corrected to mention the study locality in the title.

3. The samples size assumption of 20% is taken not from Ethiopian or African women. The SS is difficult to ensure adequacy. In such cases 50% should have been taken. In addition no justification given why design-effect if only 1.5 was taken while ti could have been 2. All these raise concerns on the adequacy of sample size.

4. The health belief model tool is a generic one. There is no mention of reliability and validity test for Ethiopian population. How can we rely in this measurement?

5. The data in Table 6 (association test) are not fully presented for most cells. In addition data only for those significantly associated is included. This is not appropriate. All variables irrespective of status if association were supposed to be presented.

**********

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: PLos one- Perceptions and knowledge of breast cancer and breast self 2022.docx

Click here for additional data file.

21 Jun 2022

PONE-D-22-07638

Perceptions and knowledge of breast cancer and breast self-examination among young adult Ethiopian women: application of the health belief model

PLOS ONE

Dear Dr. Assfa,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 23 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future.

For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocolsathttps://plos.org/protocols?utm_medium=editorial email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Alvaro Galli

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

Comments :1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf &https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Responses#: Thank you for your comment. I formatted the manuscript in accordance with PLOS ONE's style guidelines and template.

Comments: 2. you indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

Responses#: Your suggestion is much appreciated. Participants in this study, however, were young adult women aged 20 to 24, who had reached the legal age to consent to participate in the study independently under Ethiopian law. As a result, no parental or guardian consent was requested.

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Comments: Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Responses#: Thank you very much; I uploaded my data availability statement so that the minimum of data set is fully available in figshare public data repository (Doi=10.6084/m9.figshare.20103206 ,URLs= https://doi.org/10.6084/m9.figshare.20103206)

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access. We will update your Data Availability statement to reflect the information you provide in your cover letter.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

Comments: 3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Responses#: Thank you very much; I updated my data availability statement so that the minimum of data set is fully available in figshare public data repository (Doi=10.6084/m9.figshare.20103206 ,URLs= https://doi.org/10.6084/m9.figshare.20103206) .________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Perceptions and knowledge of breast cancer and breast self-examination among young adult Ethiopian women: application of the health belief model

REVIEW COMMENTS

The study was carried out to assess the knowledge and perceptions of young adult women in Southwest Ethiopia about breast cancer and breast self-examination (BSE). This is a good manuscript with very robust methods. The methodology has been comprehensibly and logically described for reproducibility. The write up and presentation good, however, some concerns need to be addressed. I recommend a major revision

Major Revision

Abstract

Methods

comments: Line 24 State the community used begin with…. A total of 392

Responses: I'm grateful to the reviewer who brought this to my attention. I have revised it. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages2, lines 24].

comments: Line 31 with a mean of 21.25 years (sd = 1.32)…. rewrite as Mean (�  SD) ie.

21.25( �  1.32)

Responses I agree and have updated line 31. The new sentence reads as follows “The respondents' ages ranged from 20 to 24, with a mean of 21.25 (�  1.32) years.” The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages2, lines 30].

comments:Line 35 “on occasion” should be replaced with…occasionally

Response #: I agree and have changed “on occasion” to “occasionally”. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages2, lines 34].

Conclusion

comments: BC should be defined on first use

Response #: This is a valid observation. “BC” has been replaced with “breast cancer”. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages2, lines 39].

Introduction

comments: Line 53 delete “lying”

Response #: I agree and have removed the term "lying" from the sentence.

comments: Line 55 is the sentence in reference to Ethiopia? If otherwise can author back up with references?

Response #: Thank you for sharing your thoughts. I've provided references to back it up. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages3, lines 52].

comments: Line 61 “Young women's cancers are mostly diagnosed at an advanced stage” Could be rewritten as….. Young women with cancer are often diagnosed with advanced stage breast cancer.

Response #: I agree with you, and I've rewritten it as follows: “Young women with cancer are often diagnosed with advanced stage breast cancer.” The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages3, lines 58].

comments:Line 72 these references does not speak BSE in Ethiopia but rather other African countries. Could a reference to that effect be included? Or sentence rephrased?

Response #: This observation is correct. I have included a reference to Ethiopia’s BSE problem. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages4, lines 73].

Materials and Methods

comments:Line 89 period design…? What is that exactly

Response #: I am sorry for the error. “Study area, study period, and study design" was supposed to be the meaning. I've fixed the problem, and it's now written as “study area and study design”. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages5, lines 95].

comments:Line 99 study design: Information on study design is quite scanty I recommend a beef up. Or can be merged with study area… as study area and study design.

Response #: I welcome your insightful suggestion, and it has been combined with the study area and study design.

comments: Line 103 were the young adults purposively selected? Please state so.

Response #: Thank you for alerting me to this; however, I do not believe it is better to state so. Because I used a probability sampling approach rather than a purposive approach in the recruitment process. I hope you will keep me updated on your second version revision process if I don't get your view point right.

comments: Line 125 The data were collected by 25 trained health extension workers under the supervision of five health officers and nurses….Considering this information, I find it intriguing that this manuscript is a sole authorship one. Any comments on this?

Response #: Thank you for drawing my attention to this. I think it is important to briefly describe my data collectors who are the Health Extension Workers (HEW). According to Ethiopia's present health-care delivery system, each kebele (a smaller administrative unit) is allotted one or two HEW. They are dominantly female who expected to be well-versed in the community's culture and to be native speakers of the local language. They provide 16 different packages of basic health services. They also do a home visit and organize health and associated data, which is then documented in an organized manner in each family folder in their health post. In general, HEWs are valuable information sources with a broad spectrum of knowledge about their society. That's why I used them to gather my data. For each selected kebele, I used one HEW as responsible data collector to gather data in their respective kebele only without sending them to other kebele to keep their routine tasks on track as usual. That is why the data collectors’ number seems to be higher.

comments:Line 126… “that were closed households or had no participants were visited three times”. Should be rephrased sentence seem incomplete.

Response #: Thank you so much for your good insight, I have rephrased the sentence and the new sentence reads as follows: “Households that were either closed or lacked a respondent were visited three times.” The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages7, lines 131].

comments: Line 133 “signals” ... change to “signs”

Response #: I agree with you, I have changed “signals” to “signs”. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages7, lines 139].

Comments: Line 142 BSE forms?

Response #: My apologies for using unfamiliar terminology, it was to mean a tool to measure BSE. I have rewritten it as “BSE knowledge measurement” The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages7, lines 148].

comments:Line 188 the appropriate consent for participation should be a written informed consent.

Response #: I agree with you that written informed consent is preferable. Even if I use verbal consent, data collectors fully explain the study's purpose, anonymity, confidentiality, and voluntariness of participation before obtaining participants' consent or collecting data.

Results

comments: Line 193 Mean and SD data should be presented in standard formats write as…. Mean (�  SD)

Response #: Thank you for your comment, I have revised and the result has been amended and the new sentence reads as follows: “The participants' ages ranged from 20 to 24, with a mean of 21.25(�  1.32) years.” The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages10, lines 199].

comments:Table 1 remove the year in the title.

Response #: I agree with you, I have removed the ‘year” in the title of table 1 [pages10, lines 205].

comments:If the questionnaire was self-administered, how was the 2.4% illiterate population assessed using the questionnaire? This must be elaborated in the methods.

Response #: I appreciate the reviewer bringing this to my attention. In response to reviewers' suggestions, I revised and added additional elaboration to the data collection procedure. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages7, lines 134-138].

comments:Table 1 A 7.8% of married young adult in the study area is worth a mention in the discussion.

Response #: Thank you for taking the time to leave such an insightful comment. In the discussion section of the manuscript, I mentioned the marital status of the study participants. The modifications made are noted in the document's track changed section. The changes are reflected in the amended manuscript as well [pages 19, lines 316-323].

comments: Mean And SD data should be presented in standard formats through the manuscript

Response #: I agree with you and I have rewritten the Mean and SD in standard format [page 10, line 199]

comments: Percent should be written as Percent (%) to avoid the use of the symbol through the table

Response #: I agree with you and I have written the Percent as Percent (%) [ table 1 column 4 row1] and the symbols % in the table 1 have been removed [ table 1 column 4].

comments:Academic status could be replaced with Educational Background.

Response #: Thank you for the feedback I have replaced “Academic status” by “Educational Background” [table 1 column 1 row 4]

comments: The inclusion of the year in the table and figure titles should be revised.

Response #: Thank you for the suggestion, I have revised the year in all table and fig title [page 10, line 205] [page 11, line 216,217] [page 13, line 228,231] [page 14, line 238] [page 15, line 248] and [page 16, line 261,262].

comments: Table 2 Percent should be accompanied by its Symbol.

Response #: Thank you, Percent in able 2 has written as Percent (%) [page 11, table 2 column 4]

comments: Line 240.. title is not reflective of the information provided

Response #: Thank you for your feedback; if my understanding of your concern about line 240 is correct, it is a subheading given for young adult women's perception towards breast cancer and BSE, not the title of the table (table-4) above it. Young adult women's perceptions of breast cancer and BSE have been described under this subheading, which includes their perceived (susceptibility, severity, benefit, barriers, threat, outcome expectation or net benefit of BSE, and perceived confidence or self-efficacy). I have slightly modified the subheading. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages 15, lines 240].

Discussion

comments: Line 273. only one study is cited.

Response #: I agree and have updated with two additional references. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages 18, lines 284].

comments: Line 275.. what is accounting for the poor knowledge in your study area?

Response #: Thank you for the question. It is possible that this is due to the fact that cancer receives less attention [page 17,278-279]

comments: Line 267 why so? Any suggestions to improve this outcome. That should a more precise focus of the discussion. Not merely stating what the data says.

Response #: Thank you for taking the time to leave such an insightful comment. I've included possible contributing factors as well as recommendations for raising young women's awareness of breast health. The changes are added in the track changed manuscript document. They are also found on the revised manuscript document on [page 17, lines 278-280].

comments: Line 283 what is accounting for this low/poor knowledge BSE in south Ethiopia or your study population. Explain

Response #: Thank you for your valuable insight. I have added and discussed the possible contributing factors for respondents (young adult women) poor knowledge in my study area. The changes are added in the track changed manuscript document. They are also found on the revised manuscript document on [page 18, lines 300-303].

comments: Use consistent decimal points for all the percentage sated in the tables and discussion

Response #: I appreciate and thank you for your thoughtful remarks. I agree with your point of view. All fractions have been rounded to the nearest two decimal places for all the percentages sated in the paper. The changes are made in the track changed manuscript document

comments:Line 311 it is .. rather than it’s.

Response #: I have replaced the word “it’s” by “it is” [page 20, lines 333].

comments:Line 317 “Confidence is supposed to come after knowledge”. Can be rewritten as….. “Knowledge builds confidence”

Response #: I accepted your suggestion and have rewritten as “Knowledge builds confidence” The changes are added in the track changed manuscript document. They are also found on the revised/amended manuscript document on [page 20, lines 339-340].

comments: Line 323 what some of these barriers… as they are not mentioned clearly in the write up

Response #: Thank you for your question and suggestion. In this study perceived barriers of BSE were measured using 7 items stated as: (1) BSE is embarrassing to me, (2) BSE takes too much time, (3) It is hard to remember to do breast examination, (4) I am afraid I would not be able to do breast self-exams,(5) I don't have enough privacy to do breast examination, (6) BSE is not necessary if you have a breast exam by a healthcare provider and (7) I have other problems more important than doing BSE. Overall, lack of knowledge, skill and privacy to perform BSE are some of the barriers. Apart from that, believing that BSE embracing, and time-consuming activity which is also related with lower knowledge, giving less priority for them practices compared to another problem which they believe important than BSE. The changes are added in the track changed manuscript document. They are also found on the revised/amended manuscript document on [page 20, Line 345-346].

comments:Line 328 it is .. rather than it’s..

Response #: Thank you, I have replaced the word “it’s” by “it is” [ page 21, Line 350].

comments: Line 332 I think that….. “The possible limitation of this work is that perceptions and behavioral practices of other breast cancer screening methods, such as clinical breast examination and mammography, were not assessed”. …. Is not the scope of the study and thus does not constitute a study limitation but may be a recommendation for additional studies. Do Reconsider!

Response #: Thank you for your valuable suggestion. The statement “The possible limitation of this work is that perceptions and behavioral practices of other breast cancer screening methods, such as clinical breast examination and mammography, were not assessed” has been deleted. The changes are added in the track changed manuscript document.

Conclusion

comments: Line 339 may not be necessary as part of the conclusion. Conclusion should be precise, concise, straight to the point.

Response #: The statement in conclusion “In this study, health beliefs and reported breast self-examination practices of young adult women were assessed.” has been removed as suggested by reviewer. The changes are added in the track changed manuscript document.

Reviewer #2:

comments:1. It is not clear why only women 20-24 were included in the study while older women are also eligible for BSE. This raises a question in the significance of the study? Otherwise, the findings need to be put in context and discussed accordingly

Response #: I appreciated and thank you for your valuable insight. I have provided additional points to answer why only young adult women (20-24 years old) were included in my study. The change has been highlighted in the track changed manuscript documented. It is found on [page 3 lines number 58-61], [page 4, line number 74-76] and [page 4, line number 81-83] in the revised manuscript document.

comments:2. The title of the study seems as if the study is generalizable to Ethiopian women but only included women in one town. This is misleading and need to be corrected to mention the study locality in the title

Response #: Thank you for your concern and question. I agree with you, thus I've slightly modified the title to look like: “Perceptions and knowledge of breast cancer and breast self-examination among young adult women in South west Ethiopia: application of the health belief model”. The change has been highlighted in the track changed manuscript documented and it is found on [page 1, lines number 2] in the revised manuscript document.

comments:3. The samples size assumption of 20% is taken not from Ethiopian or African women. The SS is difficult to ensure adequacy. In such cases 50% should have been taken. In addition, no justification given why design-effect if only 1.5 was taken while ti could have been 2. All these raise concerns on the adequacy of sample size.

Response #: I appreciate the reviewer who brought this to my attention. I totally agree that the safest choice for obtaining the largest sample size is to use a population proportion of 50%. When it comes to the design effect, researchers adopt a default value of 1.5 to 2.0 when determining sample size because the design effect (deff) is typically regarded as unknown before to a survey. To account for the expense, workload, and time required to collect data from a geographically scattered study population, I utilized the design effect 1.5 and p=0.203 in my sample.

comments:4. The health belief model tool is a generic one. There is no mention of reliability and validity test for Ethiopian population. How can we rely in this measurement?

Response #: I agree with you and thank you for your concern. I've reported the Cronbach alpha as a measure of consistency[page 8, L 163-164]. An expert panel was consulted to ensure face validity when the tool's validity was examined.

comments:5. The data in Table 6 (association test) are not fully presented for most cells. In addition, data only for those significantly associated is included. This is not appropriate. All variables irrespective of status if association were supposed to be presented.

Response #: Thank you for taking the time to provide me with your valuable input. A change has been made to the table. If my understanding is correct, the table contained all variables, independent of their significant status. Continuous independent variables were denoted by the letter “a” in superscript style, and their cells remained vacant. The change has been highlighted in the track changed manuscript documented and it is found on [page 17, line number 262-263] and [table 6 column 1 row 9-11] in the revised manuscript document.________________________________________

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Reviewer #1: No

Reviewer #2: No

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Thank you

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Submitted filename: Response to Reviewers.docx

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12 Aug 2022

17 Aug 2022

August, 2022

From: Authors

To: PLOS ONE editorials

Subject: Response to reviewers

Dear Editor and reviewers:

I would like to thank the editors and reviewers for their time, careful reading, and thorough and helpful remarks and questions about my manuscript, as well as the opportunity to improve and resubmit it.

I believe that my revised paper has substantially improved as a result of the reviewers’ remarks. I am glad to submit the revised research manuscript for consideration in PLOS ONE.

I responded to each reviewer's questions, comments, and suggested revisions one by one. I used the same letter to write my responses after copying the review decision from the editorial manager's submission menu. Editors' and reviewers' questions and comments are italicized, and my responses to the reviewers' comments are presented in plain text immediately below them. All of the modifications I made in the revised manuscript were referenced by page and line numbers. Please, follow my responses in a yellow mark to every comment or question in a green mark.

Once again, thank you for your time and attention to my paper, and I eagerly await your response.

Sincerely!

Kenzudin Assfa Mossa (corresponding author)

Wolkite University

kenzaheri@gmail.com

+251923702054

PONE-D-22-07638R1

Perceptions and knowledge of breast cancer and breast self-examination among young adult women in southwest Ethiopia: application of the health belief model

PLOS ONE

Dear Dr. Assfa,

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Comments: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: I appreciate the suggestions. I checked the reference list; it is complete, correct, and free of any references that have been retracted. Scite (https://scite.ai/users/kenza-abazinab-pn5Ej/reference-checks) revealed no references that had been retracted or that had editorial concerns. In addition, I haven't changed the reference list.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: (No Response)

______________________________________

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Reviewer #1: Yes

________________________________________

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Reviewer #1: Yes

________________________________________

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Reviewer #1: Yes

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Reviewer #1: While most of the comment raised have been addressed in a few needs to be looked into.

Abstract

Methods

Comments: Line 24 which community Again, I suggest you State the community employed for the study.

Response: I'm appreciative to the reviewer who made me aware of this. It has been updated and the new sentence read as: “A community-based cross-sectional study was carried out in Gurage zone, southwest Ethiopia, in 2021.”. The track changed document shows the modifications that have been made. Pages 2 and line 24 of the revised manuscript document contain the modifications.

Comments: Line 48… replace occurred with occurs

Response: I agree and the term occurred replaced by occurs. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages3, lines 49].

Comments: Line 58.. again look at line 58.. the repetition of young women in the 2 sentences is not appropriate and should be modified.

Response: Thank you for the insightful comments. The pronoun "they" was used in place of "young adult women" in the second sentence reads as: "They have a variety of issues, including a higher likelihood of biologically aggressive illness and metastatic disease at diagnosis, which results in a worse prognosis, more aggressive treatments and long-term treatment-related toxicities, and unique psychosocial concerns". The track changed document shows the modifications that have been made. Pages 3 and lines 59 of the revised manuscript document contain the modifications.

Comments: Line 134… references for where questionnaire was adapted from, should be stated.

Response: This is a valid observation. I have added references for where questionnaire was adapted from. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages7, lines 135-136].

Comments: Line 139 use society… not society’s

Response: I agree, and I've changed the word "society's" in the sentence with the word society. Pages 7 and line 140 of the revised manuscript document contain the modifications.

Comments: Line 194 Again… the appropriate consent for participation should be a written informed consent not verbal agreement. This an important part of the study.

Response: Thank you for sharing your thoughts. I have revised it. The new sentence read as follow: “The purpose of the study was communicated to the respondents, and signed consent from each participant was obtained prior to data collection." The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [page10, lines 195-197].

Comments: Line 216 and 217 … why do you have titles for tables and figures? Why present the same information in Tables and Figures. Explain please.

Response: Your thoughtful concern is appreciated. The difference between the data shown in table 2 and fig. 1 is that the table pertains to the frequency distribution of responses given to each of the 11 items used to measure respondents' knowledge of breast cancer risk factors. In response to your suggestion, I eventually combined the data from Fig 1 into the table 2 and eliminated the Fig. The changes made are indicated in track changed document and found on the revised manuscript document [pages11, lines 215-217]. To overall knowledge of respondents about breast cancer risk factors categorized into three categories: low, moderate, and high. The frequency distribution is shown in the last three rows of table 2, page 12 of the revised manuscript.

Comments: Line 228 should read….. Respondents knowledge about early warning signs of breast cancer, Gurage zone

Response: Thank you so much for your comment, I have rephrased the title and the new sentence reads as: “Respondents knowledge about early warning signs of breast cancer, Gurage zone”. The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages13, lines 229].

Comments: In table 3… sd.. should be SD….. out of 11?explain please.

Response: I agree with you, I have changed “sd” to “SD”. 11 is the sum score of the 11 items I used to generate the composite score of respondents' warning sign-related knowledge of breast cancer. The revised manuscript document (pages 13 and table 3) and the track changed document both indicate the changes that were made.

Comments: Line 292 A stronger justification for difference is imperative.

Response: thank you so much for valuable suggestions, I have added the possible factors that could contributed the reported difference in knowledge. the new sentences read as: “Since older and married women are more interested in and aware of BC (20,37,38), this difference could be explained by our younger participants (20–24 years of age), who were younger than those in Beirut (18–65 years), and whose proportion of married people (7.77%) was significantly lower than Beirut's (49.5%) (36)”. The changes made are indicated in track changed document and also found on the revised manuscript document [pages18, lines 292-296].

Comments: Line 294 delete ..participated

Response: I agree with your suggestion, and the term “participated” removed from the sentence. The changes made are indicated in track changed document.

Comments: Line 354… rewrite as…..only young adult women participated in the study.

Response: Thank you for your comment, I have revised it and the new sentence reads as: “Since only young adult women participated in the study, it does not reflect the perceptions and knowledge of young adult males.” The changes made are indicated in track changed document. The changes are also found on the revised manuscript document [pages21, lines 358-359].

Comments: Line 359… why threats?

Response: I appreciate the query. It is well established that a slight or moderate threat plays a big part in making people worry about certain health issues, such as breast cancer. According to the findings of this study, which are shown in table 5, a significant number (96%) of survey participants were less concerned about breast cancer. Because of this it has been included in the conclusion.

________________________________________

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Reviewer #1: No

________________________________________

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Thank you

The Author

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

8 Sep 2022

Perceptions and knowledge of breast cancer and breast self-examination among young adult women in South west Ethiopia: application of the health belief model

PONE-D-22-07638R2

Dear Dr. Assfa,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Alvaro Galli

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

All the comments have been addressed and changes added; in the current form (Revision number 2) the manscript is accepted for publication.

Reviewers' comments:

12 Sep 2022

PONE-D-22-07638R2

Perceptions and knowledge of breast cancer and breast self-examination among young adult women in southwest Ethiopia: application of the health belief model

Dear Dr. Assfa Mossa:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

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Academic Editor

PLOS ONE